'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health

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'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health

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Randy Dotinga

For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).

Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them. 

In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).

“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said. 

Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”

Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.

“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”

After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?

“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”

To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”

Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy. 

Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”

Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.

“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’  I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”

Christie reported no disclosures.

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For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).

Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them. 

In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).

“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said. 

Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”

Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.

“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”

After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?

“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”

To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”

Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy. 

Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”

Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.

“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’  I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”

Christie reported no disclosures.

For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).

Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them. 

In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).

“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said. 

Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”

Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.

“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”

After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?

“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”

To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”

Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy. 

Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”

Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.

“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’  I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”

Christie reported no disclosures.

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Centralized Psychosocial Distress Screening Led by RN Care Coordinator

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Lisa Lobdell, MSN, RN
Judy Lim, MD
Pankaj Gupta, MD

Background

Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.

Objectives

Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.

Methods

All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.

Results

Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.

Conclusions

Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.

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Lisa Lobdell, MSN, RN
Judy Lim, MD
Pankaj Gupta, MD
Author(s)
Lisa Lobdell, MSN, RN
Judy Lim, MD
Pankaj Gupta, MD

Background

Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.

Objectives

Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.

Methods

All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.

Results

Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.

Conclusions

Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.

Background

Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.

Objectives

Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.

Methods

All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.

Results

Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.

Conclusions

Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.

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Assessing the Impact of Antidepressants on Cancer Treatment: A Retrospective Analysis of 14 Antineoplastic Agents

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Assessing the Impact of Antidepressants on Cancer Treatment: A Retrospective Analysis of 14 Antineoplastic Agents

Author(s)
Thu-Lan T. Luong
Brian J. Reinhardt, MS
Karen J. Shou, DO
Oskar F. Kigelman, MD
Kimberly M. Greenfield, MPH
Eric F. Torres Gutierrez, MS
Michael K. Zamani, MS

Cancer patients experience depression at rates > 5 times that of the general population.1-11 Despite an increase in palliative care use, depression rates continued to rise.2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.5 This issue also impacts families and caregivers.1 A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.11

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.14 Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.64

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.14 Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.75 NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

0825FED-AVAHO-Anti-T1

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

0825FED-AVAHO-Anti-T2

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

0825FED-AVAHO-Anti-T3
Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

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Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

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Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.79

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

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  84. Simon S. FDA approves Jelmyto (mitomycin gel) for urothelial cancer. American Cancer Society. April 20, 2020. Accessed April 4, 2025. https://www.cancer.org/cancer/latest-news/fda-approves-jelmyto-mitomycin-gel-for-urothelial-cancer.html
  85. Pantziarka P, Sukhatme V, Bouche G, Meheus L, Sukhatme VP. Repurposing drugs in oncology (ReDO)- diclofenac as an anti-cancer agent. Ecancermedicalscience. 2016;10:610. doi:10.3332/ecancer.2016.610
  86. Choi S, Kim S, Park J, Lee SE, Kim C, Kang D. Diclofenac: a nonsteroidal anti-inflammatory drug inducing cancer cell death by inhibiting microtubule polymerization and autophagy flux. Antioxidants (Basel). 2022;11(5):1009. doi:10.3390/antiox11051009
  87. Tontonoz M. The ABCs of BCG: oldest approved immunotherapy gets new explanation. Memorial Sloan Kettering Cancer Center. July 17, 2020. Accessed April 4, 2025. https://www.mskcc.org/news/oldest-approved-immunotherapy-gets-new-explanation
  88. Jordan VC. Tamoxifen as the first targeted long-term adjuvant therapy for breast cancer. Endocr Relat Cancer. 2014;21(3):R235-R246. doi:10.1530/ERC-14-0092
  89. Cole MP, Jones CT, Todd ID. A new anti-oestrogenic agent in late breast cancer. An early clinical appraisal of ICI46474. Br J Cancer. 1971;25(2):270-275. doi:10.1038/bjc.1971.33
  90. Jordan VC. Tamoxifen: a most unlikely pioneering medicine. Nat Rev Drug Discov. 2003;2(3):205-213. doi:10.1038/nrd1031
  91. Maximov PY, McDaniel RE, Jordan VC. Tamoxifen: Pioneering Medicine in Breast Cancer. Springer Basel; 2013. Accessed April 4, 2025. https://link.springer.com/book/10.1007/978-3-0348-0664-0
  92. Taxol (paclitaxel). Prescribing information. Bristol-Myers Squibb Company; 2011. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020262s049lbl.pdf
  93. Abraxane (paclitaxel). Prescribing information. Celgene Corporation; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021660s047lbl.pdf
  94. Tarceva (erlotinib). Prescribing information. OSI Pharmaceuticals, LLC; 2016. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021743s025lbl.pdf
  95. Docetaxel. Prescribing information. Sichuan Hyiyu Pharmaceutical Co.; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215813s000lbl.pdf
  96. Alimta (pemetrexed). Prescribing information. Teva Pharmaceuticals; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/208419s004lbl.pdf
  97. Tagrisso (osimertinib). Prescribing information. Astra- Zeneca Pharmaceuticals; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/208065s021lbl.pdf
  98. Iressa (gefitinib). Prescribing information. AstraZeneca Pharmaceuticals; 2018. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/206995s003lbl.pdf
  99. Kadcyla (ado-trastuzumab emtansine). Prescribing information. Genentech, Inc.; 2013. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/125427lbl.pdf
  100. Alecensa (alectinib). Prescribing information. Genetech, Inc.; 2017. Accessed April 4, 2025. https:// www.accessdata.fda.gov/drugsatfda_docs/label/2017/208434s003lbl.pdf
  101. Xalkori (crizotinib). Prescribing information. Pfizer Laboratories; 2022. Accessed April 4, 2025. https:// www.accessdata.fda.gov/drugsatfda_docs/label/2022/202570s033lbl.pdf
  102. Lorbrena (lorlatinib). Prescribing information. Pfizer Laboratories; 2018. Accessed April 14, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210868s000lbl.pdf
  103. Alunbrig (brigatinib). Prescribing information. Takeda Pharmaceutical Company; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/208772s008lbl.pdf
  104. Rozlytrek (entrectinib). Prescribing information. Genentech, Inc.; 2019. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/212725s000lbl.pdf
  105. Herceptin (trastuzumab). Prescribing information. Genentech, Inc.; 2010. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103792s5250lbl.pdf
  106. Cybalta (duloxetine). Prescribing information. Eli Lilly and Company; 2017. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021427s049lbl.pdf
  107. Effexor XR (venlafaxine). Prescribing information. Pfizer Wyeth Pharmaceuticals Inc; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/020699s112lbl.pdf
  108. Desyrel (trazodone hydrochloride). Prescribing information. Pragma Pharmaceuticals; 2017. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018207s032lbl.pdf
  109. Sertraline hydrochloride. Prescribing information. Almatica Pharma LLC; 2021. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215133s000lbl.pdf
  110. Remeron (mirtazapine). Prescribing information. Merck & Co. Inc; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/020415s029,%20021208s019lbl.pdf
  111. Celexa (citalopram). Prescribing information. Allergan USA Inc; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/020822s041lbl.pdf
  112. information. GlaxoSmithKline; 2019. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/020358s066lbl.pdf
  113. Amitriptyline hydrochloride tablet. Prescribing information. Quality Care Products LLC; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/spl/data/0f12f50f-7087-46e7-a2e6-356b4c566c9f/0f12f50f-7087-46e7-a2e6-356b4c566c9f.xml
  114. Lexapro (escitalopram). Prescribing information. AbbVie Inc; 2023. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/021323s055,021365s039lbl.pdf
  115. Fluoxetine. Prescribing information. Edgemont Pharmaceutical, LLC; 2017. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/202133s004s005lbl.pdf
  116. Paxil (paroxetine). Prescribing Information. Apotex Inc; 2021. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/020031s077lbl.pdf
  117. Pamelor (nortriptyline HCl). Prescribing information. Mallinckrodt, Inc; 2012. Accessed April 4, 2025. https:// www.accessdata.fda.gov/drugsatfda_docs/label/2012/018012s029,018013s061lbl.pdf
  118. Silenor (doxepin). Prescribing information. Currax Pharmaceuticals; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/022036s006lbl.pdf
  119. Tofranil-PM (imipramine pamote). Prescribing information. Mallinckrodt, Inc; 2014. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/017090s078lbl.pdf
  120. Norpramin (desipramine hydrochloride). Prescribing information. Sanofi-aventis U.S. LLC; 2014. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/014399s069lbl.pdf
  121. Khedezla (desvenlafaxine). Prescribing information. Osmotical Pharmaceutical US LLC; 2019. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/204683s006lbl.pdf
  122. Nefazodone hydrochloride. Prescribing information. Bryant Ranch Prepack; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/spl/data/0bd4c34a-4f43-4c84-8b98-1d074cba97d5/0bd4c34a-4f43-4c84-8b98-1d074cba97d5.xml
  123. Grassi L, Nanni MG, Rodin G, Li M, Caruso R. The use of antidepressants in oncology: a review and practical tips for oncologists. Ann Oncol. 2018;29(1):101-111. doi:10.1093/annonc/mdx526
  124. Lee E, Park Y, Li D, Rodriguez-Fuguet A, Wang X, Zhang WC. Antidepressant use and lung cancer risk and survival: a meta-analysis of observational studies. Cancer Res Commun. 2023;3(6):1013-1025. doi:10.1158/2767-9764.CRC-23-0003
  125. Olfson M, Marcus SC. National patterns in antidepressant medication treatment. Arch Gen Psychiatry. 2009;66(8):848 -856. doi:10.1001/archgenpsychiatry.2009.81
  126. Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med. 2012;10(4):304-311. doi:10.1370/afm.1371
  127. Cowan DT, Wilson-Barnett J, Griffiths P, Allan LG. A survey of chronic noncancer pain patients prescribed opioid analgesics. Pain Med. 2003;4(4):340-351. doi:10.1111/j.1526-4637.2003.03038.x
  128. Breckenridge J, Clark JD. Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain. J Pain. 2003;4(6):344-350. doi:10.1016/s1526-5900(03)00638-2
  129. Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain. 2010;26(1):1-8. doi:10.1097/AJP.0b013e3181b99f35
  130. Sullivan MD, Edlund MJ, Fan MY, DeVries A, Braden JB, Martin BC. Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: the TROUP study. Pain. 2010;150(2):332-339. doi:10.1016/j.pain.2010.05.020
  131. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92. doi:10.7326/0003-4819-152-2-201001190-00006
  132. Haddad P. Do antidepressants have any potential to cause addiction? J Psychopharmacol. 1999;13(3):300- 307. doi:10.1177/026988119901300321
  133. Lakeview Health Staff. America’s most abused antidepressants. Lakeview Health. January 24, 2004. Accessed April 4, 2025. https://www.lakeviewhealth.com/blog/us-most-abused-antidepressants/
  134. Greenhouse Treatment Center Editorial Staff. Addiction to antidepressants: is it possible? America Addiction Centers: Greenhouse Treatment Center. Updated April 23, 2024. Accessed April 4, 2025. https://greenhousetreatment.com/prescription-medication/antidepressants/
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Thu-Lan T. Luonga; Brian J. Reinhardt, MSa; Karen J. Shou, DOb; Oskar F. Kigelman, MDa; Kimberly M. Greenfield, MPHd; Eric F. Torres Gutierrez, MSa; Michael K. Zamani, MSa

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aWalter Reed National Military Medical Center, Bethesda, Maryland  
bTripler Army Medical Center, Honolulu, Hawaii  
cThe Joint Pathology Center, Silver Spring, Maryland

Correspondence: Thu-Lan Luong (thu-lan.t.luong.civ@ health.mil)

Fed Pract. 2025;42(suppl 3). Published online August 18. doi:10.12788/fp.0586

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AVAHO
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Thu-Lan T. Luong
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Karen J. Shou, DO
Oskar F. Kigelman, MD
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Eric F. Torres Gutierrez, MS
Michael K. Zamani, MS
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Thu-Lan T. Luong
Brian J. Reinhardt, MS
Karen J. Shou, DO
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Michael K. Zamani, MS
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Author disclosures  
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

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aWalter Reed National Military Medical Center, Bethesda, Maryland  
bTripler Army Medical Center, Honolulu, Hawaii  
cThe Joint Pathology Center, Silver Spring, Maryland

Correspondence: Thu-Lan Luong (thu-lan.t.luong.civ@ health.mil)

Fed Pract. 2025;42(suppl 3). Published online August 18. doi:10.12788/fp.0586

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Thu-Lan T. Luonga; Brian J. Reinhardt, MSa; Karen J. Shou, DOb; Oskar F. Kigelman, MDa; Kimberly M. Greenfield, MPHd; Eric F. Torres Gutierrez, MSa; Michael K. Zamani, MSa

Author disclosures  
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Author affiliations  
aWalter Reed National Military Medical Center, Bethesda, Maryland  
bTripler Army Medical Center, Honolulu, Hawaii  
cThe Joint Pathology Center, Silver Spring, Maryland

Correspondence: Thu-Lan Luong (thu-lan.t.luong.civ@ health.mil)

Fed Pract. 2025;42(suppl 3). Published online August 18. doi:10.12788/fp.0586

Article PDF
0825FED AVAHO Antidepress_0.pdf
Article PDF
0825FED AVAHO Antidepress_0.pdf

Cancer patients experience depression at rates > 5 times that of the general population.1-11 Despite an increase in palliative care use, depression rates continued to rise.2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.5 This issue also impacts families and caregivers.1 A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.11

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.14 Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.64

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.14 Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.75 NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

0825FED-AVAHO-Anti-T1

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

0825FED-AVAHO-Anti-T2

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

0825FED-AVAHO-Anti-T3
Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

0825FED-AVAHO-Anti-F10825FED-AVAHO-Anti-T40825FED-AVAHO-Anti-T5

Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

0825FED-AVAHO-Anti-F20825FED-AVAHO-Anti-F3

Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.79

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

Cancer patients experience depression at rates > 5 times that of the general population.1-11 Despite an increase in palliative care use, depression rates continued to rise.2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.5 This issue also impacts families and caregivers.1 A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.11

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.14 Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.64

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.14 Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.75 NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

0825FED-AVAHO-Anti-T1

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

0825FED-AVAHO-Anti-T2

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

0825FED-AVAHO-Anti-T3
Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

0825FED-AVAHO-Anti-F10825FED-AVAHO-Anti-T40825FED-AVAHO-Anti-T5

Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

0825FED-AVAHO-Anti-F20825FED-AVAHO-Anti-F3

Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.79

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

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  116. Paxil (paroxetine). Prescribing Information. Apotex Inc; 2021. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/020031s077lbl.pdf
  117. Pamelor (nortriptyline HCl). Prescribing information. Mallinckrodt, Inc; 2012. Accessed April 4, 2025. https:// www.accessdata.fda.gov/drugsatfda_docs/label/2012/018012s029,018013s061lbl.pdf
  118. Silenor (doxepin). Prescribing information. Currax Pharmaceuticals; 2020. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/022036s006lbl.pdf
  119. Tofranil-PM (imipramine pamote). Prescribing information. Mallinckrodt, Inc; 2014. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/017090s078lbl.pdf
  120. Norpramin (desipramine hydrochloride). Prescribing information. Sanofi-aventis U.S. LLC; 2014. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/014399s069lbl.pdf
  121. Khedezla (desvenlafaxine). Prescribing information. Osmotical Pharmaceutical US LLC; 2019. Accessed April 4, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/204683s006lbl.pdf
  122. Nefazodone hydrochloride. Prescribing information. Bryant Ranch Prepack; 2022. Accessed April 4, 2025. https://www.accessdata.fda.gov/spl/data/0bd4c34a-4f43-4c84-8b98-1d074cba97d5/0bd4c34a-4f43-4c84-8b98-1d074cba97d5.xml
  123. Grassi L, Nanni MG, Rodin G, Li M, Caruso R. The use of antidepressants in oncology: a review and practical tips for oncologists. Ann Oncol. 2018;29(1):101-111. doi:10.1093/annonc/mdx526
  124. Lee E, Park Y, Li D, Rodriguez-Fuguet A, Wang X, Zhang WC. Antidepressant use and lung cancer risk and survival: a meta-analysis of observational studies. Cancer Res Commun. 2023;3(6):1013-1025. doi:10.1158/2767-9764.CRC-23-0003
  125. Olfson M, Marcus SC. National patterns in antidepressant medication treatment. Arch Gen Psychiatry. 2009;66(8):848 -856. doi:10.1001/archgenpsychiatry.2009.81
  126. Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med. 2012;10(4):304-311. doi:10.1370/afm.1371
  127. Cowan DT, Wilson-Barnett J, Griffiths P, Allan LG. A survey of chronic noncancer pain patients prescribed opioid analgesics. Pain Med. 2003;4(4):340-351. doi:10.1111/j.1526-4637.2003.03038.x
  128. Breckenridge J, Clark JD. Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain. J Pain. 2003;4(6):344-350. doi:10.1016/s1526-5900(03)00638-2
  129. Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain. 2010;26(1):1-8. doi:10.1097/AJP.0b013e3181b99f35
  130. Sullivan MD, Edlund MJ, Fan MY, DeVries A, Braden JB, Martin BC. Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: the TROUP study. Pain. 2010;150(2):332-339. doi:10.1016/j.pain.2010.05.020
  131. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92. doi:10.7326/0003-4819-152-2-201001190-00006
  132. Haddad P. Do antidepressants have any potential to cause addiction? J Psychopharmacol. 1999;13(3):300- 307. doi:10.1177/026988119901300321
  133. Lakeview Health Staff. America’s most abused antidepressants. Lakeview Health. January 24, 2004. Accessed April 4, 2025. https://www.lakeviewhealth.com/blog/us-most-abused-antidepressants/
  134. Greenhouse Treatment Center Editorial Staff. Addiction to antidepressants: is it possible? America Addiction Centers: Greenhouse Treatment Center. Updated April 23, 2024. Accessed April 4, 2025. https://greenhousetreatment.com/prescription-medication/antidepressants/
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  1. US Department of Veterans Affairs, Office of Suicide Prevention. 2024 National Veteran Suicide Prevention Annual Report. 2024. https://www.mentalhealth.va.gov/suicide_prevention/data.asp.
  2. Tenso K, et al. JAMA Netw Open. 2024;7(11):e2443054. doi:10.1001/jamanetworkopen.2024.43054
  3. Saulnier KG, et al. JAMA Netw Open. 2024;7(12):e2452144. doi:10.1001/jamanetworkopen.2024.52144
  4. Elser H, et al. Am J Epidemiol. 2025;194(2):123-132. doi:10.1093/aje/kwaf002
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References
  1. US Department of Veterans Affairs, Office of Suicide Prevention. 2024 National Veteran Suicide Prevention Annual Report. 2024. https://www.mentalhealth.va.gov/suicide_prevention/data.asp.
  2. Tenso K, et al. JAMA Netw Open. 2024;7(11):e2443054. doi:10.1001/jamanetworkopen.2024.43054
  3. Saulnier KG, et al. JAMA Netw Open. 2024;7(12):e2452144. doi:10.1001/jamanetworkopen.2024.52144
  4. Elser H, et al. Am J Epidemiol. 2025;194(2):123-132. doi:10.1093/aje/kwaf002
References
  1. US Department of Veterans Affairs, Office of Suicide Prevention. 2024 National Veteran Suicide Prevention Annual Report. 2024. https://www.mentalhealth.va.gov/suicide_prevention/data.asp.
  2. Tenso K, et al. JAMA Netw Open. 2024;7(11):e2443054. doi:10.1001/jamanetworkopen.2024.43054
  3. Saulnier KG, et al. JAMA Netw Open. 2024;7(12):e2452144. doi:10.1001/jamanetworkopen.2024.52144
  4. Elser H, et al. Am J Epidemiol. 2025;194(2):123-132. doi:10.1093/aje/kwaf002
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Suicide is the second leading cause of death for US veterans aged 18 to 44 years.1 The 2024 National Veteran Suicide Prevention Annual Report disclosed that of the 6407 veterans who died from suicide in 2022, 60% had a prior mental health diagnosis.1 The report showed improved suicide rates among veterans with certain mental health conditions, such as depression, PTSD, and anxiety, from 2001 to 2022, potentially due to expanded mental health care access for patients with trauma and increased telehealth availability.1,2 For conditions like PTSD, receiving first-line evidence-based treatment also lowered suicide risk.3 Veteran suicide rates have risen 16.2% for those with opioid use disorder since 2001, while falling 13.7% for alcohol use disorder—though the latter rose 1.2% between 2021 and 2022.1

If you or someone you know is having thoughts of suicide, call or text 988 to reach out to the National Suicide Prevention Lifeline, or contact the Veterans Crisis Line: www.veterancrisisline.net.

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Development of a VA Clinician Resource to Facilitate Care Among Veterans Experiencing Homelessness

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Evan Polzer, MA
Lindsey Monteith, PhD
Lisa Brenner, PhD
Nazanin Bahraini, PhD
Kenneth Bruemmer, LCSW
Ronald Calderon, MSW
Sonya Gabrielian, MD, MPH
Shawn Liu, MSW
Bridget Matarazzo, PhD
Tiara Peterkin, LCSW
Joseph Simonetti, MD, MPH
Matthew Stimmel, PhD
Jack Tsai, PhD, MSCP
Ryan Holliday, PhD

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.3

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.4 To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.10 They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.13 As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

0425FED-MH-Homeless_F1

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”23 Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."24 The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”25 The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.26 This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.31

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).28

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

References
  1. Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
  2. Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
  3. Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
  4. Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
  5. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
  6. Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
  7. Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
  8. Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
  9. Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
  10. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  11. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  12. Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
  13. Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
  14. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
  15. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
  16. Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
  17. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
  18. Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
  19. Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
  20. Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
  21. Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
  22. Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
  23. Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
  24. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  25. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  26. Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
  27. Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
  28. Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
  29. Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
  30. Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
  31. Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.
Article PDF
0425FED MH Homeless.pdf
Author and Disclosure Information

Evan Polzer, MAa; Lindsey Monteith, PhDa,b; Lisa Brenner, PhDa,b; Nazanin Bahraini, PhDa,b; Kenneth Bruemmer, LCSWc; Ronald Calderon, MSWd; Sonya Gabrielian, MD, MPHe; Shawn Liu, MSWc; Bridget Matarazzo, PhDa,b; Tiara Peterkin, LCSWa,c; Joseph Simonetti, MD, MPHa; Matthew Stimmel, PhDc; Jack Tsai, PhD, MSCPc,f,g; Ryan Holliday, PhDa,b

Author affiliations
aVA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
bUniversity of Colorado, Boulder
cVeterans Health Administration Homeless Programs Office, Washington, DC
dVeterans Affairs Greater Los Angeles Health Care System, California
eUniversity of California Los Angeles
fYale University, New Haven, Connecticut
gUniversity of Texas Health Science Center, Houston

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

Issue
Federal Practitioner - 42(4)s
Publications
Federal Practitioner
Topics
Mental Health
Emergency Medicine
Page Number
1-8
Sections
Program Profile
Author(s)
Evan Polzer, MA
Lindsey Monteith, PhD
Lisa Brenner, PhD
Nazanin Bahraini, PhD
Kenneth Bruemmer, LCSW
Ronald Calderon, MSW
Sonya Gabrielian, MD, MPH
Shawn Liu, MSW
Bridget Matarazzo, PhD
Tiara Peterkin, LCSW
Joseph Simonetti, MD, MPH
Matthew Stimmel, PhD
Jack Tsai, PhD, MSCP
Ryan Holliday, PhD
Author(s)
Evan Polzer, MA
Lindsey Monteith, PhD
Lisa Brenner, PhD
Nazanin Bahraini, PhD
Kenneth Bruemmer, LCSW
Ronald Calderon, MSW
Sonya Gabrielian, MD, MPH
Shawn Liu, MSW
Bridget Matarazzo, PhD
Tiara Peterkin, LCSW
Joseph Simonetti, MD, MPH
Matthew Stimmel, PhD
Jack Tsai, PhD, MSCP
Ryan Holliday, PhD
Author and Disclosure Information

Evan Polzer, MAa; Lindsey Monteith, PhDa,b; Lisa Brenner, PhDa,b; Nazanin Bahraini, PhDa,b; Kenneth Bruemmer, LCSWc; Ronald Calderon, MSWd; Sonya Gabrielian, MD, MPHe; Shawn Liu, MSWc; Bridget Matarazzo, PhDa,b; Tiara Peterkin, LCSWa,c; Joseph Simonetti, MD, MPHa; Matthew Stimmel, PhDc; Jack Tsai, PhD, MSCPc,f,g; Ryan Holliday, PhDa,b

Author affiliations
aVA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
bUniversity of Colorado, Boulder
cVeterans Health Administration Homeless Programs Office, Washington, DC
dVeterans Affairs Greater Los Angeles Health Care System, California
eUniversity of California Los Angeles
fYale University, New Haven, Connecticut
gUniversity of Texas Health Science Center, Houston

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

Author and Disclosure Information

Evan Polzer, MAa; Lindsey Monteith, PhDa,b; Lisa Brenner, PhDa,b; Nazanin Bahraini, PhDa,b; Kenneth Bruemmer, LCSWc; Ronald Calderon, MSWd; Sonya Gabrielian, MD, MPHe; Shawn Liu, MSWc; Bridget Matarazzo, PhDa,b; Tiara Peterkin, LCSWa,c; Joseph Simonetti, MD, MPHa; Matthew Stimmel, PhDc; Jack Tsai, PhD, MSCPc,f,g; Ryan Holliday, PhDa,b

Author affiliations
aVA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
bUniversity of Colorado, Boulder
cVeterans Health Administration Homeless Programs Office, Washington, DC
dVeterans Affairs Greater Los Angeles Health Care System, California
eUniversity of California Los Angeles
fYale University, New Haven, Connecticut
gUniversity of Texas Health Science Center, Houston

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

Article PDF
0425FED MH Homeless.pdf
Article PDF
0425FED MH Homeless.pdf

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.3

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.4 To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.10 They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.13 As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

0425FED-MH-Homeless_F1

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”23 Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."24 The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”25 The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.26 This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.31

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).28

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.3

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.4 To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.10 They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.13 As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

0425FED-MH-Homeless_F1

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”23 Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."24 The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”25 The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.26 This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.31

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).28

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

References
  1. Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
  2. Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
  3. Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
  4. Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
  5. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
  6. Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
  7. Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
  8. Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
  9. Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
  10. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  11. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  12. Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
  13. Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
  14. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
  15. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
  16. Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
  17. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
  18. Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
  19. Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
  20. Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
  21. Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
  22. Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
  23. Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
  24. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  25. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  26. Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
  27. Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
  28. Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
  29. Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
  30. Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
  31. Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.
References
  1. Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
  2. Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
  3. Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
  4. Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
  5. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
  6. Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
  7. Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
  8. Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
  9. Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
  10. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  11. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  12. Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
  13. Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
  14. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
  15. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
  16. Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
  17. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
  18. Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
  19. Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
  20. Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
  21. Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
  22. Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
  23. Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
  24. Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
  25. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
  26. Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
  27. Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
  28. Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
  29. Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
  30. Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
  31. Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.
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Suicide Prevention Grant Program Reauthorized

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Suicide Prevention Grant Program Reauthorized

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Jan Dyer

Community-based organizations that provide suicide-prevention services can now access about $52.5 million in US Department of Veterans Affairs (VA) grants. The grant is part of the 3-year Staff Sergeant Fox Suicide Prevention Grant Program, which honors Parker Gordon Fox, a sniper instructor at the U.S. Army Infantry School at Fort Benning, Georgia, who died by suicide in 2020. In consecutive Congressional hearings, lawmakers called for the reauthorization of the program to address gaps in VA care.

“It has been a game-changer for so many veterans,” Sen. Richard Blumenthal (D-CT) said. 

The money provides or coordinates primarily nonclinical suicide prevention services, including outreach and linkage to VA and community resources. Services also may include baseline mental health screenings, case management and peer support, education on suicide risk, VA benefits assistance, and emergency clinical services.

Since its inception in 2022, the program has awarded $157.5 million to 95 organizations in 43 states, US territories, and tribal lands. Speaking before the House Committee on Veterans’ Affairs on May 15, VA Secretary Doug Collins praised the Fox program for bringing “different voices into the conversation,” but added it wasn’t enough. He noted that the veteran suicide rate has not changed since 2008, despite the VA annually spending $588 million on suicide prevention over the past few years.

In an op-ed, Russell Lemle, a senior policy analyst at the Veterans Healthcare Policy Institute, disputed Collins' characterization of veteran suicides. Between 2008 and 2022 (the last year for which complete data is available), US deaths by suicide increased 37% while the number of veteran deaths by suicide fell 2%. “This data collection was the single best part of the program,” he argued, calling for reauthorization to continue requiring data-targeted solutions.

According to a 2024 VA interim report on the Fox grant program, grantees had completed > 16,590 outreach contacts and engaged 3204 participants as of September 30, 2023. An additional 864 individuals were onboarding at the time of the report.

The current version of the grant program requires grantees to use validated tools, including the VA Data Collection Tool, and other assessments furnished by VA to determine the effectiveness of the suicide prevention services. They must also provide each participant with a satisfaction survey and submit periodic and annual financial and performance reports.

Despite the Trump administration’s cuts and cancellations to the federal workforce and federal programs, Collins told the Senate committee he is firmly on the side of working with community-based organizations like the Fox grant program to broaden the VA’s reach: “I want to use grants and programs like [the Fox grant program] to reach out beyond the scope of where we’re currently reaching, to say how can we actually touch the veteran that’s not being touched right now by these programs,” Collins said. “We’ve got to do better at using the grants, using our programs to go outside the normal bubble and use others to help get the word out.” 

Grant applications are due in July and VA will choose awardees in September. Organizations can apply for grants worth up to $750,000 and may apply to renew awards from year to year throughout the length of the program.

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Jan Dyer

Community-based organizations that provide suicide-prevention services can now access about $52.5 million in US Department of Veterans Affairs (VA) grants. The grant is part of the 3-year Staff Sergeant Fox Suicide Prevention Grant Program, which honors Parker Gordon Fox, a sniper instructor at the U.S. Army Infantry School at Fort Benning, Georgia, who died by suicide in 2020. In consecutive Congressional hearings, lawmakers called for the reauthorization of the program to address gaps in VA care.

“It has been a game-changer for so many veterans,” Sen. Richard Blumenthal (D-CT) said. 

The money provides or coordinates primarily nonclinical suicide prevention services, including outreach and linkage to VA and community resources. Services also may include baseline mental health screenings, case management and peer support, education on suicide risk, VA benefits assistance, and emergency clinical services.

Since its inception in 2022, the program has awarded $157.5 million to 95 organizations in 43 states, US territories, and tribal lands. Speaking before the House Committee on Veterans’ Affairs on May 15, VA Secretary Doug Collins praised the Fox program for bringing “different voices into the conversation,” but added it wasn’t enough. He noted that the veteran suicide rate has not changed since 2008, despite the VA annually spending $588 million on suicide prevention over the past few years.

In an op-ed, Russell Lemle, a senior policy analyst at the Veterans Healthcare Policy Institute, disputed Collins' characterization of veteran suicides. Between 2008 and 2022 (the last year for which complete data is available), US deaths by suicide increased 37% while the number of veteran deaths by suicide fell 2%. “This data collection was the single best part of the program,” he argued, calling for reauthorization to continue requiring data-targeted solutions.

According to a 2024 VA interim report on the Fox grant program, grantees had completed > 16,590 outreach contacts and engaged 3204 participants as of September 30, 2023. An additional 864 individuals were onboarding at the time of the report.

The current version of the grant program requires grantees to use validated tools, including the VA Data Collection Tool, and other assessments furnished by VA to determine the effectiveness of the suicide prevention services. They must also provide each participant with a satisfaction survey and submit periodic and annual financial and performance reports.

Despite the Trump administration’s cuts and cancellations to the federal workforce and federal programs, Collins told the Senate committee he is firmly on the side of working with community-based organizations like the Fox grant program to broaden the VA’s reach: “I want to use grants and programs like [the Fox grant program] to reach out beyond the scope of where we’re currently reaching, to say how can we actually touch the veteran that’s not being touched right now by these programs,” Collins said. “We’ve got to do better at using the grants, using our programs to go outside the normal bubble and use others to help get the word out.” 

Grant applications are due in July and VA will choose awardees in September. Organizations can apply for grants worth up to $750,000 and may apply to renew awards from year to year throughout the length of the program.

Community-based organizations that provide suicide-prevention services can now access about $52.5 million in US Department of Veterans Affairs (VA) grants. The grant is part of the 3-year Staff Sergeant Fox Suicide Prevention Grant Program, which honors Parker Gordon Fox, a sniper instructor at the U.S. Army Infantry School at Fort Benning, Georgia, who died by suicide in 2020. In consecutive Congressional hearings, lawmakers called for the reauthorization of the program to address gaps in VA care.

“It has been a game-changer for so many veterans,” Sen. Richard Blumenthal (D-CT) said. 

The money provides or coordinates primarily nonclinical suicide prevention services, including outreach and linkage to VA and community resources. Services also may include baseline mental health screenings, case management and peer support, education on suicide risk, VA benefits assistance, and emergency clinical services.

Since its inception in 2022, the program has awarded $157.5 million to 95 organizations in 43 states, US territories, and tribal lands. Speaking before the House Committee on Veterans’ Affairs on May 15, VA Secretary Doug Collins praised the Fox program for bringing “different voices into the conversation,” but added it wasn’t enough. He noted that the veteran suicide rate has not changed since 2008, despite the VA annually spending $588 million on suicide prevention over the past few years.

In an op-ed, Russell Lemle, a senior policy analyst at the Veterans Healthcare Policy Institute, disputed Collins' characterization of veteran suicides. Between 2008 and 2022 (the last year for which complete data is available), US deaths by suicide increased 37% while the number of veteran deaths by suicide fell 2%. “This data collection was the single best part of the program,” he argued, calling for reauthorization to continue requiring data-targeted solutions.

According to a 2024 VA interim report on the Fox grant program, grantees had completed > 16,590 outreach contacts and engaged 3204 participants as of September 30, 2023. An additional 864 individuals were onboarding at the time of the report.

The current version of the grant program requires grantees to use validated tools, including the VA Data Collection Tool, and other assessments furnished by VA to determine the effectiveness of the suicide prevention services. They must also provide each participant with a satisfaction survey and submit periodic and annual financial and performance reports.

Despite the Trump administration’s cuts and cancellations to the federal workforce and federal programs, Collins told the Senate committee he is firmly on the side of working with community-based organizations like the Fox grant program to broaden the VA’s reach: “I want to use grants and programs like [the Fox grant program] to reach out beyond the scope of where we’re currently reaching, to say how can we actually touch the veteran that’s not being touched right now by these programs,” Collins said. “We’ve got to do better at using the grants, using our programs to go outside the normal bubble and use others to help get the word out.” 

Grant applications are due in July and VA will choose awardees in September. Organizations can apply for grants worth up to $750,000 and may apply to renew awards from year to year throughout the length of the program.

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Impact of Multisite Patient Education on Pharmacotherapy for Veterans With Alcohol Use Disorder

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Impact of Multisite Patient Education on Pharmacotherapy for Veterans With Alcohol Use Disorder

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Julie R. Beauchamp, PharmD
Robert Malmstrom, PharmD
Ramona Shayegani, PharmD
Steve T. Flynn, PharmD, BCPS
Amy E. Robinson, PharmD
Jennifer R. Marin, PharmD, BCPS
David B. Huberman, PhD
Janice M. Taylor, PharmD, BCPS
Scott E. Mambourg, PharmD, BCPS

Excessive alcohol use is one of the leading preventable causes of death in the United States, responsible for about 178,000 deaths annually and an average of 488 daily deaths in 2020 and 2021.1Alcohol-related deaths increased by 49% between 2006 and 2019.2 This trend continued during the COVID-19 pandemic, with death certificates that listed alcohol increasing by > 25% from 2019 to 2020, and another 10% in 2021.3 This increase of alcohol-related deaths includes those as a direct result of chronic alcohol use, such as alcoholic cardiomyopathy, alcoholic hepatitis and cirrhosis, and alcohol-induced pancreatitis, as well as a result of acute use such as alcohol poisoning, suicide by exposure to alcohol, and alcohol-impaired driving fatalities.4

Excessive alcohol consumption poses other serious risks, including cases when intake is abruptly reduced without proper management. Alcohol withdrawal syndrome (AWS) can vary in severity, with potentially life-threatening complications such as hallucinations, seizures, and delirium tremens.5

These risks highlight the importance of professional intervention and support, not only to mitigate risks associated with AWS, but provide a pathway towards recovery from alcohol use disorder (AUD).

According to the 2022 National Survey on Drug Use and Health, 28.8 million US adults had AUD in the prior year, yet only 7.6% of these individuals received treatment and an even smaller group (2.2%) received medication-assisted treatment for alcohol.6,7 This is despite American Psychiatric Association guidelines for the pharmacological treatment of patients with AUD, including the use of naltrexone, acamprosate, disulfiram, topiramate, or gabapentin, depending on therapy goals, past medication trials, medication contraindications, and patient preference.8 Several of these medications are approved by the US Food and Drug Administration (FDA) for the treatment of AUD and have support for effectiveness from randomized controlled trials and meta-analyses.9-11

Clinical practice guidelines for the management of substance use disorders (SUDs) from the US Department of Veterans Affairs (VA) and US Department of Defense have strong recommendations for naltrexone and topiramate as first-line pharmacotherapies for moderate to severe AUD. Acamprosate and disulfiram are weak recommendations as alternative options. Gabapentin is a weak recommendation for cases where first-line treatments are contraindicated or ineffective. The guidelines emphasize the importance of a comprehensive approach to AUD treatment, including psychosocial interventions in addition to pharmacotherapy.12

A 2023 national survey found veterans reported higher alcohol consumption than nonveterans.13 At the end of fiscal year 2023, > 4.4 million veterans—6% of Veterans Health Administration patients—had been diagnosed with AUD.14 However, > 87% of these patients nationally, and 88% of Veterans Integrated Service Network (VISN) 21 patients, were not receiving naltrexone, acamprosate, disulfiram, or topiramate as part of their treatment. The VA Academic Detailing Service (ADS) now includes AUD pharmacotherapy as a campaign focus, highlighting its importance. The ADS is a pharmacy educational outreach program that uses unbiased clinical guidelines to promote aligning prescribing behavior with best practices. Academic detailing methods include speaking with health care practitioners (HCPs), and direct-to-consumer (DTC) patient education.

ADS campaigns include DTC educational handouts. Past ADS projects and research using DTC have demonstrated a significant improvement in outcomes and positively influencing patients’ pharmacotherapy treatment. 15,16 A VA quality improvement project found a positive correlation between the initiation of AUD pharmacotherapy and engagement with mental health care following the distribution of AUD DTC patient education. 17 This project aimed to apply the same principles of prior research to explore the use of DTC across multiple facilities within VISN 21 to increase AUD pharmacotherapy. VISN 21 includes VA facilities and clinics across the Pacific Islands, Nevada, and California and serves about 350,000 veterans.

METHODS

A prospective cohort of VISN 21 veterans with or at high risk for AUD was identified using the VA ADS AUD Dashboard. The cohort included those not on acamprosate, disulfiram, naltrexone, topiramate, or gabapentin for treatment of AUD and had an elevated Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score of ≥ 6 (high risk) with an AUD diagnosis or ≥ 8 (severe risk) without a diagnosis. The AUDIT-C scores used in the dashboard are supported by the VA AUD clinician guide as the minimum scores when AUD pharmacotherapy should be offered to patients.18 Prescriptions filled outside the VA were not included in this dashboard.

Data and patient information were collected using the VA Corporate Data Warehouse. To be eligible, veterans needed a valid mailing address within the VISN 21 region and a primary care, mental health, or SUD clinician prescriber visit scheduled between October 1, 2023, and January 31, 2024. Veterans were excluded if they were in hospice, had a 1-year mortality risk score > 50% based on their Care Assessment Need (CAN) score, or facility leadership opted out of project involvement. Patients with both severe renal and hepatic impairments were excluded because they were ineligible for AUD pharmacotherapy. However, veterans with either renal or hepatic impairment (but not both) were included, as they could be potential candidates for ≥ 1 AUD pharmacotherapy option.

Initial correspondence with facilities was initiated through local academic detailers. A local champion was identified for the 1 facility without an academic detailer. Facilities could opt in or out of the project. Approval was provided by the local pharmacy and therapeutics committee, pharmacy, primary care, or psychiatry leadership. Approval process and clinician involvement varied by site.

Education

The selected AUD patient education was designed and approved by the national VA ADS (eappendix). The DTC patient education provided general knowledge about alcohol, including what constitutes a standard amount of alcohol, what is considered heavy drinking, risks of heavy drinking, creating a plan with a clinician to reduce and manage withdrawal symptoms, and additional resources. The DTC was accompanied by a cover letter that included a local facility contact number.

A centralized mailing facility was used for all materials. VA Northern California Health Care System provided the funding to cover the cost of postage. The list of veterans to be contacted was updated on a rolling basis and DTC education was mailed 2 weeks prior to their scheduled prescriber visit.

The eligible cohort of 1260 veterans received DTC education. A comparator group of 2048 veterans that did not receive DTC education was obtained retrospectively by using the same inclusion and exclusion criteria with a scheduled primary care, mental health, or SUD HCP visit from October 1, 2022, to January 31, 2023. The outcomes assessed were within 30 days of the scheduled visit, with the primary outcome as the initiation of AUD-related pharmacotherapy and the secondary outcome as the placement of a consultation for mental health or SUD services. Any consultations sent to Behavioral Health, Addiction, Mental Health, Psychiatric, and SUD services following the HCP visit, within the specified time frame, were used for the secondary outcome.

Matching and Analysis

A 1-to-1 nearest neighbor propensity score (PS) matching without replacement was used to pair the 1260 veterans from the intervention group with similarly scored comparator group veterans for a PS-matched final dataset of 2520 veterans. The PS model was a multivariate logistic regression with the outcome being exposure and comparator group status. Baseline characteristics used in the PS model were age, birth sex, race, facility of care, baseline AUDIT-C score, and days between project start and scheduled appointment. Covariate imbalance for the PS-matched sample was assessed to ensure the standardized mean difference for all covariates fell under a 0.1 threshold (Figure).19

0525FED-eAUD-F1

A frequency table was provided to compare the discrete distributions of the baseline characteristics in the intervention and comparator groups. Logistic regression analysis was performed to evaluate the association between DTC education exposure and pharmacotherapy initiation, while controlling for potential confounders. Univariate and multivariate P value results for each variable included in the model were reported along with the multivariate odds ratios (ORs) and their associated 95% CIs. Logistic regression analyses were run for both outcomes. Each model included the exposure and comparator group status as well as the baseline characteristics included in the PS model. Statistical significance was set at P < .05. All statistical analyses were performed with R version 4.2.1.

RESULTS

Two of 7 VISN 21 sites did not participate, and 3 had restrictions on participation. DTC education was mailed about 2 weeks prior to scheduled visit for 1260 veterans; 53.6% identified as White, 37.6% were aged 41 to 60 years, and 79.2% had an AUDIT-C ≥ 8 (Table 1). Of those mailed education, there were 173 no-show appointments (13.7%). Thirty-two veterans (2.5%) in the DTC group and 33 veterans (2.6%) in the comparator group received an AUD-related pharmacotherapy prescription (P = .88) (Table 2). One hundred seventy-one veterans (13.6%) in the DTC group and 160 veterans (12.7%) in the comparator group had a consult placed for mental health or SUD services within 30 days of their appointment (P = .59) (Table 3).

0525FED-eAUD-T10525FED-eAUD-T20525FED-eAUD-T3

DISCUSSION

This project did not yield statistically significant differences in either the primary or secondary outcomes within the 30-day follow-up window and found limited impact from the DTC educational outreach to veterans. The percentage of veterans that received AUD-related pharmacotherapy or consultations for mental health or SUD services was similarly low in the DTC and comparator groups. These findings suggest that although DTC education may raise awareness, it may not be sufficient on its own to drive changes in prescribing behavior or referral patterns without system-level support.

Addiction is a complex disease faced with stigma and requiring readiness by both the HCP and patient to move forward in support and treatment. The consequences of stigma can be severe: the more stigma perceived by a person with AUD, the less likely they are to seek treatment.20 Stigma may exist even within HCPs and may lead to compromised care including shortened visits, less engagement, and less empathy.19 Cultural attitude towards alcohol use and intoxication can also be influenced through a wide range of sources including social media, movies, music, and television. Studies have shown targeted alcohol marketing may result in the development of positive beliefs about drinking and expand environments where alcohol use is socially acceptable and encouraged.21 These factors can impact drinking behavior, including the onset of drinking, binge drinking, and increased alcohol consumption.22

Three VISN 21 sites in this study had restrictions on or excluded primary care from participation. Leadership at some of these facilities were concerned that primary care teams did not have the bandwidth to take on additional items and/or there was variable primary care readiness for initiating AUD pharmacotherapy. Further attempts should be made to integrate primary care into the process of initiating AUD treatment as significant research suggests that integrated care models for AUD may be associated with improved process and outcome measures of care.23

There are several differences between this quality improvement project and prior research investigating the impact of DTC education for other conditions, such as the EMPOWER randomized controlled trial and VISN 22 project, which both demonstrated effectiveness of DTC education for reducing benzodiazepine use in geriatric veterans. 15,16 These studies focused on reducing or stopping pharmacotherapy use, whereas this project sought to promote the initiation of AUD pharmacotherapy. These studies evaluated outcomes at least 6 months postindex date, whereas this project evaluated outcomes within 30 days postappointment. Furthermore, the educational content varied significantly. Other projects provided patients with information focused on specific medications and interventions, such as benzodiazepine tapering, while this project mailed general information on heavy drinking, its risks, and strategies for cutting back, without mentioning pharmacotherapy. The DTC material used in this project was chosen because it was a preapproved national VA ADS resource, which expedited the project timeline by avoiding the need for additional approvals at each participating site. These differences may impact the observed effectiveness of DTC education in this project, especially regarding the primary outcome.

Strengths and Limitations

This quality improvement project sent a large sample of veterans DTC education in a clinical setting across multiple sites. Additionally, PS matching methods were used to balance covariates between the comparator and DTC education group, thereby simulating a randomized controlled trial and reducing selection bias. The project brought attention to the VISN 21 AUD treatment rates, stimulated conversation across sites about available treatments and resources for AUD, and sparked collaboration between academic detailing, mental health, and primary care services. The time frame for visits was selected during the winter; the National Institute on Alcohol Abuse and Alcoholism notes this is a time when people may be more likely to engage in excessive alcohol consumption than at other times of the year.24

The 30-day time frame for outcomes may have been too short to observe changes in prescribing or referral patterns. Additionally, the comparator group was comprised of veterans seen from October 1, 2022, to January 31, 2023, where seasonal timing may have influenced alcohol consumption behaviors and skewed the results. There were also no-show appointments in the DTC education group (13.7%), though it is likely some patients rescheduled and still received AUD pharmacotherapy within 30 days of the original appointment. Finally, it was not possible to confirm whether a patient opened and read the education that was mailed to them. This may be another reason to explore electronic distribution of DTC education. This all may have contributed to the lack of statistically significant differences in both the primary and secondary outcomes.

There was a high level of variability between facility participation in the project. Two of 7 sites did not participate, and 3 sites restricted primary care engagement. This represents a significant limitation, particularly for the secondary outcome of placing consultations for MH or SUD services. Facilities that only included mental health or SUD HCPs may have resulted in lower consultation rates due to their inherent specialization, reducing the likelihood of self-referrals.

The project may overestimate prescribed AUD pharmacotherapy in the primary outcome due to potential misclassification of medications. While the project adhered to the national VA ADS AUD dashboard’s definition of AUD pharmacotherapy, including acamprosate, disulfiram, naltrexone, topiramate, and gabapentin, some of these medications have multiple indications. For example, gabapentin is commonly prescribed for peripheral neuropathy, and topiramate is used to treat migraines and seizures. The multipurpose use adds uncertainty about whether they were prescribed specifically for AUD treatment, especially in cases where the HCP is responsible for treating a broad range of disease states, as in primary care.

CONCLUSIONS

Results of this quality improvement project did not show a statistically significant difference between patients sent DTC education and the comparator group for the initiation of AUD pharmacotherapy or placement of a consult to mental health or SUD services within 30 days of their scheduled visit. Future studies may seek to implement stricter criteria to confirm the intended use of topiramate and gabapentin, such as looking for keywords in the prescription instructions for use, performing chart reviews, and/or only including these medications if prescribed by a mental health or SUD HCP. Alternatively, future studies may consider limiting the analysis to only FDA-approved AUD medications: acamprosate, disulfiram, and naltrexone. It is vital to continue to enhance primary care HCP readiness to treat AUD, given the existing relationships and trust they often have with patients. Electronic methods for distributing DTC education could also be advantageous, as these methods may have the ability to track whether a message has been opened and read. Despite a lack of statistical significance, this project sparked crucial conversations and collaboration around AUD, available treatments, and addressing potential barriers to connecting patients to care within VISN 21.

References
  1. Centers for Disease Control and Prevention. Facts about U.S. deaths from excessive alcohol use. August 6, 2024. Accessed February 5, 2025. https://www.cdc.gov/alcohol/facts-stats/
  2. State Health Access Data Assistance Center. Escalating alcohol-involved death rates: trends and variation across the nation and in the states from 2006 to 2019. April 19, 2021. Accessed February 5, 2025. https://www.shadac.org/escalating-alcohol-involved-death-rates-trends-and-variation-across-nation-and-states-2006-2019
  3. National Institute on Alcohol Abuse and Alcoholism. Alcohol- related emergencies and deaths in the United States. Updated November 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states
  4. Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from excessive alcohol use - United States, 2016- 2021. MMWR Morb Mortal Wkly Rep. 2024;73(8):154-161. doi:10.15585/mmwr.mm7308a1
  5. Canver BR, Newman RK, Gomez AE. Alcohol Withdrawal Syndrome. In: StatPearls. StatPearls Publishing; 2024.
  6. National Institute on Alcohol Abuse and Alcoholism. Alcohol treatment in the United States. Updated January 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-treatment-united-states
  7. National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder (AUD) in the United States: age groups and demographic characteristics. Updated September 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
  8. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86-90. doi:10.1176/appi.ajp.2017.1750101
  9. Blodgett JC, Del Re AC, Maisel NC, Finney JW. A meta-analysis of topiramate’s effects for individuals with alcohol use disorders. Alcohol Clin Exp Res. 2014;38(6):1481-1488. doi:10.1111/acer.12411
  10. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x
  11. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628
  12. US Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. August 2021. Accessed February 5, 2025. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPG.pdf
  13. Ranney RM, Bernhard PA, Vogt D, et al. Alcohol use and treatment utilization in a national sample of veterans and nonveterans. J Subst Use Addict Treat. 2023;146:208964. doi:10.1016/j.josat.2023.208964
  14. US Department of Veterans Affairs, Pharmacy Benefit Management Service, Academic Detailing Service. AUD Trend Report. https://vaww.pbi.cdw.va.gov/PBIRS/Pages/ReportViewer.aspx?/GPE/PBM_AD/SSRS/AUD/AUD_TrendReport
  15. Mendes MA, Smith JP, Marin JK, et al. Reducing benzodiazepine prescribing in older veterans: a direct-to-consumer educational brochure. Fed Pract. 2018;35(9):36-43.
  16. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949
  17. Maloney R, Funmilayo M. Acting on the AUDIT-C: implementation of direct-to-consumer education on unhealth alcohol use. Presented on March 31, 2023; Central Virginia Veterans Affairs Health Care System, Richmond, Virginia.
  18. US Department of Veterans Affairs, Pharmacy Benefit Management Service. Alcohol use disorder (AUD) – leading the charge in the treatment of AUD: a VA clinician’s guide. February 2022. Accessed February 5, 2025. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1530_AUD_ClinicianGuide_508Conformant.pdf
  19. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399-424. doi:10.1080/00273171.2011.568786
  20. National Institute on Alcohol Abuse and Alcoholism. Stigma: overcoming a pervasive barrier to optimal care. Updated January 6, 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/stigma-overcoming-pervasive-barrier-optimal-care
  21. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and cultural contexts of alcohol use: influences in a socialecological framework. Alcohol Res. 2016;38(1):35-45.
  22. Tanski SE, McClure AC, Li Z, et al. Cued recall of alcohol advertising on television and underage drinking behavior. JAMA Pediatr. 2015;169(3):264-271. doi:10.1001/jamapediatrics.2014.3345
  23. Hyland CJ, McDowell MJ, Bain PA, Huskamp HA, Busch AB. Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: a scoping review. J Subst Abuse Treat. 2023;144:108919. doi:10.1016/j.jsat.2022.108919
  24. National Institute on Alcohol Abuse and Alcoholism. The truth about holiday spirits. Updated November 2023. Accessed February 5, 2025. ,a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits">https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits
Article PDF
0525FED AUD web.pdf
Author and Disclosure Information

Julie R. Beauchamp, PharmDa; Robert Malmstrom, PharmDa; Ramona Shayegani, PharmDa; Steve T. Flynn, PharmD, BCPSa; Amy E. Robinson, PharmDa; Jennifer R. Marin, PharmD, BCPSa; David B. Huberman, PhDa; Janice M. Taylor, PharmD, BCPSa; Scott E. Mambourg, PharmD, BCPSa

Author affiliations 
aVA Sierra Pacific Network (VISN 21)

Author disclosures 
The authors report no actual or potential conflicts of interest in regard to this article.

Correspondence: Julie Beauchamp (julie.beauchamp@ va.gov)

Fed Pract. 2025;42(5). Published online May 17. doi:10.12788/fp.0562

Issue
Federal Practitioner - 42(5)
Publications
Federal Practitioner
Topics
Mental Health
Pharmacy
Primary Care/Internal Medicine
Page Number
1-8
Sections
Original Research
Author(s)
Julie R. Beauchamp, PharmD
Robert Malmstrom, PharmD
Ramona Shayegani, PharmD
Steve T. Flynn, PharmD, BCPS
Amy E. Robinson, PharmD
Jennifer R. Marin, PharmD, BCPS
David B. Huberman, PhD
Janice M. Taylor, PharmD, BCPS
Scott E. Mambourg, PharmD, BCPS
Author(s)
Julie R. Beauchamp, PharmD
Robert Malmstrom, PharmD
Ramona Shayegani, PharmD
Steve T. Flynn, PharmD, BCPS
Amy E. Robinson, PharmD
Jennifer R. Marin, PharmD, BCPS
David B. Huberman, PhD
Janice M. Taylor, PharmD, BCPS
Scott E. Mambourg, PharmD, BCPS
Author and Disclosure Information

Julie R. Beauchamp, PharmDa; Robert Malmstrom, PharmDa; Ramona Shayegani, PharmDa; Steve T. Flynn, PharmD, BCPSa; Amy E. Robinson, PharmDa; Jennifer R. Marin, PharmD, BCPSa; David B. Huberman, PhDa; Janice M. Taylor, PharmD, BCPSa; Scott E. Mambourg, PharmD, BCPSa

Author affiliations 
aVA Sierra Pacific Network (VISN 21)

Author disclosures 
The authors report no actual or potential conflicts of interest in regard to this article.

Correspondence: Julie Beauchamp (julie.beauchamp@ va.gov)

Fed Pract. 2025;42(5). Published online May 17. doi:10.12788/fp.0562

Author and Disclosure Information

Julie R. Beauchamp, PharmDa; Robert Malmstrom, PharmDa; Ramona Shayegani, PharmDa; Steve T. Flynn, PharmD, BCPSa; Amy E. Robinson, PharmDa; Jennifer R. Marin, PharmD, BCPSa; David B. Huberman, PhDa; Janice M. Taylor, PharmD, BCPSa; Scott E. Mambourg, PharmD, BCPSa

Author affiliations 
aVA Sierra Pacific Network (VISN 21)

Author disclosures 
The authors report no actual or potential conflicts of interest in regard to this article.

Correspondence: Julie Beauchamp (julie.beauchamp@ va.gov)

Fed Pract. 2025;42(5). Published online May 17. doi:10.12788/fp.0562

Article PDF
0525FED AUD web.pdf
Article PDF
0525FED AUD web.pdf

Excessive alcohol use is one of the leading preventable causes of death in the United States, responsible for about 178,000 deaths annually and an average of 488 daily deaths in 2020 and 2021.1Alcohol-related deaths increased by 49% between 2006 and 2019.2 This trend continued during the COVID-19 pandemic, with death certificates that listed alcohol increasing by > 25% from 2019 to 2020, and another 10% in 2021.3 This increase of alcohol-related deaths includes those as a direct result of chronic alcohol use, such as alcoholic cardiomyopathy, alcoholic hepatitis and cirrhosis, and alcohol-induced pancreatitis, as well as a result of acute use such as alcohol poisoning, suicide by exposure to alcohol, and alcohol-impaired driving fatalities.4

Excessive alcohol consumption poses other serious risks, including cases when intake is abruptly reduced without proper management. Alcohol withdrawal syndrome (AWS) can vary in severity, with potentially life-threatening complications such as hallucinations, seizures, and delirium tremens.5

These risks highlight the importance of professional intervention and support, not only to mitigate risks associated with AWS, but provide a pathway towards recovery from alcohol use disorder (AUD).

According to the 2022 National Survey on Drug Use and Health, 28.8 million US adults had AUD in the prior year, yet only 7.6% of these individuals received treatment and an even smaller group (2.2%) received medication-assisted treatment for alcohol.6,7 This is despite American Psychiatric Association guidelines for the pharmacological treatment of patients with AUD, including the use of naltrexone, acamprosate, disulfiram, topiramate, or gabapentin, depending on therapy goals, past medication trials, medication contraindications, and patient preference.8 Several of these medications are approved by the US Food and Drug Administration (FDA) for the treatment of AUD and have support for effectiveness from randomized controlled trials and meta-analyses.9-11

Clinical practice guidelines for the management of substance use disorders (SUDs) from the US Department of Veterans Affairs (VA) and US Department of Defense have strong recommendations for naltrexone and topiramate as first-line pharmacotherapies for moderate to severe AUD. Acamprosate and disulfiram are weak recommendations as alternative options. Gabapentin is a weak recommendation for cases where first-line treatments are contraindicated or ineffective. The guidelines emphasize the importance of a comprehensive approach to AUD treatment, including psychosocial interventions in addition to pharmacotherapy.12

A 2023 national survey found veterans reported higher alcohol consumption than nonveterans.13 At the end of fiscal year 2023, > 4.4 million veterans—6% of Veterans Health Administration patients—had been diagnosed with AUD.14 However, > 87% of these patients nationally, and 88% of Veterans Integrated Service Network (VISN) 21 patients, were not receiving naltrexone, acamprosate, disulfiram, or topiramate as part of their treatment. The VA Academic Detailing Service (ADS) now includes AUD pharmacotherapy as a campaign focus, highlighting its importance. The ADS is a pharmacy educational outreach program that uses unbiased clinical guidelines to promote aligning prescribing behavior with best practices. Academic detailing methods include speaking with health care practitioners (HCPs), and direct-to-consumer (DTC) patient education.

ADS campaigns include DTC educational handouts. Past ADS projects and research using DTC have demonstrated a significant improvement in outcomes and positively influencing patients’ pharmacotherapy treatment. 15,16 A VA quality improvement project found a positive correlation between the initiation of AUD pharmacotherapy and engagement with mental health care following the distribution of AUD DTC patient education. 17 This project aimed to apply the same principles of prior research to explore the use of DTC across multiple facilities within VISN 21 to increase AUD pharmacotherapy. VISN 21 includes VA facilities and clinics across the Pacific Islands, Nevada, and California and serves about 350,000 veterans.

METHODS

A prospective cohort of VISN 21 veterans with or at high risk for AUD was identified using the VA ADS AUD Dashboard. The cohort included those not on acamprosate, disulfiram, naltrexone, topiramate, or gabapentin for treatment of AUD and had an elevated Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score of ≥ 6 (high risk) with an AUD diagnosis or ≥ 8 (severe risk) without a diagnosis. The AUDIT-C scores used in the dashboard are supported by the VA AUD clinician guide as the minimum scores when AUD pharmacotherapy should be offered to patients.18 Prescriptions filled outside the VA were not included in this dashboard.

Data and patient information were collected using the VA Corporate Data Warehouse. To be eligible, veterans needed a valid mailing address within the VISN 21 region and a primary care, mental health, or SUD clinician prescriber visit scheduled between October 1, 2023, and January 31, 2024. Veterans were excluded if they were in hospice, had a 1-year mortality risk score > 50% based on their Care Assessment Need (CAN) score, or facility leadership opted out of project involvement. Patients with both severe renal and hepatic impairments were excluded because they were ineligible for AUD pharmacotherapy. However, veterans with either renal or hepatic impairment (but not both) were included, as they could be potential candidates for ≥ 1 AUD pharmacotherapy option.

Initial correspondence with facilities was initiated through local academic detailers. A local champion was identified for the 1 facility without an academic detailer. Facilities could opt in or out of the project. Approval was provided by the local pharmacy and therapeutics committee, pharmacy, primary care, or psychiatry leadership. Approval process and clinician involvement varied by site.

Education

The selected AUD patient education was designed and approved by the national VA ADS (eappendix). The DTC patient education provided general knowledge about alcohol, including what constitutes a standard amount of alcohol, what is considered heavy drinking, risks of heavy drinking, creating a plan with a clinician to reduce and manage withdrawal symptoms, and additional resources. The DTC was accompanied by a cover letter that included a local facility contact number.

A centralized mailing facility was used for all materials. VA Northern California Health Care System provided the funding to cover the cost of postage. The list of veterans to be contacted was updated on a rolling basis and DTC education was mailed 2 weeks prior to their scheduled prescriber visit.

The eligible cohort of 1260 veterans received DTC education. A comparator group of 2048 veterans that did not receive DTC education was obtained retrospectively by using the same inclusion and exclusion criteria with a scheduled primary care, mental health, or SUD HCP visit from October 1, 2022, to January 31, 2023. The outcomes assessed were within 30 days of the scheduled visit, with the primary outcome as the initiation of AUD-related pharmacotherapy and the secondary outcome as the placement of a consultation for mental health or SUD services. Any consultations sent to Behavioral Health, Addiction, Mental Health, Psychiatric, and SUD services following the HCP visit, within the specified time frame, were used for the secondary outcome.

Matching and Analysis

A 1-to-1 nearest neighbor propensity score (PS) matching without replacement was used to pair the 1260 veterans from the intervention group with similarly scored comparator group veterans for a PS-matched final dataset of 2520 veterans. The PS model was a multivariate logistic regression with the outcome being exposure and comparator group status. Baseline characteristics used in the PS model were age, birth sex, race, facility of care, baseline AUDIT-C score, and days between project start and scheduled appointment. Covariate imbalance for the PS-matched sample was assessed to ensure the standardized mean difference for all covariates fell under a 0.1 threshold (Figure).19

0525FED-eAUD-F1

A frequency table was provided to compare the discrete distributions of the baseline characteristics in the intervention and comparator groups. Logistic regression analysis was performed to evaluate the association between DTC education exposure and pharmacotherapy initiation, while controlling for potential confounders. Univariate and multivariate P value results for each variable included in the model were reported along with the multivariate odds ratios (ORs) and their associated 95% CIs. Logistic regression analyses were run for both outcomes. Each model included the exposure and comparator group status as well as the baseline characteristics included in the PS model. Statistical significance was set at P < .05. All statistical analyses were performed with R version 4.2.1.

RESULTS

Two of 7 VISN 21 sites did not participate, and 3 had restrictions on participation. DTC education was mailed about 2 weeks prior to scheduled visit for 1260 veterans; 53.6% identified as White, 37.6% were aged 41 to 60 years, and 79.2% had an AUDIT-C ≥ 8 (Table 1). Of those mailed education, there were 173 no-show appointments (13.7%). Thirty-two veterans (2.5%) in the DTC group and 33 veterans (2.6%) in the comparator group received an AUD-related pharmacotherapy prescription (P = .88) (Table 2). One hundred seventy-one veterans (13.6%) in the DTC group and 160 veterans (12.7%) in the comparator group had a consult placed for mental health or SUD services within 30 days of their appointment (P = .59) (Table 3).

0525FED-eAUD-T10525FED-eAUD-T20525FED-eAUD-T3

DISCUSSION

This project did not yield statistically significant differences in either the primary or secondary outcomes within the 30-day follow-up window and found limited impact from the DTC educational outreach to veterans. The percentage of veterans that received AUD-related pharmacotherapy or consultations for mental health or SUD services was similarly low in the DTC and comparator groups. These findings suggest that although DTC education may raise awareness, it may not be sufficient on its own to drive changes in prescribing behavior or referral patterns without system-level support.

Addiction is a complex disease faced with stigma and requiring readiness by both the HCP and patient to move forward in support and treatment. The consequences of stigma can be severe: the more stigma perceived by a person with AUD, the less likely they are to seek treatment.20 Stigma may exist even within HCPs and may lead to compromised care including shortened visits, less engagement, and less empathy.19 Cultural attitude towards alcohol use and intoxication can also be influenced through a wide range of sources including social media, movies, music, and television. Studies have shown targeted alcohol marketing may result in the development of positive beliefs about drinking and expand environments where alcohol use is socially acceptable and encouraged.21 These factors can impact drinking behavior, including the onset of drinking, binge drinking, and increased alcohol consumption.22

Three VISN 21 sites in this study had restrictions on or excluded primary care from participation. Leadership at some of these facilities were concerned that primary care teams did not have the bandwidth to take on additional items and/or there was variable primary care readiness for initiating AUD pharmacotherapy. Further attempts should be made to integrate primary care into the process of initiating AUD treatment as significant research suggests that integrated care models for AUD may be associated with improved process and outcome measures of care.23

There are several differences between this quality improvement project and prior research investigating the impact of DTC education for other conditions, such as the EMPOWER randomized controlled trial and VISN 22 project, which both demonstrated effectiveness of DTC education for reducing benzodiazepine use in geriatric veterans. 15,16 These studies focused on reducing or stopping pharmacotherapy use, whereas this project sought to promote the initiation of AUD pharmacotherapy. These studies evaluated outcomes at least 6 months postindex date, whereas this project evaluated outcomes within 30 days postappointment. Furthermore, the educational content varied significantly. Other projects provided patients with information focused on specific medications and interventions, such as benzodiazepine tapering, while this project mailed general information on heavy drinking, its risks, and strategies for cutting back, without mentioning pharmacotherapy. The DTC material used in this project was chosen because it was a preapproved national VA ADS resource, which expedited the project timeline by avoiding the need for additional approvals at each participating site. These differences may impact the observed effectiveness of DTC education in this project, especially regarding the primary outcome.

Strengths and Limitations

This quality improvement project sent a large sample of veterans DTC education in a clinical setting across multiple sites. Additionally, PS matching methods were used to balance covariates between the comparator and DTC education group, thereby simulating a randomized controlled trial and reducing selection bias. The project brought attention to the VISN 21 AUD treatment rates, stimulated conversation across sites about available treatments and resources for AUD, and sparked collaboration between academic detailing, mental health, and primary care services. The time frame for visits was selected during the winter; the National Institute on Alcohol Abuse and Alcoholism notes this is a time when people may be more likely to engage in excessive alcohol consumption than at other times of the year.24

The 30-day time frame for outcomes may have been too short to observe changes in prescribing or referral patterns. Additionally, the comparator group was comprised of veterans seen from October 1, 2022, to January 31, 2023, where seasonal timing may have influenced alcohol consumption behaviors and skewed the results. There were also no-show appointments in the DTC education group (13.7%), though it is likely some patients rescheduled and still received AUD pharmacotherapy within 30 days of the original appointment. Finally, it was not possible to confirm whether a patient opened and read the education that was mailed to them. This may be another reason to explore electronic distribution of DTC education. This all may have contributed to the lack of statistically significant differences in both the primary and secondary outcomes.

There was a high level of variability between facility participation in the project. Two of 7 sites did not participate, and 3 sites restricted primary care engagement. This represents a significant limitation, particularly for the secondary outcome of placing consultations for MH or SUD services. Facilities that only included mental health or SUD HCPs may have resulted in lower consultation rates due to their inherent specialization, reducing the likelihood of self-referrals.

The project may overestimate prescribed AUD pharmacotherapy in the primary outcome due to potential misclassification of medications. While the project adhered to the national VA ADS AUD dashboard’s definition of AUD pharmacotherapy, including acamprosate, disulfiram, naltrexone, topiramate, and gabapentin, some of these medications have multiple indications. For example, gabapentin is commonly prescribed for peripheral neuropathy, and topiramate is used to treat migraines and seizures. The multipurpose use adds uncertainty about whether they were prescribed specifically for AUD treatment, especially in cases where the HCP is responsible for treating a broad range of disease states, as in primary care.

CONCLUSIONS

Results of this quality improvement project did not show a statistically significant difference between patients sent DTC education and the comparator group for the initiation of AUD pharmacotherapy or placement of a consult to mental health or SUD services within 30 days of their scheduled visit. Future studies may seek to implement stricter criteria to confirm the intended use of topiramate and gabapentin, such as looking for keywords in the prescription instructions for use, performing chart reviews, and/or only including these medications if prescribed by a mental health or SUD HCP. Alternatively, future studies may consider limiting the analysis to only FDA-approved AUD medications: acamprosate, disulfiram, and naltrexone. It is vital to continue to enhance primary care HCP readiness to treat AUD, given the existing relationships and trust they often have with patients. Electronic methods for distributing DTC education could also be advantageous, as these methods may have the ability to track whether a message has been opened and read. Despite a lack of statistical significance, this project sparked crucial conversations and collaboration around AUD, available treatments, and addressing potential barriers to connecting patients to care within VISN 21.

Excessive alcohol use is one of the leading preventable causes of death in the United States, responsible for about 178,000 deaths annually and an average of 488 daily deaths in 2020 and 2021.1Alcohol-related deaths increased by 49% between 2006 and 2019.2 This trend continued during the COVID-19 pandemic, with death certificates that listed alcohol increasing by > 25% from 2019 to 2020, and another 10% in 2021.3 This increase of alcohol-related deaths includes those as a direct result of chronic alcohol use, such as alcoholic cardiomyopathy, alcoholic hepatitis and cirrhosis, and alcohol-induced pancreatitis, as well as a result of acute use such as alcohol poisoning, suicide by exposure to alcohol, and alcohol-impaired driving fatalities.4

Excessive alcohol consumption poses other serious risks, including cases when intake is abruptly reduced without proper management. Alcohol withdrawal syndrome (AWS) can vary in severity, with potentially life-threatening complications such as hallucinations, seizures, and delirium tremens.5

These risks highlight the importance of professional intervention and support, not only to mitigate risks associated with AWS, but provide a pathway towards recovery from alcohol use disorder (AUD).

According to the 2022 National Survey on Drug Use and Health, 28.8 million US adults had AUD in the prior year, yet only 7.6% of these individuals received treatment and an even smaller group (2.2%) received medication-assisted treatment for alcohol.6,7 This is despite American Psychiatric Association guidelines for the pharmacological treatment of patients with AUD, including the use of naltrexone, acamprosate, disulfiram, topiramate, or gabapentin, depending on therapy goals, past medication trials, medication contraindications, and patient preference.8 Several of these medications are approved by the US Food and Drug Administration (FDA) for the treatment of AUD and have support for effectiveness from randomized controlled trials and meta-analyses.9-11

Clinical practice guidelines for the management of substance use disorders (SUDs) from the US Department of Veterans Affairs (VA) and US Department of Defense have strong recommendations for naltrexone and topiramate as first-line pharmacotherapies for moderate to severe AUD. Acamprosate and disulfiram are weak recommendations as alternative options. Gabapentin is a weak recommendation for cases where first-line treatments are contraindicated or ineffective. The guidelines emphasize the importance of a comprehensive approach to AUD treatment, including psychosocial interventions in addition to pharmacotherapy.12

A 2023 national survey found veterans reported higher alcohol consumption than nonveterans.13 At the end of fiscal year 2023, > 4.4 million veterans—6% of Veterans Health Administration patients—had been diagnosed with AUD.14 However, > 87% of these patients nationally, and 88% of Veterans Integrated Service Network (VISN) 21 patients, were not receiving naltrexone, acamprosate, disulfiram, or topiramate as part of their treatment. The VA Academic Detailing Service (ADS) now includes AUD pharmacotherapy as a campaign focus, highlighting its importance. The ADS is a pharmacy educational outreach program that uses unbiased clinical guidelines to promote aligning prescribing behavior with best practices. Academic detailing methods include speaking with health care practitioners (HCPs), and direct-to-consumer (DTC) patient education.

ADS campaigns include DTC educational handouts. Past ADS projects and research using DTC have demonstrated a significant improvement in outcomes and positively influencing patients’ pharmacotherapy treatment. 15,16 A VA quality improvement project found a positive correlation between the initiation of AUD pharmacotherapy and engagement with mental health care following the distribution of AUD DTC patient education. 17 This project aimed to apply the same principles of prior research to explore the use of DTC across multiple facilities within VISN 21 to increase AUD pharmacotherapy. VISN 21 includes VA facilities and clinics across the Pacific Islands, Nevada, and California and serves about 350,000 veterans.

METHODS

A prospective cohort of VISN 21 veterans with or at high risk for AUD was identified using the VA ADS AUD Dashboard. The cohort included those not on acamprosate, disulfiram, naltrexone, topiramate, or gabapentin for treatment of AUD and had an elevated Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score of ≥ 6 (high risk) with an AUD diagnosis or ≥ 8 (severe risk) without a diagnosis. The AUDIT-C scores used in the dashboard are supported by the VA AUD clinician guide as the minimum scores when AUD pharmacotherapy should be offered to patients.18 Prescriptions filled outside the VA were not included in this dashboard.

Data and patient information were collected using the VA Corporate Data Warehouse. To be eligible, veterans needed a valid mailing address within the VISN 21 region and a primary care, mental health, or SUD clinician prescriber visit scheduled between October 1, 2023, and January 31, 2024. Veterans were excluded if they were in hospice, had a 1-year mortality risk score > 50% based on their Care Assessment Need (CAN) score, or facility leadership opted out of project involvement. Patients with both severe renal and hepatic impairments were excluded because they were ineligible for AUD pharmacotherapy. However, veterans with either renal or hepatic impairment (but not both) were included, as they could be potential candidates for ≥ 1 AUD pharmacotherapy option.

Initial correspondence with facilities was initiated through local academic detailers. A local champion was identified for the 1 facility without an academic detailer. Facilities could opt in or out of the project. Approval was provided by the local pharmacy and therapeutics committee, pharmacy, primary care, or psychiatry leadership. Approval process and clinician involvement varied by site.

Education

The selected AUD patient education was designed and approved by the national VA ADS (eappendix). The DTC patient education provided general knowledge about alcohol, including what constitutes a standard amount of alcohol, what is considered heavy drinking, risks of heavy drinking, creating a plan with a clinician to reduce and manage withdrawal symptoms, and additional resources. The DTC was accompanied by a cover letter that included a local facility contact number.

A centralized mailing facility was used for all materials. VA Northern California Health Care System provided the funding to cover the cost of postage. The list of veterans to be contacted was updated on a rolling basis and DTC education was mailed 2 weeks prior to their scheduled prescriber visit.

The eligible cohort of 1260 veterans received DTC education. A comparator group of 2048 veterans that did not receive DTC education was obtained retrospectively by using the same inclusion and exclusion criteria with a scheduled primary care, mental health, or SUD HCP visit from October 1, 2022, to January 31, 2023. The outcomes assessed were within 30 days of the scheduled visit, with the primary outcome as the initiation of AUD-related pharmacotherapy and the secondary outcome as the placement of a consultation for mental health or SUD services. Any consultations sent to Behavioral Health, Addiction, Mental Health, Psychiatric, and SUD services following the HCP visit, within the specified time frame, were used for the secondary outcome.

Matching and Analysis

A 1-to-1 nearest neighbor propensity score (PS) matching without replacement was used to pair the 1260 veterans from the intervention group with similarly scored comparator group veterans for a PS-matched final dataset of 2520 veterans. The PS model was a multivariate logistic regression with the outcome being exposure and comparator group status. Baseline characteristics used in the PS model were age, birth sex, race, facility of care, baseline AUDIT-C score, and days between project start and scheduled appointment. Covariate imbalance for the PS-matched sample was assessed to ensure the standardized mean difference for all covariates fell under a 0.1 threshold (Figure).19

0525FED-eAUD-F1

A frequency table was provided to compare the discrete distributions of the baseline characteristics in the intervention and comparator groups. Logistic regression analysis was performed to evaluate the association between DTC education exposure and pharmacotherapy initiation, while controlling for potential confounders. Univariate and multivariate P value results for each variable included in the model were reported along with the multivariate odds ratios (ORs) and their associated 95% CIs. Logistic regression analyses were run for both outcomes. Each model included the exposure and comparator group status as well as the baseline characteristics included in the PS model. Statistical significance was set at P < .05. All statistical analyses were performed with R version 4.2.1.

RESULTS

Two of 7 VISN 21 sites did not participate, and 3 had restrictions on participation. DTC education was mailed about 2 weeks prior to scheduled visit for 1260 veterans; 53.6% identified as White, 37.6% were aged 41 to 60 years, and 79.2% had an AUDIT-C ≥ 8 (Table 1). Of those mailed education, there were 173 no-show appointments (13.7%). Thirty-two veterans (2.5%) in the DTC group and 33 veterans (2.6%) in the comparator group received an AUD-related pharmacotherapy prescription (P = .88) (Table 2). One hundred seventy-one veterans (13.6%) in the DTC group and 160 veterans (12.7%) in the comparator group had a consult placed for mental health or SUD services within 30 days of their appointment (P = .59) (Table 3).

0525FED-eAUD-T10525FED-eAUD-T20525FED-eAUD-T3

DISCUSSION

This project did not yield statistically significant differences in either the primary or secondary outcomes within the 30-day follow-up window and found limited impact from the DTC educational outreach to veterans. The percentage of veterans that received AUD-related pharmacotherapy or consultations for mental health or SUD services was similarly low in the DTC and comparator groups. These findings suggest that although DTC education may raise awareness, it may not be sufficient on its own to drive changes in prescribing behavior or referral patterns without system-level support.

Addiction is a complex disease faced with stigma and requiring readiness by both the HCP and patient to move forward in support and treatment. The consequences of stigma can be severe: the more stigma perceived by a person with AUD, the less likely they are to seek treatment.20 Stigma may exist even within HCPs and may lead to compromised care including shortened visits, less engagement, and less empathy.19 Cultural attitude towards alcohol use and intoxication can also be influenced through a wide range of sources including social media, movies, music, and television. Studies have shown targeted alcohol marketing may result in the development of positive beliefs about drinking and expand environments where alcohol use is socially acceptable and encouraged.21 These factors can impact drinking behavior, including the onset of drinking, binge drinking, and increased alcohol consumption.22

Three VISN 21 sites in this study had restrictions on or excluded primary care from participation. Leadership at some of these facilities were concerned that primary care teams did not have the bandwidth to take on additional items and/or there was variable primary care readiness for initiating AUD pharmacotherapy. Further attempts should be made to integrate primary care into the process of initiating AUD treatment as significant research suggests that integrated care models for AUD may be associated with improved process and outcome measures of care.23

There are several differences between this quality improvement project and prior research investigating the impact of DTC education for other conditions, such as the EMPOWER randomized controlled trial and VISN 22 project, which both demonstrated effectiveness of DTC education for reducing benzodiazepine use in geriatric veterans. 15,16 These studies focused on reducing or stopping pharmacotherapy use, whereas this project sought to promote the initiation of AUD pharmacotherapy. These studies evaluated outcomes at least 6 months postindex date, whereas this project evaluated outcomes within 30 days postappointment. Furthermore, the educational content varied significantly. Other projects provided patients with information focused on specific medications and interventions, such as benzodiazepine tapering, while this project mailed general information on heavy drinking, its risks, and strategies for cutting back, without mentioning pharmacotherapy. The DTC material used in this project was chosen because it was a preapproved national VA ADS resource, which expedited the project timeline by avoiding the need for additional approvals at each participating site. These differences may impact the observed effectiveness of DTC education in this project, especially regarding the primary outcome.

Strengths and Limitations

This quality improvement project sent a large sample of veterans DTC education in a clinical setting across multiple sites. Additionally, PS matching methods were used to balance covariates between the comparator and DTC education group, thereby simulating a randomized controlled trial and reducing selection bias. The project brought attention to the VISN 21 AUD treatment rates, stimulated conversation across sites about available treatments and resources for AUD, and sparked collaboration between academic detailing, mental health, and primary care services. The time frame for visits was selected during the winter; the National Institute on Alcohol Abuse and Alcoholism notes this is a time when people may be more likely to engage in excessive alcohol consumption than at other times of the year.24

The 30-day time frame for outcomes may have been too short to observe changes in prescribing or referral patterns. Additionally, the comparator group was comprised of veterans seen from October 1, 2022, to January 31, 2023, where seasonal timing may have influenced alcohol consumption behaviors and skewed the results. There were also no-show appointments in the DTC education group (13.7%), though it is likely some patients rescheduled and still received AUD pharmacotherapy within 30 days of the original appointment. Finally, it was not possible to confirm whether a patient opened and read the education that was mailed to them. This may be another reason to explore electronic distribution of DTC education. This all may have contributed to the lack of statistically significant differences in both the primary and secondary outcomes.

There was a high level of variability between facility participation in the project. Two of 7 sites did not participate, and 3 sites restricted primary care engagement. This represents a significant limitation, particularly for the secondary outcome of placing consultations for MH or SUD services. Facilities that only included mental health or SUD HCPs may have resulted in lower consultation rates due to their inherent specialization, reducing the likelihood of self-referrals.

The project may overestimate prescribed AUD pharmacotherapy in the primary outcome due to potential misclassification of medications. While the project adhered to the national VA ADS AUD dashboard’s definition of AUD pharmacotherapy, including acamprosate, disulfiram, naltrexone, topiramate, and gabapentin, some of these medications have multiple indications. For example, gabapentin is commonly prescribed for peripheral neuropathy, and topiramate is used to treat migraines and seizures. The multipurpose use adds uncertainty about whether they were prescribed specifically for AUD treatment, especially in cases where the HCP is responsible for treating a broad range of disease states, as in primary care.

CONCLUSIONS

Results of this quality improvement project did not show a statistically significant difference between patients sent DTC education and the comparator group for the initiation of AUD pharmacotherapy or placement of a consult to mental health or SUD services within 30 days of their scheduled visit. Future studies may seek to implement stricter criteria to confirm the intended use of topiramate and gabapentin, such as looking for keywords in the prescription instructions for use, performing chart reviews, and/or only including these medications if prescribed by a mental health or SUD HCP. Alternatively, future studies may consider limiting the analysis to only FDA-approved AUD medications: acamprosate, disulfiram, and naltrexone. It is vital to continue to enhance primary care HCP readiness to treat AUD, given the existing relationships and trust they often have with patients. Electronic methods for distributing DTC education could also be advantageous, as these methods may have the ability to track whether a message has been opened and read. Despite a lack of statistical significance, this project sparked crucial conversations and collaboration around AUD, available treatments, and addressing potential barriers to connecting patients to care within VISN 21.

References
  1. Centers for Disease Control and Prevention. Facts about U.S. deaths from excessive alcohol use. August 6, 2024. Accessed February 5, 2025. https://www.cdc.gov/alcohol/facts-stats/
  2. State Health Access Data Assistance Center. Escalating alcohol-involved death rates: trends and variation across the nation and in the states from 2006 to 2019. April 19, 2021. Accessed February 5, 2025. https://www.shadac.org/escalating-alcohol-involved-death-rates-trends-and-variation-across-nation-and-states-2006-2019
  3. National Institute on Alcohol Abuse and Alcoholism. Alcohol- related emergencies and deaths in the United States. Updated November 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states
  4. Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from excessive alcohol use - United States, 2016- 2021. MMWR Morb Mortal Wkly Rep. 2024;73(8):154-161. doi:10.15585/mmwr.mm7308a1
  5. Canver BR, Newman RK, Gomez AE. Alcohol Withdrawal Syndrome. In: StatPearls. StatPearls Publishing; 2024.
  6. National Institute on Alcohol Abuse and Alcoholism. Alcohol treatment in the United States. Updated January 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-treatment-united-states
  7. National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder (AUD) in the United States: age groups and demographic characteristics. Updated September 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
  8. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86-90. doi:10.1176/appi.ajp.2017.1750101
  9. Blodgett JC, Del Re AC, Maisel NC, Finney JW. A meta-analysis of topiramate’s effects for individuals with alcohol use disorders. Alcohol Clin Exp Res. 2014;38(6):1481-1488. doi:10.1111/acer.12411
  10. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x
  11. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628
  12. US Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. August 2021. Accessed February 5, 2025. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPG.pdf
  13. Ranney RM, Bernhard PA, Vogt D, et al. Alcohol use and treatment utilization in a national sample of veterans and nonveterans. J Subst Use Addict Treat. 2023;146:208964. doi:10.1016/j.josat.2023.208964
  14. US Department of Veterans Affairs, Pharmacy Benefit Management Service, Academic Detailing Service. AUD Trend Report. https://vaww.pbi.cdw.va.gov/PBIRS/Pages/ReportViewer.aspx?/GPE/PBM_AD/SSRS/AUD/AUD_TrendReport
  15. Mendes MA, Smith JP, Marin JK, et al. Reducing benzodiazepine prescribing in older veterans: a direct-to-consumer educational brochure. Fed Pract. 2018;35(9):36-43.
  16. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949
  17. Maloney R, Funmilayo M. Acting on the AUDIT-C: implementation of direct-to-consumer education on unhealth alcohol use. Presented on March 31, 2023; Central Virginia Veterans Affairs Health Care System, Richmond, Virginia.
  18. US Department of Veterans Affairs, Pharmacy Benefit Management Service. Alcohol use disorder (AUD) – leading the charge in the treatment of AUD: a VA clinician’s guide. February 2022. Accessed February 5, 2025. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1530_AUD_ClinicianGuide_508Conformant.pdf
  19. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399-424. doi:10.1080/00273171.2011.568786
  20. National Institute on Alcohol Abuse and Alcoholism. Stigma: overcoming a pervasive barrier to optimal care. Updated January 6, 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/stigma-overcoming-pervasive-barrier-optimal-care
  21. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and cultural contexts of alcohol use: influences in a socialecological framework. Alcohol Res. 2016;38(1):35-45.
  22. Tanski SE, McClure AC, Li Z, et al. Cued recall of alcohol advertising on television and underage drinking behavior. JAMA Pediatr. 2015;169(3):264-271. doi:10.1001/jamapediatrics.2014.3345
  23. Hyland CJ, McDowell MJ, Bain PA, Huskamp HA, Busch AB. Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: a scoping review. J Subst Abuse Treat. 2023;144:108919. doi:10.1016/j.jsat.2022.108919
  24. National Institute on Alcohol Abuse and Alcoholism. The truth about holiday spirits. Updated November 2023. Accessed February 5, 2025. ,a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits">https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits
References
  1. Centers for Disease Control and Prevention. Facts about U.S. deaths from excessive alcohol use. August 6, 2024. Accessed February 5, 2025. https://www.cdc.gov/alcohol/facts-stats/
  2. State Health Access Data Assistance Center. Escalating alcohol-involved death rates: trends and variation across the nation and in the states from 2006 to 2019. April 19, 2021. Accessed February 5, 2025. https://www.shadac.org/escalating-alcohol-involved-death-rates-trends-and-variation-across-nation-and-states-2006-2019
  3. National Institute on Alcohol Abuse and Alcoholism. Alcohol- related emergencies and deaths in the United States. Updated November 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states
  4. Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from excessive alcohol use - United States, 2016- 2021. MMWR Morb Mortal Wkly Rep. 2024;73(8):154-161. doi:10.15585/mmwr.mm7308a1
  5. Canver BR, Newman RK, Gomez AE. Alcohol Withdrawal Syndrome. In: StatPearls. StatPearls Publishing; 2024.
  6. National Institute on Alcohol Abuse and Alcoholism. Alcohol treatment in the United States. Updated January 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-treatment-united-states
  7. National Institute on Alcohol Abuse and Alcoholism. Alcohol use disorder (AUD) in the United States: age groups and demographic characteristics. Updated September 2024. Accessed February 5, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
  8. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86-90. doi:10.1176/appi.ajp.2017.1750101
  9. Blodgett JC, Del Re AC, Maisel NC, Finney JW. A meta-analysis of topiramate’s effects for individuals with alcohol use disorders. Alcohol Clin Exp Res. 2014;38(6):1481-1488. doi:10.1111/acer.12411
  10. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x
  11. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628
  12. US Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of substance use disorders. August 2021. Accessed February 5, 2025. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPG.pdf
  13. Ranney RM, Bernhard PA, Vogt D, et al. Alcohol use and treatment utilization in a national sample of veterans and nonveterans. J Subst Use Addict Treat. 2023;146:208964. doi:10.1016/j.josat.2023.208964
  14. US Department of Veterans Affairs, Pharmacy Benefit Management Service, Academic Detailing Service. AUD Trend Report. https://vaww.pbi.cdw.va.gov/PBIRS/Pages/ReportViewer.aspx?/GPE/PBM_AD/SSRS/AUD/AUD_TrendReport
  15. Mendes MA, Smith JP, Marin JK, et al. Reducing benzodiazepine prescribing in older veterans: a direct-to-consumer educational brochure. Fed Pract. 2018;35(9):36-43.
  16. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949
  17. Maloney R, Funmilayo M. Acting on the AUDIT-C: implementation of direct-to-consumer education on unhealth alcohol use. Presented on March 31, 2023; Central Virginia Veterans Affairs Health Care System, Richmond, Virginia.
  18. US Department of Veterans Affairs, Pharmacy Benefit Management Service. Alcohol use disorder (AUD) – leading the charge in the treatment of AUD: a VA clinician’s guide. February 2022. Accessed February 5, 2025. https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1530_AUD_ClinicianGuide_508Conformant.pdf
  19. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399-424. doi:10.1080/00273171.2011.568786
  20. National Institute on Alcohol Abuse and Alcoholism. Stigma: overcoming a pervasive barrier to optimal care. Updated January 6, 2025. Accessed February 5, 2025. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/stigma-overcoming-pervasive-barrier-optimal-care
  21. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and cultural contexts of alcohol use: influences in a socialecological framework. Alcohol Res. 2016;38(1):35-45.
  22. Tanski SE, McClure AC, Li Z, et al. Cued recall of alcohol advertising on television and underage drinking behavior. JAMA Pediatr. 2015;169(3):264-271. doi:10.1001/jamapediatrics.2014.3345
  23. Hyland CJ, McDowell MJ, Bain PA, Huskamp HA, Busch AB. Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: a scoping review. J Subst Abuse Treat. 2023;144:108919. doi:10.1016/j.jsat.2022.108919
  24. National Institute on Alcohol Abuse and Alcoholism. The truth about holiday spirits. Updated November 2023. Accessed February 5, 2025. ,a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits">https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/truth-about-holiday-spirits
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References
  1. Staudacher HM, Black CJ, Teasdale SB, Mikocka-Walus A, Keefer L. Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management. Nat Rev Gastroenterol Hepatol. 2023;20(9):582-596. doi:10.1038/s41575-023-00794-z
  2. Ballou S, Vasant DH, Guadagnoli L, et al. A primer for the gastroenterology provider on psychosocial assessment of patients with disorders of gut-brain interaction. Neurogastroenterol Motil. 2024;36(12):e14894. doi:10.1111/nmo.14894
  3. Keefer L, Ballou SK, Drossman DA, Ringstrom G, Elsenbruch S, Ljótsson B. A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction. Gastroenterology. 2022;162(1):300-315. doi:10.1053/j.gastro.2021.09.015
  4. Goodoory VC, Khasawneh M, Thakur ER, et al. Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis. Gastroenterology. 2024;167(5):934-943.e5. doi:10.1053/j.gastro.2024.05.010
  5. Chang L, Sultan S, Lembo A, Verne GN, Smalley W, Heidelbaugh JJ. AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Constipation. Gastroenterology. 2022;163(1):118-136. doi:10.1053/j.gastro.2022.04.016
  6. Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018;154(4):1140-1171.e1. doi:10.1053/j.gastro.2017.11.279
  7. Hasan SS, Ballou S, Keefer L, Vasant DH. Improving access to gut-directed hypnotherapy for irritable bowel syndrome in the digital therapeutics’ era: Are mobile applications a “smart” solution? Neurogastroenterol Motil. 2023;35(4):e14554. doi:10.1111/nmo.14554
  8. Tarar ZI, Farooq U, Zafar Y, et al. Burden of anxiety and depression among hospitalized patients with irritable bowel syndrome: a nationwide analysis. Ir J Med Sci. 2023;192(5):2159-2166. doi:10.1007/s11845-022-03258-6
  9. Barbara G, Aziz I, Ballou S, et al. Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction. Nat Rev Gastroenterol Hepatol. doi:10.1038/s41575-024-01033-9
  10. Thakur ER, Kunik M, Jarbrink-Sehgal ME, Lackner J, Dindo L, El-Serag H. Behavior Medicine Management of Irritable Bowel Syndrome: A Referral Toolkit for Gastroenterology Providers. 2018. Accessed February 19, 2025. https://www.mirecc.va.gov/VISN16/docs/ibs-referral-toolkit.pdf
  11. Irritable bowel syndrome (IBS). Johns Hopkins Medicine website. Accessed February 19, 2025. https://www.hopkinsmedicine.org/health/conditionsanddiseases/irritable-bowel-syndrome-ibs
  12. Burton-Murray H, Guadagnoli L, Kamp K, et al. Rome Foundation Working Team Report: Consensus Statement on the Design and Conduct of Behavioural Clinical Trials for Disorders of Gut-Brain Interaction. Aliment Pharmacol Ther. 2025;61(5):787-802. doi:10.1111/apt.18482
  13. Rome GastroPsych. Rome Foundation website. Accessed February 19, 2025. https://romegipsych.org/
  14. Scarlata K, Riehl M. Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Hachette Book Group, 2025.
  15. IFFGD International Foundation for Gastrointestinal Disorders. IFFGD website. January 10, 2025. Accessed February 19, 2025. https://iffgd.org/
  16. GI Psychology: Mind Your Gut website. April 2, 2024. Accessed February 19, 2025. https://www.gipsychology.com/
  17. Drossman DA, Ruddy J. Gut Feelings: Disorders of the Gut-Brain Interaction (DGBI) and the Patient-Doctor Relationship. DrossmanCare Chapel Hill, 2020.
  18. Tuesday Night IBS website. Accessed February 19, 2025. https://www.tuesdaynightibs.com/
Author and Disclosure Information

Lin Chang, MD
Professor, David Geffen School of Medicine,
UCLA; Vice-Chief, Vatche and Tamar
Manoukian, Division of Digestive Diseases,
UCLA Digestive Diseases Center,
Los Angeles, California

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: Ardelyx; Alfasigma; Atmo; GLaxoSmithKline;
Food Marble; Vibrant; Nerva; Received research grant from: AnX Robotica;
Ironwood; Received income in an amount equal to or greater than $250
from: Alfasigma; Atmo; GLaxoSmithKline; Food Marble; Have stock options
in: Trellus Health; Food Marble; ModifyHealth

Laurie A. Keefer, PhD
Professor, Department of Medicine and
Psychiatry, Division of Gastroenterology, Icahn
School of Medicine at Mount Sinai; Gastro
Psychologist, Inflammatory Bowel Disease Center,
Mount Sinai Hospital, New York, New York

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: AbbVie; Pfizer; Eli Lilly; Reckitt Health; Johnson
and Johnson; Rome Foundation; Received research grant from: Ardelyx
Have a 5% or greater equity interest in: Trellus Health

Publications
GI and Hepatology News
Topics
IBD & Intestinal Disorders
Mental Health
Author(s)
Lin Chang, MD
Laurie A. Keefer, PhD
Author(s)
Lin Chang, MD
Laurie A. Keefer, PhD
Author and Disclosure Information

Lin Chang, MD
Professor, David Geffen School of Medicine,
UCLA; Vice-Chief, Vatche and Tamar
Manoukian, Division of Digestive Diseases,
UCLA Digestive Diseases Center,
Los Angeles, California

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: Ardelyx; Alfasigma; Atmo; GLaxoSmithKline;
Food Marble; Vibrant; Nerva; Received research grant from: AnX Robotica;
Ironwood; Received income in an amount equal to or greater than $250
from: Alfasigma; Atmo; GLaxoSmithKline; Food Marble; Have stock options
in: Trellus Health; Food Marble; ModifyHealth

Laurie A. Keefer, PhD
Professor, Department of Medicine and
Psychiatry, Division of Gastroenterology, Icahn
School of Medicine at Mount Sinai; Gastro
Psychologist, Inflammatory Bowel Disease Center,
Mount Sinai Hospital, New York, New York

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: AbbVie; Pfizer; Eli Lilly; Reckitt Health; Johnson
and Johnson; Rome Foundation; Received research grant from: Ardelyx
Have a 5% or greater equity interest in: Trellus Health

Author and Disclosure Information

Lin Chang, MD
Professor, David Geffen School of Medicine,
UCLA; Vice-Chief, Vatche and Tamar
Manoukian, Division of Digestive Diseases,
UCLA Digestive Diseases Center,
Los Angeles, California

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: Ardelyx; Alfasigma; Atmo; GLaxoSmithKline;
Food Marble; Vibrant; Nerva; Received research grant from: AnX Robotica;
Ironwood; Received income in an amount equal to or greater than $250
from: Alfasigma; Atmo; GLaxoSmithKline; Food Marble; Have stock options
in: Trellus Health; Food Marble; ModifyHealth

Laurie A. Keefer, PhD
Professor, Department of Medicine and
Psychiatry, Division of Gastroenterology, Icahn
School of Medicine at Mount Sinai; Gastro
Psychologist, Inflammatory Bowel Disease Center,
Mount Sinai Hospital, New York, New York

Disclosures: Serve(d) as a director, officer, partner, employee, advisor,
consultant, or trustee for: AbbVie; Pfizer; Eli Lilly; Reckitt Health; Johnson
and Johnson; Rome Foundation; Received research grant from: Ardelyx
Have a 5% or greater equity interest in: Trellus Health

Click to view more from Gastroenterology Data Trends 2025. 

Click to view more from Gastroenterology Data Trends 2025. 

References
  1. Staudacher HM, Black CJ, Teasdale SB, Mikocka-Walus A, Keefer L. Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management. Nat Rev Gastroenterol Hepatol. 2023;20(9):582-596. doi:10.1038/s41575-023-00794-z
  2. Ballou S, Vasant DH, Guadagnoli L, et al. A primer for the gastroenterology provider on psychosocial assessment of patients with disorders of gut-brain interaction. Neurogastroenterol Motil. 2024;36(12):e14894. doi:10.1111/nmo.14894
  3. Keefer L, Ballou SK, Drossman DA, Ringstrom G, Elsenbruch S, Ljótsson B. A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction. Gastroenterology. 2022;162(1):300-315. doi:10.1053/j.gastro.2021.09.015
  4. Goodoory VC, Khasawneh M, Thakur ER, et al. Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis. Gastroenterology. 2024;167(5):934-943.e5. doi:10.1053/j.gastro.2024.05.010
  5. Chang L, Sultan S, Lembo A, Verne GN, Smalley W, Heidelbaugh JJ. AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Constipation. Gastroenterology. 2022;163(1):118-136. doi:10.1053/j.gastro.2022.04.016
  6. Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018;154(4):1140-1171.e1. doi:10.1053/j.gastro.2017.11.279
  7. Hasan SS, Ballou S, Keefer L, Vasant DH. Improving access to gut-directed hypnotherapy for irritable bowel syndrome in the digital therapeutics’ era: Are mobile applications a “smart” solution? Neurogastroenterol Motil. 2023;35(4):e14554. doi:10.1111/nmo.14554
  8. Tarar ZI, Farooq U, Zafar Y, et al. Burden of anxiety and depression among hospitalized patients with irritable bowel syndrome: a nationwide analysis. Ir J Med Sci. 2023;192(5):2159-2166. doi:10.1007/s11845-022-03258-6
  9. Barbara G, Aziz I, Ballou S, et al. Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction. Nat Rev Gastroenterol Hepatol. doi:10.1038/s41575-024-01033-9
  10. Thakur ER, Kunik M, Jarbrink-Sehgal ME, Lackner J, Dindo L, El-Serag H. Behavior Medicine Management of Irritable Bowel Syndrome: A Referral Toolkit for Gastroenterology Providers. 2018. Accessed February 19, 2025. https://www.mirecc.va.gov/VISN16/docs/ibs-referral-toolkit.pdf
  11. Irritable bowel syndrome (IBS). Johns Hopkins Medicine website. Accessed February 19, 2025. https://www.hopkinsmedicine.org/health/conditionsanddiseases/irritable-bowel-syndrome-ibs
  12. Burton-Murray H, Guadagnoli L, Kamp K, et al. Rome Foundation Working Team Report: Consensus Statement on the Design and Conduct of Behavioural Clinical Trials for Disorders of Gut-Brain Interaction. Aliment Pharmacol Ther. 2025;61(5):787-802. doi:10.1111/apt.18482
  13. Rome GastroPsych. Rome Foundation website. Accessed February 19, 2025. https://romegipsych.org/
  14. Scarlata K, Riehl M. Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Hachette Book Group, 2025.
  15. IFFGD International Foundation for Gastrointestinal Disorders. IFFGD website. January 10, 2025. Accessed February 19, 2025. https://iffgd.org/
  16. GI Psychology: Mind Your Gut website. April 2, 2024. Accessed February 19, 2025. https://www.gipsychology.com/
  17. Drossman DA, Ruddy J. Gut Feelings: Disorders of the Gut-Brain Interaction (DGBI) and the Patient-Doctor Relationship. DrossmanCare Chapel Hill, 2020.
  18. Tuesday Night IBS website. Accessed February 19, 2025. https://www.tuesdaynightibs.com/
References
  1. Staudacher HM, Black CJ, Teasdale SB, Mikocka-Walus A, Keefer L. Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management. Nat Rev Gastroenterol Hepatol. 2023;20(9):582-596. doi:10.1038/s41575-023-00794-z
  2. Ballou S, Vasant DH, Guadagnoli L, et al. A primer for the gastroenterology provider on psychosocial assessment of patients with disorders of gut-brain interaction. Neurogastroenterol Motil. 2024;36(12):e14894. doi:10.1111/nmo.14894
  3. Keefer L, Ballou SK, Drossman DA, Ringstrom G, Elsenbruch S, Ljótsson B. A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction. Gastroenterology. 2022;162(1):300-315. doi:10.1053/j.gastro.2021.09.015
  4. Goodoory VC, Khasawneh M, Thakur ER, et al. Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis. Gastroenterology. 2024;167(5):934-943.e5. doi:10.1053/j.gastro.2024.05.010
  5. Chang L, Sultan S, Lembo A, Verne GN, Smalley W, Heidelbaugh JJ. AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Constipation. Gastroenterology. 2022;163(1):118-136. doi:10.1053/j.gastro.2022.04.016
  6. Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018;154(4):1140-1171.e1. doi:10.1053/j.gastro.2017.11.279
  7. Hasan SS, Ballou S, Keefer L, Vasant DH. Improving access to gut-directed hypnotherapy for irritable bowel syndrome in the digital therapeutics’ era: Are mobile applications a “smart” solution? Neurogastroenterol Motil. 2023;35(4):e14554. doi:10.1111/nmo.14554
  8. Tarar ZI, Farooq U, Zafar Y, et al. Burden of anxiety and depression among hospitalized patients with irritable bowel syndrome: a nationwide analysis. Ir J Med Sci. 2023;192(5):2159-2166. doi:10.1007/s11845-022-03258-6
  9. Barbara G, Aziz I, Ballou S, et al. Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction. Nat Rev Gastroenterol Hepatol. doi:10.1038/s41575-024-01033-9
  10. Thakur ER, Kunik M, Jarbrink-Sehgal ME, Lackner J, Dindo L, El-Serag H. Behavior Medicine Management of Irritable Bowel Syndrome: A Referral Toolkit for Gastroenterology Providers. 2018. Accessed February 19, 2025. https://www.mirecc.va.gov/VISN16/docs/ibs-referral-toolkit.pdf
  11. Irritable bowel syndrome (IBS). Johns Hopkins Medicine website. Accessed February 19, 2025. https://www.hopkinsmedicine.org/health/conditionsanddiseases/irritable-bowel-syndrome-ibs
  12. Burton-Murray H, Guadagnoli L, Kamp K, et al. Rome Foundation Working Team Report: Consensus Statement on the Design and Conduct of Behavioural Clinical Trials for Disorders of Gut-Brain Interaction. Aliment Pharmacol Ther. 2025;61(5):787-802. doi:10.1111/apt.18482
  13. Rome GastroPsych. Rome Foundation website. Accessed February 19, 2025. https://romegipsych.org/
  14. Scarlata K, Riehl M. Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Hachette Book Group, 2025.
  15. IFFGD International Foundation for Gastrointestinal Disorders. IFFGD website. January 10, 2025. Accessed February 19, 2025. https://iffgd.org/
  16. GI Psychology: Mind Your Gut website. April 2, 2024. Accessed February 19, 2025. https://www.gipsychology.com/
  17. Drossman DA, Ruddy J. Gut Feelings: Disorders of the Gut-Brain Interaction (DGBI) and the Patient-Doctor Relationship. DrossmanCare Chapel Hill, 2020.
  18. Tuesday Night IBS website. Accessed February 19, 2025. https://www.tuesdaynightibs.com/
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IBS: Mental Health Factors and Comorbidities

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Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, affects up to 10% of the global population.1 Psychological symptoms often are associated with IBS, increasing its burden and affecting quality of life.1-3 About one third of patients with IBS experience anxiety or depression.1 Multidisciplinary care, involving gastroenterologists, psychologists, and dietitians, is crucial to address both physical and emotional symptoms in patients with IBS.1

Effective clinical pathways vary by patient profile. Some patients may have maladaptive cognitive processes that affect coping with IBS (e.g., avoidance behaviors and symptom-related anxiety) but do not meet criteria for a psychiatric disorder.2 For these patients, referral to brain-gut behavior therapy (BGBT) is advised.2 BGBTs can include cognitive behavioral therapy (CBT), gut-directed hypnotherapy, and mindfulness-based interventions, among others.3 These approaches can improve not only mental health symptoms and symptom-related stress but also gastrointestinal (GI) symptoms.4 For patients with psychiatric illnesses, referrals to psychiatrists or psychologists specialized in the patient’s specific comorbid condition are recommended.2 It is also helpful for GI professionals to familiarize themselves with a few antidepressant medications for symptom-specific anxiety or mood symptoms when a psychiatrist is unavailable.5,6 Some antidepressants, called central neuromodulators, also improve IBS symptoms.5,6

Access to integrated IBS care remains a challenge. The number of GI psychologists is limited. Most digital applications aiming to bridge this gap have limitations, such as nonpersonalized approaches and problems with engagement.7 Other options to provide care for patients with IBS and psychological symptoms include support groups or nurse-led self-management programs, education, patient advocacy organizations, and placement of educational material in clinic waiting areas.3

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Clinicians Should Have Private Spaces for Telehealth According to VA Memo

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Jan Dyer

US Department of Veterans Affairs (VA) officials are insisting that when remote telehealth clinicians return to an office setting, they must have private workspaces “that foster trusted, confidential, and therapeutic relationships with veterans,” according to an April internal memo reported on by NPR. 

The return-to-office mandate followed a Trump Administration executive order in February indicated that mental health clinicians at the US Department of Veterans Affairs (VA) must physically return to their workplace by May 5. For some, the deadline came as early as April 14; however, that order, like many others, may now be being revised or reconsidered due to concerns that have been raised. Many mental health clinicians were hired specifically to work remotely. They worried there would simply not be enough space for them, particularly to provide confidential counseling.

Millions of veterans use telehealth to access VA care. More than 98% of VA mental health clinicians have conducted ≥ 1 video visit to screen and treat patients for anxiety, depression, posttraumatic stress disorder, and more. Telehealth has been particularly important for veterans living in rural communities.

The April VA memo stipulated that “spaces used to deliver synchronous telehealth services should offer the same level of privacy and therapeutic environment applicable to an in-person visit in the same space.”

Therapists, patients, advocacy groups, and lawmakers have expressed concern about the potential impacts the policy change could have on patient care for veterans and, above all, about what it could mean for privacy. On Mar. 27, the American Psychological Association issued a statement noting that the change “resulted in providers being asked to conduct sensitive therapy sessions in open office environments, cubicles, or shared spaces that fail to meet basic confidentiality and privacy requirements for the delivery of mental health care services.”

Twenty Democrats in the House of Representatives sent a letter to VA Secretary Doug Collins expressing concern with the return to office policy. According to the letter a VA social worker supervisor reported managing their caseload while sharing a 100 ft2 shower space with another supervisor. It also reported that Clinical Resource Hub employees were being told to report to buildings where federal employees from other agencies work. “We have heard from countless stakeholders, veterans, and Department of Veterans Affairs (VA) employees that by carrying out President Trump’s blanket return-to-office policy your administration is damaging veteran and employee trust in VA, disrupting and impeding veterans’ access to care, and creating untenable and inefficient conditions for both veterans and the VA workforce,” the letter stated.

“This is a clear violation of veterans’ privacy and VA’s obligation to protect veterans’ private health information, and risks violation of the Health Insurance Portability and Accountability Act (HIPAA),” the letter added.

The lawmakers noted that, as of March 10, the VA was exempting Veterans Crisis Line workers, most of whom had been working remotely for the past 5 years, responding to more than 10 million calls, texts, and chats. That move, they said, indicated “that you understand there will be negative impacts to veterans’ care due to the return-to-office order and that these must be mitigated.”

VA spokesperson Peter Kasperowicz called the privacy concerns “nonsensical” and blamed “fear mongering from the media.” The VA, he said, “is no longer a place where the status quo for employees is to simply phone it in from home.” He also claimed that “the small number of employees who are desperate to avoid returning to the office will do more to drive away staff and patients than VA’s commonsense return-to-office policy ever will.”

VA care, he said, would continue uninterrupted and the “VA will ensure that employees have a workspace that is appropriate for the work they do.”

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US Department of Veterans Affairs (VA) officials are insisting that when remote telehealth clinicians return to an office setting, they must have private workspaces “that foster trusted, confidential, and therapeutic relationships with veterans,” according to an April internal memo reported on by NPR. 

The return-to-office mandate followed a Trump Administration executive order in February indicated that mental health clinicians at the US Department of Veterans Affairs (VA) must physically return to their workplace by May 5. For some, the deadline came as early as April 14; however, that order, like many others, may now be being revised or reconsidered due to concerns that have been raised. Many mental health clinicians were hired specifically to work remotely. They worried there would simply not be enough space for them, particularly to provide confidential counseling.

Millions of veterans use telehealth to access VA care. More than 98% of VA mental health clinicians have conducted ≥ 1 video visit to screen and treat patients for anxiety, depression, posttraumatic stress disorder, and more. Telehealth has been particularly important for veterans living in rural communities.

The April VA memo stipulated that “spaces used to deliver synchronous telehealth services should offer the same level of privacy and therapeutic environment applicable to an in-person visit in the same space.”

Therapists, patients, advocacy groups, and lawmakers have expressed concern about the potential impacts the policy change could have on patient care for veterans and, above all, about what it could mean for privacy. On Mar. 27, the American Psychological Association issued a statement noting that the change “resulted in providers being asked to conduct sensitive therapy sessions in open office environments, cubicles, or shared spaces that fail to meet basic confidentiality and privacy requirements for the delivery of mental health care services.”

Twenty Democrats in the House of Representatives sent a letter to VA Secretary Doug Collins expressing concern with the return to office policy. According to the letter a VA social worker supervisor reported managing their caseload while sharing a 100 ft2 shower space with another supervisor. It also reported that Clinical Resource Hub employees were being told to report to buildings where federal employees from other agencies work. “We have heard from countless stakeholders, veterans, and Department of Veterans Affairs (VA) employees that by carrying out President Trump’s blanket return-to-office policy your administration is damaging veteran and employee trust in VA, disrupting and impeding veterans’ access to care, and creating untenable and inefficient conditions for both veterans and the VA workforce,” the letter stated.

“This is a clear violation of veterans’ privacy and VA’s obligation to protect veterans’ private health information, and risks violation of the Health Insurance Portability and Accountability Act (HIPAA),” the letter added.

The lawmakers noted that, as of March 10, the VA was exempting Veterans Crisis Line workers, most of whom had been working remotely for the past 5 years, responding to more than 10 million calls, texts, and chats. That move, they said, indicated “that you understand there will be negative impacts to veterans’ care due to the return-to-office order and that these must be mitigated.”

VA spokesperson Peter Kasperowicz called the privacy concerns “nonsensical” and blamed “fear mongering from the media.” The VA, he said, “is no longer a place where the status quo for employees is to simply phone it in from home.” He also claimed that “the small number of employees who are desperate to avoid returning to the office will do more to drive away staff and patients than VA’s commonsense return-to-office policy ever will.”

VA care, he said, would continue uninterrupted and the “VA will ensure that employees have a workspace that is appropriate for the work they do.”

US Department of Veterans Affairs (VA) officials are insisting that when remote telehealth clinicians return to an office setting, they must have private workspaces “that foster trusted, confidential, and therapeutic relationships with veterans,” according to an April internal memo reported on by NPR. 

The return-to-office mandate followed a Trump Administration executive order in February indicated that mental health clinicians at the US Department of Veterans Affairs (VA) must physically return to their workplace by May 5. For some, the deadline came as early as April 14; however, that order, like many others, may now be being revised or reconsidered due to concerns that have been raised. Many mental health clinicians were hired specifically to work remotely. They worried there would simply not be enough space for them, particularly to provide confidential counseling.

Millions of veterans use telehealth to access VA care. More than 98% of VA mental health clinicians have conducted ≥ 1 video visit to screen and treat patients for anxiety, depression, posttraumatic stress disorder, and more. Telehealth has been particularly important for veterans living in rural communities.

The April VA memo stipulated that “spaces used to deliver synchronous telehealth services should offer the same level of privacy and therapeutic environment applicable to an in-person visit in the same space.”

Therapists, patients, advocacy groups, and lawmakers have expressed concern about the potential impacts the policy change could have on patient care for veterans and, above all, about what it could mean for privacy. On Mar. 27, the American Psychological Association issued a statement noting that the change “resulted in providers being asked to conduct sensitive therapy sessions in open office environments, cubicles, or shared spaces that fail to meet basic confidentiality and privacy requirements for the delivery of mental health care services.”

Twenty Democrats in the House of Representatives sent a letter to VA Secretary Doug Collins expressing concern with the return to office policy. According to the letter a VA social worker supervisor reported managing their caseload while sharing a 100 ft2 shower space with another supervisor. It also reported that Clinical Resource Hub employees were being told to report to buildings where federal employees from other agencies work. “We have heard from countless stakeholders, veterans, and Department of Veterans Affairs (VA) employees that by carrying out President Trump’s blanket return-to-office policy your administration is damaging veteran and employee trust in VA, disrupting and impeding veterans’ access to care, and creating untenable and inefficient conditions for both veterans and the VA workforce,” the letter stated.

“This is a clear violation of veterans’ privacy and VA’s obligation to protect veterans’ private health information, and risks violation of the Health Insurance Portability and Accountability Act (HIPAA),” the letter added.

The lawmakers noted that, as of March 10, the VA was exempting Veterans Crisis Line workers, most of whom had been working remotely for the past 5 years, responding to more than 10 million calls, texts, and chats. That move, they said, indicated “that you understand there will be negative impacts to veterans’ care due to the return-to-office order and that these must be mitigated.”

VA spokesperson Peter Kasperowicz called the privacy concerns “nonsensical” and blamed “fear mongering from the media.” The VA, he said, “is no longer a place where the status quo for employees is to simply phone it in from home.” He also claimed that “the small number of employees who are desperate to avoid returning to the office will do more to drive away staff and patients than VA’s commonsense return-to-office policy ever will.”

VA care, he said, would continue uninterrupted and the “VA will ensure that employees have a workspace that is appropriate for the work they do.”

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The Cruelty of April: Suicide in Spring

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The Cruelty of April: Suicide in Spring

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April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot1

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.2

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.3 A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.4 This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.5

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.6 In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.7

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.8 Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. 10

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

References
  1. Elliot TS, North M. The Waste Land and Other Poems: A Norton Critical Edition. W.W. Norton & Company; 2022.
  2. Lester D. Suicide rates before, during, and after the world wars. Eur Psychiatry. 1994;9(5):262-264. doi:10.1017/S092493380000362X
  3. Centers for Disease Control Center and Prevention. National Center for Health Statistics. Fact or fiction: suicides increase during the holiday season and winter months. January 10, 2014. Accessed March 27, 2025. https://blogs.cdc.gov/nchs/2014/01/10/1121/
  4. Della DF, Allison S, Bidargaddi N, Wa SK, Bastiampillai T. An umbrella systematic review of seasonality in mood disorders and suicide risk: the impact on demand for primary behavioral health care and acute psychiatric services. Prim Care Companion CNS Disord. 2023;25(3):22r03395. doi:10.4088/PCC.22r03395
  5. Gold SA, Goodrich M, Morley SW, Stephens B, McCarthy JF. Temporal patterns of veteran suicide: variation by season, day of the week, and holidays. Suicide Life Threat Behav. 2025;55(2):e13148. doi:10.1111/sltb.13148
  6. Cho CH, Lee HJ. Why do mania and suicide occur most often in the Spring? Psychiatry Investig. 2018;15(3):232-234. doi:10.30773/pi.2017.12.20
  7. Postolache TT, Mortensen PB, Tonelli LH, et al. Seasonal spring peaks of suicide in victims with and without prior history of hospitalization for mood disorders. J Affect Disord. 2010;121(1-2):88-93. doi:10.1016/j.jad.2009.05.015
  8. Christodoulou C, Efstathiou V, Bouras G, Korkoliakou P, Lykouras L. Seasonal variation of suicide: a brief review. Encephalos. 2012;49:73-79.
  9. Shapiro M. Suicide rates spike in spring, not winter. Dome. May/June 2019. Accessed March 28, 2025. https://www.hopkinsmedicine.org/news/articles/2019/05/suicide-rates-spike-in-spring-not-winter
  10. Annenberg Public Policy Center. Suicides don’t spike around the holiday season, but Americans think they do. December 6, 2023. Accessed March 27, 2025. https:// www.asc.upenn.edu/news-events/news/suicides-dont-spike-around-holiday-season-americans-think-they-do
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Fed Pract. 2025;42(4). Published online April 14. doi:10.12788/fp.0580

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Article PDF
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Article PDF
FDP04204152.pdf

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot1

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.2

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.3 A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.4 This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.5

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.6 In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.7

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.8 Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. 10

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot1

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.2

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.3 A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.4 This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.5

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.6 In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.7

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.8 Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. 10

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

References
  1. Elliot TS, North M. The Waste Land and Other Poems: A Norton Critical Edition. W.W. Norton & Company; 2022.
  2. Lester D. Suicide rates before, during, and after the world wars. Eur Psychiatry. 1994;9(5):262-264. doi:10.1017/S092493380000362X
  3. Centers for Disease Control Center and Prevention. National Center for Health Statistics. Fact or fiction: suicides increase during the holiday season and winter months. January 10, 2014. Accessed March 27, 2025. https://blogs.cdc.gov/nchs/2014/01/10/1121/
  4. Della DF, Allison S, Bidargaddi N, Wa SK, Bastiampillai T. An umbrella systematic review of seasonality in mood disorders and suicide risk: the impact on demand for primary behavioral health care and acute psychiatric services. Prim Care Companion CNS Disord. 2023;25(3):22r03395. doi:10.4088/PCC.22r03395
  5. Gold SA, Goodrich M, Morley SW, Stephens B, McCarthy JF. Temporal patterns of veteran suicide: variation by season, day of the week, and holidays. Suicide Life Threat Behav. 2025;55(2):e13148. doi:10.1111/sltb.13148
  6. Cho CH, Lee HJ. Why do mania and suicide occur most often in the Spring? Psychiatry Investig. 2018;15(3):232-234. doi:10.30773/pi.2017.12.20
  7. Postolache TT, Mortensen PB, Tonelli LH, et al. Seasonal spring peaks of suicide in victims with and without prior history of hospitalization for mood disorders. J Affect Disord. 2010;121(1-2):88-93. doi:10.1016/j.jad.2009.05.015
  8. Christodoulou C, Efstathiou V, Bouras G, Korkoliakou P, Lykouras L. Seasonal variation of suicide: a brief review. Encephalos. 2012;49:73-79.
  9. Shapiro M. Suicide rates spike in spring, not winter. Dome. May/June 2019. Accessed March 28, 2025. https://www.hopkinsmedicine.org/news/articles/2019/05/suicide-rates-spike-in-spring-not-winter
  10. Annenberg Public Policy Center. Suicides don’t spike around the holiday season, but Americans think they do. December 6, 2023. Accessed March 27, 2025. https:// www.asc.upenn.edu/news-events/news/suicides-dont-spike-around-holiday-season-americans-think-they-do
References
  1. Elliot TS, North M. The Waste Land and Other Poems: A Norton Critical Edition. W.W. Norton & Company; 2022.
  2. Lester D. Suicide rates before, during, and after the world wars. Eur Psychiatry. 1994;9(5):262-264. doi:10.1017/S092493380000362X
  3. Centers for Disease Control Center and Prevention. National Center for Health Statistics. Fact or fiction: suicides increase during the holiday season and winter months. January 10, 2014. Accessed March 27, 2025. https://blogs.cdc.gov/nchs/2014/01/10/1121/
  4. Della DF, Allison S, Bidargaddi N, Wa SK, Bastiampillai T. An umbrella systematic review of seasonality in mood disorders and suicide risk: the impact on demand for primary behavioral health care and acute psychiatric services. Prim Care Companion CNS Disord. 2023;25(3):22r03395. doi:10.4088/PCC.22r03395
  5. Gold SA, Goodrich M, Morley SW, Stephens B, McCarthy JF. Temporal patterns of veteran suicide: variation by season, day of the week, and holidays. Suicide Life Threat Behav. 2025;55(2):e13148. doi:10.1111/sltb.13148
  6. Cho CH, Lee HJ. Why do mania and suicide occur most often in the Spring? Psychiatry Investig. 2018;15(3):232-234. doi:10.30773/pi.2017.12.20
  7. Postolache TT, Mortensen PB, Tonelli LH, et al. Seasonal spring peaks of suicide in victims with and without prior history of hospitalization for mood disorders. J Affect Disord. 2010;121(1-2):88-93. doi:10.1016/j.jad.2009.05.015
  8. Christodoulou C, Efstathiou V, Bouras G, Korkoliakou P, Lykouras L. Seasonal variation of suicide: a brief review. Encephalos. 2012;49:73-79.
  9. Shapiro M. Suicide rates spike in spring, not winter. Dome. May/June 2019. Accessed March 28, 2025. https://www.hopkinsmedicine.org/news/articles/2019/05/suicide-rates-spike-in-spring-not-winter
  10. Annenberg Public Policy Center. Suicides don’t spike around the holiday season, but Americans think they do. December 6, 2023. Accessed March 27, 2025. https:// www.asc.upenn.edu/news-events/news/suicides-dont-spike-around-holiday-season-americans-think-they-do
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The Cruelty of April: Suicide in Spring

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