Program Profile

Rural populations experience more health care disparities than urban populations, including a greater proportion of adults aged ≥ 65 years, higher poverty, and a higher prevalence of chronic comorbidities. Reported rates vary by study methodology and over time.¹ These disparities are further exacerbated by reduced access to health care practitioners (HCPs), particularly physical and mental health specialty services, and a lack of rural health care facilities.¹ HCP training programs are primarily located in urban settings and may heavily influence the geographical location and population focus of newly trained HCPs’ first positions.² As the largest provider of health professions training, the US Department of Veterans Affairs (VA) can innovate to improve the quality of education and training while supporting rural health care sustainability and health care workforce retention.^3,4 

One such innovation is expanding the implementation of telesupervision (ie, clinical supervision delivered via synchronous audio and video formats) for health professions trainees. During the COVID-19 pandemic, the literature documenting telesupervision substantially expanded across health care disciplines. These findings support telesupervision as a feasible alternative to traditional in-person supervision and suggest increased trainee comfort with telehealth use.^5,6 The literature also provides insight into considerations for the use of telesupervision, including being more intentional in the development of the supervisory relationship,^6-8 and enabling appropriate access to supervisors to support quality patient care and experiential learning.^9,10 

This quality improvement examination of telesupervision in 11 rural VA psychology training programs spanned 3 years and included 3197 monthly surveys completed by supervisors and trainees. It supported the use of telesupervision compared with in-person or mixed modality supervision across a wide range of outcomes in upholding patient safety and maintaining the quality of supervision while also expanding trainees’ comfort in implementing telehealth care. The Table summarizes how frequently supervisors observed trainees providing clinical care via live observation, video or tape reviews, or conducting cotherapy. The clinical sessions for most trainees (70.3%) were directly observed by supervisors at least monthly across all methods. We also reviewed differences in Supervisory Working Alliance Inventory (SWAI) scores, which quantify the strength of the working relationship between trainees and supervisors, across 458 rotations by position (trainee vs supervisor) and rurality (rural vs urban sites). Overall, alliance was high with mean scores of 5.5 to 6.7 on a 7-point scale. While trainees tended to report higher alliance (P < .001), there were no differences by rurality (P = .06) or the rurality × position interaction (P = .08), and the marginally significant effects were small, indicating that rurality tended to attenuate position effects (Figure). Additional analyses of modality (in-person, telesupervision, or mixed modalities) indicated no differences. Thus, trainee and supervisor data from this project identified safe, high-quality, and consistent supervisory practices. Finally, additional data highlighted the potential benefits of a mixed-modality supervision, including both in-person supervision and telesupervision.^11,12 

The expanded use of telesupervision provides several new opportunities for rural health care clinical supervisors, trainees, and veterans. Clinical supervisors who would otherwise operate as the sole HCP within their discipline or specialty at a remote clinic can increase their professional connection to a main facility and/or larger professional organization by serving as a clinical supervisor within a training program via telesupervision. This creates a greater connection to the larger mission, thereby supporting the clinical supervisor’s potential retention in their work setting.¹⁰ 

Telesupervision expands the opportunity for health professions trainees to be clinically supervised by individuals with the cultural knowledge specific to the patient population served (ie, those individuals working within or knowledgeable about the particular rural setting). This supports higher quality training and patient care, even if the trainee’s primary physical location is not colocated with the clinical supervisor. 

Telesupervision can expand the number of clinical supervisors and rotations available within a health care system or clinic, particularly for specialty services (eg, psychological testing, dermatology) that are not otherwise available within specific geographic regions. Thus, telesupervision enables a supervisor with the needed expertise, specialty, or advanced training at one clinic to supervise a trainee located hundreds to thousands of miles away while serving a veteran who may or may not be colocated with either HCP. For example, the supervisor may be located in American Samoa, supervising a trainee physically residing in Hawaii who provides telehealth patient care to a veteran in Saipan. This also enables health care systems serving rural patient populations to bolster their offerings to support future trainee recruitment. 

The more trainees increase their connection to caring for rural veterans, the greater the likelihood they will develop knowledge and contribute to these communities after completing their training. Consequently, telesupervision may be fundamental to improving rural population health, contributing to the sustainability of rural health training programs and workforce retention, increasing access to needed health care in geographical areas of shortage, and allowing trainees to receive supervision from those who are most competent in the specific needs of patients living in rural communities. 

The evolving landscape of telesupervision and associated opportunities underscores the need to bolster overall clinical supervision practices. Clinical supervision is more than assuming liability, cosigning notes, and ensuring that the standard of care is met. The provision of clinical supervision is a distinct competency separate from the delivery of clinical care. However, only a small portion of those providing clinical supervision have had formal training in supervision and the development of supervision competencies.^13,14 Thus, an HCP can be a highly proficient clinician while still being deficient in the skills needed to be a competent clinical supervisor, with a lack of training in supervision skills undermining engagement in effective supervision.¹⁵ 

Research supports the following as essential components of effective clinical supervision: a working alliance between supervisor and supervisee, inclusive of resolution of strains/ruptures, consistent provision of evaluative feedback, consistent supervision meetings, direct observation of clinical work, and opportunities for trainees to see skills modeled through experiential supervision.¹³ These elements enable investment in the long-term development of the trainee through deep and nuanced feedback provided, the supervisory relationship, access to mentoring, and assistance with articulating case formulations to enable future health care professionals to provide even better care. Engaging in effective supervision requires both the development of supervision competencies and the time allocation needed to uphold these essential elements. Although vital to quality health care, clinical supervision is not consistently reflected in labor mapping or productivity metrics. Consequently, limited dedicated time for supervision (eg, direct observation of trainees’ clinical care, reflection, and preparation to address trainees’ developmental needs) and heavy workloads remain major barriers to effective supervision.¹⁴ The continued expansion of technology-assisted supervision highlights the need for HCP duties and associated clinical supervisory skills (whether in person or via telesupervision) to become more integrated into their roles within health care settings. 

Upholding effective supervision practices within telesupervision requires thoughtful implementation. Supervisors should engage in direct observation of clinical work in a manner that enables timely correction of trainees and supplemental clinical care as needed, including interventions that assist trainees. In addition, it is essential that the supervisor provides trainees with access to scheduled, ad hoc, and emergent supervision. Furthermore, the supervisor needs to ensure that, regardless of modality, the supervisor can uphold the competency/learning goal development of the trainee (ie, meet learning needs), effectively deliver and receive constructive feedback, and model critical clinical skills relevant to the clinical training area. Of utmost importance, the supervisory oversight and type of supervision required should match the setting to ensure effective supervision. 

In some clinical settings, telesupervision may be less appropriate for upholding all elements of effective supervision while matching the needs of the clinical intervention and the trainee. Thus, supervisors need to engage in the supervisory modality that enables them to effectively intervene in clinical care according to the oversight needed. For example, a physical health care intervention may require the supervisor to provide hands-on guidance for a skill or procedure, whereas the dynamics of an inpatient mental health care setting may have patient care interactions that are not fully met by the use of telesupervision, such as complex patients’ needs, acuity, and crisis management. As telesupervision research continues to expand to better understand these applied complexities, there will be an evolving knowledge of the nuances in the application of telesupervision that best capture the benefits of telesupervision without compromising the quality of training and patient care. 

CONCLUSIONS 

Clinicians working with HCP trainees have the opportunity to use telesupervision to create a dynamic and rich learning environment while maintaining the quality of training and potentially reducing health disparities experienced by rural veterans. With this opportunity also comes the need to recognize clinical supervision as a competency and an essential role of an HCP. In doing so, a thoughtful approach to supervision will enable the powerful tool of telesupervision to be used to its highest potential in a responsible manner that does not overextend its reach. 

Rural populations experience more health care disparities than urban populations, including a greater proportion of adults aged ≥ 65 years, higher poverty, and a higher prevalence of chronic comorbidities. Reported rates vary by study methodology and over time.¹ These disparities are further exacerbated by reduced access to health care practitioners (HCPs), particularly physical and mental health specialty services, and a lack of rural health care facilities.¹ HCP training programs are primarily located in urban settings and may heavily influence the geographical location and population focus of newly trained HCPs’ first positions.² As the largest provider of health professions training, the US Department of Veterans Affairs (VA) can innovate to improve the quality of education and training while supporting rural health care sustainability and health care workforce retention.^3,4 

One such innovation is expanding the implementation of telesupervision (ie, clinical supervision delivered via synchronous audio and video formats) for health professions trainees. During the COVID-19 pandemic, the literature documenting telesupervision substantially expanded across health care disciplines. These findings support telesupervision as a feasible alternative to traditional in-person supervision and suggest increased trainee comfort with telehealth use.^5,6 The literature also provides insight into considerations for the use of telesupervision, including being more intentional in the development of the supervisory relationship,^6-8 and enabling appropriate access to supervisors to support quality patient care and experiential learning.^9,10 

This quality improvement examination of telesupervision in 11 rural VA psychology training programs spanned 3 years and included 3197 monthly surveys completed by supervisors and trainees. It supported the use of telesupervision compared with in-person or mixed modality supervision across a wide range of outcomes in upholding patient safety and maintaining the quality of supervision while also expanding trainees’ comfort in implementing telehealth care. The Table summarizes how frequently supervisors observed trainees providing clinical care via live observation, video or tape reviews, or conducting cotherapy. The clinical sessions for most trainees (70.3%) were directly observed by supervisors at least monthly across all methods. We also reviewed differences in Supervisory Working Alliance Inventory (SWAI) scores, which quantify the strength of the working relationship between trainees and supervisors, across 458 rotations by position (trainee vs supervisor) and rurality (rural vs urban sites). Overall, alliance was high with mean scores of 5.5 to 6.7 on a 7-point scale. While trainees tended to report higher alliance (P < .001), there were no differences by rurality (P = .06) or the rurality × position interaction (P = .08), and the marginally significant effects were small, indicating that rurality tended to attenuate position effects (Figure). Additional analyses of modality (in-person, telesupervision, or mixed modalities) indicated no differences. Thus, trainee and supervisor data from this project identified safe, high-quality, and consistent supervisory practices. Finally, additional data highlighted the potential benefits of a mixed-modality supervision, including both in-person supervision and telesupervision.^11,12 

The expanded use of telesupervision provides several new opportunities for rural health care clinical supervisors, trainees, and veterans. Clinical supervisors who would otherwise operate as the sole HCP within their discipline or specialty at a remote clinic can increase their professional connection to a main facility and/or larger professional organization by serving as a clinical supervisor within a training program via telesupervision. This creates a greater connection to the larger mission, thereby supporting the clinical supervisor’s potential retention in their work setting.¹⁰ 

Telesupervision expands the opportunity for health professions trainees to be clinically supervised by individuals with the cultural knowledge specific to the patient population served (ie, those individuals working within or knowledgeable about the particular rural setting). This supports higher quality training and patient care, even if the trainee’s primary physical location is not colocated with the clinical supervisor. 

Telesupervision can expand the number of clinical supervisors and rotations available within a health care system or clinic, particularly for specialty services (eg, psychological testing, dermatology) that are not otherwise available within specific geographic regions. Thus, telesupervision enables a supervisor with the needed expertise, specialty, or advanced training at one clinic to supervise a trainee located hundreds to thousands of miles away while serving a veteran who may or may not be colocated with either HCP. For example, the supervisor may be located in American Samoa, supervising a trainee physically residing in Hawaii who provides telehealth patient care to a veteran in Saipan. This also enables health care systems serving rural patient populations to bolster their offerings to support future trainee recruitment. 

The more trainees increase their connection to caring for rural veterans, the greater the likelihood they will develop knowledge and contribute to these communities after completing their training. Consequently, telesupervision may be fundamental to improving rural population health, contributing to the sustainability of rural health training programs and workforce retention, increasing access to needed health care in geographical areas of shortage, and allowing trainees to receive supervision from those who are most competent in the specific needs of patients living in rural communities. 

The evolving landscape of telesupervision and associated opportunities underscores the need to bolster overall clinical supervision practices. Clinical supervision is more than assuming liability, cosigning notes, and ensuring that the standard of care is met. The provision of clinical supervision is a distinct competency separate from the delivery of clinical care. However, only a small portion of those providing clinical supervision have had formal training in supervision and the development of supervision competencies.^13,14 Thus, an HCP can be a highly proficient clinician while still being deficient in the skills needed to be a competent clinical supervisor, with a lack of training in supervision skills undermining engagement in effective supervision.¹⁵ 

Research supports the following as essential components of effective clinical supervision: a working alliance between supervisor and supervisee, inclusive of resolution of strains/ruptures, consistent provision of evaluative feedback, consistent supervision meetings, direct observation of clinical work, and opportunities for trainees to see skills modeled through experiential supervision.¹³ These elements enable investment in the long-term development of the trainee through deep and nuanced feedback provided, the supervisory relationship, access to mentoring, and assistance with articulating case formulations to enable future health care professionals to provide even better care. Engaging in effective supervision requires both the development of supervision competencies and the time allocation needed to uphold these essential elements. Although vital to quality health care, clinical supervision is not consistently reflected in labor mapping or productivity metrics. Consequently, limited dedicated time for supervision (eg, direct observation of trainees’ clinical care, reflection, and preparation to address trainees’ developmental needs) and heavy workloads remain major barriers to effective supervision.¹⁴ The continued expansion of technology-assisted supervision highlights the need for HCP duties and associated clinical supervisory skills (whether in person or via telesupervision) to become more integrated into their roles within health care settings. 

Upholding effective supervision practices within telesupervision requires thoughtful implementation. Supervisors should engage in direct observation of clinical work in a manner that enables timely correction of trainees and supplemental clinical care as needed, including interventions that assist trainees. In addition, it is essential that the supervisor provides trainees with access to scheduled, ad hoc, and emergent supervision. Furthermore, the supervisor needs to ensure that, regardless of modality, the supervisor can uphold the competency/learning goal development of the trainee (ie, meet learning needs), effectively deliver and receive constructive feedback, and model critical clinical skills relevant to the clinical training area. Of utmost importance, the supervisory oversight and type of supervision required should match the setting to ensure effective supervision. 

In some clinical settings, telesupervision may be less appropriate for upholding all elements of effective supervision while matching the needs of the clinical intervention and the trainee. Thus, supervisors need to engage in the supervisory modality that enables them to effectively intervene in clinical care according to the oversight needed. For example, a physical health care intervention may require the supervisor to provide hands-on guidance for a skill or procedure, whereas the dynamics of an inpatient mental health care setting may have patient care interactions that are not fully met by the use of telesupervision, such as complex patients’ needs, acuity, and crisis management. As telesupervision research continues to expand to better understand these applied complexities, there will be an evolving knowledge of the nuances in the application of telesupervision that best capture the benefits of telesupervision without compromising the quality of training and patient care. 

CONCLUSIONS 

Clinicians working with HCP trainees have the opportunity to use telesupervision to create a dynamic and rich learning environment while maintaining the quality of training and potentially reducing health disparities experienced by rural veterans. With this opportunity also comes the need to recognize clinical supervision as a competency and an essential role of an HCP. In doing so, a thoughtful approach to supervision will enable the powerful tool of telesupervision to be used to its highest potential in a responsible manner that does not overextend its reach. 

Rural populations experience more health care disparities than urban populations, including a greater proportion of adults aged ≥ 65 years, higher poverty, and a higher prevalence of chronic comorbidities. Reported rates vary by study methodology and over time.¹ These disparities are further exacerbated by reduced access to health care practitioners (HCPs), particularly physical and mental health specialty services, and a lack of rural health care facilities.¹ HCP training programs are primarily located in urban settings and may heavily influence the geographical location and population focus of newly trained HCPs’ first positions.² As the largest provider of health professions training, the US Department of Veterans Affairs (VA) can innovate to improve the quality of education and training while supporting rural health care sustainability and health care workforce retention.^3,4 

One such innovation is expanding the implementation of telesupervision (ie, clinical supervision delivered via synchronous audio and video formats) for health professions trainees. During the COVID-19 pandemic, the literature documenting telesupervision substantially expanded across health care disciplines. These findings support telesupervision as a feasible alternative to traditional in-person supervision and suggest increased trainee comfort with telehealth use.^5,6 The literature also provides insight into considerations for the use of telesupervision, including being more intentional in the development of the supervisory relationship,^6-8 and enabling appropriate access to supervisors to support quality patient care and experiential learning.^9,10 

This quality improvement examination of telesupervision in 11 rural VA psychology training programs spanned 3 years and included 3197 monthly surveys completed by supervisors and trainees. It supported the use of telesupervision compared with in-person or mixed modality supervision across a wide range of outcomes in upholding patient safety and maintaining the quality of supervision while also expanding trainees’ comfort in implementing telehealth care. The Table summarizes how frequently supervisors observed trainees providing clinical care via live observation, video or tape reviews, or conducting cotherapy. The clinical sessions for most trainees (70.3%) were directly observed by supervisors at least monthly across all methods. We also reviewed differences in Supervisory Working Alliance Inventory (SWAI) scores, which quantify the strength of the working relationship between trainees and supervisors, across 458 rotations by position (trainee vs supervisor) and rurality (rural vs urban sites). Overall, alliance was high with mean scores of 5.5 to 6.7 on a 7-point scale. While trainees tended to report higher alliance (P < .001), there were no differences by rurality (P = .06) or the rurality × position interaction (P = .08), and the marginally significant effects were small, indicating that rurality tended to attenuate position effects (Figure). Additional analyses of modality (in-person, telesupervision, or mixed modalities) indicated no differences. Thus, trainee and supervisor data from this project identified safe, high-quality, and consistent supervisory practices. Finally, additional data highlighted the potential benefits of a mixed-modality supervision, including both in-person supervision and telesupervision.^11,12 

The expanded use of telesupervision provides several new opportunities for rural health care clinical supervisors, trainees, and veterans. Clinical supervisors who would otherwise operate as the sole HCP within their discipline or specialty at a remote clinic can increase their professional connection to a main facility and/or larger professional organization by serving as a clinical supervisor within a training program via telesupervision. This creates a greater connection to the larger mission, thereby supporting the clinical supervisor’s potential retention in their work setting.¹⁰ 

Telesupervision expands the opportunity for health professions trainees to be clinically supervised by individuals with the cultural knowledge specific to the patient population served (ie, those individuals working within or knowledgeable about the particular rural setting). This supports higher quality training and patient care, even if the trainee’s primary physical location is not colocated with the clinical supervisor. 

Telesupervision can expand the number of clinical supervisors and rotations available within a health care system or clinic, particularly for specialty services (eg, psychological testing, dermatology) that are not otherwise available within specific geographic regions. Thus, telesupervision enables a supervisor with the needed expertise, specialty, or advanced training at one clinic to supervise a trainee located hundreds to thousands of miles away while serving a veteran who may or may not be colocated with either HCP. For example, the supervisor may be located in American Samoa, supervising a trainee physically residing in Hawaii who provides telehealth patient care to a veteran in Saipan. This also enables health care systems serving rural patient populations to bolster their offerings to support future trainee recruitment. 

The more trainees increase their connection to caring for rural veterans, the greater the likelihood they will develop knowledge and contribute to these communities after completing their training. Consequently, telesupervision may be fundamental to improving rural population health, contributing to the sustainability of rural health training programs and workforce retention, increasing access to needed health care in geographical areas of shortage, and allowing trainees to receive supervision from those who are most competent in the specific needs of patients living in rural communities. 

The evolving landscape of telesupervision and associated opportunities underscores the need to bolster overall clinical supervision practices. Clinical supervision is more than assuming liability, cosigning notes, and ensuring that the standard of care is met. The provision of clinical supervision is a distinct competency separate from the delivery of clinical care. However, only a small portion of those providing clinical supervision have had formal training in supervision and the development of supervision competencies.^13,14 Thus, an HCP can be a highly proficient clinician while still being deficient in the skills needed to be a competent clinical supervisor, with a lack of training in supervision skills undermining engagement in effective supervision.¹⁵ 

Research supports the following as essential components of effective clinical supervision: a working alliance between supervisor and supervisee, inclusive of resolution of strains/ruptures, consistent provision of evaluative feedback, consistent supervision meetings, direct observation of clinical work, and opportunities for trainees to see skills modeled through experiential supervision.¹³ These elements enable investment in the long-term development of the trainee through deep and nuanced feedback provided, the supervisory relationship, access to mentoring, and assistance with articulating case formulations to enable future health care professionals to provide even better care. Engaging in effective supervision requires both the development of supervision competencies and the time allocation needed to uphold these essential elements. Although vital to quality health care, clinical supervision is not consistently reflected in labor mapping or productivity metrics. Consequently, limited dedicated time for supervision (eg, direct observation of trainees’ clinical care, reflection, and preparation to address trainees’ developmental needs) and heavy workloads remain major barriers to effective supervision.¹⁴ The continued expansion of technology-assisted supervision highlights the need for HCP duties and associated clinical supervisory skills (whether in person or via telesupervision) to become more integrated into their roles within health care settings. 

Upholding effective supervision practices within telesupervision requires thoughtful implementation. Supervisors should engage in direct observation of clinical work in a manner that enables timely correction of trainees and supplemental clinical care as needed, including interventions that assist trainees. In addition, it is essential that the supervisor provides trainees with access to scheduled, ad hoc, and emergent supervision. Furthermore, the supervisor needs to ensure that, regardless of modality, the supervisor can uphold the competency/learning goal development of the trainee (ie, meet learning needs), effectively deliver and receive constructive feedback, and model critical clinical skills relevant to the clinical training area. Of utmost importance, the supervisory oversight and type of supervision required should match the setting to ensure effective supervision. 

In some clinical settings, telesupervision may be less appropriate for upholding all elements of effective supervision while matching the needs of the clinical intervention and the trainee. Thus, supervisors need to engage in the supervisory modality that enables them to effectively intervene in clinical care according to the oversight needed. For example, a physical health care intervention may require the supervisor to provide hands-on guidance for a skill or procedure, whereas the dynamics of an inpatient mental health care setting may have patient care interactions that are not fully met by the use of telesupervision, such as complex patients’ needs, acuity, and crisis management. As telesupervision research continues to expand to better understand these applied complexities, there will be an evolving knowledge of the nuances in the application of telesupervision that best capture the benefits of telesupervision without compromising the quality of training and patient care. 

CONCLUSIONS 

Clinicians working with HCP trainees have the opportunity to use telesupervision to create a dynamic and rich learning environment while maintaining the quality of training and potentially reducing health disparities experienced by rural veterans. With this opportunity also comes the need to recognize clinical supervision as a competency and an essential role of an HCP. In doing so, a thoughtful approach to supervision will enable the powerful tool of telesupervision to be used to its highest potential in a responsible manner that does not overextend its reach. 

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.