Mental Health

Military sexual trauma (MST) remained “persistently prevalent” between 2013 and 2026, experiencing a slight overall increase from 7.6% to 8.2% in the time period, according to a research letter written by researchers from Yale University and the Veterans Affairs (VA) Connecticut Healthcare System and published in JAMA Psychiatry. Prevalence among female veterans jumped from 32.4% to 43.3%, with many citing MST as a factor in their decision to leave military service earlier than planned.

The researchers analyzed data from 3 independent nationally representative cohorts of veterans surveyed as part of the National Health and Resilience in Veterans Study. In 2025 and 2026, 189 veterans reported sexual harassment and 80 veterans reported sexual assault. Among female veterans, 128 (42.7%) reported harassment and 55 (21.2%) reported assault; 61 male veterans (3.6%) reported harassment and 25 (1.4%) reported assault. 

Many veterans experienced multiple MSTs. In 2025 and 2026, 61 women and 23 men reported 2 or 3 occurrences of MST, and 57 (42 women, 15 men) reported ≥ 4 occurrences. Most indicated ≥ 1 MST occurrence was perpetrated by a higher-ranking military member. Women were more likely to report ≥ 2 MST occurrences and MST perpetrated by a higher-ranking military member, according to the letter.

MST can have potentially disproportionate consequences for women in terms of military workforce composition, leadership representation, and long-term force readiness, the researchers say. Findings based on 2024 national veteran population data suggest that roughly 1 in 6 women and 1 in 100 men will leave military service after MST. 

History of MST has been independently associated with elevated risk for suicidal thoughts and behaviors, including future suicidal intent. In this study, compared with veterans without MST, those with MST had nearly triple the rates of past-year suicidal ideation and > 4 times the rates of lifetime suicide attempt. They were also significantly more likely to indicate future suicidal intent (6.9% vs 1.2%). Predicted probabilities of suicidal ideation (34.2% vs 28.3%) and suicide attempt (18.5% vs 13.4%) were significantly higher among females than males.

Female service members who experienced MST are also nearly 3 times more likely to have moderate to severe posttraumatic stress disorder (PTSD) symptoms, compared with female service members who did not experience MST. Women veterans who report MST and have PTSD are also more likely to have comorbid mental health diagnoses, including major depression, anxiety, eating disorders, and substance use disorders. 

The researchers claim the research is the first nationally representative characterization of MST contextual features and updated estimates of treatment utilization. They found that fewer than half of survivors received MST-related treatment.

In 2021, President Biden directed the US Department of Defense to establish the Independent Review Commission on Sexual Assault in the Military (IRC). An overview of the IRC commission findings underscored the need for screening. The increased risk of suicidal thoughts and behaviors, it says, makes “integration of crosscutting prevention initiatives within MST care and suicide prevention at VA” critical. 

The Veterans Health Administration universal MST screening program is part of a web of MST-related services. Analysis of medical record data demonstrates that the program yields clinically meaningful information, and increases the likelihood of mental health treatment. Despite the barriers to care for all MST survivors noted in qualitative studies, the commission report says, quantitative research agrees that veterans with a positive MST screen are more likely to engage in health care in VA.

Military sexual trauma (MST) remained “persistently prevalent” between 2013 and 2026, experiencing a slight overall increase from 7.6% to 8.2% in the time period, according to a research letter written by researchers from Yale University and the Veterans Affairs (VA) Connecticut Healthcare System and published in JAMA Psychiatry. Prevalence among female veterans jumped from 32.4% to 43.3%, with many citing MST as a factor in their decision to leave military service earlier than planned.

The researchers analyzed data from 3 independent nationally representative cohorts of veterans surveyed as part of the National Health and Resilience in Veterans Study. In 2025 and 2026, 189 veterans reported sexual harassment and 80 veterans reported sexual assault. Among female veterans, 128 (42.7%) reported harassment and 55 (21.2%) reported assault; 61 male veterans (3.6%) reported harassment and 25 (1.4%) reported assault. 

Many veterans experienced multiple MSTs. In 2025 and 2026, 61 women and 23 men reported 2 or 3 occurrences of MST, and 57 (42 women, 15 men) reported ≥ 4 occurrences. Most indicated ≥ 1 MST occurrence was perpetrated by a higher-ranking military member. Women were more likely to report ≥ 2 MST occurrences and MST perpetrated by a higher-ranking military member, according to the letter.

MST can have potentially disproportionate consequences for women in terms of military workforce composition, leadership representation, and long-term force readiness, the researchers say. Findings based on 2024 national veteran population data suggest that roughly 1 in 6 women and 1 in 100 men will leave military service after MST. 

History of MST has been independently associated with elevated risk for suicidal thoughts and behaviors, including future suicidal intent. In this study, compared with veterans without MST, those with MST had nearly triple the rates of past-year suicidal ideation and > 4 times the rates of lifetime suicide attempt. They were also significantly more likely to indicate future suicidal intent (6.9% vs 1.2%). Predicted probabilities of suicidal ideation (34.2% vs 28.3%) and suicide attempt (18.5% vs 13.4%) were significantly higher among females than males.

Female service members who experienced MST are also nearly 3 times more likely to have moderate to severe posttraumatic stress disorder (PTSD) symptoms, compared with female service members who did not experience MST. Women veterans who report MST and have PTSD are also more likely to have comorbid mental health diagnoses, including major depression, anxiety, eating disorders, and substance use disorders. 

The researchers claim the research is the first nationally representative characterization of MST contextual features and updated estimates of treatment utilization. They found that fewer than half of survivors received MST-related treatment.

In 2021, President Biden directed the US Department of Defense to establish the Independent Review Commission on Sexual Assault in the Military (IRC). An overview of the IRC commission findings underscored the need for screening. The increased risk of suicidal thoughts and behaviors, it says, makes “integration of crosscutting prevention initiatives within MST care and suicide prevention at VA” critical. 

The Veterans Health Administration universal MST screening program is part of a web of MST-related services. Analysis of medical record data demonstrates that the program yields clinically meaningful information, and increases the likelihood of mental health treatment. Despite the barriers to care for all MST survivors noted in qualitative studies, the commission report says, quantitative research agrees that veterans with a positive MST screen are more likely to engage in health care in VA.

Military sexual trauma (MST) remained “persistently prevalent” between 2013 and 2026, experiencing a slight overall increase from 7.6% to 8.2% in the time period, according to a research letter written by researchers from Yale University and the Veterans Affairs (VA) Connecticut Healthcare System and published in JAMA Psychiatry. Prevalence among female veterans jumped from 32.4% to 43.3%, with many citing MST as a factor in their decision to leave military service earlier than planned.

The researchers analyzed data from 3 independent nationally representative cohorts of veterans surveyed as part of the National Health and Resilience in Veterans Study. In 2025 and 2026, 189 veterans reported sexual harassment and 80 veterans reported sexual assault. Among female veterans, 128 (42.7%) reported harassment and 55 (21.2%) reported assault; 61 male veterans (3.6%) reported harassment and 25 (1.4%) reported assault. 

Many veterans experienced multiple MSTs. In 2025 and 2026, 61 women and 23 men reported 2 or 3 occurrences of MST, and 57 (42 women, 15 men) reported ≥ 4 occurrences. Most indicated ≥ 1 MST occurrence was perpetrated by a higher-ranking military member. Women were more likely to report ≥ 2 MST occurrences and MST perpetrated by a higher-ranking military member, according to the letter.

MST can have potentially disproportionate consequences for women in terms of military workforce composition, leadership representation, and long-term force readiness, the researchers say. Findings based on 2024 national veteran population data suggest that roughly 1 in 6 women and 1 in 100 men will leave military service after MST. 

History of MST has been independently associated with elevated risk for suicidal thoughts and behaviors, including future suicidal intent. In this study, compared with veterans without MST, those with MST had nearly triple the rates of past-year suicidal ideation and > 4 times the rates of lifetime suicide attempt. They were also significantly more likely to indicate future suicidal intent (6.9% vs 1.2%). Predicted probabilities of suicidal ideation (34.2% vs 28.3%) and suicide attempt (18.5% vs 13.4%) were significantly higher among females than males.

Female service members who experienced MST are also nearly 3 times more likely to have moderate to severe posttraumatic stress disorder (PTSD) symptoms, compared with female service members who did not experience MST. Women veterans who report MST and have PTSD are also more likely to have comorbid mental health diagnoses, including major depression, anxiety, eating disorders, and substance use disorders. 

The researchers claim the research is the first nationally representative characterization of MST contextual features and updated estimates of treatment utilization. They found that fewer than half of survivors received MST-related treatment.

In 2021, President Biden directed the US Department of Defense to establish the Independent Review Commission on Sexual Assault in the Military (IRC). An overview of the IRC commission findings underscored the need for screening. The increased risk of suicidal thoughts and behaviors, it says, makes “integration of crosscutting prevention initiatives within MST care and suicide prevention at VA” critical. 

The Veterans Health Administration universal MST screening program is part of a web of MST-related services. Analysis of medical record data demonstrates that the program yields clinically meaningful information, and increases the likelihood of mental health treatment. Despite the barriers to care for all MST survivors noted in qualitative studies, the commission report says, quantitative research agrees that veterans with a positive MST screen are more likely to engage in health care in VA.

Traumatic brain injury (TBI) is the signature injury of post-9/11 military operations, impacting > 441,000 combat veterans from 2001 to 2021 and 87% diagnosed with mild TBI (mTBI).^1,2 The most common cause of mTBI during these operations was blast exposures stemming from improvised explosive devices, rocket-propelled grenades, or land mines. mTBI was once thought to be self-limiting, lasting hours or days postinjury, but is now recognized as a complex focal and diffuse injury causing a cascade of molecular and biochemical responses with significant physiologic effects lasting for a longer duration. A significant number of combat veterans with mTBI (23%-48%) experience long-standing postconcussive symptoms (PCSs) for many years postinjury.^3-5

Developing and implementing strategies to reduce persistent symptoms associated with mTBI is of critical importance. Veterans diagnosed with mTBI and experiencing PCSs present ongoing treatment challenges to the health care system due to limited or suboptimal treatment options.^6,7 According to the 2021 US Department of Veterans Affairs (VA) and US Department of Defense (DoD) clinical guidelines for postacute mTBI, treatment for PCSs should be symptom focused. ^8,9 For instance, veterans with migraine headaches associated with mTBIs are often treated with abortive agents (eg, triptans) and preventive medications (eg, anticonvulsants and tricyclics).¹⁰ Cognitive dysfunction and insomnia are treated with cognitive rehabilitation programs, cognitive behaviorial therapy, occupational therapy, and medications (eg, hypnotics for insomnia).^11,12 The 2021 VA/DoD guidelines note that veteran and military focus groups described greater success with nonpharmacologic treatments than with pharmacologic treatments.⁸ The VA launched an enterprise-wide Whole Health Service program with the requirement that complementary and integrative health approaches must be available to veterans.¹³ As a nonpharmacologic, integrative, and noninvasive modality, neurofeedback (NFB) supports the VA Whole Health initiative and veterans’ preferences for integrative treatments.¹⁴

Neurofeedback

Rather than a symptom management approach, Defina et al described the possibilities of brain repair in TBI by treatments to enhance neuroplasticity, thereby establishing a more normalized or stable brain environment and enabling the brain to reorganize itself and function more normally.¹⁵ NFB has been shown to influence neuroplasticity,¹⁶ as evident in microstructural changes in white and gray matter¹⁷ and its ability to contribute to functional rehabilitation by restoring connectivity in specific areas of the brain that may have been impaired.¹⁸ The benefits of neuroenhancement strategies include potentially reduced pain for patients with mTBI and improved quality of life (QOL).¹⁹

NFB assists individuals by helping them become more aware of and self-regulate their physiology.^20,21 Because there are several types of NFB (eg, quantitative electroencephalography, Z-scored, α-θ) that differ in terms of equipment, mechanism of action, focus, and patient and clinician procedures, it is important to note that this study used a novel technologically advanced form of NFB, referred to as infra-low frequency (ILF) NFB. It works by reflecting a person’s brain wave activity via conventional electroencephalography back to the person through the visual cortex, thus providing relevant information to which the brain responds to improve core state regulation.²²

In 2006, ILF NFB developers sought to extend NFB capability into the slow cortical potential domain (< 0.1 Hz) and then gradually extended to lower frequencies on the basis of favorable clinical responses.^22,23 In 2017, the technology reached an ILF capacity that appeared to be helpful for several clinical issues. These developments depended on instrumentation capable of low noise signal detection down to the lowest frequency of interest. Instrumentation was developed for the purpose (eg, Bee Medic Cygnet NFB).

Although mTBI has been a clinical focus in NFB since the 1980s, there are few published studies demonstrating the efficacy of ILF NFB relating to the PCSs of interest in this study, and 2 suggested ILF NFB positively affected change in PCS severity.^24,25 Other studies found that ILF NFB decreased incidence of migraines and tension type headaches.^26,27 However, the findings of these studies had limited generalizability due to methodologic limitations, such as selection bias and small sample sizes.^24-27 Of importance to this article, there are also several publications on the efficacy of ILF NFB in clinical settings.^28-33

This article presents the second analysis of data from veterans who completed ILF NFB intervention and control group procedures during a 5-year randomized controlled trial (RCT). The RCT included veterans who experienced an mTBI while participating in post-9/11 military operations to evaluate the impact of ILF NFB on chronic PCSs, including headache, insomnia, and attention dysfunction. Initial results of this trial demonstrated significant differences between the intervention and control groups with strong effect sizes on all outcome measures at the end of treatment.³⁴

Methods

Participants included male and nonpregnant female veterans with a diagnosed mTBI during post-9/11 military operations; aged 18 to 65 years; reports of persistent (ie, > 3 months in duration) headaches, insomnia, and attention difficulties; and able to read and write English, comprehend what is read, and follow directions. mTBI diagnosis was verified for each veteran via the electronic health record. Patients were excluded if they had a severe TBI diagnosis or impaired decision-making capacity; were unable to comply with study visit schedule; or endorsed active suicidal intent on the Columbia-Suicide Severity Rating Scale.³⁵

Recruitment efforts included: (1) letters sent to eligible veterans with mTBI who were identified by clinical informatics data after waiver of Health Insurance Portability and Accountability Act was obtained; veterans could contact the research team directly or the research team would call the veteran 2 weeks after the letter was sent; (2) veterans could be referred by a clinician; and (3) veterans could self-refer based on flyers and other study marketing materials.

The study was conducted from 2019 to 2024 at Spark M. Matsunaga VA Medical Center, in Honolulu, Hawaii. Four private research spaces in compliance with human research standards were used for consent, treatment, and assessment.

Consenting Procedure and Randomization

The privacy rights of potential participants were observed, and interested veterans who met the eligibility criteria underwent an informed consent procedure and were administered the Columbia-Suicide Severity Rating Scale.³⁵ Those veterans not indicating active suicidal intent were randomized into the intervention or control group. Once randomized, the participant was enrolled and scheduled for baseline assessment.

All procedures of this study were performed in adherence with relevant laws and institutional guidelines. The study was reviewed and approved by the VA Pacific Islands Health Care System Institutional Review Board (#2019-06-JC/Promise 0003).

Outcome Measures

The outcome measures were administered at baseline, midpoint (3-7 weeks), end of treatment (6-12 weeks), and at a 2-month follow-up appointment with the research assistant or project coordinator.

The primary outcome measures include the Headache Impact Test (HIT-6), TBIQOL Headache Pain item short form, Insomnia Severity Index (ISI), Quality of Life in Neurological Disorders (Neuro-QOL) Sleep Disturbance short form, and attention measure: QIKtest Continuous Performance Test (QIKtest) (Table 1).^36-44

Secondary outcome measures included QOL After Brain Injury (QOLIBRI), Neuro- QOL Satisfaction With Roles/Activities short form (Neuro-QOL Satisfaction), Neuro-QOL Ability to Participate in Roles/Activities short form (Neuro-QOL Participate), Depression Anxiety Stress Scales (DASS-21), Patient Health Questionnaire-9 (PHQ-9), Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5), and the General Symptom Inventory (eAppendix 1).^39,42,45-52

Sample

Seventy-two participants (36 in each group) were needed to have adequate statistical power for the analysis. Presuming attrition, the goal was to recruit 100 veterans. Literature on NFB studies of patients with mTBI have reported dropout rates ranging from 10% to 30%.^53,54 Assuming a dropout rate of 28% and a moderate autocorrelation of 0.6 among repeated measures, this sample size ensured the detection of an average difference of at least 0.49 SDs with a power of 80% in the NFB intervention group compared with the control group using a 2-tailed significance level of 0.05.

Control Group

Following baseline assessment, control group participants received 8 phone calls (1 call/wk) from 1 of 4 clinical investigators over 8 to 10 weeks. During each 15-minute call, 1 of the following health topics was discussed: sleep hygiene, basic nutritional concepts, beverage choices, positive thinking, thought reframing, fitness, daily calming activity, and enhancement of focus strategies. A script for each topic was used to guide each call.

Intervention Group

Following baseline assessment, intervention group participants completed 20 half-hour ILF NFB sessions, typically receiving 3 sessions per week over an 8- to 10-week period. ILF NFB treatments were administered by 1 of 4 licensed health care employees who had received substantial ILF NFB training and achieved a skill reliability index score of 0.95, ensuring the skill level of the ILF NFB providers was equal. A script was used by the ILF NFB providers during the ILF NFB sessions to keep the interaction approach consistent with all participants.

All procedures were explained in advance to participants and voluntary participation affirmed. At the first session, participants filled out a clinical symptom checklist of 5 symptoms (eAppendix 1).^39,42,45-49 The initial rating on the symptom checklist was reflective of their experience over the past month, while in each subsequent session, participants indicated their experience of those symptoms that day. ILF NFB providers were never privy to participants’ primary or secondary outcome measures data during the study, so these recurring clinical symptom checklist ratings, as well as other feedback provided by participants on their experience within and between sessions, were the clinical data used to make decisions about ILF NFB treatment protocol.

The Othmer Optimal Response Frequency (ORF) protocol was used for participants in this study.⁵⁵ Through an iterative process, ORF protocol establishes the specific frequency point along the 0.000001 mHz to 0.1 Hz continuum, which is optimal to diminish symptoms experienced in real-time during the session (eg, tension or pain in shoulders; racing thoughts).

During each ILF NFB session, participants were seated comfortably and encouraged to look at the feedback screen. The moving images on the game screen provided almost instantaneous feedback (within 500 ms) to participants about their brain functioning, as ascertained by electrodes placed on the scalp as dictated by study protocol.⁵⁶ A standardized protocol for site placement was used beginning with T3-T4, followed by the weekly addition of a site as tolerated in the following sequence: T4-P4, FP2-T4, and FP1-T4. More information about the ILF NFB procedures are outlined in the report of the pilot study and RCT initial results.^22,34

Statistical Analysis

Eighty-seven participants were randomized, with 43 assigned to the intervention group and 44 to the control group to achieve the enrollment goal of ≥ 36 participants in each group. This report is the second analysis of data from this RCT that employed a per-protocol approach, analyzing a subset of participants who fully adhered to the study protocol and completed all study procedures. Outcome scores at baseline, midpoint, end of treatment, and 2-month follow-up were summarized as means with corresponding 95% CIs. Group comparisons at the end of treatment and 2-month follow-up time points were conducted using 2-sample t tests. All statistical tests were 2-sided with a significance level of .05 (Type I error rate). SAS software version 9.4 Maintenance 8 was used for statistical analysis. Cohen d analyses were used for effect sizes.

Results

Seventy-four participants fully adhered to the study protocol and were included in the present analyses, with 38 in the control group and 36 in the intervention group. eAppendix 2 depicts the flow of participants through this study. There were no adverse events related to treatment, and the 13 participants who withdrew typically reported difficulty with scheduling or transportation as the primary reason. This study also took place during the COVID-19 pandemic, which likely had some impact on enrollment; participants were differentially impacted by changes in employment and moves to the continental United States.

Participants were aged 30 to 60 years (mean [SD], 45.4 [8.0]). Most participants (90.5%) were male, and multiracial and White were the most common racial identities (Table 2). Participant characteristics were largely balanced across randomized groups. Similarly, test scores on the primary variables of interest in this study and secondary clinical variables assessed were comparable across participants (Table 3).

Primary Variables of Interest Analyses

This study’s hypothesis was that those who completed ILF NFB treatment per protocol would demonstrate statistically significant improvement in symptoms related to headaches, sleep disturbance, and difficulty with attention when compared with veterans in the control group. This hypothesis was partially supported. A 2-sample t test showed that veterans in the intervention group demonstrated significant improvement in headache symptoms compared with veterans in the control group on the HIT-6 at the end-of-treatment (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 1.14). This pattern also was consistent with the TBI-QOL Headache Pain item short form, with veterans in the intervention group showing improvement beyond those in the control group at the end-of-treatment (P < .001, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.83). Two-sample t tests also demonstrated significant improvement in subjective reports of sleep; those in the intervention group had significantly lower scores on the ISI at the end-of-study (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 0.97). This pattern also held true for the Neuro-QOL Sleep Disturbance short form subtest, which demonstrated significantly more improvement in the intervention group compared with the control group at the end-of-study (P < .001, d = 0.97) and 2-month follow- up assessment (P < .001, d = 0.92). improvement in attention was not supported by the present results. A 2-sample t test found no significant difference between performance on the QIKtest for veterans in the intervention group vs the control group at the end-of-study (P = .40, d = 0.19) or the 2-month follow-up (P = .43, d = 0.20) (eAppendix 3).

Secondary Variables of Interest Analysis

Secondary variables examined differences in QOL, PTSD, depressive symptoms, and general symptoms reported between veterans in the intervention and control groups. Results demonstrated that veterans in the intervention group showed improvement above and beyond those in the control group on all measures. In regard to QOL, veterans in the intervention group had significantly higher scores on the Neuro-QOL Participate subtest than those in the control group at the end-of-study (P = .01, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.62). A similar pattern was found for the Neuro-QOL Satisfaction subtest, with veterans in the intervention group showing significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.95) and 2-month follow-up assessment (P < .001, d = 0.62). This also held true on the QOLIBRI, with veterans in the intervention group demonstrating significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.92) and 2-month follow-up assessment (P < .001, d = 0.66).

Veterans in the intervention group had significantly lower scores on the PCL-5 than those in the control group at the end-of- study (P = .003, d = 0.78) and 2-month follow-up assessment (P = .001, d = 0.72). Veterans in the intervention group also had significantly lower scores on the PHQ-9 than those in the control group at the end-of-study (P < .001, d = 0.98) and 2-month follow-up assessment (P < .001, d = 0.83). Veterans in the intervention group had significantly lower scores on the DASS- 21 than those in the control group at the end-of-study (P = .002, d = 0.80) and 2-month follow-up assessment (P = .001, d = 0.77). They also had significantly lower scores on the General Symptom Inventory than those in the control group at the end-of-study (P = .02, d = 0.75) and 2-month follow-up assessment (P = .002, d = 0.57). A clinically significant shift of score occurred for each of the measures except DASS-21 (eAppendix 3). eAppendix 4 depicts the change in scores for the intervention group at the end of treatment and the clinically significant shift score of each measure.

Discussion

The results of this RCT revealed a promising impact of ILF NFB on the commonly experienced persistent PCSs of headaches and disrupted sleep. Veterans in the intervention group demonstrated statistically significant improvement in headache symptoms compared with veterans in the control group when assessed at the end of treatment and during a 2-month follow-up. The statistical significance of these improvements was also supported by large or very large effect sizes. In addition to these primary variables of interest, veterans in the intervention group notably demonstrated significant improvement compared with those in the control group in a number of secondary clinical measures, including QOL, traumatic stress-related symptoms, depressive symptoms, and general symptom report. The clinical impact was further supported by the clinically relevant shift in scores in the intervention group.

The data did not support the hypothesis that attention concerns would show significant improvement following ILF NFB. Performance on an attention measure did not differ significantly between groups at either the end-of-treatment or 2-month follow up assessment. The QIKtest, a continuous performance test used to measure attention, was a go/no-go task and calculated based on a combination of various types of errors and outlier responses. The stimulus for this task is a series of computerized, blinking lights, for which participants are tasked with discriminating targets and nontargets under time pressure. However, the order of the stimuli are consistent across administrations, rather than being randomized, introducing a potential confound of practice effects on this task since patients were administered the QIKtest 3 times in a 2-month period and again 2 months later. Veterans in the control group notably improved in their average performance of this task from baseline to the endpoint of their treatment participation and demonstrated further improvement at the 2-month follow-up assessment; this pattern would be consistent with potential practice effects and warrants caution in its interpretation for both groups.

Previously published ILF NFB clinical studies that used the QIKtest and found positive results were mostly conducted among children and teen populations across longer treatment periods. This research may indicate the QIKtest is not an appropriate measure to assess adults who have specialized training in responding to stimuli (ie, trained military personnel). This suggests the concept of attention dysfunction experienced by veterans and the best method to measure it may need to be explored further. This construct may not be related to the focus and skill in prolonged attention needed in selecting go/ no-go tasks, but rather related to a broader conceptual basis involving memory, recall, clarity of rational thought, and decision making impacted by the mTBI. For instance, a study among combat veterans with mTBI and PTSD found that performance on objective cognitive measures did not significantly correlate with their subjective reports of cognitive difficulties.⁵⁷ This reflects the pattern of the present study, in which subjective reports of attention improved over time on the clinical symptom checklist filled out by participants at each session, but the objective measure did not. The mean attention dysfunction score was 6 at session 1 and 1 to 2 at session 20 (lower scores are better on a 10-point scale).

Strengths and Limitations

This study presents results stemming from the first RCT examining clinical effectiveness of ILF NFB in a VA setting for veterans with diagnoses of mTBI. The study design shows promising external validity. Veterans were able to participate in a treatment consisting of 20 sessions over a period of typically 8 to 10 weeks, entailing 2 to 3 sessions per week, with an attrition of only 18% over the course of the study. Notably, attrition rates may have been impacted by the time course of the study, which was recruiting and running participants throughout the COVID-19 pandemic (March 2020 to May 2023). No attrition was due to the intervention itself, and no adverse reactions to ILF NFB were reported during the course of the study. Other strengths of the study include the ethnically and racially diverse participants, representative of the population of veterans in Hawaii. Additionally, all ILF NFB providers underwent supervised ILF NFB training and achieved a skill reliability index score of 0.95 prior to providing ILF NFB to the intervention group.

This study was not blinded. Neither veterans nor ILF NFB providers were blinded and were therefore aware of the randomly assigned groups. Research assistants administering the periodic assessments were meant to be blinded to condition by design; however, as the study progressed, a research assistant became unintentionally aware of each study participant's condition based on required documentation in the veteran’s health records; more notes were present for those in the intervention group (20 specialist notes) than the control group (8 notes). While the presence of a control group represents a strength relative to much of the existing ILF NFB literature, the control group in this case did not account for the total time spent with the researchers. Participants in the intervention group met with researchers for 20 total sessions as opposed to 8 telephone calls. Therefore, the study design cannot fully rule out the differential impact of demand characteristics between the 2 groups, nor can it fully address or rule out the impact of differential motivation and expectations between groups. There is also evidence that technological innovation can influence the expectations of research participants, meaning that the intervention group may have been unduly influenced by the novelty of the ILF NFB technology, to which the control group did not have exposure.⁵⁸

A second attention measure for this study would have been beneficial, perhaps in identifying true change in attention ability or providing more insight into finding better methods to assess attention among veterans with mTBI. ILF NFB demonstrated significant impact across multiple outcome measures of clinical relevance for veterans diagnosed with mTBI, including the primary outcome variables of headache and sleep. The strength of the improvements seen in these areas, supported by large practical effects as well as veterans’ subjective reports, indicates much promise. Follow-up studies may also focus on the potential effectiveness of ILF NFB as a treatment of the secondary concerns measured in this study, including traumatic stress-related and depressive symptoms, and may explore the added benefit, if any, of ILF NFB alongside other evidence-based treatments for traumatic stress-related and mood disorders (eg, cognitive behavioral therapy). Using functional magnetic resonance imaging before and after assessments to determine actual brain enhancement with ILF NFB for certain disorders in which a brain signature exists (ie, migraine) should be explored. Further examination of ILF NFB as an intervention for attention may also be warranted, using more effective measures of attention in the population of veterans with mTBI, given the concerns noted earlier. Future research on this topic will need to clearly define attention in relation to the veteran experience and use relevant measures.

Conclusions

This study supports ILF NFB as a safe, noninvasive, nonpharmacologic treatment that may be effective in addressing the complex clinical concerns of veterans diagnosed with mTBI, a population for whom effective treatments have been difficult to identify. This intervention can provide veterans with a desirable and effective nonpharmacologic alternative in their care.

Traumatic brain injury (TBI) is the signature injury of post-9/11 military operations, impacting > 441,000 combat veterans from 2001 to 2021 and 87% diagnosed with mild TBI (mTBI).^1,2 The most common cause of mTBI during these operations was blast exposures stemming from improvised explosive devices, rocket-propelled grenades, or land mines. mTBI was once thought to be self-limiting, lasting hours or days postinjury, but is now recognized as a complex focal and diffuse injury causing a cascade of molecular and biochemical responses with significant physiologic effects lasting for a longer duration. A significant number of combat veterans with mTBI (23%-48%) experience long-standing postconcussive symptoms (PCSs) for many years postinjury.^3-5

Developing and implementing strategies to reduce persistent symptoms associated with mTBI is of critical importance. Veterans diagnosed with mTBI and experiencing PCSs present ongoing treatment challenges to the health care system due to limited or suboptimal treatment options.^6,7 According to the 2021 US Department of Veterans Affairs (VA) and US Department of Defense (DoD) clinical guidelines for postacute mTBI, treatment for PCSs should be symptom focused. ^8,9 For instance, veterans with migraine headaches associated with mTBIs are often treated with abortive agents (eg, triptans) and preventive medications (eg, anticonvulsants and tricyclics).¹⁰ Cognitive dysfunction and insomnia are treated with cognitive rehabilitation programs, cognitive behaviorial therapy, occupational therapy, and medications (eg, hypnotics for insomnia).^11,12 The 2021 VA/DoD guidelines note that veteran and military focus groups described greater success with nonpharmacologic treatments than with pharmacologic treatments.⁸ The VA launched an enterprise-wide Whole Health Service program with the requirement that complementary and integrative health approaches must be available to veterans.¹³ As a nonpharmacologic, integrative, and noninvasive modality, neurofeedback (NFB) supports the VA Whole Health initiative and veterans’ preferences for integrative treatments.¹⁴

Neurofeedback

Rather than a symptom management approach, Defina et al described the possibilities of brain repair in TBI by treatments to enhance neuroplasticity, thereby establishing a more normalized or stable brain environment and enabling the brain to reorganize itself and function more normally.¹⁵ NFB has been shown to influence neuroplasticity,¹⁶ as evident in microstructural changes in white and gray matter¹⁷ and its ability to contribute to functional rehabilitation by restoring connectivity in specific areas of the brain that may have been impaired.¹⁸ The benefits of neuroenhancement strategies include potentially reduced pain for patients with mTBI and improved quality of life (QOL).¹⁹

NFB assists individuals by helping them become more aware of and self-regulate their physiology.^20,21 Because there are several types of NFB (eg, quantitative electroencephalography, Z-scored, α-θ) that differ in terms of equipment, mechanism of action, focus, and patient and clinician procedures, it is important to note that this study used a novel technologically advanced form of NFB, referred to as infra-low frequency (ILF) NFB. It works by reflecting a person’s brain wave activity via conventional electroencephalography back to the person through the visual cortex, thus providing relevant information to which the brain responds to improve core state regulation.²²

In 2006, ILF NFB developers sought to extend NFB capability into the slow cortical potential domain (< 0.1 Hz) and then gradually extended to lower frequencies on the basis of favorable clinical responses.^22,23 In 2017, the technology reached an ILF capacity that appeared to be helpful for several clinical issues. These developments depended on instrumentation capable of low noise signal detection down to the lowest frequency of interest. Instrumentation was developed for the purpose (eg, Bee Medic Cygnet NFB).

Although mTBI has been a clinical focus in NFB since the 1980s, there are few published studies demonstrating the efficacy of ILF NFB relating to the PCSs of interest in this study, and 2 suggested ILF NFB positively affected change in PCS severity.^24,25 Other studies found that ILF NFB decreased incidence of migraines and tension type headaches.^26,27 However, the findings of these studies had limited generalizability due to methodologic limitations, such as selection bias and small sample sizes.^24-27 Of importance to this article, there are also several publications on the efficacy of ILF NFB in clinical settings.^28-33

This article presents the second analysis of data from veterans who completed ILF NFB intervention and control group procedures during a 5-year randomized controlled trial (RCT). The RCT included veterans who experienced an mTBI while participating in post-9/11 military operations to evaluate the impact of ILF NFB on chronic PCSs, including headache, insomnia, and attention dysfunction. Initial results of this trial demonstrated significant differences between the intervention and control groups with strong effect sizes on all outcome measures at the end of treatment.³⁴

Methods

Participants included male and nonpregnant female veterans with a diagnosed mTBI during post-9/11 military operations; aged 18 to 65 years; reports of persistent (ie, > 3 months in duration) headaches, insomnia, and attention difficulties; and able to read and write English, comprehend what is read, and follow directions. mTBI diagnosis was verified for each veteran via the electronic health record. Patients were excluded if they had a severe TBI diagnosis or impaired decision-making capacity; were unable to comply with study visit schedule; or endorsed active suicidal intent on the Columbia-Suicide Severity Rating Scale.³⁵

Recruitment efforts included: (1) letters sent to eligible veterans with mTBI who were identified by clinical informatics data after waiver of Health Insurance Portability and Accountability Act was obtained; veterans could contact the research team directly or the research team would call the veteran 2 weeks after the letter was sent; (2) veterans could be referred by a clinician; and (3) veterans could self-refer based on flyers and other study marketing materials.

The study was conducted from 2019 to 2024 at Spark M. Matsunaga VA Medical Center, in Honolulu, Hawaii. Four private research spaces in compliance with human research standards were used for consent, treatment, and assessment.

Consenting Procedure and Randomization

The privacy rights of potential participants were observed, and interested veterans who met the eligibility criteria underwent an informed consent procedure and were administered the Columbia-Suicide Severity Rating Scale.³⁵ Those veterans not indicating active suicidal intent were randomized into the intervention or control group. Once randomized, the participant was enrolled and scheduled for baseline assessment.

All procedures of this study were performed in adherence with relevant laws and institutional guidelines. The study was reviewed and approved by the VA Pacific Islands Health Care System Institutional Review Board (#2019-06-JC/Promise 0003).

Outcome Measures

The outcome measures were administered at baseline, midpoint (3-7 weeks), end of treatment (6-12 weeks), and at a 2-month follow-up appointment with the research assistant or project coordinator.

The primary outcome measures include the Headache Impact Test (HIT-6), TBIQOL Headache Pain item short form, Insomnia Severity Index (ISI), Quality of Life in Neurological Disorders (Neuro-QOL) Sleep Disturbance short form, and attention measure: QIKtest Continuous Performance Test (QIKtest) (Table 1).^36-44

Secondary outcome measures included QOL After Brain Injury (QOLIBRI), Neuro- QOL Satisfaction With Roles/Activities short form (Neuro-QOL Satisfaction), Neuro-QOL Ability to Participate in Roles/Activities short form (Neuro-QOL Participate), Depression Anxiety Stress Scales (DASS-21), Patient Health Questionnaire-9 (PHQ-9), Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5), and the General Symptom Inventory (eAppendix 1).^39,42,45-52

Sample

Seventy-two participants (36 in each group) were needed to have adequate statistical power for the analysis. Presuming attrition, the goal was to recruit 100 veterans. Literature on NFB studies of patients with mTBI have reported dropout rates ranging from 10% to 30%.^53,54 Assuming a dropout rate of 28% and a moderate autocorrelation of 0.6 among repeated measures, this sample size ensured the detection of an average difference of at least 0.49 SDs with a power of 80% in the NFB intervention group compared with the control group using a 2-tailed significance level of 0.05.

Control Group

Following baseline assessment, control group participants received 8 phone calls (1 call/wk) from 1 of 4 clinical investigators over 8 to 10 weeks. During each 15-minute call, 1 of the following health topics was discussed: sleep hygiene, basic nutritional concepts, beverage choices, positive thinking, thought reframing, fitness, daily calming activity, and enhancement of focus strategies. A script for each topic was used to guide each call.

Intervention Group

Following baseline assessment, intervention group participants completed 20 half-hour ILF NFB sessions, typically receiving 3 sessions per week over an 8- to 10-week period. ILF NFB treatments were administered by 1 of 4 licensed health care employees who had received substantial ILF NFB training and achieved a skill reliability index score of 0.95, ensuring the skill level of the ILF NFB providers was equal. A script was used by the ILF NFB providers during the ILF NFB sessions to keep the interaction approach consistent with all participants.

All procedures were explained in advance to participants and voluntary participation affirmed. At the first session, participants filled out a clinical symptom checklist of 5 symptoms (eAppendix 1).^39,42,45-49 The initial rating on the symptom checklist was reflective of their experience over the past month, while in each subsequent session, participants indicated their experience of those symptoms that day. ILF NFB providers were never privy to participants’ primary or secondary outcome measures data during the study, so these recurring clinical symptom checklist ratings, as well as other feedback provided by participants on their experience within and between sessions, were the clinical data used to make decisions about ILF NFB treatment protocol.

The Othmer Optimal Response Frequency (ORF) protocol was used for participants in this study.⁵⁵ Through an iterative process, ORF protocol establishes the specific frequency point along the 0.000001 mHz to 0.1 Hz continuum, which is optimal to diminish symptoms experienced in real-time during the session (eg, tension or pain in shoulders; racing thoughts).

During each ILF NFB session, participants were seated comfortably and encouraged to look at the feedback screen. The moving images on the game screen provided almost instantaneous feedback (within 500 ms) to participants about their brain functioning, as ascertained by electrodes placed on the scalp as dictated by study protocol.⁵⁶ A standardized protocol for site placement was used beginning with T3-T4, followed by the weekly addition of a site as tolerated in the following sequence: T4-P4, FP2-T4, and FP1-T4. More information about the ILF NFB procedures are outlined in the report of the pilot study and RCT initial results.^22,34

Statistical Analysis

Eighty-seven participants were randomized, with 43 assigned to the intervention group and 44 to the control group to achieve the enrollment goal of ≥ 36 participants in each group. This report is the second analysis of data from this RCT that employed a per-protocol approach, analyzing a subset of participants who fully adhered to the study protocol and completed all study procedures. Outcome scores at baseline, midpoint, end of treatment, and 2-month follow-up were summarized as means with corresponding 95% CIs. Group comparisons at the end of treatment and 2-month follow-up time points were conducted using 2-sample t tests. All statistical tests were 2-sided with a significance level of .05 (Type I error rate). SAS software version 9.4 Maintenance 8 was used for statistical analysis. Cohen d analyses were used for effect sizes.

Results

Seventy-four participants fully adhered to the study protocol and were included in the present analyses, with 38 in the control group and 36 in the intervention group. eAppendix 2 depicts the flow of participants through this study. There were no adverse events related to treatment, and the 13 participants who withdrew typically reported difficulty with scheduling or transportation as the primary reason. This study also took place during the COVID-19 pandemic, which likely had some impact on enrollment; participants were differentially impacted by changes in employment and moves to the continental United States.

Participants were aged 30 to 60 years (mean [SD], 45.4 [8.0]). Most participants (90.5%) were male, and multiracial and White were the most common racial identities (Table 2). Participant characteristics were largely balanced across randomized groups. Similarly, test scores on the primary variables of interest in this study and secondary clinical variables assessed were comparable across participants (Table 3).

Primary Variables of Interest Analyses

This study’s hypothesis was that those who completed ILF NFB treatment per protocol would demonstrate statistically significant improvement in symptoms related to headaches, sleep disturbance, and difficulty with attention when compared with veterans in the control group. This hypothesis was partially supported. A 2-sample t test showed that veterans in the intervention group demonstrated significant improvement in headache symptoms compared with veterans in the control group on the HIT-6 at the end-of-treatment (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 1.14). This pattern also was consistent with the TBI-QOL Headache Pain item short form, with veterans in the intervention group showing improvement beyond those in the control group at the end-of-treatment (P < .001, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.83). Two-sample t tests also demonstrated significant improvement in subjective reports of sleep; those in the intervention group had significantly lower scores on the ISI at the end-of-study (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 0.97). This pattern also held true for the Neuro-QOL Sleep Disturbance short form subtest, which demonstrated significantly more improvement in the intervention group compared with the control group at the end-of-study (P < .001, d = 0.97) and 2-month follow- up assessment (P < .001, d = 0.92). improvement in attention was not supported by the present results. A 2-sample t test found no significant difference between performance on the QIKtest for veterans in the intervention group vs the control group at the end-of-study (P = .40, d = 0.19) or the 2-month follow-up (P = .43, d = 0.20) (eAppendix 3).

Secondary Variables of Interest Analysis

Secondary variables examined differences in QOL, PTSD, depressive symptoms, and general symptoms reported between veterans in the intervention and control groups. Results demonstrated that veterans in the intervention group showed improvement above and beyond those in the control group on all measures. In regard to QOL, veterans in the intervention group had significantly higher scores on the Neuro-QOL Participate subtest than those in the control group at the end-of-study (P = .01, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.62). A similar pattern was found for the Neuro-QOL Satisfaction subtest, with veterans in the intervention group showing significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.95) and 2-month follow-up assessment (P < .001, d = 0.62). This also held true on the QOLIBRI, with veterans in the intervention group demonstrating significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.92) and 2-month follow-up assessment (P < .001, d = 0.66).

Veterans in the intervention group had significantly lower scores on the PCL-5 than those in the control group at the end-of- study (P = .003, d = 0.78) and 2-month follow-up assessment (P = .001, d = 0.72). Veterans in the intervention group also had significantly lower scores on the PHQ-9 than those in the control group at the end-of-study (P < .001, d = 0.98) and 2-month follow-up assessment (P < .001, d = 0.83). Veterans in the intervention group had significantly lower scores on the DASS- 21 than those in the control group at the end-of-study (P = .002, d = 0.80) and 2-month follow-up assessment (P = .001, d = 0.77). They also had significantly lower scores on the General Symptom Inventory than those in the control group at the end-of-study (P = .02, d = 0.75) and 2-month follow-up assessment (P = .002, d = 0.57). A clinically significant shift of score occurred for each of the measures except DASS-21 (eAppendix 3). eAppendix 4 depicts the change in scores for the intervention group at the end of treatment and the clinically significant shift score of each measure.

Discussion

The results of this RCT revealed a promising impact of ILF NFB on the commonly experienced persistent PCSs of headaches and disrupted sleep. Veterans in the intervention group demonstrated statistically significant improvement in headache symptoms compared with veterans in the control group when assessed at the end of treatment and during a 2-month follow-up. The statistical significance of these improvements was also supported by large or very large effect sizes. In addition to these primary variables of interest, veterans in the intervention group notably demonstrated significant improvement compared with those in the control group in a number of secondary clinical measures, including QOL, traumatic stress-related symptoms, depressive symptoms, and general symptom report. The clinical impact was further supported by the clinically relevant shift in scores in the intervention group.

The data did not support the hypothesis that attention concerns would show significant improvement following ILF NFB. Performance on an attention measure did not differ significantly between groups at either the end-of-treatment or 2-month follow up assessment. The QIKtest, a continuous performance test used to measure attention, was a go/no-go task and calculated based on a combination of various types of errors and outlier responses. The stimulus for this task is a series of computerized, blinking lights, for which participants are tasked with discriminating targets and nontargets under time pressure. However, the order of the stimuli are consistent across administrations, rather than being randomized, introducing a potential confound of practice effects on this task since patients were administered the QIKtest 3 times in a 2-month period and again 2 months later. Veterans in the control group notably improved in their average performance of this task from baseline to the endpoint of their treatment participation and demonstrated further improvement at the 2-month follow-up assessment; this pattern would be consistent with potential practice effects and warrants caution in its interpretation for both groups.

Previously published ILF NFB clinical studies that used the QIKtest and found positive results were mostly conducted among children and teen populations across longer treatment periods. This research may indicate the QIKtest is not an appropriate measure to assess adults who have specialized training in responding to stimuli (ie, trained military personnel). This suggests the concept of attention dysfunction experienced by veterans and the best method to measure it may need to be explored further. This construct may not be related to the focus and skill in prolonged attention needed in selecting go/ no-go tasks, but rather related to a broader conceptual basis involving memory, recall, clarity of rational thought, and decision making impacted by the mTBI. For instance, a study among combat veterans with mTBI and PTSD found that performance on objective cognitive measures did not significantly correlate with their subjective reports of cognitive difficulties.⁵⁷ This reflects the pattern of the present study, in which subjective reports of attention improved over time on the clinical symptom checklist filled out by participants at each session, but the objective measure did not. The mean attention dysfunction score was 6 at session 1 and 1 to 2 at session 20 (lower scores are better on a 10-point scale).

Strengths and Limitations

This study presents results stemming from the first RCT examining clinical effectiveness of ILF NFB in a VA setting for veterans with diagnoses of mTBI. The study design shows promising external validity. Veterans were able to participate in a treatment consisting of 20 sessions over a period of typically 8 to 10 weeks, entailing 2 to 3 sessions per week, with an attrition of only 18% over the course of the study. Notably, attrition rates may have been impacted by the time course of the study, which was recruiting and running participants throughout the COVID-19 pandemic (March 2020 to May 2023). No attrition was due to the intervention itself, and no adverse reactions to ILF NFB were reported during the course of the study. Other strengths of the study include the ethnically and racially diverse participants, representative of the population of veterans in Hawaii. Additionally, all ILF NFB providers underwent supervised ILF NFB training and achieved a skill reliability index score of 0.95 prior to providing ILF NFB to the intervention group.

This study was not blinded. Neither veterans nor ILF NFB providers were blinded and were therefore aware of the randomly assigned groups. Research assistants administering the periodic assessments were meant to be blinded to condition by design; however, as the study progressed, a research assistant became unintentionally aware of each study participant's condition based on required documentation in the veteran’s health records; more notes were present for those in the intervention group (20 specialist notes) than the control group (8 notes). While the presence of a control group represents a strength relative to much of the existing ILF NFB literature, the control group in this case did not account for the total time spent with the researchers. Participants in the intervention group met with researchers for 20 total sessions as opposed to 8 telephone calls. Therefore, the study design cannot fully rule out the differential impact of demand characteristics between the 2 groups, nor can it fully address or rule out the impact of differential motivation and expectations between groups. There is also evidence that technological innovation can influence the expectations of research participants, meaning that the intervention group may have been unduly influenced by the novelty of the ILF NFB technology, to which the control group did not have exposure.⁵⁸

A second attention measure for this study would have been beneficial, perhaps in identifying true change in attention ability or providing more insight into finding better methods to assess attention among veterans with mTBI. ILF NFB demonstrated significant impact across multiple outcome measures of clinical relevance for veterans diagnosed with mTBI, including the primary outcome variables of headache and sleep. The strength of the improvements seen in these areas, supported by large practical effects as well as veterans’ subjective reports, indicates much promise. Follow-up studies may also focus on the potential effectiveness of ILF NFB as a treatment of the secondary concerns measured in this study, including traumatic stress-related and depressive symptoms, and may explore the added benefit, if any, of ILF NFB alongside other evidence-based treatments for traumatic stress-related and mood disorders (eg, cognitive behavioral therapy). Using functional magnetic resonance imaging before and after assessments to determine actual brain enhancement with ILF NFB for certain disorders in which a brain signature exists (ie, migraine) should be explored. Further examination of ILF NFB as an intervention for attention may also be warranted, using more effective measures of attention in the population of veterans with mTBI, given the concerns noted earlier. Future research on this topic will need to clearly define attention in relation to the veteran experience and use relevant measures.

Conclusions

This study supports ILF NFB as a safe, noninvasive, nonpharmacologic treatment that may be effective in addressing the complex clinical concerns of veterans diagnosed with mTBI, a population for whom effective treatments have been difficult to identify. This intervention can provide veterans with a desirable and effective nonpharmacologic alternative in their care.

Traumatic brain injury (TBI) is the signature injury of post-9/11 military operations, impacting > 441,000 combat veterans from 2001 to 2021 and 87% diagnosed with mild TBI (mTBI).^1,2 The most common cause of mTBI during these operations was blast exposures stemming from improvised explosive devices, rocket-propelled grenades, or land mines. mTBI was once thought to be self-limiting, lasting hours or days postinjury, but is now recognized as a complex focal and diffuse injury causing a cascade of molecular and biochemical responses with significant physiologic effects lasting for a longer duration. A significant number of combat veterans with mTBI (23%-48%) experience long-standing postconcussive symptoms (PCSs) for many years postinjury.^3-5

Developing and implementing strategies to reduce persistent symptoms associated with mTBI is of critical importance. Veterans diagnosed with mTBI and experiencing PCSs present ongoing treatment challenges to the health care system due to limited or suboptimal treatment options.^6,7 According to the 2021 US Department of Veterans Affairs (VA) and US Department of Defense (DoD) clinical guidelines for postacute mTBI, treatment for PCSs should be symptom focused. ^8,9 For instance, veterans with migraine headaches associated with mTBIs are often treated with abortive agents (eg, triptans) and preventive medications (eg, anticonvulsants and tricyclics).¹⁰ Cognitive dysfunction and insomnia are treated with cognitive rehabilitation programs, cognitive behaviorial therapy, occupational therapy, and medications (eg, hypnotics for insomnia).^11,12 The 2021 VA/DoD guidelines note that veteran and military focus groups described greater success with nonpharmacologic treatments than with pharmacologic treatments.⁸ The VA launched an enterprise-wide Whole Health Service program with the requirement that complementary and integrative health approaches must be available to veterans.¹³ As a nonpharmacologic, integrative, and noninvasive modality, neurofeedback (NFB) supports the VA Whole Health initiative and veterans’ preferences for integrative treatments.¹⁴

Neurofeedback

Rather than a symptom management approach, Defina et al described the possibilities of brain repair in TBI by treatments to enhance neuroplasticity, thereby establishing a more normalized or stable brain environment and enabling the brain to reorganize itself and function more normally.¹⁵ NFB has been shown to influence neuroplasticity,¹⁶ as evident in microstructural changes in white and gray matter¹⁷ and its ability to contribute to functional rehabilitation by restoring connectivity in specific areas of the brain that may have been impaired.¹⁸ The benefits of neuroenhancement strategies include potentially reduced pain for patients with mTBI and improved quality of life (QOL).¹⁹

NFB assists individuals by helping them become more aware of and self-regulate their physiology.^20,21 Because there are several types of NFB (eg, quantitative electroencephalography, Z-scored, α-θ) that differ in terms of equipment, mechanism of action, focus, and patient and clinician procedures, it is important to note that this study used a novel technologically advanced form of NFB, referred to as infra-low frequency (ILF) NFB. It works by reflecting a person’s brain wave activity via conventional electroencephalography back to the person through the visual cortex, thus providing relevant information to which the brain responds to improve core state regulation.²²

In 2006, ILF NFB developers sought to extend NFB capability into the slow cortical potential domain (< 0.1 Hz) and then gradually extended to lower frequencies on the basis of favorable clinical responses.^22,23 In 2017, the technology reached an ILF capacity that appeared to be helpful for several clinical issues. These developments depended on instrumentation capable of low noise signal detection down to the lowest frequency of interest. Instrumentation was developed for the purpose (eg, Bee Medic Cygnet NFB).

Although mTBI has been a clinical focus in NFB since the 1980s, there are few published studies demonstrating the efficacy of ILF NFB relating to the PCSs of interest in this study, and 2 suggested ILF NFB positively affected change in PCS severity.^24,25 Other studies found that ILF NFB decreased incidence of migraines and tension type headaches.^26,27 However, the findings of these studies had limited generalizability due to methodologic limitations, such as selection bias and small sample sizes.^24-27 Of importance to this article, there are also several publications on the efficacy of ILF NFB in clinical settings.^28-33

This article presents the second analysis of data from veterans who completed ILF NFB intervention and control group procedures during a 5-year randomized controlled trial (RCT). The RCT included veterans who experienced an mTBI while participating in post-9/11 military operations to evaluate the impact of ILF NFB on chronic PCSs, including headache, insomnia, and attention dysfunction. Initial results of this trial demonstrated significant differences between the intervention and control groups with strong effect sizes on all outcome measures at the end of treatment.³⁴

Methods

Participants included male and nonpregnant female veterans with a diagnosed mTBI during post-9/11 military operations; aged 18 to 65 years; reports of persistent (ie, > 3 months in duration) headaches, insomnia, and attention difficulties; and able to read and write English, comprehend what is read, and follow directions. mTBI diagnosis was verified for each veteran via the electronic health record. Patients were excluded if they had a severe TBI diagnosis or impaired decision-making capacity; were unable to comply with study visit schedule; or endorsed active suicidal intent on the Columbia-Suicide Severity Rating Scale.³⁵

Recruitment efforts included: (1) letters sent to eligible veterans with mTBI who were identified by clinical informatics data after waiver of Health Insurance Portability and Accountability Act was obtained; veterans could contact the research team directly or the research team would call the veteran 2 weeks after the letter was sent; (2) veterans could be referred by a clinician; and (3) veterans could self-refer based on flyers and other study marketing materials.

The study was conducted from 2019 to 2024 at Spark M. Matsunaga VA Medical Center, in Honolulu, Hawaii. Four private research spaces in compliance with human research standards were used for consent, treatment, and assessment.

Consenting Procedure and Randomization

The privacy rights of potential participants were observed, and interested veterans who met the eligibility criteria underwent an informed consent procedure and were administered the Columbia-Suicide Severity Rating Scale.³⁵ Those veterans not indicating active suicidal intent were randomized into the intervention or control group. Once randomized, the participant was enrolled and scheduled for baseline assessment.

All procedures of this study were performed in adherence with relevant laws and institutional guidelines. The study was reviewed and approved by the VA Pacific Islands Health Care System Institutional Review Board (#2019-06-JC/Promise 0003).

Outcome Measures

The outcome measures were administered at baseline, midpoint (3-7 weeks), end of treatment (6-12 weeks), and at a 2-month follow-up appointment with the research assistant or project coordinator.

The primary outcome measures include the Headache Impact Test (HIT-6), TBIQOL Headache Pain item short form, Insomnia Severity Index (ISI), Quality of Life in Neurological Disorders (Neuro-QOL) Sleep Disturbance short form, and attention measure: QIKtest Continuous Performance Test (QIKtest) (Table 1).^36-44

Secondary outcome measures included QOL After Brain Injury (QOLIBRI), Neuro- QOL Satisfaction With Roles/Activities short form (Neuro-QOL Satisfaction), Neuro-QOL Ability to Participate in Roles/Activities short form (Neuro-QOL Participate), Depression Anxiety Stress Scales (DASS-21), Patient Health Questionnaire-9 (PHQ-9), Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5), and the General Symptom Inventory (eAppendix 1).^39,42,45-52

Sample

Seventy-two participants (36 in each group) were needed to have adequate statistical power for the analysis. Presuming attrition, the goal was to recruit 100 veterans. Literature on NFB studies of patients with mTBI have reported dropout rates ranging from 10% to 30%.^53,54 Assuming a dropout rate of 28% and a moderate autocorrelation of 0.6 among repeated measures, this sample size ensured the detection of an average difference of at least 0.49 SDs with a power of 80% in the NFB intervention group compared with the control group using a 2-tailed significance level of 0.05.

Control Group

Following baseline assessment, control group participants received 8 phone calls (1 call/wk) from 1 of 4 clinical investigators over 8 to 10 weeks. During each 15-minute call, 1 of the following health topics was discussed: sleep hygiene, basic nutritional concepts, beverage choices, positive thinking, thought reframing, fitness, daily calming activity, and enhancement of focus strategies. A script for each topic was used to guide each call.

Intervention Group

Following baseline assessment, intervention group participants completed 20 half-hour ILF NFB sessions, typically receiving 3 sessions per week over an 8- to 10-week period. ILF NFB treatments were administered by 1 of 4 licensed health care employees who had received substantial ILF NFB training and achieved a skill reliability index score of 0.95, ensuring the skill level of the ILF NFB providers was equal. A script was used by the ILF NFB providers during the ILF NFB sessions to keep the interaction approach consistent with all participants.

All procedures were explained in advance to participants and voluntary participation affirmed. At the first session, participants filled out a clinical symptom checklist of 5 symptoms (eAppendix 1).^39,42,45-49 The initial rating on the symptom checklist was reflective of their experience over the past month, while in each subsequent session, participants indicated their experience of those symptoms that day. ILF NFB providers were never privy to participants’ primary or secondary outcome measures data during the study, so these recurring clinical symptom checklist ratings, as well as other feedback provided by participants on their experience within and between sessions, were the clinical data used to make decisions about ILF NFB treatment protocol.

The Othmer Optimal Response Frequency (ORF) protocol was used for participants in this study.⁵⁵ Through an iterative process, ORF protocol establishes the specific frequency point along the 0.000001 mHz to 0.1 Hz continuum, which is optimal to diminish symptoms experienced in real-time during the session (eg, tension or pain in shoulders; racing thoughts).

During each ILF NFB session, participants were seated comfortably and encouraged to look at the feedback screen. The moving images on the game screen provided almost instantaneous feedback (within 500 ms) to participants about their brain functioning, as ascertained by electrodes placed on the scalp as dictated by study protocol.⁵⁶ A standardized protocol for site placement was used beginning with T3-T4, followed by the weekly addition of a site as tolerated in the following sequence: T4-P4, FP2-T4, and FP1-T4. More information about the ILF NFB procedures are outlined in the report of the pilot study and RCT initial results.^22,34

Statistical Analysis

Eighty-seven participants were randomized, with 43 assigned to the intervention group and 44 to the control group to achieve the enrollment goal of ≥ 36 participants in each group. This report is the second analysis of data from this RCT that employed a per-protocol approach, analyzing a subset of participants who fully adhered to the study protocol and completed all study procedures. Outcome scores at baseline, midpoint, end of treatment, and 2-month follow-up were summarized as means with corresponding 95% CIs. Group comparisons at the end of treatment and 2-month follow-up time points were conducted using 2-sample t tests. All statistical tests were 2-sided with a significance level of .05 (Type I error rate). SAS software version 9.4 Maintenance 8 was used for statistical analysis. Cohen d analyses were used for effect sizes.

Results

Seventy-four participants fully adhered to the study protocol and were included in the present analyses, with 38 in the control group and 36 in the intervention group. eAppendix 2 depicts the flow of participants through this study. There were no adverse events related to treatment, and the 13 participants who withdrew typically reported difficulty with scheduling or transportation as the primary reason. This study also took place during the COVID-19 pandemic, which likely had some impact on enrollment; participants were differentially impacted by changes in employment and moves to the continental United States.

Participants were aged 30 to 60 years (mean [SD], 45.4 [8.0]). Most participants (90.5%) were male, and multiracial and White were the most common racial identities (Table 2). Participant characteristics were largely balanced across randomized groups. Similarly, test scores on the primary variables of interest in this study and secondary clinical variables assessed were comparable across participants (Table 3).

Primary Variables of Interest Analyses

This study’s hypothesis was that those who completed ILF NFB treatment per protocol would demonstrate statistically significant improvement in symptoms related to headaches, sleep disturbance, and difficulty with attention when compared with veterans in the control group. This hypothesis was partially supported. A 2-sample t test showed that veterans in the intervention group demonstrated significant improvement in headache symptoms compared with veterans in the control group on the HIT-6 at the end-of-treatment (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 1.14). This pattern also was consistent with the TBI-QOL Headache Pain item short form, with veterans in the intervention group showing improvement beyond those in the control group at the end-of-treatment (P < .001, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.83). Two-sample t tests also demonstrated significant improvement in subjective reports of sleep; those in the intervention group had significantly lower scores on the ISI at the end-of-study (P < .001, d = 1.53) and 2-month follow-up assessment (P < .001, d = 0.97). This pattern also held true for the Neuro-QOL Sleep Disturbance short form subtest, which demonstrated significantly more improvement in the intervention group compared with the control group at the end-of-study (P < .001, d = 0.97) and 2-month follow- up assessment (P < .001, d = 0.92). improvement in attention was not supported by the present results. A 2-sample t test found no significant difference between performance on the QIKtest for veterans in the intervention group vs the control group at the end-of-study (P = .40, d = 0.19) or the 2-month follow-up (P = .43, d = 0.20) (eAppendix 3).

Secondary Variables of Interest Analysis

Secondary variables examined differences in QOL, PTSD, depressive symptoms, and general symptoms reported between veterans in the intervention and control groups. Results demonstrated that veterans in the intervention group showed improvement above and beyond those in the control group on all measures. In regard to QOL, veterans in the intervention group had significantly higher scores on the Neuro-QOL Participate subtest than those in the control group at the end-of-study (P = .01, d = 0.89) and 2-month follow-up assessment (P < .001, d = 0.62). A similar pattern was found for the Neuro-QOL Satisfaction subtest, with veterans in the intervention group showing significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.95) and 2-month follow-up assessment (P < .001, d = 0.62). This also held true on the QOLIBRI, with veterans in the intervention group demonstrating significantly higher scores than those in the control group at the end-of-study (P = .001, d = 0.92) and 2-month follow-up assessment (P < .001, d = 0.66).

Veterans in the intervention group had significantly lower scores on the PCL-5 than those in the control group at the end-of- study (P = .003, d = 0.78) and 2-month follow-up assessment (P = .001, d = 0.72). Veterans in the intervention group also had significantly lower scores on the PHQ-9 than those in the control group at the end-of-study (P < .001, d = 0.98) and 2-month follow-up assessment (P < .001, d = 0.83). Veterans in the intervention group had significantly lower scores on the DASS- 21 than those in the control group at the end-of-study (P = .002, d = 0.80) and 2-month follow-up assessment (P = .001, d = 0.77). They also had significantly lower scores on the General Symptom Inventory than those in the control group at the end-of-study (P = .02, d = 0.75) and 2-month follow-up assessment (P = .002, d = 0.57). A clinically significant shift of score occurred for each of the measures except DASS-21 (eAppendix 3). eAppendix 4 depicts the change in scores for the intervention group at the end of treatment and the clinically significant shift score of each measure.

Discussion

The results of this RCT revealed a promising impact of ILF NFB on the commonly experienced persistent PCSs of headaches and disrupted sleep. Veterans in the intervention group demonstrated statistically significant improvement in headache symptoms compared with veterans in the control group when assessed at the end of treatment and during a 2-month follow-up. The statistical significance of these improvements was also supported by large or very large effect sizes. In addition to these primary variables of interest, veterans in the intervention group notably demonstrated significant improvement compared with those in the control group in a number of secondary clinical measures, including QOL, traumatic stress-related symptoms, depressive symptoms, and general symptom report. The clinical impact was further supported by the clinically relevant shift in scores in the intervention group.

The data did not support the hypothesis that attention concerns would show significant improvement following ILF NFB. Performance on an attention measure did not differ significantly between groups at either the end-of-treatment or 2-month follow up assessment. The QIKtest, a continuous performance test used to measure attention, was a go/no-go task and calculated based on a combination of various types of errors and outlier responses. The stimulus for this task is a series of computerized, blinking lights, for which participants are tasked with discriminating targets and nontargets under time pressure. However, the order of the stimuli are consistent across administrations, rather than being randomized, introducing a potential confound of practice effects on this task since patients were administered the QIKtest 3 times in a 2-month period and again 2 months later. Veterans in the control group notably improved in their average performance of this task from baseline to the endpoint of their treatment participation and demonstrated further improvement at the 2-month follow-up assessment; this pattern would be consistent with potential practice effects and warrants caution in its interpretation for both groups.

Previously published ILF NFB clinical studies that used the QIKtest and found positive results were mostly conducted among children and teen populations across longer treatment periods. This research may indicate the QIKtest is not an appropriate measure to assess adults who have specialized training in responding to stimuli (ie, trained military personnel). This suggests the concept of attention dysfunction experienced by veterans and the best method to measure it may need to be explored further. This construct may not be related to the focus and skill in prolonged attention needed in selecting go/ no-go tasks, but rather related to a broader conceptual basis involving memory, recall, clarity of rational thought, and decision making impacted by the mTBI. For instance, a study among combat veterans with mTBI and PTSD found that performance on objective cognitive measures did not significantly correlate with their subjective reports of cognitive difficulties.⁵⁷ This reflects the pattern of the present study, in which subjective reports of attention improved over time on the clinical symptom checklist filled out by participants at each session, but the objective measure did not. The mean attention dysfunction score was 6 at session 1 and 1 to 2 at session 20 (lower scores are better on a 10-point scale).

Strengths and Limitations

This study presents results stemming from the first RCT examining clinical effectiveness of ILF NFB in a VA setting for veterans with diagnoses of mTBI. The study design shows promising external validity. Veterans were able to participate in a treatment consisting of 20 sessions over a period of typically 8 to 10 weeks, entailing 2 to 3 sessions per week, with an attrition of only 18% over the course of the study. Notably, attrition rates may have been impacted by the time course of the study, which was recruiting and running participants throughout the COVID-19 pandemic (March 2020 to May 2023). No attrition was due to the intervention itself, and no adverse reactions to ILF NFB were reported during the course of the study. Other strengths of the study include the ethnically and racially diverse participants, representative of the population of veterans in Hawaii. Additionally, all ILF NFB providers underwent supervised ILF NFB training and achieved a skill reliability index score of 0.95 prior to providing ILF NFB to the intervention group.

This study was not blinded. Neither veterans nor ILF NFB providers were blinded and were therefore aware of the randomly assigned groups. Research assistants administering the periodic assessments were meant to be blinded to condition by design; however, as the study progressed, a research assistant became unintentionally aware of each study participant's condition based on required documentation in the veteran’s health records; more notes were present for those in the intervention group (20 specialist notes) than the control group (8 notes). While the presence of a control group represents a strength relative to much of the existing ILF NFB literature, the control group in this case did not account for the total time spent with the researchers. Participants in the intervention group met with researchers for 20 total sessions as opposed to 8 telephone calls. Therefore, the study design cannot fully rule out the differential impact of demand characteristics between the 2 groups, nor can it fully address or rule out the impact of differential motivation and expectations between groups. There is also evidence that technological innovation can influence the expectations of research participants, meaning that the intervention group may have been unduly influenced by the novelty of the ILF NFB technology, to which the control group did not have exposure.⁵⁸

A second attention measure for this study would have been beneficial, perhaps in identifying true change in attention ability or providing more insight into finding better methods to assess attention among veterans with mTBI. ILF NFB demonstrated significant impact across multiple outcome measures of clinical relevance for veterans diagnosed with mTBI, including the primary outcome variables of headache and sleep. The strength of the improvements seen in these areas, supported by large practical effects as well as veterans’ subjective reports, indicates much promise. Follow-up studies may also focus on the potential effectiveness of ILF NFB as a treatment of the secondary concerns measured in this study, including traumatic stress-related and depressive symptoms, and may explore the added benefit, if any, of ILF NFB alongside other evidence-based treatments for traumatic stress-related and mood disorders (eg, cognitive behavioral therapy). Using functional magnetic resonance imaging before and after assessments to determine actual brain enhancement with ILF NFB for certain disorders in which a brain signature exists (ie, migraine) should be explored. Further examination of ILF NFB as an intervention for attention may also be warranted, using more effective measures of attention in the population of veterans with mTBI, given the concerns noted earlier. Future research on this topic will need to clearly define attention in relation to the veteran experience and use relevant measures.

Conclusions

This study supports ILF NFB as a safe, noninvasive, nonpharmacologic treatment that may be effective in addressing the complex clinical concerns of veterans diagnosed with mTBI, a population for whom effective treatments have been difficult to identify. This intervention can provide veterans with a desirable and effective nonpharmacologic alternative in their care.

TOPLINE: Among veterans and demographically matched nonveterans from 2002 to 2019, higher state household firearm ownership was associated with higher rates of deaths by suicide, while greater state firearm law restrictiveness was associated with lower rates of deaths by suicide. In 2017 to 2019 models, these associations were seen for both veterans and matched nonveterans and driven primarily by firearm deaths by suicide rates.

METHODOLOGY:

• US state-level data across 6 consecutive 3-year periods from 2002-2019, stratified suicide rates by veteran status (veteran vs matched nonveterans) and method (firearm vs nonfirearm). 

• Data sources included US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention counts matched to the National Death Index, plus Centers for Disease Control suicide counts and population estimates by sex and age. 

• Participants included veterans with state- and period-specific death suicide counts and population denominators from the VetPop model, and a matched nonveteran comparison created by comparing state deaths by suicide data to veterans’ age and gender distributions. 

• Exposure measures included annual state household firearm ownership rate estimates carried forward to 2017-2019, and a 7-item state firearm policy restrictiveness index derived from the RAND Corporation state firearm law database.

TAKEAWAY:

• Average death by suicide rates from 2002-2019 were 28.2 per 100,000 for veterans and 27.5 per 100,000 for matched nonveterans, with most deaths involving a firearm. 

• Across states, the maximum average death by suicide rate was about 3 times the minimum over the study period, and veteran and matched nonveteran state patterns aligned closely. 

• Higher household firearm ownership was associated with higher firearm death by suicide rates for veterans and matched nonveterans from 2017-2019.

• Greater firearm law restrictiveness, equivalent to 3 additional restrictive laws, was associated with fewer firearm deaths by suicide for veterans and matched nonveterans from 2017-2019.

IN PRACTICE: “The results suggest that changes to state firearm laws and policies should be investigated as a possibly cost-effective primary prevention strategy for reducing suicide rates among veterans and nonveterans,” the authors wrote.

SOURCE:The study was led by Andrew R. Morral, PhD, RAND Corporation in Arlington, Virginia, and Terry L. Schell, PhD, and Adam Scherling, RAND Corporation in Santa Monica, California and published online in Injury Prevention.

LIMITATIONS: The estimates are correlational and should not be interpreted as causal effect estimates, as most interstate variation in gun ownership and firearm laws predates the beginning of the available VA death by suicide data, limiting the analytical approach to identify causal effects. VA does not share microdata on veteran suicide, requiring construction of a matched comparison sample of nonveterans by estimating veteran decedent removal from general population suicide totals within cells of a 5-way table based on publicly released 3-way tables, introducing imprecision. Veteran suicide counts are known to undercount suicides among veterans who separated from the military prior to 1974, likely resulting in a slight underestimate of veteran suicide rates for the oldest cohort of veterans, particularly in earlier study periods. Restricting analysis to identify modeled effects solely through limited changes in state firearm ownership and policies during the study period yields imprecise effect estimates.

DISCLOSURES: This work received support from a grant provided by The RAND Epstein Family Veterans Policy Research Institute, established through a contribution from Daniel J. Epstein via the Epstein Family Foundation. Neither the Institute, the Foundation, nor Mr. Epstein participated in the design, conduct, analysis, or drafting of this report. The authors disclosed no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: Among veterans and demographically matched nonveterans from 2002 to 2019, higher state household firearm ownership was associated with higher rates of deaths by suicide, while greater state firearm law restrictiveness was associated with lower rates of deaths by suicide. In 2017 to 2019 models, these associations were seen for both veterans and matched nonveterans and driven primarily by firearm deaths by suicide rates.

METHODOLOGY:

• US state-level data across 6 consecutive 3-year periods from 2002-2019, stratified suicide rates by veteran status (veteran vs matched nonveterans) and method (firearm vs nonfirearm). 

• Data sources included US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention counts matched to the National Death Index, plus Centers for Disease Control suicide counts and population estimates by sex and age. 

• Participants included veterans with state- and period-specific death suicide counts and population denominators from the VetPop model, and a matched nonveteran comparison created by comparing state deaths by suicide data to veterans’ age and gender distributions. 

• Exposure measures included annual state household firearm ownership rate estimates carried forward to 2017-2019, and a 7-item state firearm policy restrictiveness index derived from the RAND Corporation state firearm law database.

TAKEAWAY:

• Average death by suicide rates from 2002-2019 were 28.2 per 100,000 for veterans and 27.5 per 100,000 for matched nonveterans, with most deaths involving a firearm. 

• Across states, the maximum average death by suicide rate was about 3 times the minimum over the study period, and veteran and matched nonveteran state patterns aligned closely. 

• Higher household firearm ownership was associated with higher firearm death by suicide rates for veterans and matched nonveterans from 2017-2019.

• Greater firearm law restrictiveness, equivalent to 3 additional restrictive laws, was associated with fewer firearm deaths by suicide for veterans and matched nonveterans from 2017-2019.

IN PRACTICE: “The results suggest that changes to state firearm laws and policies should be investigated as a possibly cost-effective primary prevention strategy for reducing suicide rates among veterans and nonveterans,” the authors wrote.

SOURCE:The study was led by Andrew R. Morral, PhD, RAND Corporation in Arlington, Virginia, and Terry L. Schell, PhD, and Adam Scherling, RAND Corporation in Santa Monica, California and published online in Injury Prevention.

LIMITATIONS: The estimates are correlational and should not be interpreted as causal effect estimates, as most interstate variation in gun ownership and firearm laws predates the beginning of the available VA death by suicide data, limiting the analytical approach to identify causal effects. VA does not share microdata on veteran suicide, requiring construction of a matched comparison sample of nonveterans by estimating veteran decedent removal from general population suicide totals within cells of a 5-way table based on publicly released 3-way tables, introducing imprecision. Veteran suicide counts are known to undercount suicides among veterans who separated from the military prior to 1974, likely resulting in a slight underestimate of veteran suicide rates for the oldest cohort of veterans, particularly in earlier study periods. Restricting analysis to identify modeled effects solely through limited changes in state firearm ownership and policies during the study period yields imprecise effect estimates.

DISCLOSURES: This work received support from a grant provided by The RAND Epstein Family Veterans Policy Research Institute, established through a contribution from Daniel J. Epstein via the Epstein Family Foundation. Neither the Institute, the Foundation, nor Mr. Epstein participated in the design, conduct, analysis, or drafting of this report. The authors disclosed no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: Among veterans and demographically matched nonveterans from 2002 to 2019, higher state household firearm ownership was associated with higher rates of deaths by suicide, while greater state firearm law restrictiveness was associated with lower rates of deaths by suicide. In 2017 to 2019 models, these associations were seen for both veterans and matched nonveterans and driven primarily by firearm deaths by suicide rates.

METHODOLOGY:

• US state-level data across 6 consecutive 3-year periods from 2002-2019, stratified suicide rates by veteran status (veteran vs matched nonveterans) and method (firearm vs nonfirearm). 

• Data sources included US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention counts matched to the National Death Index, plus Centers for Disease Control suicide counts and population estimates by sex and age. 

• Participants included veterans with state- and period-specific death suicide counts and population denominators from the VetPop model, and a matched nonveteran comparison created by comparing state deaths by suicide data to veterans’ age and gender distributions. 

• Exposure measures included annual state household firearm ownership rate estimates carried forward to 2017-2019, and a 7-item state firearm policy restrictiveness index derived from the RAND Corporation state firearm law database.

TAKEAWAY:

• Average death by suicide rates from 2002-2019 were 28.2 per 100,000 for veterans and 27.5 per 100,000 for matched nonveterans, with most deaths involving a firearm. 

• Across states, the maximum average death by suicide rate was about 3 times the minimum over the study period, and veteran and matched nonveteran state patterns aligned closely. 

• Higher household firearm ownership was associated with higher firearm death by suicide rates for veterans and matched nonveterans from 2017-2019.

• Greater firearm law restrictiveness, equivalent to 3 additional restrictive laws, was associated with fewer firearm deaths by suicide for veterans and matched nonveterans from 2017-2019.

IN PRACTICE: “The results suggest that changes to state firearm laws and policies should be investigated as a possibly cost-effective primary prevention strategy for reducing suicide rates among veterans and nonveterans,” the authors wrote.

SOURCE:The study was led by Andrew R. Morral, PhD, RAND Corporation in Arlington, Virginia, and Terry L. Schell, PhD, and Adam Scherling, RAND Corporation in Santa Monica, California and published online in Injury Prevention.

LIMITATIONS: The estimates are correlational and should not be interpreted as causal effect estimates, as most interstate variation in gun ownership and firearm laws predates the beginning of the available VA death by suicide data, limiting the analytical approach to identify causal effects. VA does not share microdata on veteran suicide, requiring construction of a matched comparison sample of nonveterans by estimating veteran decedent removal from general population suicide totals within cells of a 5-way table based on publicly released 3-way tables, introducing imprecision. Veteran suicide counts are known to undercount suicides among veterans who separated from the military prior to 1974, likely resulting in a slight underestimate of veteran suicide rates for the oldest cohort of veterans, particularly in earlier study periods. Restricting analysis to identify modeled effects solely through limited changes in state firearm ownership and policies during the study period yields imprecise effect estimates.

DISCLOSURES: This work received support from a grant provided by The RAND Epstein Family Veterans Policy Research Institute, established through a contribution from Daniel J. Epstein via the Epstein Family Foundation. Neither the Institute, the Foundation, nor Mr. Epstein participated in the design, conduct, analysis, or drafting of this report. The authors disclosed no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Blast exposure has been associated with a wide range of negative outcomes, including alterations in brain structure and function, poorer cognitive functioning, and increased severity of psychiatric and health symptoms. Long-term effects also include chronic secondary downstream effects, such as neuroinflammation, neurotoxicity, cellular senescence, and neurodegeneration.

Now, a recent US Department of Veterans Affairs (VA) study of 114 post-9/11 combat veterans suggests that lifetime blast exposure severity is independently associated with accelerated epigenetic aging, even after accounting for PTSD and TBI. The field of epigenetics refers to how environment influences genes by changing the chemicals attached to them. 

This cross-sectional study analyzed participants enrolled in 2 coordinated VA research protocols: the Chronic Effects of Neurotrauma Consortium Study 34 and the Post-Deployment Mental Health Study. Researchers measured biological aging using DunedinPACE, an epigenetic biomarker derived from whole-blood DNA methylation data.

Greater blast exposure severity was significantly associated with faster DunedinPACE. Mild TBI history was also independently associated with faster aging, whereas PTSD diagnosis was not. No significant interaction effects were observed. Exploratory analyses suggested that higher-intensity and more frequent blast exposures contributed to more accelerated aging. 

The researchers said their findings suggest that accelerated biological aging may represent a pathway linking blast exposure to increased vulnerability for age-related disease and could inform early identification of at-risk veterans. 

Preclinical work has “undeniably demonstrated that primary blast forces can directly induce neurotrauma with associated, ongoing symptoms,” according to the authors of a 2024 study. “[H]owever, these findings have not translated into clinical work.” Most human studies of blast exposure use data obtained from assessments of TBI. That approach is limited, they said, because blast exposure does not always result in symptoms of concussion or TBI, and clinical symptoms of TBI are not necessary for blast-induced neurotrauma to occur. 

Moreover, understanding how and why blast exposure often results in negative consequences is still lagging, and interventions and treatments have lagged comparatively, the researchers noted. In large part, they added, this is because there is no broadly endorsed definition of blast exposure. They illustrated their point with examples of terms used in earlier research: blast TBI, primary blast TBI, pressure severity, distance from the blast, and frequency of exposure. The lack of standardized language, they suggested, “prevents synthesis of existing literature into a cohesive understanding of the field.”

Those researchers called for concerted and collaborative efforts to advance the study of blast exposure, including developing a standardized definition of blast exposure and curating an empirical literature base allowing clear comparisons of results across studies. They also urged raising awareness about blast-related negative outcomes with education at all levels: continuing education opportunities, round tables at annual conference meetings, grand rounds in hospital or academic medical center settings, and journal clubs.

Blast exposure has been associated with a wide range of negative outcomes, including alterations in brain structure and function, poorer cognitive functioning, and increased severity of psychiatric and health symptoms. Long-term effects also include chronic secondary downstream effects, such as neuroinflammation, neurotoxicity, cellular senescence, and neurodegeneration.

Now, a recent US Department of Veterans Affairs (VA) study of 114 post-9/11 combat veterans suggests that lifetime blast exposure severity is independently associated with accelerated epigenetic aging, even after accounting for PTSD and TBI. The field of epigenetics refers to how environment influences genes by changing the chemicals attached to them. 

This cross-sectional study analyzed participants enrolled in 2 coordinated VA research protocols: the Chronic Effects of Neurotrauma Consortium Study 34 and the Post-Deployment Mental Health Study. Researchers measured biological aging using DunedinPACE, an epigenetic biomarker derived from whole-blood DNA methylation data.

Greater blast exposure severity was significantly associated with faster DunedinPACE. Mild TBI history was also independently associated with faster aging, whereas PTSD diagnosis was not. No significant interaction effects were observed. Exploratory analyses suggested that higher-intensity and more frequent blast exposures contributed to more accelerated aging. 

The researchers said their findings suggest that accelerated biological aging may represent a pathway linking blast exposure to increased vulnerability for age-related disease and could inform early identification of at-risk veterans. 

Preclinical work has “undeniably demonstrated that primary blast forces can directly induce neurotrauma with associated, ongoing symptoms,” according to the authors of a 2024 study. “[H]owever, these findings have not translated into clinical work.” Most human studies of blast exposure use data obtained from assessments of TBI. That approach is limited, they said, because blast exposure does not always result in symptoms of concussion or TBI, and clinical symptoms of TBI are not necessary for blast-induced neurotrauma to occur. 

Moreover, understanding how and why blast exposure often results in negative consequences is still lagging, and interventions and treatments have lagged comparatively, the researchers noted. In large part, they added, this is because there is no broadly endorsed definition of blast exposure. They illustrated their point with examples of terms used in earlier research: blast TBI, primary blast TBI, pressure severity, distance from the blast, and frequency of exposure. The lack of standardized language, they suggested, “prevents synthesis of existing literature into a cohesive understanding of the field.”

Those researchers called for concerted and collaborative efforts to advance the study of blast exposure, including developing a standardized definition of blast exposure and curating an empirical literature base allowing clear comparisons of results across studies. They also urged raising awareness about blast-related negative outcomes with education at all levels: continuing education opportunities, round tables at annual conference meetings, grand rounds in hospital or academic medical center settings, and journal clubs.

Blast exposure has been associated with a wide range of negative outcomes, including alterations in brain structure and function, poorer cognitive functioning, and increased severity of psychiatric and health symptoms. Long-term effects also include chronic secondary downstream effects, such as neuroinflammation, neurotoxicity, cellular senescence, and neurodegeneration.

Now, a recent US Department of Veterans Affairs (VA) study of 114 post-9/11 combat veterans suggests that lifetime blast exposure severity is independently associated with accelerated epigenetic aging, even after accounting for PTSD and TBI. The field of epigenetics refers to how environment influences genes by changing the chemicals attached to them. 

This cross-sectional study analyzed participants enrolled in 2 coordinated VA research protocols: the Chronic Effects of Neurotrauma Consortium Study 34 and the Post-Deployment Mental Health Study. Researchers measured biological aging using DunedinPACE, an epigenetic biomarker derived from whole-blood DNA methylation data.

Greater blast exposure severity was significantly associated with faster DunedinPACE. Mild TBI history was also independently associated with faster aging, whereas PTSD diagnosis was not. No significant interaction effects were observed. Exploratory analyses suggested that higher-intensity and more frequent blast exposures contributed to more accelerated aging. 

The researchers said their findings suggest that accelerated biological aging may represent a pathway linking blast exposure to increased vulnerability for age-related disease and could inform early identification of at-risk veterans. 

Preclinical work has “undeniably demonstrated that primary blast forces can directly induce neurotrauma with associated, ongoing symptoms,” according to the authors of a 2024 study. “[H]owever, these findings have not translated into clinical work.” Most human studies of blast exposure use data obtained from assessments of TBI. That approach is limited, they said, because blast exposure does not always result in symptoms of concussion or TBI, and clinical symptoms of TBI are not necessary for blast-induced neurotrauma to occur. 

Moreover, understanding how and why blast exposure often results in negative consequences is still lagging, and interventions and treatments have lagged comparatively, the researchers noted. In large part, they added, this is because there is no broadly endorsed definition of blast exposure. They illustrated their point with examples of terms used in earlier research: blast TBI, primary blast TBI, pressure severity, distance from the blast, and frequency of exposure. The lack of standardized language, they suggested, “prevents synthesis of existing literature into a cohesive understanding of the field.”

Those researchers called for concerted and collaborative efforts to advance the study of blast exposure, including developing a standardized definition of blast exposure and curating an empirical literature base allowing clear comparisons of results across studies. They also urged raising awareness about blast-related negative outcomes with education at all levels: continuing education opportunities, round tables at annual conference meetings, grand rounds in hospital or academic medical center settings, and journal clubs.

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.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.