Group Motivational Interviewing (GMI) For Homeless Veterans in VA Services

描述(由申请人提供)： 对退伍军人医疗保健的预期影响：弗吉尼亚州制定了一个雄心勃勃的目标，到2015年结束退伍军人中的无家可归现象。HUD-VASH和Grant&Per Diem(GPD)是帮助退伍军人摆脱无家可归的两个主要退伍军人住房计划。退伍军人在退伍军人住房中滥用药物是导致精神病理恶化和住房不稳定的主要风险因素。尽管最近采取了住房优先的方法，但许多退伍军人住房计划缺乏管理物质使用障碍(SUDS)的工作人员基础设施。这是一个严重的问题，因为退伍军人中60%(保守估计)有肥皂泡，这些退伍军人比没有肥皂泡的退伍军人表现出更严重的精神病理。这些问题要求退伍军人住房中的SUD计划必须高效部署、易于部署到现有服务上，并且只需最少的工作人员即可操作。本研究解决了退伍军人退伍军人治疗服务中目前的空白，因为它调查了适应动机访谈的治疗的有效性、实施过程和成本估计，这是一种经验性支持的干预措施，在减少物质使用和提高治疗参与度方面具有强大的影响，以小组形式被称为针对退伍军人和退伍军人的团体动机访谈(GMI)。该项目的数据如果被证明是有希望的，将为在退伍军人事务部住房中为高度脆弱的无家可归退伍军人在实现住房稳定方面取得最大成功的GMI传播和实施行动方案奠定基础。背景：在退伍军人管理局的住房中，有很大的需求来解决肥胖症。患有肥皂泡的无家可归退伍军人很容易退出治疗，使他们容易复发，而他们在参与退伍军人住房期间继续进行门诊护理会改善临床结果。根据系统评价，与不治疗相比，个体化心肌梗死降低了SUD的发生率，但是劳动密集型的。随着退伍军人管理局迈向“住房优先”的模式，更多无家可归的退伍军人将在退伍军人住房中继续使用药物，向这些患者提供GMI(可能不那么劳动密集型)将对启动和维持他们的康复以及提高他们的心理社会融合和生活质量将是重要的。 在PI之前进行的一项对照试验中，GMI导致在双重诊断的退伍军人中，与常规治疗相比，GMI显著增加了门诊治疗参与度，减少了物质使用。目的：研究目标与退伍军人事务部的住房建议一致，重点放在患者康复、卫生服务促进和治疗实施评估上。GMI将在以下方面与对照治疗条件(CT)进行比较：(具体目标I；五个结果：(主要H1)：治疗投入；(主要H1)：物质使用；(次要H2)：心理社会融合(例如，社会支持、社区参与)；(次要H3)生活质量/精神指数；(次要H4)：在6个月的随访中从事有组织/生产性工作活动的天数。具体目标二涉及记录(A)形成性(例如，发展)、(B)过程和(C)总结性成果的过程评价；具体目标三涉及从直接成本、工作人员间接成本、资本成本和未来实施和传播研究的工作量计量方面估算干预成本。方法：随机对照试验，比较GMI和CT对五个关键结果的影响。退伍军人住房服务中心的186名退伍军人(每个治疗部门93名)将被诊断为酗酒或药物滥用/依赖。招聘将在查尔斯顿VAMC HUD-VASH和GPD进行。参与者将被随机分配到(1)GMI或(2)CT，每组包括4个疗程，并将在1、3和6个月时进行评估。患有非物质相关的DSM-IV-TR主要轴I障碍(例如，MDD、PTSD)的参与者将有资格参加研究。将使用广义线性混合模型(GLMM)方法进行分析。

DESCRIPTION (provided by applicant): Anticipated Impacts on Veterans Health Care: VA set an ambitious goal for ending homelessness among Veterans by 2015. HUD-VASH and Grant & Per Diem (GPD) are two primary VA housing programs to help Veterans exit homelessness. Substance abuse among Veterans in VA housing is a major risk factor for worsening psychopathology and housing instability. Despite recent adoption of a Housing First approach, many VA housing programs lack the staff infrastructure to manage substance use disorders (SUDs). This is a significant problem as 60% (conservative estimate) of Veterans in VA housing have SUDs and these Veterans show greater psychopathology compared to their counterparts without SUDs. These issues warrant substantial need for SUD programs in VA housing that are efficient to deploy, easily layered onto existing services, and require minimal staff to operate. The current study addresses this current void in VA treatment services in that it investigates the effectiveness, implementation process, and cost estimate of treatment of an adaptation of motivational interviewing, an empirically supported intervention with strong impact on reducing substance use and enhancing treatment engagement, in a group format, referred to as Group Motivational Interviewing (GMI) for Veterans with SUDs in VA housing. Data from this project, if shown to be promising, will establish the basis of a GMI dissemination and implementation course of action for highly vulnerable homeless Veterans in VA housing for achieving their greatest success in attaining housing stability. Background: There is a significant need for 'wraparound' treatment services in VA housing for addressing SUDs. Homeless Veterans with SUDs are vulnerable to treatment dropout, rendering them susceptible to relapse, while their continuation in outpatient care during their participation in VA housing leads to improved clinical outcomes. According to systematic reviews, individual MI reduces the incidence of SUD, when compared to no treatment, but is labor intensive. As VA moves toward a 'Housing First' paradigm where greater numbers of homeless Veterans will continue to use substances while in VA housing, delivery of GMI (which may be less labor intensive) to these patients will be important for initiating and maintaining their recovery as well as enhancing their psychosocial integration and quality of life. In a prior controlled trial conducted by the PI, GMI resulted in significantly higher outpatient treatment engagement and lower substance use compared to treatment-as-usual among dually diagnosed Veterans. Objectives: Study objectives are consistent with VA housing recommendations focusing on patient recovery, health services promotion, and treatment implementation evaluation. GMI will be compared to a control treatment condition (CT) on (Specific Aim I; Five outcomes: (Primary H1): treatment engagement; (Primary H1): substance use; (Secondary H2): psychosocial integration (e.g., social support, community participation); (Secondary H3) quality of life/psychiatric indices; and (Secondary H4): number of days engaging in structured/productive work activities in the 6-month follow up. Specific Aim II involves a process evaluation for documenting (A) formative (e.g., developmental), (B) process, and (C) summative outcomes; and Specific Aim III involves estimation of cost of intervention in terms of direct costs, indirect costs of staff, costs of capital and workload measures for future implementation and dissemination research. Methods: Randomized controlled trial comparing GMI to CT across five critical outcomes. 186 Veterans in VA housing services (93 per treatment arm) will be enrolled with a diagnosis of alcohol or drug abuse/dependence. Recruitment will take place in Charleston VAMC HUD-VASH & GPD. Participants will be randomly assigned to (1) GMI or (2) CT, each consisting of 4 sessions, and will be evaluated at 1, 3, and 6 months. Participants with a non-substance related DSM-IV-TR major Axis I disorder (e.g., MDD, PTSD) will be eligible for the study. Analyses will be conducted using generalized linear mixed models (GLMM) approach.