Understanding Impact of VHA's New Suicidal Ideation Screening Initiative: Veteran's Perspective

背景：以人群为基础的自杀意念(SI)筛查计划正在成为标准做法。 今年，VHA正在实施一项新的多阶段SI筛查和评估程序，即VA Risk-ID。然而， 先前的研究表明，退伍军人在筛查期间披露SI经常感到不舒服，而且 退伍军人通常不会透露自杀前就诊时的SI。此外，几乎什么都没有 了解SI筛查经历可能如何影响后续的治疗参与度。已知的因素 与治疗接触相关，包括有效的患者-临床医生沟通、治疗性 联盟，以及协作式治疗计划。对SI筛查的负面看法有可能 对退伍军人舒适度披露和讨论SI，以及随后的护理投入产生不利影响。 意义/影响：预防自杀是VHA的首要任务，并优化高危人群的参与 退伍军人的治疗至关重要。该项目解决了主要差距：1)它将产生知识 关于基于人群的SI筛查过程的积极和潜在的负面影响；2)它将 从患者的角度生成有关SI筛查的全面信息；以及3)它将检查 筛查经历与后续护理参与度之间的关系。 创新：这个项目将使用一种混合方法来描述 主要从初级保健和精神卫生环境中筛查SI的退伍军人的治疗 对于退伍军人，从最初的抑郁症或创伤后应激障碍筛查开始，直到筛查后6个月。 具体目标：(1)在全国分层随机抽样的退伍军人中进行初级保健和精神筛查 健康，使用定量调查，描述退伍军人在退伍军人风险ID筛查和临床中的经历 对筛选进行的评估；(2)对以下人员进行半结构化的定性访谈 参加SI筛查的退伍军人和工作人员，目标是确定改进筛查和 筛查后的参与度；(3)在初级保健中接受筛查的退伍军人群体中，检查 哪些筛查过程变量与6个月以上的精神卫生治疗利用率有关。 方法：这个为期3年的混合方法项目将利用来自国家、 退伍军人的分层随机抽样。在目标1中，我们将在退伍军人管理局Risk-ID之后立即邮寄招聘信 对2,000名退伍军人进行初级保健筛查，对2,000名退伍军人进行专科精神健康筛查 在过去12个月内没有接受过精神健康治疗的人。应答者将被邀请完成 调查包括评估筛查、患者与护理团队互动和 感知到的关爱和披露的障碍。在目标2中，根据目标1的调查结果，多达约40个 从调查队列中确定的退伍军人将参加半结构化面试。我们还将采访 来自三个或更多VHA机构的初级保健和精神卫生机构的多达40名临床工作人员。 定性分析将优先确定临床团队检测和应对SI的更多方法 令人满意且有效。在目标3中，在接受初级保健筛查的退伍军人群体中，我们将检查 筛查结果和调查变量与后续参与的关联程度 心理健康治疗6个月以上。结果将包括接受专门的精神健康检查(当 参考)和抗抑郁剂填充(当供应商推荐时)。VHA的企业数据仓库将 提供护理利用数据。多变量模型将根据患者、护理团队和地点的特点进行调整。 下一步/实施：该项目将为VHA的SI的进一步开发和实施提供信息 筛选过程，并为1)初级保健新干预措施的开发和测试奠定基础 和精神卫生保健团队，以改善SI筛查和护理参与度；以及2)其他研究 研究有自杀风险的退伍军人的早期护理经历对健康结果的影响。

Background: Population-based screening programs for suicidal ideation (SI) are becoming standard practice. This year, VHA is implementing a new multi-stage SI screening and evaluation process, VA Risk-ID. However, prior research has shown that Veterans often feel uncomfortable disclosing SI during screening, and that Veterans frequently do not disclose SI at healthcare visits proximal to suicide. Further, there is almost nothing known about how SI screening experiences may impact subsequent treatment engagement. Factors known to be associated with treatment engagement include effective patient-clinician communication, therapeutic alliance, and collaborative treatment planning. Negative perceptions of SI screening have the potential to adversely affect Veteran comfort disclosing and discussing SI, as well as subsequent engagement in care. Significance/Impact: Suicide prevention is VHA’s highest priority, and optimizing engagement of at-risk Veterans in treatment is of critical importance. This project addresses key gaps: 1) It will generate knowledge about both positive and potentially negative impacts of a population-based SI screening process; 2) It will generate comprehensive information about SI screening from the perspective of patients; and 3) It will examine the relationship between screening experiences and subsequent engagement in care. Innovation: This project will use a mixed methods approach to characterize the “natural history” of the treatment of Veterans screened for SI in primary care and mental health settings primarily from the perspective of Veterans, from the point of initial depression or PTSD screening until 6 months after screening. Specific Aims: (1) In a national, stratified random sample of Veterans screened in primary care and mental health, using quantitative surveys, characterize Veteran experiences with VA Risk-ID screening and clinical evaluation that takes place in response to screening; (2) Conduct semi-structured qualitative interviews with Veterans and staff who participate in SI screening, with the goal of identifying ways to improve screening and engagement after screening; (3) Among the group of Veterans screened in primary care, examine the extent to which screening process variables are associated with mental health treatment utilization over 6 months. Methodology: This 3-year mixed-methods project will utilize quantitative and qualitative data from a national, stratified random sample of Veterans. In Aim 1, we will mail recruitment letters immediately after VA Risk-ID screening to 2,000 Veterans screened in primary care and 2,000 Veterans screened in specialty mental health who have not received mental health treatment in the prior 12 months. Respondents will be invited to complete surveys including measures assessing satisfaction with screening, patient-care team interactions and perceived barriers to care and disclosure. In Aim 2, informed by Aim 1 survey results, up to approximately 40 Veterans identified from the survey cohorts will participate in semi-structured interviews. We will also interview up to 40 clinical staff members from primary care and mental health settings of three or more VHA facilities. Qualitative analyses will prioritize identification of ways for clinical teams to detect and respond to SI more satisfactorily and effectively. In Aim 3, within the group of Veterans screened in primary care, we will examine the extent to which screening results and survey variables are associated with subsequent engagement in mental health treatment over 6 months. Outcomes will include specialty mental health visits attended (when referred) and antidepressant fills (when recommended by providers). VHA’s Corporate Data Warehouse will provide care utilization data. Multivariable models will adjust for patient and care team and site characteristics. Next Steps/Implementation: This project will inform further development and implementation of VHA’s SI screening processes, and lay groundwork for 1) development and testing of new interventions for primary care and mental health care teams to improve SI screening and care engagement; and 2) additional research examining the impacts of early care experiences of Veterans at risk for suicide on health outcomes.