Publications by authors named "David A Smelson"

26 Publications

  • Page 1 of 1

Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans.

Soc Sci Med 2021 07 2;281:114096. Epub 2021 Jun 2.

Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA; Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, 01730, USA.

Rationale: Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability.

Methods: The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects.

Results: Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels.

Conclusion: Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.
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July 2021

Targeting women veteran's stress-induced drinking with cognitive reappraisal: Mechanisms and moderators of change.

J Subst Abuse Treat 2021 Apr 14;130:108408. Epub 2021 Apr 14.

VA Central Western Massachusetts, Division of Research and Education, 421 North Main Street, Leeds, MA 01053, United States of America; University of Massachusetts Medical School, Department of Psychiatry, 365 Plantation Street Biotech One, Worcester, MA 01605, United States of America.

Emotion dysregulation mediates the effects of stress on drinking among individuals with co-occurring emotional and alcohol use disorders (AUD). The current study examined the effects of cognitive reappraisal (CR), an adaptive emotion regulation strategy, on mechanisms that contribute to drinking (alcohol craving, inhibitory control) among 50 women veterans. In session one, participants were randomized to one of two 50-min "microinterventions", either to learn a CR coping strategy or receive non-therapeutic psychoeducation control. In session two, all participants underwent a personalized stress induction, after which women in the experimental condition were instructed to use CR to reduce stress, while those in the control group were instructed to sit quietly. Craving and inhibitory control were measured at post-stress induction and after using CR/sitting quietly. Moderating effects of AUD, depression, and PTSD severity were assessed. Craving and inhibitory control improved among women in both conditions (CR or sitting quietly), with no main effect of condition. Condition by AUD severity had a significant interaction effect (b = 0.018, p = .013), whereby women with more severe AUD had greater decreases in craving after sitting quietly, and women with less severe AUD had greater decreases in craving after CR. The opposite pattern was observed for inhibitory control (b = 6.45, p = .004), with women with less severe AUD having greater decreases in inhibitory control after sitting quietly, and women with more severe AUD having greater decreases in inhibitory control after CR. Results highlight CR's immediate effects on alcohol-related outcomes and the important role of symptom severity.
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April 2021

Risk-need-responsivity and its application in behavioral health settings: A feasibility study of a treatment planning support tool.

Behav Sci Law 2021 Feb 10;39(1):44-64. Epub 2021 Feb 10.

Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

The risk-need-responsivity (RNR) model suggests several key practices for justice-involved populations under correctional supervision. Behavioral health treatment planning aligned with RNR principles for offender populations with co-occurring mental health and substance use disorders (CODs) could be one method for integrating RNR into clinical care. To explore a unique approach to working with behavioral health and RNR principles, the authors implemented a mixed-methods feasibility study of the acceptability, usability, and utility of a newly developed RNR treatment planning support tool (RNR TST). The tool was implemented in a re-entry program serving adults with co-occurring mental health and opioid use disorders. Chart reviews of RNR TSTs (N = 55) and a focus group (N = 14 re-entry clinical staff) were conducted. Ninety-six percent of the RNR TSTs incorporated the use of a validated risk-need assessment and 70% of the RNR TSTs were semi-complete to complete. Focus group interviews highlighted behavioral health staff perspectives on the acceptability, usability, and utility of the RNR TST. This novel RNR TST has the potential to assist behavioral health providers in integrating RNR principles into treatment planning. Further development and testing are needed to determine its impact on client care and outcomes.
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February 2021

Embedding a Co-occurring Disorders Rehabilitation Intervention in Veterans Courts: A Pilot Study with Male Veterans.

Community Ment Health J 2020 07 31;56(5):970-977. Epub 2020 Jan 31.

Massachusetts Department of Mental Health, Boston, MA, USA.

Veterans treatment courts (VTCs) have expanded dramatically despite their limited empirical base. This pilot study examined MISSION-Criminal Justice (CJ), a co-occurring disorders wraparound intervention, delivered alongside two VTCs. Baseline data from 26 male veterans enrolled in two VTCs and MISSION-CJ, and 6-month follow-up data for 18 of the 26 veterans, are presented. Veterans on average were 37.5 years old, 85% Caucasian, had significant histories of criminal justice involvement (14.3 lifetime arrests), had an average of 14.7 years of alcohol use and 9.3 years of illicit drug use, and roughly three-quarters reported mental health symptomatology. At 6-month follow-up, veterans demonstrated improvements in behavioral health, substance use, and criminal justice outcomes. This study demonstrated promising preliminary outcomes of MISSION-CJ in VTCs. A randomized controlled trial is a critical next step to examine whether these outcomes remain consistent with a more rigorous design.
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July 2020

Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals.

J Dual Diagn 2018 Oct-Dec;14(4):247-256. Epub 2019 Jan 4.

d DMA Health Strategies , Boston , Massachusetts , USA.

Objective: Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area.

Methods: This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments.

Results: At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment.

Conclusions: This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.
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September 2019

Overdose risk for veterans receiving opioids from multiple sources.

Am J Manag Care 2018 11;24(11):536-540

Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730. Email:

Objectives: The aim of this study was to evaluate whether veterans in Massachusetts receiving opioids and/or benzodiazepines from both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of adverse events compared with those receiving opioids at VHA pharmacies only.

Study Design: A cohort study of veterans who filled a prescription for any Schedule II through V substance at a Massachusetts VHA pharmacy. Prescriptions were recorded in the Massachusetts Department of Public Health Chapter 55 data set.

Methods: The study sample included 16,866 veterans residing in Massachusetts, of whom 9238 (54.8%) received controlled substances from VHA pharmacies only and 7628 (45.2%) had filled prescriptions at both VHA and non-VHA pharmacies ("dual care users") between October 1, 2013, and December 31, 2015. Our primary outcomes were nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality.

Results: Compared with VHA-only users, more dual care users resided in rural areas (12.6% vs 10.6%), received high-dose opioid therapy (26.3% vs 7.3%), had concurrent prescriptions of opioids and benzodiazepines (34.8% vs 8.2%), and had opioid use disorder (6.8% vs 1.6%) (P <.0001 for all). In adjusted models, dual care users had higher odds of nonfatal opioid overdose (odds ratio [OR], 1.29; 95% CI, 0.98-1.71) and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93) compared with VHA-only users. Dual care use was not associated with fatal opioid overdoses.

Conclusions: Among veterans in Massachusetts, receipt of opioids from multiple sources was associated with worse outcomes, specifically nonfatal opioid overdose and mortality. Better information sharing between VHA and non-VHA pharmacies and prescribers has the potential to improve patient safety.
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November 2018

An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial.

BMC Health Serv Res 2018 May 5;18(1):332. Epub 2018 May 5.

VA National Center on Homelessness among Veterans, Bedford, MA, 01730, USA.

Background: Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet.

Methods: This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models.

Results: Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received "higher" and "lower" intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use.

Conclusions: Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care.

Trial Registration:, registration number: NCT01430741 , registered July 26, 2011.
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May 2018

A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs.

Implement Sci 2017 04 4;12(1):46. Epub 2017 Apr 4.

VA National Center on Homelessness among Veterans, Washington, DC, USA.

Background: Homeless veterans often have multiple health care and psychosocial needs, including assistance with access to housing and health care, as well as support for ongoing treatment engagement. The Department of Veterans Affairs (VA) developed specialized Homeless Patient Alignment Care Teams (HPACT) with the goal of offering an integrated, "one-stop program" to address housing and health care needs of homeless veterans. However, while 70% of HPACT's veteran enrollees have co-occurring mental health and substance use disorders, HPACT does not have a uniform, embedded treatment protocol for this subpopulation. One wraparound intervention designed to address the needs of homeless veterans with co-occurring mental health and substance use disorders which is suitable to be integrated into HPACT clinic sites is the evidence-based practice called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet. Despite the promise of MISSION-Vet within HPACT clinics, implementation of an evidence-based intervention within a busy program like HPACT can be difficult. The current study is being undertaken to identify an appropriate implementation strategy for MISSION-Vet within HPACT. The study will test the implementation platform called Facilitation and compared to implementation as usual (IU). The aims of this study are as follows: (1) Compare the extent to which IU or Facilitation strategies achieve fidelity to the MISSION-Vet intervention as delivered by HPACT homeless provider staff. (2) Compare the effects of Facilitation and IU strategies on the National HPACT Performance Measures. (3) Compare the effects of IU and Facilitation on the permanent housing status. (4) Identify and describe key stakeholders' (patients, providers, staff) experiences with, and perspectives on, the barriers to, and facilitators of implementing MISSION.

Design: Type III Hybrid modified stepped wedge implementation comparing IU to Facilitation across seven HPACT teams in three sites in the greater Los Angeles VA system. This is a cluster randomized trial.

Discussion: Integrating MISSION-Vet within HPACT has the potential to improve the health of thousands of veterans, but it is crucial to implement the intervention appropriately in order for it to succeed. The lessons learned in this protocol could assist with a larger roll-out of MISSION within HPACT. This protocol is registered with and was assigned the number NCT 02942979.
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April 2017

Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy.

Implement Sci 2017 03 9;12(1):34. Epub 2017 Mar 9.

VA National Center on Homelessness Among Veterans, Philadelphia, PA, USA.

Background: Incorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO).

Methods: This Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2 years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview.

Results: No case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet.

Conclusions: This project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet.

Trial Registration: NCT01430741.
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March 2017

Integrating Permanent Supportive Housing and Co-Occurring Disorders Treatment for Individuals Who Are Homeless.

J Dual Diagn 2016 Apr-Jun;12(2):193-201. Epub 2016 Apr 11.

a Department of Psychiatry , University of Massachusetts Medical School , Worcester , Massachusetts , USA.

Objectives: While permanent housing, addictions, and mental health treatment are often critical needs to achieve housing stability and community reintegration, few studies have systematically integrated them into a single comprehensive approach for people experiencing chronic homelessness. This pilot study examined the feasibility and preliminary outcomes of systematically integrating permanent supportive housing and an evidence-based co-occurring disorders intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION).

Methods: This single-group open pilot enrolled 107 people with co-occurring disorders experiencing chronic homelessness from two Massachusetts inner-city and rural areas. Enrolled subjects were interested in receiving permanent supportive housing along with 1 year of MISSION services. Data were collected through baseline and 6- and 12-month follow-up assessments.

Results: Participants (Mage = 49.52 years, SD = 10.61) were mostly male (76.6%), Caucasian (52.3%), and unemployed (86.0%), with an average of 8.34 years (SD = 8.01) of homelessness. Self-reported lifetime problems with anxiety (75.7%) and depression (76.6%) were common, as was use of alcohol (30.8%), cannabis (31.8%), and cocaine (15.9%). Almost all participants (95.3%) were placed into permanent housing, which took on average 42.6 days from enrollment (SD = 50.09). Among those placed, nearly 80% of the clients were able to retain housing through the end of the study. Overall retention was high, with 86.0% remaining in MISSION treatment until the end of the study. While there were no significant changes in rehospitalization, service utilization, or substance use, there were modest significant mental health symptom improvements from baseline to program completion.

Conclusions: This pilot study suggests that co-occurring disorder interventions like MISSION are feasible to integrate with permanent supportive housing despite the somewhat differing philosophies, and preliminary data suggested substantial improvements in housing and modest improvements in mental health symptoms. While caution is warranted given the lack of a comparison group, these findings are consistent with other rigorous studies using MISSION among homeless individuals who did not receive permanent supportive housing.
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September 2017

Gambling involvement indicative of underlying behavioral and mental health disorders.

Am J Addict 2016 Mar 12;25(2):160-72. Epub 2016 Feb 12.

School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts.

Background And Objectives: In spite of increased gambling opportunities, risk factors associated with recreational gambling remain poorly understood. This study assessed behavioral risk factors associated with frequency of recreational gambling.

Methods: Data were derived from the 2013 Massachusetts Behavioral Risk Factor Surveillance System. Gambling frequency was divided into two or more times per week, 1-4 times a month, less than 10 times in total, and not at all. Health risk behaviors included smoking, drinking, obesity, seat belt use, and sleep patterns. Multivariate logistic regression was used to assess relationships between overall gambling participation and gambling frequency and behavioral risk behaviors. Final analytical sample included 3,988 survey respondents. Statistical analyses were performed using STATA.

Results: Significant differences exist in the socio-demographic characteristics of recreational gamblers. Highest gambling frequency is associated with increased odds of alcohol consumption (ie, having at least one alcohol drink during the past 30 days) (OR 1.9; p < .05), binge drinking (ie, having five or more alcohol drinks at least once during the past 30 days) (OR 3.7; p < .001), and tobacco use (ie, having smoked at least 100 cigarettes in a lifetime) (OR 3.4; p < .001). The odds of having fourteen days of poor mental health are twofold for recreational gamblers who gamble two or more times per week (OR 2.2; p < .05).

Conclusion And Scientific Significance: Differing behavioral and mental health risk factors emerge among recreational gamblers by gambling frequency. Gambling frequency may be a better proxy for assessing the risk of developing gambling related behavioral disorders than overall endorsement of gambling participation.
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March 2016

Telephone Smoking-Cessation Counseling for Smokers in Mental Health Clinics: A Patient-Randomized Controlled Trial.

Am J Prev Med 2016 Apr 17;50(4):518-527. Epub 2015 Dec 17.

VA NY Harbor Healthcare System, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York.

Introduction: People with a mental health diagnosis have high rates of tobacco use and encounter limited availability of tobacco treatment targeted to their needs. This study compared the effectiveness of a specialized telephone smoking-cessation intervention developed for mental health patients with standard state quit-line counseling.

Design: RCT.

Setting/participants: The study was conducted at six Veterans Health Administration facilities in the Northeast U.S. Participants were 577 mental health clinic patients referred by their providers for smoking-cessation treatment.

Intervention: From 2010 to 2012, the study implemented a telephone program that included patient referral from a mental health provider, mailed cessation medications, and telephone counseling. Participants were randomized to receive a specialized multisession telephone counseling protocol (n=270) or transfer to their state's quit-line for counseling (n=307).

Main Outcome Measures: Participants completed telephone surveys at baseline, 2 months, and 6 months. The study's primary outcome was self-reported 30-day abstinence at 6 months. Secondary outcomes were self-reported 30-day abstinence, counseling satisfaction and counseling content at 2 months, and self-reported use of cessation treatment and quit attempts at 6 months. Logistic regression was used to compare treatment groups on outcomes, controlling for baseline cigarettes per day and site. Inverse probability weighting and multiple imputation were used to handle missing abstinence outcomes. Data were analyzed in 2014-2015.

Results: At 6 months, participants in the specialized counseling arm were more likely to report 30-day abstinence (26% vs 18%, OR=1.62, 95% CI=1.24, 2.11). There was no significant group difference in abstinence at 2 months (18% vs 14%, OR=1.31, 95% CI=0.49, 3.49). Participants in the specialized arm were more likely to be assisted with developing a quit plan; receive follow-up calls after quitting; and receive counseling on several domains, including motivation, confidence, smoking triggers, coping with urges, and mental health symptoms (all p<0.05). Specialized counseling participants were more satisfied with treatment and more likely to find the counseling useful (p<0.05).

Conclusions: The specialized counseling intervention was more effective at helping patients quit than transfer to a state quit-line. Patients were more satisfied with the specialized counseling program.

Trial Registration: This study is registered at NCT00724308.
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April 2016

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans.

PeerJ 2015 30;3:e1096. Epub 2015 Jul 30.

Department of Veterans Affairs, Edith Nourse Rogers VA Hospital , Bedford, MA , USA ; VA National Center on Homelessness among Veterans , Philadelphia, PA and Bedford, MA , USA ; Department of Psychiatry, University of Massachusetts Medical School , Worcester, MA , USA.

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans' IT use. This study examines homeless veterans' access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.
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August 2015

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs.

Implement Sci 2015 May 28;10:79. Epub 2015 May 28.

VA Center for Healthcare Organization and Implementation Research, Bedford, MA, USA.

Background: The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO).

Methods/design: In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU-standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model.

Discussion: This project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection-via a fidelity measure embedded into the VA Computerized Patient Record System-began as each site initiated MISSION-Vet, between April 2013 and January 2014.

Trial Registration: NCT01430741.
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May 2015

The potential for health-related uses of mobile phones and internet with homeless veterans: results from a multisite survey.

Telemed J E Health 2014 Sep 21;20(9):801-9. Epub 2014 Jul 21.

1 Center for Healthcare Organization and Implementation Research, Department of Veterans Affairs , Edith Nourse Rogers VA Hospital, Bedford, Massachusetts.

Background: Addressing the health needs of homeless veterans is a priority in the United States, and, although information technologies can potentially improve access to and engagement in care, little is known about this population's use of information technologies or their willingness to use technologies to communicate with healthcare providers and systems.

Materials And Methods: This study fills this gap through a survey of homeless veterans' use of information technologies and their attitudes about using these technologies to assist with accessing needed healthcare services.

Results: Among the 106 homeless veterans surveyed, 89% had a mobile phone (one-third were smartphones), and 76% used the Internet. Among those with a mobile phone, 71% used text messaging. Nearly all respondents (93%) were interested in receiving mobile phone reminders (text message or phone call) about upcoming medical appointments, and a similar proportion (88%) wanted mobile phone outreach asking if they would like to schedule an appointment if they had not been seen by a health provider in over a year. In addition, respondents already used these technologies for information and communication related to health, housing, and jobs.

Conclusions: These findings suggest new avenues for communication and health interventions for hard-to-reach homeless veterans.
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September 2014

A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders.

Psychol Serv 2013 May 17;10(2):161-7. Epub 2012 Dec 17.

Edith Nourse Rogers Memorial VA Medical Center, Bedford, and University of Massachusetts Medical School, Worcester, MA, USA.

This article reports the results of a low-intensity wraparound intervention, Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION), to augment Treatment as Usual (TAU) and engage and retain homeless veterans with a co-occurring disorder (COD) in care. Using a quasi-experimental design, 333 homeless veterans were enrolled, 218 who received MISSION along with TAU and 115 who received TAU alone. Group assignment was based on MISSION treatment slot availability at time of enrollment. Compared with TAU alone, individuals receiving MISSION demonstrated greater outpatient session attendance within the 30 days before the 12-month follow up assessment and a larger decline from baseline in the number of psychiatric hospitalization nights. Individuals in the MISSION and TAU-only groups both showed statistically significant improvements in substance use and related problems at 12 months, with those in MISSION less likely to drink to intoxication and experience serious tension or anxiety. Although this study confirmed that compared with TAU alone, MISSION along with TAU is effective in augmenting usual care and engaging and retaining homeless veterans in treatment, some caution is warranted as this study did not involve random assignment. These results, however, are similar to a recent study involving a briefer version of the intervention which included random assignment. Based on these findings, MISSION is being further studied in the joint Department of Housing and Urban Development (HUD) - Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program, which offers rapid housing placement and case management to aid in housing maintenance.
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May 2013

The phenomenon of drug craving.

J Psychoactive Drugs 2008 Sep;40(3):255-61

Department of Health Science, California State University, Fullerton, CA 92634, USA.

The phenomenology of drug craving has become the focus of much research within addictive disorders because of the belief that desire plays a role in maintaining the addiction. Many of the studies have focused on the activation of neural pathways, particularly within the dopamine system in response to specific events or stimuli. While many of these studies have focused on a particular drug of choice, little has been done across addictive disorders. This article will present and review phenomena that induce drug craving, as well as delineate precise neural pathways which are activated during craving and specific neurobiological markers which are associated with an increased risk for drug craving and other forms of addictive behavior.
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September 2008

Pharmacological treatment of schizophrenia and co-occurring substance use disorders.

CNS Drugs 2008 ;22(11):903-16

Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, Massachusetts, USA.

Substance abuse among individuals with schizophrenia is common and is often associated with poor clinical outcomes. Comprehensive, integrated pharmacological and psychosocial treatments have been shown to improve these outcomes. While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring substance use disorders, this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic. This article focuses on and reviews studies involving US FDA-approved medications for co-occurring substance abuse problems among individuals with schizophrenia.Comprehensive treatment for individuals with schizophrenia and co-occurring substance use disorders must include specialized, integrated psychosocial intervention. Most approaches use some combination of cognitive-behavioural therapy, motivational enhancement therapy and assertive case management. The research on antipsychotic and other pharmacological treatments is also reviewed, as well as psychosocial treatments for individuals with schizophrenia and co-occurring substance use disorders, and clinical recommendations to optimize care for this population are offered.
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January 2009

The efficacy of olanzapine for decreasing cue-elicited craving in individuals with schizophrenia and cocaine dependence: a preliminary report.

J Clin Psychopharmacol 2006 Feb;26(1):9-12

Department of Veterans Affairs, New Jersey Health Care System, Lyons, NJ 07939-5000, USA.

Objective: Although a growing body of research suggests that atypical neuroleptic medications are efficacious in the treatment of cocaine addiction among individuals with schizophrenia, more rigorously controlled trials are needed. To extend this research, we performed a 6-week double-blind study comparing olanzapine to haloperidol with the primary objective of reducing cue-elicited cocaine craving and the secondary aims of decreasing substance use, improving psychiatric symptoms, and determining an effect size for future studies.

Methods: Thirty-one subjects with cocaine dependence and schizophrenia were randomized to olanzapine or haloperidol, underwent a cue-exposure procedure, and completed psychiatric and substance abuse ratings.

Results: Individuals in the olanzapine group who completed the study had a significant reduction on the energy subscale of the Voris Cocaine Craving Scale at study completion compared with individuals in the haloperidol group. The olanzapine-treated group also had lower, but not statistically significant, PANSS General Psychopathology Subscale scores and fewer positive urine toxicology screens compared with those in the haloperidol group.

Conclusion: This small, but rigorously controlled, pilot trial provides additional evidence for the use of atypical antipsychotics for the treatment of individuals with co-occurring schizophrenia and cocaine dependence. Reductions in craving were associated with medium to large effect sizes.
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February 2006

The validity and reliability of a brief measure of cocaine craving.

Drug Alcohol Depend 2006 Jul 27;83(3):233-7. Epub 2005 Dec 27.

Mental Health and Behavioral Sciences, Department of Veterans Affairs-New Jersey Health Care System, Lyons Campus Bldg. 143, 1521 Knollcroft Road, Lyons, NJ 07930-5000, USA.

Introduction: Although craving plays an important role in relapse, there are few brief, valid and reliable instruments to measure the desire to use cocaine in routine clinical practice. The 45-item Cocaine Craving Questionnaire-Now (CCQ-Now) is widely used in research, but its length makes its use in everyday clinical work relatively impractical. This study sought to determine the psychometric properties of the CCQ-Brief, a measure composed of 10 items from the CCQ-Now, in treatment-seeking cocaine abusers.

Method: Subjects with cocaine abuse or dependence (n=247) completed the CCQ-Brief, the CCQ-Now, the Voris Cocaine Craving Scale, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and the Addiction Severity Index.

Results: The CCQ-Brief was significantly correlated with the CCQ-Now (r=.85, p<.01), the CCQ-Now with the items in common with the CCQ-Brief removed (r=.78, p<.01), all four subscales of the VCCS (craving intensity: r=.47, p<.01; mood: r=.27, p<.01; energy: r=.30, p<.01; sick feelings: r=.28, p<.01), the BDI-II (r=.39, p<.01), the BAI (r=.35, p<.01) and recent drug use (r=.26, p<.01). The internal consistency of the CCQ-Brief was strong (alpha=.90).

Discussion: The CCQ-Brief is a valid and reliable instrument that can be easily administered as a measure of current cocaine craving.
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July 2006

A double-blind placebo-controlled pilot study of risperidone for decreasing cue-elicited craving in recently withdrawn cocaine dependent patients.

J Subst Abuse Treat 2004 Jul;27(1):45-9

Department of Veterans Affairs, VISN 3 Mental Illness Research, Education and Clinical Center, Bronx, NY, USA.

Cocaine use causes an initial increase in dopamine and serotonin neurotransmission that is largely responsible for the pleasurable and reinforcing effects of the drug. Dysregulation of these neurotransmitters during withdrawal plays an important role in craving. Recent research has focused on the use of dopamine and serotonin antagonists early in recovery to reduce cocaine craving in both schizophrenic and non-schizophrenic cocaine dependent patients. This 2-week, double blind, placebo-controlled study compared risperidone vs. placebo in reducing cue-elicited cocaine craving. Thirty-four subjects with cocaine dependence were randomized to either risperidone or a placebo and underwent a weekly cue-exposure procedure. Although both groups had a reduction in craving over time, there were no significant differences among those treated with risperidone (n=19) compared to those taking a placebo (n=16) on the four craving dimensions. The results do not support the hypothesis that risperidone reduces cocaine craving among non-schizophrenic cocaine-dependent individuals.
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July 2004

Cognitive disparity in schizophrenics with and without cocaine dependency.

J Subst Abuse Treat 2003 Jan;24(1):75-9

Department of Veterans Affairs, VISN 3 Mental Illness, Research, Education and Clinical Center, Bronx, NY 10451, USA.

Although cognition has been investigated in individuals with schizophrenia and in non-schizophrenic cocaine abusers, few studies have focused on cocaine-abusing schizophrenics. Previous studies have shown contradictory results despite the fact that individuals with schizophrenia and cocaine dependence have worse long-term outcomes, and that each disorder separately is associated with neuropsychological impairment. The present study intended to clarify these inconsistencies with a comprehensive neuropsychological battery. Twenty-four cocaine-dependent schizophrenics and 23 non-drug abusing schizophrenics were recruited from the VA. Participants were administered tests focusing on motor skills, processing speed, attention, concentration, and executive functioning. While individuals with schizophrenia and cocaine dependence performed worse on the Grooved Peg Board and the Stroop A, the non-drug abusing schizophrenics performed worse on Trails Part A and B. However, a MANOVA failed to show group differences in overall neuropsychological performance. These findings are similar to the existing literature and suggest that cocaine may compromise motor functioning.
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January 2003

An analysis of cue reactivity among persons with and without schizophrenia who are addicted to cocaine.

Psychiatr Serv 2002 Dec;53(12):1612-6

Department of Veterans Affairs Mental Illness Research, Education, and Clinical Center, VISN3, Bronx, NY, USA.

Objective: Persons with schizophrenia who are addicted to cocaine experience more psychiatric and substance abuse relapses and worse long-term outcomes than persons with only one of these conditions. This study examined whether individuals with cocaine dependence and schizophrenia experience more cue-elicited craving than those without schizophrenia.

Methods: Ninety-one cocaine-dependent participants who had been abstinent from cocaine for at least 72 hours were recruited from substance abuse treatment programs in the Veterans Affairs New Jersey Health Care System. The study used a cue-exposure paradigm to stimulate cocaine craving. A self-report instrument was used to measure changes from baseline in four areas: craving intensity, happy or depressed mood, increased or decreased energy, and physical health or sickness.

Results: The participants with schizophrenia (N=35) reported significantly more cocaine craving than those without schizophrenia (N=56). When data for participants who were cue reactive were analyzed without regard to diagnosis, 97 percent of the cocaine-dependent participants with schizophrenia were cue reactive, compared with 43 percent of those without schizophrenia.

Conclusions: Future research on cocaine dependence should focus on craving, particularly among patients with coexisting psychiatric disorders.
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December 2002

Risperidone decreases craving and relapses in individuals with schizophrenia and cocaine dependence.

Can J Psychiatry 2002 Sep;47(7):671-5

Department of Veterans Affairs, VISN 3 Mental Illness, Research, Education and Clinical Center, Lyons, New Jersey, USA.

Objective: To examine the efficacy of atypical neuroleptics for decreasing craving and drug relapses during protracted withdrawal in individuals dually diagnosed with schizophrenia and cocaine dependence.

Method: We conducted a 6-week, open-label pilot study comparing risperidone with typical neuroleptics in a sample of withdrawn cocaine-dependent schizophrenia patients.

Results: Preliminary results suggest that individuals treated with risperidone had significantly less cue-elicited craving and substance abuse relapses at study completion. Further, they showed a trend toward a greater reduction in negative and global symptoms of schizophrenia.

Conclusion: Atypical neuroleptics may help reduce craving and relapses in this population. Future research should include more rigorous double-blind placebo-controlled studies with this class of medications.
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September 2002

Executive and motor skill functioning among cocaine-dependent schizophrenics and non-drug-abusing schizophrenics.

J Nerv Ment Dis 2002 Mar;190(3):200-2

VA New Jersey Health Care System, Lyons and East Orange, New Jersey, MH&BS (116A), 151 Knollcroft Road, Lyons, New Jersey 07939, USA.

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March 2002