As a clinical health psychologist and a health services researcher, Dr. Trivedi envisions a culturally attuned health care system that are not only patient centered, but framily centered. Such a system would engage and empower framily (family members and friends) in navigating the healthcare system on the patient’s behalf while receiving the culturally attuned supports and services receive that they need. Her studies have provided insights into how framilies and chronically and seriously ill patients collaborate around their mutual health, understanding the impact of their interpersonal relationship on chronic illness self-management, and the individual, dyadic, and systems-level barriers that they encounter. She has developed two technology-enabled dyadic self-management programs to address the stress management needs of both patients and their framily. She has been PI or co-I on several VA and NIH funded projects, including the funded Elizabeth Dole Center of Excellence for Veterans and Caregiver Research. This is a 4-site, virtual center of excellence to understand and address the unmet needs of caregivers of seriously ill Veterans. She serves as the Director of Caregiving and Family Systems at the Stanford Center for Asian Health Research and Education (CARE). A secondary interest for Dr. Trivedi is to improve the management of mental health conditions in primary care settings. She has conducted several national evaluations on the effects of the VA patient centered medical home model on Veterans with mental health conditions. These studies have formed the basis of policy briefs that have influenced VA policy. Her work has been recognized through several awards, including a VA HSR&D Career Development Award, Sojourns Scholars Leadership Program, and American Psychological Association's Leadership Institute for Women in Psychology. Dr. Trivedi is passionate about training the next generation and frequently mentors graduate students, psychology interns, and postdoctoral and post-residency fellows. She is the Training Director at the Center for Innovation to Implementation at the VA Palo Alto Health Care System and the national Training Director of the Elizabeth Dole National Center of Excellence for Veteran and Caregiver Research, and provides regular mentorship to 12-15 postdoctoral and post-residency fellows focusing on health services research, medical informatics, and the science of informal caregiving. She serves on the Health Policy council of the Society for Health Psychology and is part of the Research Collaborative of the National Alliance of Caregiving.

Academic Appointments

  • Associate Professor - University Medical Line, Psychiatry and Behavioral Sciences

Administrative Appointments

  • Associate Faculty, Center for Asian Health Research and Education (2019 - Present)
  • Faculty Affiliate, Stanford Palliative Care Center for Excellence (2018 - Present)
  • Assistant Professor, Dept of Psychiatry and Behavioral Sciences, Stanford University (2016 - Present)
  • Faculty Affiliate, Stanford Community Health Promotion Research Center (2016 - Present)
  • Faculty Affiliate, Stanford Center for Longevity, Stanford University (2016 - Present)
  • Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System (2013 - Present)
  • Research Assistant Professor, Dept. of Health Services, University of Washington (2009 - 2013)

Honors & Awards

  • Outstanding Abstract Award, Society for Behavioral Medicine, Population Health Sciences Special Interest Group. (April 2021)
  • Citation Abstract Award, Society for Behavioral Medicine (April 2020)
  • Annual Chairman's Award for Education Excellence, Department of Psychiatry and Behavioral Sciences, Stanford University (2020)
  • Finalist (one of three) for VA Health Services Research and Development Paper of the Year, VA Health Services Research & Development (2020)
  • Leadership Institute for Women in Psychology, American Psychological Association (2020)
  • Sojourns Scholars Leadership Award, Cambia Health Foundation (2019-2021)
  • Annual Chairman's Award on Leadership and Professionalism, Department of Psychiatry and Behavioral Sciences, Stanford University (2019)
  • McCormick Faculty Fellowship Award for Women Leaders in Medicine, Stanford University (2017)
  • Presidential Citation, Society for Health Psychology (Division 38 of the American Psychological Association) (2015)
  • Early Career Professional Travel Award, American Psychological Association (2013)
  • Fellow, NIH OBSSR Summer Institute on the Design and Conduct of RCT Involving Behavioral Interventions (2010)
  • Fellow, “Mind-Body Science, Tools, and Strategies”, NHLBI Pittsburgh Mind-Body Center Summer Institute (2010)
  • Fellow, "Interventions: Reducing Risk and Promoting Adjustment to Disease”, NHLBI Pittsburgh Mind-Body Center Summer Institute (2009)
  • Fellow, 14th Annual Summer Research Institute in Geriatric Psychiatry (2008)
  • Citation Poster (top 5% of all abstracts), American Psychosomatic Society (2006)
  • Young Scholar Award, American Psychosomatic Society (2006)
  • Citation Poster (top 5% of all abstracts), American Psychosomatic Society (2003)
  • Claire Hamilton Travel Award, Duke University (2002)
  • Harold H. Moon Outstanding Graduate Student Award, Augusta Area Psychological Association (1998)
  • Inductee, Phi Kappa Phi National Multidisciplinary Honor Society (1998)
  • Outstanding Graduate Student Award, Dept. of Psychology, Augusta State University (1998)
  • First in Psychology (Major), Maharaja Sayajirao University of Baroda, India (1996)
  • Shri Janardan C. Mehta Gold Medal for Bachelor of Arts, Maharaja Sayajirao University of Baroda, India (1996)
  • First in Sociology (Minor), Maharaja Sayajirao University of Baroda, India (1995)
  • Inductee, Psi Chi, National Honor Society for Psychology (1995)

Boards, Advisory Committees, Professional Organizations

  • Lead, Wellness Subcommittee on Caregiving, Dept of Psychiatry and Behavioral Sciences, Stanford University (2019 - Present)
  • Member, VA National Caregiver Subcommittee to Determine National Assessment Guidelines (2019 - Present)
  • Member, Society of Behavioral Medicine (2019 - Present)
  • Advisor, Stanford Health Care Caregiver Initiative (2018 - Present)
  • Co-director, Stanford/Intermountain Fellowship in Population Health Sciences (2018 - Present)
  • Member, Health Policy Council, Society for Health Psychology (2018 - Present)
  • Member, National Academies of Medicine (Digital Health Collaborative Workgroup) (2018 - Present)
  • Co-Director, Postdoctoral Fellowship in Health Services Research, Center for Innovation to Implementation, VA Palo Alto (2017 - Present)
  • Co-Director, Research Fellowship in Medical Informatics, Center for Innovation to Implementation, VA Palo Alto (2017 - Present)
  • Co-Director, Postresidency Fellowship in Health Services Research, Center for Innovation to Implementation, VA Palo Alto (2017 - Present)
  • Education Lead, Center for Innovation to Implementation, VA Palo Alto Health Care System (2017 - Present)
  • Member, Gerontological Society of America (2017 - Present)
  • Expert Consultant, Technical Expert Panel for an evidence synthesis of “Impact of informal caregiving on care recipients with mental illness/mental health issues and/or cognitive impairment” (2017 - 2017)
  • Chair, VA National Caregiver Research Interest Group (2016 - Present)
  • Chair, Mental Health Workgroup, VA National PACT Evaluation (2012 - 2018)
  • Member, Branding Task Force, Society for Health Psychology (Div 38 of American Psychological Association) (2012 - 2015)
  • Executive Committee Member, Early Career Professional Council, Society for Health Psychology (Div 38 of American Psychological Association) (2010 - 2013)
  • Web Liaison, Society for Health Psychology (Div 38 of American Psychological Association) (2010 - 2013)
  • Member, American Psychological Association (2001 - Present)

Professional Education

  • Fellowship, Duke University Medical Center, Health Services Research (2009)
  • BA, Maharaja Sayajirao University of Baroda (India), Clinical Psychology (1996)
  • MS, Augusta State University, Clinical Psychology (1998)
  • MA, Duke University, Clinical Psychology (Health track) (2004)
  • PhD, Duke University, Clinical Psychology (Health track) (2006)

Current Research and Scholarly Interests

Enhancing the role of informal caregivers in chronic disease self-management; assessment and treatment of mental illness in primary care settings; psychosocial antecedents and consequences of cardiovascular disease.

Clinical Trials

  • Caring Others Increasing EngageMent in PACT Not Recruiting

    This trial will compare two methods of increasing engagement in care and success in diabetes management, among patients with diabetes with high-risk features, who also have family members involved in their care.

    Stanford is currently not accepting patients for this trial.

    View full details


  • Elizabeth Dole Center for Veteran and Caregiver Research, VA Palo Alto

    This 4 site national center of excellence was funded by the VA to understand the unmet needs of caregivers and develop strategies to meet these needs. Dr. Trivedi is site PI and part of core leadership. The local pilot will focus on evaluating caregivers' access to home and community based services, and develop a technology enabled tool to connect caregivers to existing resources.


    795 Willow Rd Menlo Park CA

  • Testing a web-based self-management program for chronically ill patients and their families, VA Palo Alto/Stanford

    We have developed and are pilot testing a behavioral intervention that targets the stress management needs of patients who have chronic medical or mental illnesses, and their families.


    795 Willow Rd Menlo Park CA

  • SUCCEED: A dyadic self-management program for patients with heart failure and their families, Stanford University

    We are conducting a pilot test of a 5 session, telephone-based, self-management program that targets the needs of patients with heart failure and their family members.


    VA Palo Alto/Stanford

  • SAFAD: South Asian Framily Approaches to Diseases, Stanford University

    In this project, we aim to understand the unmet needs of South Asian women with breast cancer and their framily-family and friends-and use these insights to develop an intervention to improve culturally tailored care.


    Stanford, CA and surrounding communities

2023-24 Courses

Stanford Advisees

Graduate and Fellowship Programs

  • Community Health and Prevention Research (Masters Program)

All Publications

  • Supporting Veterans, Caregivers, and Providers in Rural Regions With Tele-Geriatric Psychiatry Consultation: A Mixed Methods Pilot Study. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry Gould, C. E., Carlson, C., Alfaro, A. J., Trivedi, R., Savell, A. D., Mehta, P. S., Burningham, Z., Peeples, A., Filips, J. 2023


    Cross-facility tele-geriatric psychiatry consultation is a promising model for providing specialty services to regions lacking sufficient geriatric psychiatry expertise. This evaluation focused on assessing the feasibility and acceptability of a consultation program developed by a geriatric psychiatrist in a Veterans Health Administration regional telehealth hub.Concurrent, mixed methods program evaluation.A region served by a VA health care system telehealth hub.Patients with at least 1 geriatric mental health encounter with a geriatric psychiatrist consultant during a 1 year-period; referring providers.Virtual psychiatric evaluation of Veterans with time-limited follow-up and e-consultation with providers.Interviews with consultant, medical record data, and referring provider surveys.Three hundred fifteen Veterans (M = 76.0 ± 9.64 years; 40% rural-dwelling) had 666 encounters (M = 2.11 ± 1.78) with most occurring via clinical video telehealth (n = 443; 67.6%), e-consultation (n = 99; 15.1%), or video to home (n = 95; 14.5%). Most encounters were related to neurocognitive disorders, depressive disorders, trauma-related disorders, or serious mental illness. Referring providers (N = 58) highly recommended the program, reported high satisfaction, followed through with recommendations, and believed that this program increased access to geriatric psychiatry.This single program was shown to be feasible, acceptable, and valued by the referring providers. The findings highlighted the complex presentations of Veterans referred, and the current unmet need of providers of such Veterans, providing impetus for wider implementation.

    View details for DOI 10.1016/j.jagp.2023.01.005

    View details for PubMedID 36754647

  • Delivering Virtual Care to Patients with Cognitive Impairment within the Veterans Health Administration: Multi-level Barriers and Solutions. Journal of technology in behavioral science Gould, C. E., Iyer, S., Filips, J., Alfaro, A. J., Carlson, C., Trivedi, R. 2022: 1-9


    Older patients with cognitive impairment, including dementia, may benefit from virtual care that increases access to geriatric specialties. Here, we identify clinician-level strategies to address the numerous barriers that reduce utilization of virtual services. We describe two innovative programs in the Veterans Health Administration that deliver geriatric medicine and geriatric psychiatry services virtually. This commentary outlines concrete strategies addressing identified barriers, including technology access, digital literacy, and ambivalence and communication challenges during video visits. Two virtual care programs (tele-geriatric psychiatry consultation; tele-dementia care) that address complex medical and mental health issues in older adults with cognitive impairment are described. The Consolidated Framework for Implementation Research (CFIR) is used to categorize the clinician-level strategies and program elements as they relate to the implementation domains and constructs. Clinicians can use education strategies prior to and during virtual care visits to facilitate access to video, optimize the virtual experience, and promote information retention. These strategies rely on aspects of the inner setting, outer setting, and characteristics of individuals. The two virtual programs vary in their intervention characteristics and the inner setting, yet both programs share similar characteristics of individuals. Key elements contributing to adoption and sustainment of these virtual care programs for patients with cognitive impairment include the relative advantage of virtual care to leverage access to specialists over alternative solutions in each setting. Other factors to consider include the importance of communication, program champions, and the role of the Veterans Health Administration.

    View details for DOI 10.1007/s41347-022-00291-1

    View details for PubMedID 36530384

  • Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes: A Randomized Clinical Trial. JAMA network open Rosland, A., Piette, J. D., Trivedi, R., Lee, A., Stoll, S., Youk, A. O., Obrosky, D. S., Deverts, D., Kerr, E. A., Heisler, M. 2022; 5 (11): e2237960


    Importance: More than 75% of US adults with diabetes do not meet treatment goals. More effective support from family and friends ("supporters") may improve diabetes management and outcomes.Objective: To determine if the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention improves patient activation, diabetes management, and outcomes compared with standard care.Design, Setting, and Participants: This randomized clinical trial was conducted from November 2016 to August 2019 among participants recruited from 2 Veterans Health Administration primary care sites. All patient participants were adults aged 30 to 70 years with diabetes who had hemoglobin A1c (HbA1c) levels greater than 8% of total hemoglobin (to convert to proportion of total hemoglobin, multiply by 0.01) or systolic blood pressure (SBP) higher than 150 mm Hg; each participating patient had an adult supporter. Of 1119 recruited, 239 patient-supporter dyads were enrolled between November 2016 and May 2018, randomized 1:1 to receive the CO-IMPACT intervention or standard care, and followed up for 12 to 15 months. Investigators and analysts were blinded to group assignment.Interventions: Patient-supporter dyads received a health coaching session focused on dyadic information sharing and positive support techniques, then 12 months of biweekly automated monitoring telephone calls to prompt dyadic actions to meet diabetes goals, coaching calls to help dyads prepare for primary care visits, and after-visit summaries. Standard-care dyads received general diabetes education materials only.Main Outcomes and Measures: Intent-to-treat analyses were conducted according to baseline dyad assignment. Primary prespecified outcomes were 12-month changes in Patient Activation Measure-13 (PAM-13) and UK Prospective Diabetes Study (UKPDS) 5-year diabetes-specific cardiac event risk scores. Secondary outcomes included 12-month changes in HbA1c levels, SBP, diabetes self-management behaviors, diabetes distress, diabetes management self-efficacy, and satisfaction with health system support for the involvement of family supporters. Changes in outcome measures between baseline and 12 months were analyzed using linear regression models.Results: A total of 239 dyads enrolled; among patient participants, the mean (SD) age was 60 (8.9) years, and 231 (96.7%) were male. The mean (SD) baseline HbA1c level was 8.5% (1.6%) and SBP was 140.2 mm Hg (18.4 mm Hg). A total of 168 patients (70.3%) lived with their enrolled supporter; 229 patients (95.8%) had complete 12-month outcome data. In intention-to-treat analyses vs standard care, CO-IMPACT patients had greater 12-month improvements in PAM-13 scores (intervention effect, 2.60 points; 95% CI, 0.02-5.18 points; P=.048) but nonsignificant differences in UKPDS 5-year cardiac risk (intervention effect, 1.01 points; 95% CI, -0.74 to 2.77 points; P=.26). Patients in the CO-IMPACT arm also had greater 12-month improvements in healthy eating (intervention effect, 0.71 d/wk; 95% CI, 0.20-1.22 d/wk; P=.007), diabetes self-efficacy (intervention effect, 0.40 points; 95% CI, 0.09-0.71 points; P=.01), and satisfaction with health system support for the family supporter participants' involvement (intervention effect, 0.28 points; 95% CI, 0.07-0.49 points; P=.009); however, the 2 arms had similar improvements in HbA1c levels and in other measures.Conclusions and Relevance: In this randomized clinical trial, the CO-IMPACT intervention successfully engaged patient-supporter dyads and led to improved patient activation and self-efficacy. Physiological outcomes improved similarly in both arms. More intensive direct coaching of supporters, or targeting patients with less preexisting support or fewer diabetes management resources, may have greater impact.Trial Registration: Identifier: NCT02328326.

    View details for DOI 10.1001/jamanetworkopen.2022.37960

    View details for PubMedID 36374502

  • CHALLENGES AND SUPPORTS FOR VETERAN CAREGIVERS DURING THE COVID-19 PANDEMIC: A MIXED-METHODS STUDY Penney, L., Noel, P., Hernandez-Swift, K., Leykum, L., Trivedi, R., Dang, S., Kalvesmaki, A., Butler, J. OXFORD UNIV PRESS. 2022: 288
  • CULTURALLY CONCORDANT CARE: CLINICIAN PERSPECTIVES ON PROVIDING CANCER CARE TO SOUTH ASIANS Singh, N., Manja, V., Pukhraj, A., Risbud, R., Desai, S., Schapira, L., Lorenz, K., Trivedi, R. OXFORD UNIV PRESS. 2022: 636
  • SOCIAL SUPPORT DYNAMICS FOR SOUTH ASIAN BREAST CANCER PATIENTS: AN ANALYSIS CONDUCTED USING ATLAS CAREMAPS Trivedi, R., Pukhraj, A., Desai, S., Shah, R., Risbud, R., Schapira, L., Gallagher-Thompson, D., Lorenz, K. OXFORD UNIV PRESS. 2022: 599
  • UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HCBS AMONG CAREGIVERS OF VETERANS OF ALL ERAS Trivedi, R., Ngo, V., Lee, T., Humber, M., Risbud, R., Desai, S., Jacobs, J., Gallagher-Thompson, D. OXFORD UNIV PRESS. 2022: 45
  • It Takes a Village Interpersonal Factors That Enhance Management of Heart Failure Risbud, R. D., Kim, J., Trivedi, R. B. LIPPINCOTT WILLIAMS & WILKINS. 2022: E160-E168


    Heart failure (HF) management can be improved by involving framily (family and friends) who provide valuable support. Less is known about how dyadic interactions or interactions between dyads and their extended care networks positively impact life with HF.This study aimed to understand the positive behavioral, cognitive, and social factors through which patient-framily dyads manage health together.Heart failure patient-framily dyads were recruited through Stanford heart failure clinics. Participants completed a 45-minute semistructured interview that elicited their experiences with managing HF. Interviews were audio recorded, transcribed for analysis, and independently coded by 2 team members using thematic analyses.Seventeen dyads (n = 34) participated in the study; 47% of patients and 78% of framily were women. Mean (SD) age of patients was 66 (14) years, and mean (SD) age of framily caregivers was 59 (12.3) years. Three themes showcased the positive contributions of dyadic HF management: (1) management of HF was perceived as successful when individuals in a dyad both received support from a shared care network; (2) when strength of the interpersonal relationship and love were the main motivators for care, dyads reported a positive outlook on quality of life with HF; and (3) the framily caregivers' own health conditions affected the dyadic relationship and perceived success with HF management.Social support by an external network and mutual support within a patient-framily dyad both create an environment of optimism and effective coping, making successful HF management possible. A dyad's success with these factors may result in better condition management and perceived quality of life.

    View details for DOI 10.1097/JCN.0000000000000862

    View details for Web of Science ID 000838819000007

    View details for PubMedID 35952314

  • Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. Journal of general internal medicine Trivedi, R. B., Rossi, F. S., Javier, S. J., Greene, L., Singer, S. J., Vanneman, M. E., Goldstein, M., Zulman, D. M. 2022


    BACKGROUND: Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions.OBJECTIVE: To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions.DESIGN: Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data.PARTICIPANTS: 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization.MAIN OUTCOME AND MEASURES: The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care.KEY RESULTS: In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30).CONCLUSIONS: Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.

    View details for DOI 10.1007/s11606-022-07705-z

    View details for PubMedID 35869316

  • Systematic Review of Dyadic Interventions for Ambulatory Care Sensitive Conditions: Current Evidence and Key Gaps. Clinical gerontologist Wooldridge, J. S., Rossi, F. S., Anderson, C., Yarish, N. M., Pukhraj, A., Trivedi, R. B. 2022: 1-29


    OBJECTIVES: Identify non-pharmacological interventions to support patient/caregiver dyads with ACSCs; review the effects of dyadic interventions on health services outcomes; and review the effectiveness of dyadic interventions on patient and caregiver biopsychosocial outcomes.METHODS: A systematic review of randomized controlled trials (RCTs).RESULTS: Twenty-six manuscripts representing 20 unique RCTs (Mean N = 154 patients, 140 caregivers) were eligible. Eleven RCTs examined caregiving in patients with HF, seven with T2DM, one with COPD, and one with mixed ACSCs. Dyadic interventions for ACSCs were diverse in terms of length and content, with most including an educational component. Only 4/26 included studies had a low risk of bias. Interventions were most successful at improving quality of life, clinical health outcomes, health behaviors, and health services outcomes, with fewer improvements in patient mental health outcomes, psychosocial outcomes, relationship outcomes, and caregiver outcomes in general. The largest effect sizes were reported from trials focused on T2DM.CONCLUSIONS: High-quality research with consistent measuring instruments is needed to understand which interventions are associated with improved patient and caregiver outcomes.CLINICAL IMPLICATIONS: There may be clinically relevant benefits to including caregivers in interventions for patients with ACSCs, and clinicians should consider this when devising treatment plans.

    View details for DOI 10.1080/07317115.2022.2086089

    View details for PubMedID 35713392

  • Patterns of Adverse Childhood Experiences and Cardiovascular Risk Factors in U.S. Adults. Stress and health : journal of the International Society for the Investigation of Stress Wooldridge, J. S., Tynan, M., Rossi, F. S., Gasperi, M., McLean, C. L., Bosch, J., Trivedi, R. B., Herbert, M. S., Afari, N. 2022


    Adverse Childhood Experiences (ACEs) are associated with poor health yet, we know little about how distinct patterns of ACE types are associated with cardiovascular (CVD) risk factors. The current study 1) examined associations of latent ACE classes with modifiable CVD risk factors including high cholesterol, smoking, diabetes, hypertension, high triglycerides, physical inactivity, overweight/obesity, and lifetime depression; and 2) examined the impact of socioeconomic status-related (SES) factors on these relationships. Using a cross-sectional analysis of the NESARC-III (n=36,309) data, four latent classes of ACEs were previously identified: 1) low adversity, 2) primarily household dysfunction, 3) primarily maltreatment, and 4) multiple adversity types. We examined the association of these classes with CVD risk factors in adulthood and subsequently, the same model accounting for SES-related factors. Tobacco smoking, overweight/obesity, and lifetime depression were each associated with higher odds of being in classes 2, 3, and 4 than class 1, respectively. These relationships held after adjusting for SES-related factors. Class 4 was associated with the most CVD risk factors, including high triglycerides and high cholesterol after controlling for SES-related factors. The consistent associations between tobacco smoking, overweight/obesity, and lifetime depression with each adverse ACE profile, even after controlling for SES, suggest behavioral CVD prevention programs should target these CVD risk factors simultaneously. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/smi.3167

    View details for PubMedID 35618265

  • Author Correction: Care-seeking and delay of care during COPD exacerbations. NPJ primary care respiratory medicine Locke, E. R., Young, J. P., Battaglia, C., Simpson, T. L., Trivedi, R., Simons, C., Fortney, J. C., Hebert, P., Swenson, E. R., Edelman, J., Fan, V. S. 2022; 32 (1): 16

    View details for DOI 10.1038/s41533-022-00279-7

    View details for PubMedID 35462558

  • CAREGIVING FOR LOVED ONES AT HIGH RISK FOR SEVERE COVID-19 ILLNESS. Suresh, M., Humber, M. B., Jacobs, J., Thomas, S. C., Lee, T., Risbud, R. D., Trivedi, R. B. OXFORD UNIV PRESS INC. 2022: S62
  • UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HOME AND COMMUNITY-BASED SERVICES AMONG CAREGIVERS OF VETERANS OF ALL ERAS Trivedi, R. B., Desai, S., Risbud, R. D., Humber, M. B., Lee, T., Ngo, V., Jacobs, J., Yefimova, M., Lorenz, K., Asch, S. M., Gallagher-Thompson, D. OXFORD UNIV PRESS INC. 2022: S582
  • Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health services research Zulman, D. M., Greene, L., Slightam, C., Singer, S. J., Maciejewski, M. L., Goldstein, M. K., Vanneman, M. E., Yoon, J., Trivedi, R. B., Wagner, T., Asch, S. M., Boothroyd, D. 2022


    OBJECTIVE: To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.DATA SOURCES: Veterans Affairs (VA) and Medicare data.STUDY DESIGN: We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.DATA EXTRACTION METHODS: We extracted data for 130,704 VA patients ≥65years old with a hospitalization risk ≥90th percentile and≥four outpatient visits in the baseline year.PRINCIPAL FINDINGS: Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI=1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).CONCLUSIONS: Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

    View details for DOI 10.1111/1475-6773.13956

    View details for PubMedID 35178702

  • Recommendations to Improve Health Outcomes Through Recognizing and Supporting Caregivers. Journal of general internal medicine Leykum, L. K., Penney, L. S., Dang, S., Trivedi, R. B., Noel, P. H., Pugh, J. A., Shepherd-Banigan, M. E., Pugh, M. J., Rupper, R., Finley, E., Parish-Johnson, J., Delgado, R., Peacock, K., Kalvesmaki, A., Van Houtven, C. H. 1800

    View details for DOI 10.1007/s11606-021-07247-w

    View details for PubMedID 34981348

  • Care-seeking and delay of care during COPD exacerbations. NPJ primary care respiratory medicine Locke, E. R., Young, J. P., Battaglia, C., Simpson, T. L., Trivedi, R., Simons, C., Fortney, J. C., Hebert, P., Swenson, E. R., Edelman, J., Fan, V. S. 2022; 32 (1): 7


    Patients who receive earlier treatment for acute exacerbations of chronic obstructive pulmonary disease (COPD) have a better prognosis, including earlier symptom resolution and reduced risk of future emergency-department visits (ED) or hospitalizations. However, many patients delay seeking care or do not report worsening symptoms to their healthcare provider. In this study, we aimed to understand how patients perceived their breathing symptoms and identify factors that led to seeking or delaying care for an acute exacerbation of COPD. We conducted semistructured interviews with 60 individuals following a recent COPD exacerbation. Participants were identified from a larger study of outpatients with COPD by purposive sampling by exacerbation type: 15 untreated, 15 treated with prednisone and/or antibiotics in the outpatient setting, 16 treated in an urgent care or ED setting, and 14 hospitalized. Data were analyzed using inductive content analysis. Participants were primarily male (97%) with a mean age of 69.1 ± 6.9 years, mean FEV1 1.42 (±0.63), and mean mMRC dyspnea of 2.7 (±1.1). We identified 4 primary themes: (i) access and attitudinal barriers contribute to reluctance to seek care, (ii) waiting is a typical response to new exacerbations, (iii) transitioning from waiting to care-seeking: the tipping point, and (iv) learning from and avoiding worse outcomes. Interventions to encourage earlier care-seeking for COPD exacerbations should consider individuals' existing self-management approaches, address attitudinal barriers to seeking care, and consider health-system changes to increase access to non-emergent outpatient treatment for exacerbations.Clinical Trial Registration NCT02725294.

    View details for DOI 10.1038/s41533-022-00269-9

    View details for PubMedID 35169140

  • Patient and Supporter Factors Affecting Engagement With Diabetes Telehealth AMERICAN JOURNAL OF MANAGED CARE Zupa, M. F., Piette, J. D., Stoll, S. C., Obrosky, D., Boudreaux-Kelly, M., Youk, A. O., Overholt, L., Trivedi, R., Heisler, M., Rosland, A. 2021; 27 (10): 409-+


    To assess what patient, family supporter, and call characteristics predicted whether patients completed automated and coach-provided calls in a telehealth diabetes intervention.A total of 123 adults with type 2 diabetes and high glycated hemoglobin A1c (HbA1c) or blood pressure, enrolled with a family supporter, received automated interactive voice response (IVR) and coach-provided visit preparation calls over 12 months.Data from baseline surveys and diabetes-related clinical information from patient medical records were entered into multilevel, multivariate regression models of associations between participant and call characteristics with call completion.A total of 76.3% of 2784 IVR calls and 75.8% of 367 visit preparation calls were completed. For IVR calls, patients with recent call-triggered provider alerts had higher odds of call completion (adjusted odds ratio [AOR], 3.5; 95% CI, 2.2-5.5); those with depressive symptoms (AOR, 0.4; 95% CI, 0.2-0.9), higher HbA1c (AOR, 0.8; 95% CI, 0.6-0.99), and more months in the study (AOR, 0.9; 95% CI, 0.87-0.94 per month) had lower odds. For visit preparation calls, higher patient activation scores predicted higher call completion (AOR, 1.4; 95% CI, 1.1-1.9); patient college education predicted less call completion (AOR, 0.3; 95% CI, 0.2-0.6). Supporter help taking medications predicted less completion of both call types. Patient age did not predict call completion.Patients of all ages completed telehealth calls at a high rate. Automated IVR calls were completed more often when urgent issues were identified to patients' providers, but less often if patients had high HbA1c or depression. Visit preparation call content should be tailored to patient education level. Family help with medications may identify patients needing additional support to engage with telehealth.

    View details for DOI 10.37765/ajmc.2021.88758

    View details for Web of Science ID 000710956700008

    View details for PubMedID 34668669

  • Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study. BMJ quality & safety Kaboli, P. J., Augustine, M. R., Haraldsson, B., Mohr, N. M., Howren, M. B., Jones, M. P., Trivedi, R. 2021


    BACKGROUND: Veteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA).OBJECTIVE: To examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors.METHODS: Retrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011-2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%-90%, 90.1%-95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution.RESULTS: From 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%-82.2%) to 65.4% (IQR 53.9%-79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%-90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%-95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time.CONCLUSIONS: High VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution.

    View details for DOI 10.1136/bmjqs-2020-012975

    View details for PubMedID 34400537

  • Impact of a Dyadic Intervention on Family Supporter Involvement in Helping Adults Manage Type 2 Diabetes. Journal of general internal medicine Zupa, M. F., Lee, A., Piette, J. D., Trivedi, R., Youk, A., Heisler, M., Rosland, A. 2021


    BACKGROUND: Family support for adults' diabetes care is associated with improved self-management and outcomes, but healthcare providers lack structured ways to engage those supporters.OBJECTIVE: Assess the impact of a patient-supporter diabetes management intervention on supporters' engagement in patients' diabetes care, support techniques, and caregiving experience.DESIGN: Multivariate regression models examined between-group differences in support-related measures observed as part of a larger trial randomizing participants to a dyadic intervention versus usual care.PARTICIPANTS: A total of 239 adults with type 2 diabetes and either A1c >8% or systolic blood pressure >160mmHg enrolled with a family supporter.INTERVENTION: Health coaches provided training on positive support techniques and facilitated self-management information sharing and goal-setting.MAIN MEASURES: Patient and supporter reports at baseline and 12 months of supporter roles in diabetes care and caregiving experience.RESULTS: At 12 months, intervention-assigned patients had higher odds of reporting increased supporter involvement in remembering medical appointments (AOR 2.74, 95% CI 1.44, 5.21), performing home testing (AOR 2.40, 95% CI 1.29, 4.46), accessing online portals (AOR 2.34, 95% CI 1.29, 4.30), deciding when to contact healthcare providers (AOR 2.12, 95% CI 1.15, 3.91), and refilling medications (AOR 2.10, 95% CI 1.14, 3.89), but not with attending medical appointments or with healthy eating and exercise. Intervention-assigned patients reported increased supporter use of autonomy supportive communication (+0.27 points on a 7-point scale, p=0.02) and goal-setting techniques (+0.30 points on a 5-point scale, p=0.01). There were no differences at 12 months in change scores measuring supporter distress about patients' diabetes or caregiving burden. Intervention-assigned supporters had significantly larger increases in satisfaction with health system support for their role (+0.88 points on a 10-point scale, p=0.01).CONCLUSIONS: A dyadic patient-supporter intervention led to increased family supporter involvement in diabetes self-management and increased use of positive support techniques, without increasing caregiver stress.

    View details for DOI 10.1007/s11606-021-06946-8

    View details for PubMedID 34240285

  • Caregiver Experiences and Roles in Care Seeking During COPD Exacerbations: A Qualitative Study. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine Suresh, M., Young, J., Fan, V., Simons, C., Battaglia, C., Simpson, T. L., Fortney, J. C., Locke, E. R., Trivedi, R. 2021


    BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating illness characterized by exacerbations that require timely intervention. COPD patients often rely on informal caregivers-relatives or friends-for assistance with functioning and support. Caregivers perform roles that may be particularly important during acute exacerbations in monitoring symptoms and seeking medical intervention. However, little is known about caregivers' roles and experiences as they support their patients during exacerbations.PURPOSE: To explore the experiences, roles in care seeking, and needs of caregivers during COPD exacerbations.METHODS: Semi-structured interviews were conducted with 24 caregivers of Veterans with COPD who experienced a recent exacerbation. Interviews were recorded, transcribed, and analyzed using inductive content analysis.RESULTS: Five themes arose: (a) caregivers reported continuously monitoring changes in patients symptom severity to identify exacerbations; (b) caregivers described emotional reactions evoked by exacerbations and constant vigilance; (c) caregivers described disagreements with their patient in interpreting symptoms and determining the need for care seeking; (d) caregivers noted uncertainty regarding their roles and responsibilities in pursuing care and their approaches to promote care varied; and (e) expressed their need for additional information and support. Caregivers of patients with COPD often influence whether and when patients seek care during exacerbations. Discrepancies in symptom evaluations between patients and caregivers paired with the lack of information and support available to caregivers are related to delays in care seeking. Clinical practice should foster self-management support to patient-caregiver dyads to increase caregiver confidence and patient openness to their input during exacerbations.

    View details for DOI 10.1093/abm/kaab045

    View details for PubMedID 34165138

  • Long-term care service mix in the Veterans Health Administration after home care expansion. Health services research Jacobs, J. C., Wagner, T. H., Trivedi, R., Lorenz, K., Van Houtven, C. H. 2021


    OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.DATA SOURCES: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.STUDY DESIGN: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n=943) and nonusers (n=6106). We used a difference-in-differences approach with a person fixed-effects estimator.DATA COLLECTION/EXTRACTION METHODS: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.PRINCIPAL FINDINGS: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health.CONCLUSIONS: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.

    View details for DOI 10.1111/1475-6773.13687

    View details for PubMedID 34085283

  • Relationship Between Adult and Family Supporter Health Literacy Levels and Supporter Roles in Diabetes Management FAMILIES SYSTEMS & HEALTH Fields, B., Lee, A., Piette, J. D., Trivedi, R., Mor, M. K., Obrosky, D., Heisler, M., Rosland, A. 2021; 39 (2): 224-233


    Among adults with Type 2 diabetes, low health literacy (HL) is a risk factor for negative health outcomes. Support from family and friends can improve adults' self-management and health-related outcomes. We examined whether supporters provided unique help to adults with diabetes and low HL and whether HL was associated with adults' perception of supporter helpfulness.We used cross-sectional baseline survey data from 239 adult patients with diabetes enrolled in a randomized controlled trial with a support person. Patients reported level of supporter involvement with self-management roles. HL among patients and supporters was assessed using a validated HL screening tool. Patient perception of supporter helpfulness was assessed with a single item. We used multivariable logistic regression to examine associations of patient and supporter HL levels with supporter roles and patients' perception of supporter helpfulness.Patients with low HL were more likely to have a supporter with low HL (39% vs. 26%, p = .04). Patients with low HL had higher odds of receiving supporter help with calling health care providers (adjusted odds ratio [AOR] = 2.09, 95% CI [1.00, 4.39]), remembering medical appointments (AOR = 2.24, 95% CI [1.07, 4.69]), and giving directions when blood sugars were low (AOR = 2.51, 95% CI [1.20, 5.37]). Neither patient nor supporter HL was significantly associated with patients' perception of supporter helpfulness.Adults with diabetes and low HL reported more supporter involvement with specific self-management tasks than patients with adequate HL. Providers could consider targeted involvement of supporters to assist patients with chronic diseases and low HL, although they should be aware that supporters may be challenged by low HL. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

    View details for DOI 10.1037/fsh0000503

    View details for Web of Science ID 000687054400006

    View details for PubMedID 33370140

  • Psychotherapy and Depressive Symptom Trajectories Among VA Patients: Comparing Dose-Effect and Good-Enough Level Models JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Lee, A. A., Sripada, R. K., Hale, A. C., Ganoczy, D., Trivedi, R. B., Arnow, B., Pfeiffer, P. N. 2021; 89 (5): 379-392


    Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

    View details for DOI 10.1037/ccp0000645

    View details for Web of Science ID 000662048500002

    View details for PubMedID 34124925

  • ENGAGING FAMILY SUPPORTERS TO IMPROVE DIABETES OUTCOMES: A RANDOMIZED CONTROLLED TRIAL Rosland, A. K., Piette, J., Trivedi, R. B., Lee, A. A., Zupa, M., Stoll, S. C., Mor, M. K., Obrosky, D., Lovelace, E., Kerr, E., Heisler, M. OXFORD UNIV PRESS INC. 2021: S189
  • Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. Journal of medical Internet research Yank, V., Gale, R. C., Nevedal, A., Okwara, L., Koenig, C. J., Trivedi, R. B., Dupke, N. J., Kabat, M., Asch, S. M. 2021; 23 (1): e16495


    BACKGROUND: Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated.OBJECTIVE: This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed.METHODS: We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time.RESULTS: A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers.CONCLUSIONS: This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.

    View details for DOI 10.2196/16495

    View details for PubMedID 33410759

  • Supporting Indian and other South Asians facing COVID-19 and other serious illnesses. Journal of pain and symptom management Trivedi, R., Lorenz, K. A. 2021

    View details for DOI 10.1016/j.jpainsymman.2021.06.024

    View details for PubMedID 34271145

  • "Relationship between substance use disorder (SUD) and healthcare fragmentation patterns in veterans at high-risk for hospitalization" (SW19) Rossi, F., Timko, C., Javier, S. J., Zulman, D. M., Greene, L., Singer, S., Vanneman, M. E., Goldstein, M., Trivedi, R. BMC. 2020
  • Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration CHRONIC ILLNESS Slightam, C., Risbud, R., Guetterman, T. C., Nevedal, A. L., Nelson, K. M., Piette, J. D., Trivedi, R. B. 2020: 1742395320966366


    Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians.Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies.Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF.Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.

    View details for DOI 10.1177/1742395320966366

    View details for Web of Science ID 000598454900001

    View details for PubMedID 33115281

  • Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA network open Leung, L. B., Rubenstein, L. V., Post, E. P., Trivedi, R. B., Hamilton, A. B., Yoon, J., Jaske, E., Yano, E. M. 2020; 3 (10): e2020955


    Importance: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care.Objective: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women.Design, Setting, and Participants: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020.Exposures: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year.Main Outcomes and Measures: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration.Results: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P<.001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P<.001) and total costs (men: beta [SE], 2.23 [0.10]; women: beta [SE], 1.24 [0.15]; P=.06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P<.001).Conclusions and Relevance: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.

    View details for DOI 10.1001/jamanetworkopen.2020.20955

    View details for PubMedID 33079197

  • "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients CHRONIC ILLNESS Schwartz, R., Zulman, D., Gray, C., Goldstein, M. K., Trivedi, R. 2020; 16 (3): 201–11
  • OUTPATIENT CARE FRAGMENTATION PATTERNS AND ASSOCIATION WITH HOSPITALIZATION IN HIGH-RISK VA PATIENTS Zulman, D. M., Greene, A. L., Wagner, T. H., Maciejewski, M., Singer, S., Slightam, C., Trivedi, R., Vanneman, M., Asch, S., Yoon, J., Goldstein, M. K., Boothroyd, D. SPRINGER. 2020: S216
  • ASSOCIATION BETWEEN ACUTE INPATIENT BED AVAILABILITY AND RISK OF SUICIDE FOR PSYCHIATRIC PATIENTS Kaboli, P. J., Haraldsson, B., Simonetti, J. A., Howren, M., Jones, M., Mohr, N., Augustine, M. R., Trivedi, R. SPRINGER. 2020: S31
  • ENGAGING FAMILY SUPPORTERS TO IMPROVE DIABETES OUTCOMES: A RANDOMIZED CONTROLLED TRIAL Rosland, A., Piette, J. D., Trivedi, R., Lee, A. A., Zupa, M., Stoll, S., Mor, M. K., Obrosky, D., Lovelace, E., Kerr, E. A., Heisler, M. SPRINGER. 2020: S110
  • Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers. Gerontology & geriatrics education Wyman, M. F., Voils, C. I., Trivedi, R., Boyle, L., Goldman, D., Umucu, E., Zuelsdorff, M., Johnson, A. L., Gleason, C. E. 2020: 1–12


    Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N=65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.

    View details for DOI 10.1080/02701960.2020.1764356

    View details for PubMedID 32420824

  • Autonomy support from informal health supporters: links with self-care activities, healthcare engagement, metabolic outcomes, and cardiac risk among Veterans with type 2 diabetes. Journal of behavioral medicine Lee, A. A., Heisler, M. n., Trivedi, R. n., Leukel, P. n., Mor, M. K., Rosland, A. M. 2020


    This study examined the role of autonomy support from adults' informal health supporters (family or friends) in diabetes-specific health behaviors and health outcomes. Using baseline data from 239 Veterans with type 2 diabetes at risk of complications enrolled in behavioral trial, we examined associations between autonomy support from a support person and that support person's co-residence with the participant's diabetes self-care activities, patient activation, cardiometabolic measures, and predicted risk of a cardiac event. Autonomy support from supporters was associated with significantly increased adherence to healthy lifestyle behaviors (diet, p < .001 and exercise, p = .003); higher patient activation (p < .001); greater patient efficacy in interacting with healthcare providers, and lower 5-year (p = .044) and 10-year (p = .027) predicted cardiac risk. Autonomy support was not significantly associated with diabetes-specific behaviors (checking blood glucose, foot care, or medication taking); or hemoglobin A1c, systolic blood pressure, or non-HDL cholesterol. There was a significant interaction of autonomy support and supporter residence in one model such that lack of autonomy support was associated with lower patient activation only among individuals with in-home supporters. No other interactions were significant. Findings suggest that autonomy support from family and friends may play a role in patient self-management, patient activation, and lower cardiac risk.

    View details for DOI 10.1007/s10865-020-00196-5

    View details for PubMedID 33247416

  • Perceptions of time spent pursuing cancer care among patients, caregivers, and oncology professionals. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Hall, E. T., Sridhar, D. n., Singhal, S. n., Fardeen, T. n., Lahijani, S. n., Trivedi, R. n., Gray, C. n., Schapira, L. n. 2020


    Patients with cancer spend significant time receiving treatment and recovering from side effects. Little is known about how patients and their caregivers perceive time spent receiving cancer treatment and how this impacts health-related quality of life (HRQoL). Our study aims to characterize perceptions of time invested in receiving cancer therapy as experienced by patients, caregivers, and oncology professionals.We conducted semi-structured interviews with patients undergoing treatment for advanced lung cancer and melanoma, their informal caregivers, and oncology professionals (physicians, nurses, social workers, and chaplains). Participants received and provided care at a tertiary cancer center. Interviews were audiorecorded and transcribed verbatim. Transcripts were analyzed qualitatively using predominantly inductive coding to identify themes relating to time perception and cancer care.We interviewed 29 participants (11 patients, 7 informal caregivers, and 11 oncology professionals) and found they consistently differentiated between time remaining in life ("existential time") and time required to manage cancer treatment and symptoms ("chronological time"). Patients and caregivers reported distress around the mechanics of oncologic care that interrupted their daily lives (hobbies, activities). Participants described the impact of time invested in cancer care on dimensions of quality of life, ranging from minimal to substantial negative impact.We found that the time spent undergoing cancer treatment affects well-being and often prevents patients and caregivers from participating in meaningful activities. The investment of personal time undergoing cancer therapy for patients with advanced solid tumors merits further study and can enhance communication between patients, caregivers, and their oncologists.

    View details for DOI 10.1007/s00520-020-05763-9

    View details for PubMedID 32935204

  • Diabetes Distress Among Dyads of Patients and Their Health Supporters: Links With Functional Support, Metabolic Outcomes, and Cardiac Risk. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine Lee, A. A., Heisler, M. n., Trivedi, R. n., Obrosky, D. S., Mor, M. K., Piette, J. D., Rosland, A. M. 2020


    Patients with diabetes (PWD) often experience diabetes distress which is associated with worse self-management and glycemic control. In contrast, PWD who receive support from family and friends (supporters) have better diabetes outcomes.To examine the associations of PWD diabetes distress and supporters' distress about PWDs' diabetes with supporters' roles and PWD cardiometabolic outcomes.We used baseline data from 239 adults with Type 2 diabetes and their supporters participating in a longitudinal trial. PWD and supporter diabetes distress (high vs. low) were determined using the Problem Areas in Diabetes Scale-5. Outcomes included PWD-reported help from supporters with self-care activities, supporter-reported strain, PWD metabolic outcomes (glycemic control [HbA1c], systolic blood pressure [SBP], and non-HDL cholesterol) and 5 and 10 year risk of cardiac event (calculated using the United Kingdom Prospective Diabetes Study algorithm).PWDs with high diabetes distress were more likely to report that their supporters helped with taking medications, coordinating medical care, and home glucose testing (p's < .05), but not more likely to report help with diet or exercise. High supporter distress was associated with greater supporter strain (p < .001). High supporter diabetes distress was associated with higher PWD HbA1c (p = .045), non-HDL cholesterol (p = .011), and 5 (p = .002) and 10 year (p = .001) cardiac risk.Adults with high diabetes distress report more supporter help with medically focused self-management but not with diet and exercise. Supporter distress about PWD diabetes was consistently associated with worse outcomes. PWD diabetes distress had mixed associations with their diabetes outcomes.

    View details for DOI 10.1093/abm/kaaa081

    View details for PubMedID 33044495

  • Characteristics and Injury Mechanisms of Veteran Primary Care Suicide Decedents with and without Diagnosed Mental Illness. Journal of general internal medicine Simonetti, J. A., Piegari, R. n., Maynard, C. n., Brenner, L. A., Mori, A. n., Post, E. P., Nelson, K. n., Trivedi, R. n. 2020


    In the United States, suicide rates are increasing among nearly all age groups. Primary care is a critical setting for suicide prevention, where interventions often rely on identifying mental health conditions as indicators of elevated suicide risk.Quantify the proportion of suicide decedents within primary care who had no antecedent mental health or substance use diagnosis.Retrospective cohort study.Veterans who received Veterans Health Administration (VHA) primary care any time from 2000 to 2014 and died by suicide before 2015 (n = 27,741).We categorized decedents by whether they had any mental health or substance use diagnosis (yes/no) using ICD-9 codes available from VHA records. We compared sociodemographic, clinical, and suicide mechanism characteristics between groups using chi-square, Student's T, or Wilcoxon tests.Forty-five percent of decedents had no mental health or substance use diagnosis. Decedents without such a diagnosis were older (68 vs. 57 years, p < 0.001), and more likely to be male (98.3% vs. 95.8%, p < 0.001), non-Hispanic White (90.6% vs. 87.9%, p < 0.001), married/partnered (50.4% vs. 36.6%, p < 0.001), and without military service-connected disability benefits (72.6% vs. 56.9%, p < 0.001). They were also more likely to die from firearm injury (78.9% vs. 60.7%, p < 0.001). There were statistically significant differences in physical health between groups, but the magnitudes of those differences were small. Decedents without a mental health or substance use diagnosis had significantly shorter durations of enrollment in VHA healthcare, less healthcare utilization in their last year of life, and had little utilization aside from primary care visits.From 2000 to 2014, of nearly thirty thousand VHA primary care patients who died by suicide, almost half had no antecedent mental health or substance use diagnosis. Within VHA primary care settings, suicide risk screening for those with and without such a diagnosis is indicated.

    View details for DOI 10.1007/s11606-020-05787-1

    View details for PubMedID 32219647

  • Caring for Caregivers during COVID-19. Journal of the American Geriatrics Society Dang, S. n., Penney, L. S., Trivedi, R. n., Noel, P. H., Pugh, M. J., Finley, E. n., Pugh, J. A., Van Houtven, C. H., Leykum, L. n. 2020

    View details for DOI 10.1111/jgs.16726

    View details for PubMedID 32638348

  • The Dyadic Experience of Managing Heart Failure: A Qualitative Investigation. The Journal of cardiovascular nursing Kim, J. S., Risbud, R., Gray, C., Banerjee, D., Trivedi, R. 2019


    BACKGROUND: Self-management of heart failure (HF) is often a joint venture between patients and their friends and family ("framily"). However, this joint experience is often overlooked in clinical care.OBJECTIVES: The aim of this study was to understand the cognitive, emotional, and relational elements affecting the experience of patient-framily member dyads managing HF.METHODS: Participants were patients with HF receiving care at a university hospital and their framily. Dyads participated in 30- to 45-minute semistructured interviews before their clinic visit. Transcribed interviews were analyzed using thematic analyses. Interviews were coded independently and checked for interrater agreement before the final coded data set was developed. Participants were recruited until thematic saturation was attained.RESULTS: A total of 16 patient-framily member dyads and 1 triad (n = 35) participated in the study; 47.1% of patients and 77.8% of framily members were female. Patients were 66 years old (SD, 14 years) and framily members were 59 years old (SD, 12.3 years). Three aspects of the dyadic experience emerged in the themes: (1) health beliefs of dyads were characterized by acceptance and optimism, but also pessimism; (2) negative emotions influenced the dyadic experience; (3) the closeness of their interpersonal relationships influenced their contributions to managing HF.CONCLUSIONS: Our study suggests that greater attention to the experience and interpersonal relationships of dyads has the potential for improving HF self-management and facilitating patient-centered care.

    View details for DOI 10.1097/JCN.0000000000000605

    View details for PubMedID 31738215

  • Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms AGING & MENTAL HEALTH Bouldin, E. D., Aikens, J. E., Piette, J. D., Trivedi, R. B. 2019; 23 (9): 1122–29
  • Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter JOURNAL OF GERIATRIC PSYCHIATRY AND NEUROLOGY Schwartz, R., Trivedi, R., Gray, C., Lorenz, K. A., Zulman, D. 2019; 32 (5): 246–56
  • Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access. Health affairs (Project Hope) Leung, L. B., Rubenstein, L. V., Yoon, J., Post, E. P., Jaske, E., Wells, K. B., Trivedi, R. B. 2019; 38 (8): 1281–88


    Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11percent more mental health and 40percent more primary care visits but also with 9percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.

    View details for DOI 10.1377/hlthaff.2019.00270

    View details for PubMedID 31381382

  • Clinical Care Quality Among Veterans Health Administration Patients With Mental Illness Following Medical Home Implementation. Psychiatric services (Washington, D.C.) Browne, K. C., Hoerster, K. D., Piegari, R., Fortney, J. C., Nelson, K. N., Post, E. P., Fihn, S. D., Mori, A. M., Trivedi, R. B. 2019: appips201800474


    OBJECTIVE: This study sought to compare quality of care following medical home implementation among Veterans Health Administration (VHA) primary care patients with and without mental illness.METHODS: VHA primary care patients seen between April 2010 and March 2013 whose medical records were reviewed by the VHA External Peer Review Program were identified. The proportion of patients meeting quality indicators in each mental illness group (depression, posttraumatic stress disorder, anxiety disorder, substance use disorder, serious mental illness, and any mental illness) was compared with the proportion of patients without mental illness. Sample sizes ranged from 210,864 to 236,421. Differences of 5.0% or greater were deemed clinically important, and higher proportions indicated higher quality of care across 33 clinical indicators.RESULTS: The proportion of veterans meeting clinical quality indicators ranged from 64.7% to 99.6%. Differences of ≥5.0% between veterans with and without mental illness were detected in six of 33 indicators. A greater proportion of veterans with mental illness received influenza immunizations (age 50-64) and had documented left ventricular functioning (among veterans with chronic heart failure) compared with veterans without mental illness. A lower proportion of veterans with substance use disorders or severe mental illness received colorectal cancer screening or met indicators related to recommended medications if diagnosed as having diabetes or ischemic heart disease.CONCLUSIONS: Contrary to earlier reports of lower-quality care, patients with and without mental illness had similar preventive and chronic disease management care quality following medical home implementation.

    View details for DOI 10.1176/

    View details for PubMedID 31310189

  • Can We Improve Patient Adherence by Harnessing Social Forces? JOURNAL OF GENERAL INTERNAL MEDICINE Trivedi, R., Asch, S. M. 2019; 34 (6): 785–86
  • Can We Improve Patient Adherence by Harnessing Social Forces? Journal of general internal medicine Trivedi, R., Asch, S. M. 2019

    View details for PubMedID 30887442

  • "WHAT IS HAPPENING?", "HOW BAD IS IT?", "WHAT CAN I DO?": CAREGIVER EXPERIENCE AND CARE SEEKING DURING COPD EXACERBATIONS Young, J. P., Fan, V. S., Simons, C., Battaglia, C., Simpson, T., Locke, E., Swenson, E., Edelman, J. D., Kramer, C., Trivedi, R. OXFORD UNIV PRESS INC. 2019: S628
  • Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter. Journal of geriatric psychiatry and neurology Schwartz, R. n., Trivedi, R. n., Gray, C. n., Lorenz, K. A., Zulman, D. n. 2019: 891988719845509


    For patients with Parkinson's disease (PD), effective communication during neurology encounters is critical to ensuring the treatment plan maximizes quality of life. However, few research studies have engaged neurologists as key experts in identifying opportunities to optimize the clinical encounter. In this study, 16 neurologists from 4 clinic sites participated in hour-long semistructured interviews targeting opportunities to better address patients' quality of life needs.Neurologists identified opportunities to meet needs across 4 domains: (1) PD patient education materials and self-management tools to facilitate clinical communication; (2) techniques for improving clinical communication, including strategies for eliciting nonmotor symptoms and contextualizing symptoms to better meet patient quality of life needs; (3) addressing system-level barriers, including time constraints and the lack of an identified specialist referral network; and (4) training in how to lead difficult conversations.Neurologists identified specific barriers, and proposed solutions, to improving care delivery for patients with PD. Integrating practice tools to address quality of life needs, training neurologists in communication around end-of-life care, and strengthening referral networks for rehabilitation and psychosocial support hold promise for improving quality of life for patients with PD.

    View details for PubMedID 31046525

  • Understanding communal coping among patients and informal caregivers with heart failure: A mixed methods secondary analysis of patient-caregiver dyads. Heart & lung : the journal of critical care Wooldridge, J. S., Gray, C. n., Pukhraj, A. n., Geller, J. n., Trivedi, R. B. 2019


    Dyads that view illnesses as shared stressors ("shared appraisal"), and collaboratively respond to it, have better outcomes. This process, known as communal coping, has received little attention in heart failure (HF).To examine communal coping among patient-caregiver dyads managing HF.We conducted semi-structured interviews with 34 dyads. Shared appraisal was measured using we-ratio, as calculated with Linguistic Inquiry Word Count. We-ratio was divided into "high" and "low" for patients and caregivers, and concordance was examined. Thematic analyses were used to explore collaboration.Caregivers had higher we-ratios than patients (p=.005); 29.6% and 33.3% dyads were concordant on high and low "we-ratio," respectively. In thematic analyses, we found that 1) dyads collaborated around diet, appointments, and medications, but less around physical activity; 2) dyads collaborated across all illnesses, not just HF; and 3) dyads concordant on high we-ratio reported stronger collaborations.Communal coping varied by shared appraisal and collaboration. Understanding this variability may help develop tailored self-management interventions.

    View details for DOI 10.1016/j.hrtlng.2019.05.008

    View details for PubMedID 31171368

  • Mortality Among Veterans with Major Mental Illnesses Seen in Primary Care: Results of a National Study of Veteran Deaths. Journal of general internal medicine Trivedi, R. B., Post, E. P., Piegari, R. n., Simonetti, J. n., Boyko, E. J., Asch, S. M., Mori, A. n., Arnow, B. A., Fihn, S. D., Nelson, K. M., Maynard, C. n. 2019


    Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses.To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses.Retrospective cohort study of decedents.Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index.Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses.Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001).Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness.

    View details for DOI 10.1007/s11606-019-05307-w

    View details for PubMedID 31667746

  • Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers. The Journal of cardiovascular nursing Trivedi, R. B., Slightam, C. n., Nevedal, A. n., Guetterman, T. C., Fan, V. S., Nelson, K. M., Rosland, A. M., Heidenreich, P. A., Timko, C. n., Asch, S. M., Piette, J. D. 2019


    Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.

    View details for DOI 10.1097/JCN.0000000000000591

    View details for PubMedID 31365440

  • Relationship and communication characteristics associated with agreement between heart failure patients and their Carepartners on patient depressive symptoms. Aging & mental health Bouldin, E. D., Aikens, J. E., Piette, J. D., Trivedi, R. B. 2018: 1–8


    OBJECTIVES: Informal caregivers who recognize patients' depressive symptoms can better support self-care and encourage patients to seek treatment. We examined patient-caregiver agreement among patients with heart failure (HF). Our objectives were to (1) identify distinct groups of HF patients and their out-of-home informal caregivers (CarePartners) based on their relationship and communication characteristics, and (2) compare how these groups agree on the patients' depressive symptoms.METHOD: We used baseline data from a comparative effectiveness trial of a self-care support program for veterans with HF treated in outpatient clinics from 2009-2012. We used a cross-sectional design and latent class analysis (LCA) approach to identify distinct groups of patient-CarePartner dyads (n=201) based on relationship and communication characteristics then evaluated agreement on patients' depressive symptoms within these groups.RESULTS: The LCA analysis identified four groups: Collaborative (n=102 dyads, 51%), Avoidant (n=33 dyads, 16%), Distant (n=35 dyads, 17%), and Antagonistic (n=31 dyads, 15%). Dyadic agreement on the patients' depressive symptoms was highest in the Distant (Kappa (kappa)=0.44, r=0.39) and Collaborative groups (kappa=0.19, r=0.32), and relatively poor in the Avoidant (kappa=-0.20, r=0.17) and Antagonistic (kappa=-0.01, r=0.004) groups. Patients in Avoidant (61%) and Antagonistic groups (74%) more frequently had depression based on self-report than patients in Collaborative (46%) and Distant (34%) groups.CONCLUSION: Caregiver relationships in HF tend to be either Collaborative, Avoidant, Distant, or Antagonistic. Patients' depressive symptoms may negatively affect how they communicate with their caregivers. At the same time, improved patient-caregiver communication could enhance dyadic consensus about the patient's depressive symptoms.

    View details for PubMedID 30569750

  • Disability Rating, Age at Death, and Cause of Death in US Veterans with Service-Connected Conditions MILITARY MEDICINE Maynard, C., Trivedi, R., Nelson, K., Fihn, S. D. 2018; 183 (11-12): E371–E376


    The association between disability and cause of death in Veterans with service-connected disabilities has not been studied. The objective of this study was to compare age at death, military service and disability characteristics, including disability rating, and cause of death by year of birth. We also examined cause of death for specific service-connected conditions.This study used information from the VETSNET file, which is a snapshot of selected items from the Veterans Benefits Administration corporate database. We also used the National Death Index (NDI) for Veterans which is part of the VA Suicide Data Repository. In VETSNET, there were 758,324 Veterans who had a service-connected condition and died between the years 2004 and 2014. Using the scrambled social security number to link the two files resulted in 605,493 (80%) deceased Veterans. Age at death, sex, and underlying cause of death were obtained from the NDI for Veterans and military service characteristics and types of disability were acquired from VETSNET. We constructed age categories corresponding to period of service; birth years 1938 and earlier corresponded to Korea and World War II ("oldest"), birth years 1939-1957 to the Vietnam era ("middle"), and birth years 1958 and later to post Vietnam, Gulf War, and the more recent conflicts in Iraq and Afghanistan ("youngest").Sixty-two percent were in the oldest age category, 34% in the middle group, and 4% in the youngest one. The overall age at death was 75 ± 13 yr. Only 1.6% of decedents were women; among women 25% were in the youngest age group, while among men only 4% were in the youngest group. Most decedents were enlisted personnel, and 60% served in the U.S. Army. Nearly 61% had a disability rating of >50% and for the middle age group 54% had a disability rating of 100%. The most common service-connected conditions were tinnitus, hearing loss, and post-traumatic stress disorder (PTSD). In the oldest group, nearly half of deaths were due to cancer or cardiovascular conditions and <2% were due to external causes. In the youngest group, cardiovascular disease and cancer accounted for about 1/3 of deaths, whereas external causes or deaths due to accidents, suicide, or assault accounted for nearly 33% of deaths. For Veterans with service-connected PTSD or major depression; 6.5% of deaths were due to external causes whereas for Veterans without these conditions, only 3.1% were due to external causes.The finding of premature death due to external causes in the youngest age group as well as the finding of higher proportions of external causes in those with PTSD or major depression should be of great concern to those who care for Veterans.

    View details for PubMedID 29590473

  • Comparing Preventable Hospitalizations Among Veterans With and Without Mental Illnesses Before and After Implementation of PACT. Psychiatric services (Washington, D.C.) Trivedi, R., Sylling, P., Post, E. P., Wong, E. S., Mori, A. M., Fihn, S. D., Nelson, K. 2018: appips201700316


    OBJECTIVES:: The authors examined whether the rate of preventable hospitalizations among veterans with mental illness changed after implementation of the Department of Veterans Affairs (VA) primary care medical home-Patient Aligned Care Teams (PACT).METHODS:: A 12-year retrospective cohort analysis was conducted of data from 9,206,017 veterans seen in 942 VA primary care clinics between October 2003 and March 2015. Preventable hospitalizations were those related to ambulatory care-sensitive conditions (ACSCs), identified with ICD-9 codes. Changes in rates of ACSC-related hospitalizations were compared between patients with and without mental illness in two age groups (<65, ≥65). Patients with mental illness diagnoses were grouped as follows: depression, posttraumatic stress disorder, anxiety, substance use disorder, and serious mental illness. Interrupted time-series analysis was used to model long-term trends and detect deviations after PACT implementation.RESULTS:: There was an overall increase in mental illness diagnoses across both age groups. Among older veterans (≥65) with any mental illness, the rate (per 1,000 patients) of ACSC-related hospitalizations was five fewer in the post-PACT period, compared with the pre-PACT period. Among younger veterans (<65), there was a slight increase in ACSC-related hospitalizations in years 3-5 post-PACT if they had any mental illness (.6 per 1,000 patients), depression (.3), anxiety (1.4), or a substance use disorder (.6).CONCLUSIONS:: In this retrospective, observational study examining large systemwide changes in clinical practice, mental illness was more likely to be diagnosed after PACT implementation, compared with before, and results suggested a benefit of PACT implementation among older veterans in terms of a reduction in ACSC-related hospitalizations.

    View details for PubMedID 30301446

  • Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial TRIALS Rosland, A., Piette, J. D., Trivedi, R., Kerr, E. A., Stoll, S., Tremblay, A., Heisler, M. 2018; 19: 394


    Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care ("family supporters"). These family supporters are an important resource who could be leveraged to improve patients' engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications.We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients' primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients' diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient's diabetes care.If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients' available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and, NCT02328326 . Registered on 31 December 2014.

    View details for DOI 10.1186/s13063-018-2785-2

    View details for Web of Science ID 000439668100001

    View details for PubMedID 30041685

    View details for PubMedCentralID PMC6057090

  • Emotional Impact of Illness and Care on Patients with Advanced Kidney Disease CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY O'Hare, A. M., Richards, C., Szarka, J., McFarland, L. V., Showalter, W., Vig, E. K., Sudore, R. L., Crowley, S. T., Trivedi, R., Taylor, J. S. 2018; 13 (7): 1022–29


    The highly specialized and technologically focused approach to care inherent to many health systems can adversely affect patients' emotional experiences of illness, while also obscuring these effects from the clinician's view. We describe what we learned from patients with advanced kidney disease about the emotional impact of illness and care.As part of an ongoing study on advance care planning, we conducted semistructured interviews at the VA Puget Sound Healthcare System in Seattle, Washington, with 27 patients with advanced kidney disease between April of 2014 and May of 2016. Of these, ten (37%) were receiving center hemodialysis, five (19%) were receiving peritoneal dialysis, and 12 (44%) had an eGFR≤20 ml/min per 1.73 m2 and had not started dialysis. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory methods.We here describe three emergent themes related to patients' emotional experiences of care and illness: (1) emotional impact of interactions with individual providers: when providers seemed to lack insight into the patient's experience of illness and treatment, this could engender a sense of mistrust, abandonment, isolation, and/or alienation; (2) emotional impact of encounters with the health care system: just as they could be affected emotionally by interactions with individual providers, patients could also be affected by how care was organized, which could similarly lead to feelings of mistrust, abandonment, isolation, and/or alienation; and (3) emotional impact of meaning-making: patients struggled to make sense of their illness experience, worked to apportion blame, and were often quick to blame themselves and to assume that their illness could have been prevented.Interactions with individual providers and with the wider health system coupled with patients' own struggles to make meaning of their illness can take a large emotional toll. A deeper appreciation of patients' emotional experiences may offer important opportunities to improve care.

    View details for PubMedID 29954826

    View details for PubMedCentralID PMC6032592

  • Mutuality and heart failure self-care in patients and their informal caregivers EUROPEAN JOURNAL OF CARDIOVASCULAR NURSING Hooker, S. A., Schmiege, S. J., Trivedi, R. B., Amoyal, N. R., Bekelman, D. B. 2018; 17 (2): 102–13


    Heart failure is a progressive condition characterized by frequent hospitalizations for exacerbated symptoms. Informal family caregivers may help patients improve self-care, which may in turn reduce hospitalizations. However, little is known about how mutuality, defined as the quality of the patient-caregiver relationship, and caregiver burden affect self-care.This study examines the associations among mutuality, patient self-care confidence (beliefs in abilities to engage in self-care behaviors) and maintenance (behaviors such as medication adherence, activity, and low salt intake), caregiver confidence in and maintenance of patient care, and caregiver perceived burden.This study used cross-sectional baseline data from a multi-site randomized clinical trial of a symptom and psychosocial care intervention. Patient-caregiver dyads ( N=99) completed self-report surveys of mutuality and self-care confidence and maintenance, and caregivers completed a measure of caregiver burden. Path analysis, with actor (effects within a person) partner (effects across the dyad) interdependence model paths and regression models were used to examine the associations among mutuality, caregiver burden, and self-care.The majority of patients ( M age=66, 21% female) and caregivers ( M age=57, 81% female) were spouses (60%). The path model demonstrated significant actor effects; patients and caregivers with better mutuality were more confident in patient self-care ( p<.05). Partner effects were not significant. Regression models indicated that caregivers with greater mutuality reported less perceived burden ( p<.01).Mutuality in patient-caregiver dyads is associated with patient self-care and caregiver burden and may be an important intervention target to improve self-care and reduce hospitalizations.

    View details for PubMedID 28868917

  • "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients. Chronic illness Schwartz, R. n., Zulman, D. n., Gray, C. n., Goldstein, M. K., Trivedi, R. n. 2018: 1742395318799852


    Objectives Parkinson's disease presents an evolving challenge for patients and families due to an unpredictable disease trajectory and symptoms that complicate social interactions. In this study, we explore neurologists' perspectives on the challenges Parkinson's disease presents for families and the strategies they use to improve communication and quality of life. Methods We conducted hour-long semi-structured interviews with 16 neurologists at 4 care delivery institutions in the San Francisco Bay Area, focusing on techniques neurologists use to support families through the Parkinson's disease journey. Results Neurologists identified strategies for addressing caregiver-patient disagreements around symptom accuracy and negotiating driving safety. Family education is needed to contextualize patient symptoms and to identify psychosocial support resources. Unmet caregiver needs remain, particularly in the form of psychosocial support, respite care and support for unequal gender dynamics in the Parkinson's disease caregiving experience. Discussion Family members of Parkinson's disease patients face unique caregiving and interpersonal challenges due to the nature of the disease. Targeted education and structural support are needed to alleviate current burdens and allow for improved patient- and family-centered care.

    View details for PubMedID 30208725

  • Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes CHRONIC ILLNESS Bouldin, E. D., Trivedi, R. B., Reiber, G. E., Rosland, A., Silverman, J. B., Krieger, J., Nelson, K. M. 2017; 13 (4): 239–50


    Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

    View details for PubMedID 29119864

  • "Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease. Clinical journal of the American Society of Nephrology O'Hare, A. M., Szarka, J., McFarland, L. V., Vig, E. K., Sudore, R. L., Crowley, S., Reinke, L. F., Trivedi, R., Taylor, J. S. 2017; 12 (6): 930-938


    Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease.As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes.The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient.Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.

    View details for DOI 10.2215/CJN.12721216

    View details for PubMedID 28356337

  • Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities. Administration and policy in mental health Cooper, D. C., Helfrich, C. D., Thielke, S. M., Trivedi, R. B., Nelson, K. M., Reiber, G. E., Eugenio, E. C., Beaver, K., Nugent-Carney, J., Fan, V. S. 2016: -?


    We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

    View details for PubMedID 27909877

  • Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway? CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY O'Hare, A. M., Szarka, J., McFarland, L. V., Taylor, J. S., Sudore, R. L., Trivedi, R., Reinke, L. F., Vig, E. K. 2016; 11 (5): 855-866


    There is growing interest in efforts to enhance advance care planning for patients with kidney disease. Our goal was to elicit the perspectives on advance care planning of multidisciplinary providers who care for patients with advanced kidney disease.Between April and December of 2014, we conducted semistructured interviews at the Department of Veterans Affairs Puget Sound Health Care System with 26 providers from a range of disciplines and specialties who care for patients with advanced kidney disease. Participants were asked about their perspectives and experiences related to advance care planning in this population. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory.The comments of providers interviewed for this study spoke to significant system-level barriers to supporting the process of advance care planning for patients with advanced kidney disease. We identified four overlapping themes: (1) medical care for this population is complex and fragmented across settings and providers and over time; (2) lack of a shared understanding and vision of advance care planning and its relationship with other aspects of care, such as dialysis decision making; (3) unclear locus of responsibility and authority for advance care planning; and (4) lack of active collaboration and communication around advance care planning among different providers caring for the same patients.The comments of providers who care for patients with advanced kidney disease spotlight both the need for and the challenges to interdisciplinary collaboration around advance care planning for this population. Systematic efforts at a variety of organizational levels will likely be needed to support teamwork around advance care planning among the different providers who care for patients with advanced kidney disease.

    View details for DOI 10.2215/CJN.11351015

    View details for Web of Science ID 000375460200017

    View details for PubMedID 27084877

    View details for PubMedCentralID PMC4858488

  • A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Frontiers in public health Trivedi, R., Slightam, C., Fan, V. S., Rosland, A., Nelson, K., Timko, C., Asch, S. M., Zeliadt, S. B., Heidenreich, P., Hebert, P. L., Piette, J. D. 2016; 4: 171-?


    Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

    View details for DOI 10.3389/fpubh.2016.00171

    View details for PubMedID 27626029

    View details for PubMedCentralID PMC5004799

  • Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans. American journal of public health Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., Maynard, C., Arnow, B., Curtis, I., Fihn, S. D., Nelson, K. 2015; 105 (12): 2564-2569


    We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI).A total of 4 461 208 veterans were seen in the Veterans Health Administration's patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement.A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes.Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.

    View details for DOI 10.2105/AJPH.2015.302836

    View details for PubMedID 26474009

  • Participant exclusion criteria in treatment research on neurological disorders: Are unrepresentative study samples problematic? CONTEMPORARY CLINICAL TRIALS Trivedi, R. B., Humphreys, K. 2015; 44: 20-25


    Exclusion criteria are an important determinant of the external validity of treatment research findings, yet the prevalence and impact of exclusion criteria have not been studied systematically. Our objective was to describe prevalent exclusion criteria in treatment research on neurological disorders and to analyze their impact on sample representativeness and generalizability of findings.Narrative literature review of studies focusing on treatment for neurological disorders. Studies were identified from PubMed and bibliographies.Eight studies were included in the narrative review: 3 studies focused on Alzheimer's disease/dementia, 2 each focused on traumatic brain injury (TBI) and epilepsy, and 1 focused on amyotrophic lateral sclerosis (ALS). The total number of patients screened across all studies was 20,018, of which 14,721 (73.5%) were excluded. An average of 6 exclusion criteria was applied. The criteria that contributed most to exclusion were the presence of comorbid psychiatric conditions, a history of alcohol or other substance misuse, and cognitive impairments. Women and the elderly were underrepresented among included samples. Race/ethnicity proportions were seldom reported.Exclusion criteria are used extensively in neurological treatment research and prevent about 3 in 4 patients from participating in research. This limits the generalizability of current findings. Further, because excluded individuals are disproportionately from vulnerable populations, extensive exclusion also raises ethical concerns. Exclusion criteria should be used only in cases where there is a strong rationale so that neurological treatment research can make a greater impact on clinical care.

    View details for DOI 10.1016/j.cct.2015.07.009

    View details for Web of Science ID 000362616300003

  • Participant exclusion criteria in treatment research on neurological disorders: Are unrepresentative study samples problematic? Contemporary clinical trials Trivedi, R. B., Humphreys, K. 2015; 44: 20-25


    Exclusion criteria are an important determinant of the external validity of treatment research findings, yet the prevalence and impact of exclusion criteria have not been studied systematically. Our objective was to describe prevalent exclusion criteria in treatment research on neurological disorders and to analyze their impact on sample representativeness and generalizability of findings.Narrative literature review of studies focusing on treatment for neurological disorders. Studies were identified from PubMed and bibliographies.Eight studies were included in the narrative review: 3 studies focused on Alzheimer's disease/dementia, 2 each focused on traumatic brain injury (TBI) and epilepsy, and 1 focused on amyotrophic lateral sclerosis (ALS). The total number of patients screened across all studies was 20,018, of which 14,721 (73.5%) were excluded. An average of 6 exclusion criteria was applied. The criteria that contributed most to exclusion were the presence of comorbid psychiatric conditions, a history of alcohol or other substance misuse, and cognitive impairments. Women and the elderly were underrepresented among included samples. Race/ethnicity proportions were seldom reported.Exclusion criteria are used extensively in neurological treatment research and prevent about 3 in 4 patients from participating in research. This limits the generalizability of current findings. Further, because excluded individuals are disproportionately from vulnerable populations, extensive exclusion also raises ethical concerns. Exclusion criteria should be used only in cases where there is a strong rationale so that neurological treatment research can make a greater impact on clinical care.

    View details for DOI 10.1016/j.cct.2015.07.009

    View details for PubMedID 26188162

  • Potential Impact of Incorporating a Patient-Selected Support Person into mHealth for Depression JOURNAL OF GENERAL INTERNAL MEDICINE Aikens, J. E., Trivedi, R., Heapy, A., Pfeiffer, P. N., Piette, J. D. 2015; 30 (6): 797-803


    Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients' trusted confidants.To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.Patient preference trial.Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients' clinicians were automatically notified of urgent patient issues.Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16-1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14-1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.Incorporating the "human factor" of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.

    View details for DOI 10.1007/s11606-015-3208-7

    View details for Web of Science ID 000354961100019

    View details for PubMedID 25666218

  • Shedding light on the association between social support and adherence in hypertension: a comment on Magrin et Al. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine Trivedi, R. B., Piette, J. D. 2015; 49 (3): 297-8

    View details for DOI 10.1007/s12160-014-9682-z

    View details for PubMedID 25591658

  • A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial JOURNAL OF MEDICAL INTERNET RESEARCH Piette, J. D., Striplin, D., Marinec, N., Chen, J., Trivedi, R. B., Aron, D. C., Fisher, L., Aikens, J. E. 2015; 17 (6)


    Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers' needs for information about the patient's status or how the caregiver can help.We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a "CarePartner" outside their household. Patients randomized to "standard mHealth" (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients' responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to "mHealth+CP" (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient's status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients' medication adherence and caregiver communication. mHealth+CP may also decrease patients' risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective NCT00555360; (Archived by WebCite at

    View details for DOI 10.2196/jmir.4550

    View details for Web of Science ID 000356819800009

    View details for PubMedID 26063161

  • Integrating Support Persons into Diabetes Telemonitoring to Improve Self-Management and Medication Adherence JOURNAL OF GENERAL INTERNAL MEDICINE Aikens, J. E., Trivedi, R., Aron, D. C., Piette, J. D. 2015; 30 (3): 319-326


    The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients' baseline level of psychological distress.The study was a quasi-experimental patient preference trial.The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient's health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0-4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.Of 98 initially nonadherent patients, 42% opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: -1.17 vs. -0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25% per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.

    View details for DOI 10.1007/s11606-014-3101-9

    View details for Web of Science ID 000350886500012

    View details for PubMedID 25421436

  • Angina Symptom Burden Associated with Depression Status Among Veterans with Ischemic Heart Disease ANNALS OF BEHAVIORAL MEDICINE Trivedi, R., Gerrity, M., Rumsfeld, J. S., Spertus, J. A., Sun, H., McDonell, M., Doak, M., Lucas, L., Fihn, S. D. 2015; 49 (1): 58-65


    Angina and depression are common in ischemic heart disease (IHD), but their association remains understudied.This study was conducted in order to evaluate the association of 1 year change in depression with change in patient-reported outcomes of stable angina.Five hundred sixty-nine stable angina patients completed the Seattle Angina Questionnaire and Patient Health Questionnaire (PHQ) at baseline and 1 year. Participants were divided into four groups: not depressed, new onset of depression at 1 year, remitted at 1 year, and persistently depressed. Associations between depression and angina symptoms were evaluated using regression models.Compared to those not depressed, newly depressed participants reported more angina (β = -11.7, p < 0.001) and physical limitations (β = -11.8, p < 0.001) and lower treatment satisfaction (β = -15.03, p < 0.001) and quality of life (β = -15.4, p < 0.001). Persistently depressed participants reported physical limitations (β = -7.4, p < 0.05), lower treatment satisfaction (β = -10.1, p < 0.001), and poorer quality of life (β = -10.03, p < 0.001).Changes in depression scores and angina outcomes were significantly associated.

    View details for DOI 10.1007/s12160-014-9629-4

    View details for Web of Science ID 000350050800009

    View details for PubMedID 25008432

  • Antidepressant Adherence and Risk of Coronary Artery Disease Hospitalizations in Older and Younger Adults with Depression JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Cooper, D. C., Trivedi, R. B., Nelson, K. M., Reiber, G. E., Eugenio, E. C., Beaver, K. A., Fan, V. S. 2014; 62 (7): 1238-1245


    To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression.Retrospective cohort study.Department of Veterans Affairs outpatient clinics nationwide.Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups.After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models.Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults.Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.

    View details for DOI 10.1111/jgs.12849

    View details for Web of Science ID 000340482000004

    View details for PubMedID 24890000

  • Diabetes self-management support using mHealth and enhanced informal caregiving. Journal of diabetes and its complications Aikens, J. E., Zivin, K., Trivedi, R., Piette, J. D. 2014; 28 (2): 171-176


    To characterize diabetes patient engagement and clinician notifications for an mHealth interactive voice response (IVR) service.Observational study.For three to six months, VA patients with diabetes received weekly IVR calls assessing health status and self-care along with tailored education. Patients could enroll with an informal caregiver who received suggestions on self-management support. Notifications were issued to clinicians when patients reported significant problems.Patients (n=303) participated for a total of 5684 patient-weeks, during which 84% of calls were completed. The odds of call completion decreased over time (AOR=0.96, p<0.001), and were lower among unmarried patients (AOR=0.67, p=0.038) and those who had difficulties with health literacy (AOR=0.67, p=0.039), diabetes-related distress (AOR=0.30, p=0.018), or medication nonadherence (AOR=0.57, p=0.002). Twenty-one clinician notifications were triggered per 100 patient-weeks. The odds of notification were higher during the early weeks of the program (AOR=0.95, p<0.001) and among patients who were older (AOR=1.03, p=0.004) or more physically impaired (AOR=0.97, p<0.001).By providing information that is reliable, valid, and actionable, IVR-based mHealth services may increase access to between-visit monitoring and diabetes self-management support. The system detects abnormal glycemia and blood pressure levels that might otherwise go unreported, although thresholds for clinician notifications might require adjustment to avoid overloading clinicians. Patient engagement might be enhanced by addressing health literacy and psychological distress.

    View details for DOI 10.1016/j.jdiacomp.2013.11.008

    View details for PubMedID 24374137

    View details for PubMedCentralID PMC3943823

  • Recruitment and retention rates in behavioral trials involving patients and a support person: A systematic review. Contemporary clinical trials Trivedi, R. B., Szarka, J. G., Beaver, K., Brousseau, K., Nevins, E., Yancy, W. S., Slade, A., Voils, C. I. 2013; 36 (1): 307-318


    Recruitment and retention challenges impede the study of behavioral interventions among patient-support person dyads.The aim of the study was to characterize recruitment and retention rates of behavioral interventions involving dyads.Using PRISMA guidelines and with the guidance of a medical librarian, we searched Medline, EMBASE, Cochrane Controlled Trials, PsycInfo, and CINAHL from inception until July 2011. Eligible articles involved RCTs of behavioral interventions targeting adult patients with a non-psychiatric illness and a support person. Sample and study characteristics, recruitment and retention strategies, and recruitment and retention rates were abstracted in duplicate. Quality of reporting was determined on a 5-point scale. Due to the heterogeneity in data reporting and missing data, a narrative synthesis was undertaken.53 unique studies involving 8081 dyads were included. 9 studies were ascertained to have a "high quality" of reporting. A majority of the studies did not report target sample size, time to complete recruitment, and sample sizes at each follow-up time point. Strategies employed to recruit support persons were rarely reported. 16 studies did not report the number of dyads screened. The mean recruitment rate was 51.2% (range: 4.3%-95.4%), and mean retention rate was 77.5% (range: 36%-100%).Details regarding recruitment and retention methodology were sparse in these interventions. Where available, data suggests that resources need to be devoted towards recruitment of sample but that retention rates are generally adequate.

    View details for DOI 10.1016/j.cct.2013.07.009

    View details for PubMedID 23916918

  • A preliminary exploration of the feasibility of offering men information about potential prostate cancer treatment options before they know their biopsy results BMC MEDICAL INFORMATICS AND DECISION MAKING Zeliadt, S. B., Hannon, P. A., Trivedi, R. B., Bonner, L. M., Vu, T. T., Simons, C., Kimmie, C. A., Hu, E. Y., Zipperer, C., Lin, D. W. 2013; 13


    A small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making.Men with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic's usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18).A total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results.In this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.

    View details for DOI 10.1186/1472-6947-13-19

    View details for Web of Science ID 000316224400001

    View details for PubMedID 23388205

  • Factors associated with presenting > 12 hours after symptom onset of acute myocardial infarction among Veteran men BMC CARDIOVASCULAR DISORDERS McDermott, K., Maynard, C., Trivedi, R., Lowy, E., Fihn, S. 2012; 12


    Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) ("late presenters"). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation.In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation.Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]).A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.

    View details for DOI 10.1186/1471-2261-12-82

    View details for Web of Science ID 000311604500001

    View details for PubMedID 23020779

  • The Influence of Informal Caregivers on Adherence in COPD Patients ANNALS OF BEHAVIORAL MEDICINE Trivedi, R. B., Bryson, C. L., Udris, E., Au, D. H. 2012; 44 (1): 66-72


    Contributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.This study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.Three hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.Compared with the "no caregiver" group, antihypertensive medications adherence was higher in the "spousal caregiver" (0.68 vs. 0.81; 95% CI=0.04 and 0.22) and "non-spousal caregiver" (0.68 vs. 0.80; 95% CI=0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the "spousal caregiver" group (0.60 vs.0.80; 95% CI=0.05 and 0.43). Patients in the "spousal caregiver" group had fewer current smokers compared with the "no caregiver" (χ(2)=16.08; p<0.001) and "non-spousal caregiver" (χ(2)=5.07; p<0.05) groups; those in the "non-spousal caregiver" group reported fewer smokers than the "no caregiver" group (χ(2)=4.54; p<0.05).Caregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

    View details for DOI 10.1007/s12160-012-9355-8

    View details for Web of Science ID 000308822700010

    View details for PubMedID 22422104



    Because evidence-based psychotherapies of 12 to 20 sessions can be perceived as too lengthy and time intensive for the treatment of depression in primary care, a number of studies have examined abbreviated psychotherapy protocols. The purpose of this study was to conduct a systematic review and meta-analysis to determine the efficacy of brief psychotherapy (i.e., < or =8 sessions) for depression.We used combined literature searches in PubMed, EMBASE, PsycINFO, and an Internet-accessible database of clinical trials of psychotherapy to conduct two systematic searches: one for existing systematic reviews and another for randomized controlled trials (RCTs). Included studies examined evidence-based psychotherapy(s) of eight or fewer sessions, focused on adults with depression, contained an acceptable control condition, were published in English, and used validated measures of depressive symptoms. Results: We retained 2 systematic reviews and 15 RCTs evaluating cognitive behavioral therapy, problem-solving therapy, and mindfulness-based cognitive therapy. The systematic reviews found brief psychotherapies to be more efficacious than control, with effect sizes ranging from -0.33 to -0.25. Our meta-analysis found six to eight sessions of cognitive behavioral therapy to be more efficacious than control (ES -0.42, 95% CI -0.74 to -0.10, 12 = 56%). A sensitivity analysis controlled for statistical heterogeneity but showed smaller treatment effects (ES -0.24, 95% CI -0.42 to -0.06, 12 = 0%).Depression can be efficaciously treated with six to eight sessions of psychotherapy, particularly cognitive behavioral therapy and problem-solving therapy. Access to non-pharmacologic treatments for depression could be improved by training healthcare providers to deliver brief psychotherapies.

    View details for DOI 10.2190/PM.43.2.c

    View details for Web of Science ID 000305727700003

    View details for PubMedID 22849036

  • Examining the Interrelatedness of Patient and Spousal Stress in Heart Failure Conceptual Model and Pilot Data JOURNAL OF CARDIOVASCULAR NURSING Trivedi, R. B., Piette, J., Fihn, S. D., Edelman, D. 2012; 27 (1): 24-32


    Recent research has highlighted the positive influence that spouses can have on patient outcomes. It is not clear whether patients and spouses influence each other's well-being reciprocally or whether spousal well-being affects the success of patients' disease management. Our goals were 2-fold: (a) to propose a conceptual framework to examine the reciprocity between patient and spouses' well-being, especially as it relates to disease management, and (b) to begin to assess the validity of this model using pilot data.Twenty-three veterans with heart failure (HF) and their spouses were recruited into a pilot cross-sectional observational study. Participants completed psychosocial surveys to assess depressive symptoms, caregiver burden, relationship satisfaction, and disease management. Descriptive analyses and bivariate correlations between these measures were calculated.Using standard cutoffs, analyses suggested clinically significant depressive symptoms in patients (Center for Epidemiological Studies-Depression score >16; mean, 21.8 [SD, 13]) and a high level of caregiver burden among spouses (Zarit Burden Interview score >15; mean, 22.4 [SD, 15.4]). Both patients and spouses reported high relationship satisfaction levels (Dyadic Adjustment Scale score >100; mean, 112.6 [SD, 26.5] and 115.9 [SD, 14.4], respectively). On average, patients reported poor disease management (Self-care of Heart Failure Index subscale <70 across all subscales: confidence = 53.3 [SD, 28.2]; maintenance = 59.7 [SD, 17.3]; management = 54.0 [SD, 19.4]). Patient depressive symptoms were positively correlated with spouse depressive symptoms (r = 0.53) and caregiver burden (r = 0.64; all P's < .05). Spouses' depressive symptoms were additionally correlated with lower levels of perceived social support among patients (r = -0.47), poor patient relationship satisfaction (r = -0.51), and worse patient confidence in HF management (r = -0.48). Greater caregiver burden was associated with more patient disease complaints (r = 0.49), poorer patients' relationship satisfaction (r = -0.72), and poorer patients' perceived social support (r = -0.73).These results provide preliminary support to the proposed conceptual model. Further research is necessary to determine which spousal factors appear to be most relevant to disease management. Disease management interventions may benefit from engaging spouses in a way that enhances their role without adding to their burden.

    View details for DOI 10.1097/JCN.0b013e3182129ce7

    View details for Web of Science ID 000298376900004

    View details for PubMedID 21743348

  • Examination of the Utility of Psychotherapy for Patients with Treatment Resistant Depression: A Systematic Review JOURNAL OF GENERAL INTERNAL MEDICINE Trivedi, R. B., Nieuwsma, J. A., Williams, J. W. 2011; 26 (6): 643-650


    To examine the utility of psychotherapy in managing treatment resistant depression.PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies.Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted.Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy.Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

    View details for DOI 10.1007/s11606-010-1608-2

    View details for Web of Science ID 000290576600016

    View details for PubMedID 21184287

    View details for PubMedCentralID PMC3101965

  • Worsening Depressive Symptoms Are Associated With Adverse Clinical Outcomes in Patients With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Sherwood, A., Blumenthal, J. A., Hinderliter, A. L., Koch, G. G., Adams, K. F., Dupree, C. S., Bensimhon, D. R., Johnson, K. S., Trivedi, R., Bowers, M., Christenson, R. H., O'Connor, C. M. 2011; 57 (4): 418-423


    The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients.Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes.One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up).The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro-B-type natriuretic peptide level, and prior hospitalizations.Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

    View details for DOI 10.1016/j.jacc.2010.09.031

    View details for Web of Science ID 000286376500006

    View details for PubMedID 21251581

  • Cardiovascular hemodynamics during stress in premenopausal versus postmenopausal women MENOPAUSE-THE JOURNAL OF THE NORTH AMERICAN MENOPAUSE SOCIETY Sherwood, A., Park, S. B., Hughes, J. W., Blumenthal, J. A., Hinderliter, A., Trivedi, R., McFetridge-Durdle, J. 2010; 17 (2): 403-409


    After menopause, women are at an increased risk of cardiovascular disease. The present study assessed cardiovascular hemodynamics in premenopausal versus postmenopausal women, with a focus on systemic vascular resistance (SVR) at rest and during stress. Sympathetic nervous system activity and cardiovascular adrenergic receptor (AR) function were also examined.A total of 90 women (45 premenopausal and 45 postmenopausal) completed a laboratory protocol composed of a resting baseline and four mental stress tasks. Measurements included blood pressure, cardiac output, SVR, and plasma catecholamine level. In addition, alpha- and beta-AR responsiveness to the infusion of selective pharmacological agonists was assessed.Compared with premenopausal women, postmenopausal women were characterized by similar blood pressure but lower cardiac output and higher SVR, both at rest and during stress (Ps < 0.05). Postmenopausal women also had higher baseline plasma norepinephrine levels (P = 0.007) and reduced beta-AR responsiveness (P = 0.02), although differences in beta-AR responsiveness may have been confounded by aging effects.After menopause, women exhibit altered sympathetic nervous system activity and a sustained increase in hemodynamic load that may contribute to pathological structural and functional changes in the heart and blood vessels.

    View details for DOI 10.1097/gme.0b013e3181b9b061

    View details for Web of Science ID 000275485200031

    View details for PubMedID 19770780

  • Is there a nonadherent subtype of hypertensive patient? A latent class analysis approach PATIENT PREFERENCE AND ADHERENCE Trivedi, R. B., Ayotte, B. J., Thorpe, C. T., Edelman, D., Bosworth, H. B. 2010; 4: 255-262


    To determine subtypes of adherence, 636 hypertensive patients (48% White, 34% male) reported adherence to medications, diet, exercise, smoking, and home blood pressure monitoring. A latent class analysis approach was used to identify subgroups that adhere to these five self-management behaviors. Fit statistics suggested two latent classes. The first class (labeled "more adherent") included patients with greater probability of adhering to recommendations compared with the second class (labeled "less adherent") with regard to nonsmoking (97.7% versus 76.3%), medications (75.5% versus 49.5%), diet (70.7% versus 46.9%), exercise (63.4% versus 27.2%), and blood pressure monitoring (32% versus 3.4%). Logistic regression analyses used to characterize the two classes showed that "more adherent" participants were more likely to report full-time employment, adequate income, and better emotional and physical well-being. Results suggest the presence of a less adherent subtype of hypertensive patients. Behavioral interventions designed to improve adherence might best target these at-risk patients for greater treatment efficiency.

    View details for Web of Science ID 000208215200031

    View details for PubMedID 20694185

  • Coping styles in heart failure patients with depressive symptoms JOURNAL OF PSYCHOSOMATIC RESEARCH Trivedi, R. B., Blumenthal, J. A., O'Connor, C., Adams, K., Hinderliter, A., Dupree, C., Johnson, K., Sherwood, A. 2009; 67 (4): 339-346


    Elevated depressive symptoms have been linked to poorer prognosis in heart failure (HF) patients. Our objective was to identify coping styles associated with depressive symptoms in HF patients.A total of 222 stable HF patients (32.75% female, 45.4% non-Hispanic black) completed multiple questionnaires. Beck Depression Inventory (BDI) assessed depressive symptoms, Life Orientation Test (LOT-R) assessed optimism, ENRICHD Social Support Inventory (ESSI) and Perceived Social Support Scale (PSSS) assessed social support, and COPE assessed coping styles. Linear regression analyses were employed to assess the association of coping styles with continuous BDI scores. Logistic regression analyses were performed using BDI scores dichotomized into BDI<10 vs. BDI> or =10, to identify coping styles accompanying clinically significant depressive symptoms.In linear regression models, higher BDI scores were associated with lower scores on the acceptance (beta=-.14), humor (beta=-.15), planning (beta=-.15), and emotional support (beta=-.14) subscales of the COPE, and higher scores on the behavioral disengagement (beta=.41), denial (beta=.33), venting (beta=.25), and mental disengagement (beta=.22) subscales. Higher PSSS and ESSI scores were associated with lower BDI scores (beta=-.32 and -.25, respectively). Higher LOT-R scores were associated with higher BDI scores (beta=.39, P<.001). In logistical regression models, BDI> or =10 was associated with greater likelihood of behavioral disengagement (OR=1.3), denial (OR=1.2), mental disengagement (OR=1.3), venting (OR=1.2), and pessimism (OR=1.2), and lower perceived social support measured by PSSS (OR=.92) and ESSI (OR=.92).Depressive symptoms in HF patients are associated with avoidant coping, lower perceived social support, and pessimism. Results raise the possibility that interventions designed to improve coping may reduce depressive symptoms.

    View details for DOI 10.1016/j.jpsychores.2009.05.014

    View details for Web of Science ID 000270567700009

    View details for PubMedID 19773027



    Health-related knowledge is an important component in the self-management of chronic illnesses. The objective of this study was to more accurately assess racial differences in hypertension knowledge by using a latent variable modeling approach that controlled for sociodemographic factors and accounted for measurement issues in the assessment of hypertension knowledge. Cross-sectional data from 1,177 participants (45% African American; 35% female) were analyzed using a multiple indicator multiple causes (MIMIC) modeling approach. Available sociodemographic data included race, education, sex, financial status, and age. All participants completed six items on a hypertension knowledge questionnaire. Overall, the final model suggested that females, Whites, and patients with at least a high school diploma had higher latent knowledge scores than males, African Americans, and patients with less than a high school diploma, respectively. The model also detected differential item functioning (DIF) based on race for two of the items. Specifically, the error rate for African Americans was lower than would be expected given the lower level of latent knowledge on the items, on the questions related to: (a) the association between high blood pressure and kidney disease, and (b) the increased risk African Americans have for developing hypertension. Not accounting for DIF resulted in the difference between Whites and African Americans to be underestimated. These results are discussed in the context of the need for careful measurement of health-related constructs, and how measurement-related issues can result in an inaccurate estimation of racial differences in hypertension knowledge.

    View details for Web of Science ID 000264494100006

    View details for PubMedID 19341159

  • Evidence synthesis for determining the responsiveness of depression questionnaires and optimal treatment duration for antidepressant medications. Williams, J. W., Slubicki, M. N., Tweedy, D. S., Bradford, D. W., Trivedi, R. B., Baker, D. Department of Veterans Affairs. 2009 ; VA Evidence-based Synthesis Reports


    According to projections from the World Health Organization, depression will be the second leading cause of disability in the developed world by 2020. Primary care clinicians care for approximately two thirds of depressed individuals. In 2000, the U.S. economic burden of depressive disorders was estimated to be 83.1 billion dollars. This included 31% direct medical costs, 7% suicide-related mortality costs, and 62% workplace costs. A variety of strategies have been tested to improve patient outcomes. Among these, integrated care models have emerged as both effective and cost effective. A recent systematic review identifies symptom monitoring as a key element of these integrated care models. However, the review did not identify the standardized depression scales that are responsive to clinically important change. A separate but important issue raised by Veterans Administration (VA) Stakeholders is how long to continue antidepressant medication for patients who respond to acute phase treatment. Clinical guidelines recommend continuation treatment for 4-6 months for uncomplicated major depression and some national performance measures are linked to these guidelines. However, clinical guidelines for longer-term maintenance phase treatment are more variable and performance indicators (e.g., Healthcare Effectiveness Data and Information Set, HEDIS) do not address maintenance phase treatment. A better understanding of the evidence for long-term treatment efficacy with antidepressants would inform guidelines and performance measurement.

  • The association of emotional well-being and marital status with treatment adherence among patients with hypertension JOURNAL OF BEHAVIORAL MEDICINE Trivedi, R. B., Ayotte, B., Edelman, D., Bosworth, H. B. 2008; 31 (6): 489-497


    We were interested in examining the relationship between psychosocial factors and hypertension-related behaviors. We hypothesized that lower emotional well-being and unmarried status would be related to higher BP, poorer medication adherence, greater difficulty adhering to diet and exercise, and current smoking. In a cross-sectional design, 636 hypertensive patients completed the Mental Component Summary (MCS) Scale of the SF-12 and rated their difficulty with adherence to diet, exercise, and medication-taking. In logistic regression analyses, lower MCS scores were associated with difficulty adhering to diet (OR = 0.97, p < .05) and exercise (OR = 0.97, p < .01), and current smoking status (OR = 0.98, p < .05). Being married was associated with higher probability of medication adherence (OR = 1.66, p < .01) and a lower probability of being a current smoker (OR = 0.34, p < .0001). Neither MCS scores nor being married were related to BP levels in adjusted analyses. Results emphasize the importance of assessing psychosocial factors to optimize hypertension treatment.

    View details for DOI 10.1007/s10865-008-9173-4

    View details for Web of Science ID 000260663000004

    View details for PubMedID 18780175

  • Relationship of depression to mortality and hospitalization in patients with heart failure Archives of Internal Medicine Sherwood, A., Blumenthal, J. A., Trivedi, R., Johnson, K. S., O'Connor, C., Adams, K. A., Sueta-Dupree, C., Waugh, R. A., Bensimhon, D. R., Gaulden, L., Koch, G. G., Hinderliter, A. L. 2007; 167: 367-373
  • Donepezil for Cognitive Decline Following Coronary Artery Bypass Surgery: A Pilot Randomized Controlled Trial PSYCHOPHARMACOLOGY BULLETIN Doraiswamy, P. M., Babyak, M. A., Hennig, T., Trivedi, R., White, W. D., Mathew, J. P., Newman, M. F., Blumenthal, J. A. 2007; 40 (2): 54-62


    To study the effect of donepezil in treating patients with cognitive decline following coronary artery bypass graft (CABG) surgery.Forty-four patients, with at least a 0.5 SD decline at 1 year post-CABG on at least one cognitive domain compared to their pre-CABG baseline score, were randomized to treatment with donepezil (titrated to 10 mg daily) or placebo in a 12-week double-blind, single center, randomized study. A composite cognitive change score served as the primary outcome. Secondary outcome measures included tests of memory, attention, psychomotor speed, and executive function.The composite cognitive outcome did not show significant treatment effects. Secondary measures varied in their sensitivity to donepezil effects with the largest effects seen on the Wechsler Visual Memory Scale-Delayed and Immediate recall tests. More than twice (52% vs. 22%) as many donepezil-treated patients showed a significant improvement compared with placebo patients on Delayed recall. Tests with weak effect sizes and minimal trends favoring donepezil were the Boston Naming and Digit Symbol. However, most of the other instruments (e.g., Digit Span, Trails B, and Controlled Word Association) showed no treatment benefits. More donepezil-treated than placebo-treated patients experienced diarrhea, but other adverse effects and safety measures did not differ between groups.In the post-CABG mild cognitive decline setting, donepezil did not improve composite cognitive performance but improved some aspects of memory. Donepezil was well tolerated and had no significant effects on EKG parameters. Because of limitations such as small sample size and multiplicity of tests, these findings are preliminary but add to our knowledge of cholinergic effects in vascular mild cognitive decline.

    View details for Web of Science ID 000207792600004

    View details for PubMedID 17514186

  • Genetic and environmental influences on anger expression, John Henryism, and stressful life events: The Georgia cardiovascular twin study PSYCHOSOMATIC MEDICINE Wang, X. L., Trivedi, R., Treiber, F., Snieder, H. 2005; 67 (1): 16-23


    To examine the genetic and/or environmental origin of variation and covariation of perceived stressful life events and two stress-related coping styles, anger expression and John Henryism.Data were available from 306 European American (EA) and 213 African American (AA) twin pairs, including monozygotic and dizygotic of same as well as opposite sex (mean age, 14.8 +/- 3.1 years; range, 10.0-25.9 years). Anger expression, John Henryism, and life events were measured with the Anger Expression Scale (subscales: Anger-in, Anger-out, and Anger-control), the John Henryism Active Coping Scale, and the Adolescent Resources Challenges Scale, respectively.Model fitting showed no ethnic or sex differences for any of the scales. All traits showed at least some degree of familial resemblance, best explained by shared environment for Anger-in (18%), heritability for Anger-control (34%), John Henryism (34%), and life events (47%), and a combination of heritability (14% and 15%) and shared environment (10% and 20%) for Anger-out and overall anger expression, respectively. The remaining part of the variation for all traits was explained by environmental influences that are unique to the individual. Anger expression and life events were correlated (r = 0.28), and bivariate genetic modeling showed that 61% of this correlation was mediated by common genetic factors.Individual differences in coping styles and life events in youth can be explained by moderate genetic and substantial environmental influences, of which most are idiosyncratic to the individual. The association between anger expression and life events is largely the result of common genes.

    View details for DOI 10.1097/01.psy.0000146331.10104.d4

    View details for Web of Science ID 000226673700003

    View details for PubMedID 15673619