We proposed a pre-implementation study to establish the transportability of an evidence-based approach with demonstrated efficacy and effectiveness, the Short-Term Assessment of Risk and Treatability (START), to the VA system with the ultimate goal of improving clinical decision-making and care of Veterans with SUD. This project has two aims: (1) To determine whether START can be implemented successfully in VA healthcare facilities. (2) To evaluate whether START assessments accurately predict suicidality, aggression, and related high-risk behaviors among Veterans with SUD.
Compared to the general population, Veterans are at elevated risk for multiple, inter-related negative outcomes, including suicide and violence. These high-risk behaviors are especially prominent among Veterans with substance use disorder (SUD), who often present with co-morbid mental disorders. As a result, clinicians working in VA must routinely assess the risks clients present to themselves and others. Few instruments have been validated for assessing risks among Veterans; however, these typically focus on one adverse outcome -for example, suicide or violence-to the exclusion of others. To the extent that high-risk behaviors co-occur, a comprehensive and coordinated assessment and intervention strategy may produce the greatest benefits to client health and safety, as well as to the safety of clients' families and the public.
This project employed a mixed-methods design. The study plan was to collect data through interviews and surveys with clinicians conducting START assessments every three months; self-report measures completed by Veterans at study enrollment and 3-month follow-up, and client feedback interviews completed by a subsample of Veterans at follow-up. We planned two study sites to aid recruitment (VA Boston and the Bedford VA). Baseline START assessments were conducted by the study assessor with Veterans who met these inclusion criteria: for current SUD diagnosis and able to speak/read English. The same assessor administered the START 90 days after baseline assessment. Also, self-report measures completed by Veterans were: Behavior and Symptom Identification Scale-24; Brief Addiction Monitor; PSTD Checklist; Psychiatric Diagnostic Screening Questionnaire; Short-Form Health Survey-12; the Stigma Scale for Receiving Psychological Help; and START Outcome Scale. The goal was to recruit 74 Veterans, with a target of 60 completing both baseline and follow-up assessments (sample size based on power analysis).
None (see Status section for reasons).
Several aspects of the proposal were noteworthy: (1) SUD is a high priority area for VA patient care. (2) We sought to address one of the current HSR&D research priorities: improving mental and behavioral interventions (3) Our approach was theoretically-grounded in implementation science, and also included an economic analysis component. (4) START is within the public domain, supporting dissemination throughout VA and enhancing sustainability beyond the lifespan of the project. For these reasons, our study was anticipated to have both high relevance to and a significant impact on the delivery of health care to Veterans with SUD. If successful our next step would have been to conduct an RCT evaluating the implementation START in VA healthcare facilities. However, the ultimate impact of the project did not meet the anticipated impact. We had to terminate the study due to significant difficulties (as detailed in the Status section of this report).
External Links for this Project
None at this time.