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Background Elderly patients frequently suffer from problems in speech discrimination especially in noisy situation, and they also have several problems from using amplifications devices especially binaural amplification. This necessitates the need for central auditory evaluation in association of peripheral auditory evaluation. The aim of the present study was to explore the effects of aging on dichotic listening performance. This was a case-control study conducted at the Audiology Unit, ENT Department. Participant were 46 individuals within the age range of 60 to 89 years with no history of neurological disorder or cognitive impairment, and all the participants were of high social class. Forty-five adult individuals (control group) with the age range 32–57 years, with no history of neurological disorders. Both cases and control groups were subjected to otological examination, immittancemetry, puretone audiometry, speech audiometry, and central auditory processing assessment by the use of central questionnaire for elderly and dichotic digits (version II) test. Results The elderly group scored significantly depressed scores of dichotic digits’ test, especially in the left ear than in the adult group. Conclusion Dichotic listening ability was significantly affected in elderly patients.

There has been extensive concern about suicide among veterans, but no study has examined rates and correlates of suicidality in the highly vulnerable group of veterans receiving Veterans Health Administration (VHA) intensive case management services. Veterans participating in a national program evaluation were surveyed at the time of program entry and 6 months later. Sociodemographic and clinical characteristics were documented along with elements of program service delivery. Chi square tests were used to compare rates of suicidality (defined as either having made or threatened an attempt) at baseline and at the 6-month follow-up. Analysis of variance was also used to compare suicidal and non-suicidal veterans at follow-up. Logistic regression analysis was then used to identify independent correlates of suicidality 6 months after program entry. Among the 9921 veterans who later completed follow-up assessments 989 (10.0%) had reported suicidal behavior at program entry as compared to only 250 (2.51%) at 6 months (p < 0.0001). Multivariable logistic regression analysis showed suicidality at 6 months to be associated with suicidality at admission, increased subjective distress on the Brief Symptom Inventory (especially on depression items), violent behavior and decreased quality of life since admission, along with a greater likelihood of receiving crisis intervention, but not other services. Among veterans receiving intensive case management services from VHA, suicidal behavior declined by 75% from admission to 6 months (10–2.5%) and was associated with suicidality prior to program entry, worsening subjective symptoms and greater receipt of crisis intervention services.

Alzheimer disease (AD) imposes a severe burden on patients and their caregivers. Although there is substantial evidence of the adverse impact of burden, considerably less is known about its specific correlates and potential causes. The authors use data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)-AD study to examine the relationship of burden and depression among AD caregivers to patient and caregiver sociodemographic characteristics, patients' cognitive status, psychiatric and behavioral symptoms, functional abilities, quality of life, and intensity of care provided by caregivers. CATIE-AD included outpatients in usual care settings and assessed treatment outcomes during 9 months. Data were examined from 421 ambulatory outpatients with a diagnosis of dementia of the Alzheimer type or probable AD with agitation or psychosis. Measures: The Burden Interview, the Beck Depression Inventory, and the Caregiver Distress Scale were used to evaluate caregiver burden. More severe psychiatric and behavioral problems and decreased patient quality of life, as well as lower functional capability were significantly associated with higher levels of burden and depression among caregivers at baseline. Six-month changes showed that decreased symptoms and improved quality of life were associated with decreased burden and accounted for most of the explained variance in change in burden measures. Severity of psychiatric symptoms, behavioral disturbances, and patients' quality of life are the main correlates of caregivers' experience burden. Psychosocial and pharmacologic interventions targeting these two aspects of the disorder are likely to not only alleviate patient suffering but also promote caregiver well-being.

Background In this secondary analysis of the VA Augmentation and Switching Treatments for Improving Depression Outcomes (VAST‐D) study we used antidepressant response trajectories to assess the association of treatment and multiple clinical/demographic factors with the probability of response. Methods Using data from VAST‐D, a multi‐site, randomized, single‐blind trial with parallel‐assignment to one of three treatment interventions in 1522 Veterans whose major depressive disorder was unresponsive to at least one antidepressant trial, we evaluated response patterns using group‐based trajectory modeling (GBTM). A weighted multinomial logistic regression analysis with backward elimination and additional exploratory analyses were performed to evaluate the association of multiple clinical/demographic factors with the probability of inclusion into specific trajectories. Additional exploratory analyses were used to identify factors associated with trajectory group membership that could have been missed in the primary analysis. Results GBTM showed the best fit for depression symptom change was comprised of six trajectories, with some trajectories demonstrating minimal improvement and others showing a high probability of remission. High baseline depression and anxiety severity scores decreased, and early improvement increased, the likelihood of inclusion into the most responsive trajectory in both the GBTM and exploratory analyses. Conclusion While multiple factors influence responsiveness, the probability of inclusion into a specific depression symptom trajectory is most strongly influenced by three factors: baseline depression, baseline anxiety, and the presence of early improvement. Highlights In a large study of U.S. Veterans with moderate to severe depression group‐based trajectory modeling demonstrated six response trajectories as the best fit for depression symptom change over time. A weighted multinomial logistic regression analysis with backward elimination identified multiple factors influencing antidepressant responsiveness, but response trajectories are most strongly influenced by three factors: baseline depression, baseline anxiety, and the presence of early improvement.

Assertive Community Treatment (ACT) for people with severe mental illness is an effective approach that is increasingly implemented in rural areas. Low-cost methods of evaluating fidelity to program models are needed to assure services are delivered as intended. In 2007, the Veterans Health Administration implemented an ACT-like Mental Health Intensive Case Management (ACT/ICM) program for SMI veterans in rural areas. This study demonstrates the use of administrative data, reflecting patient characteristics and intensity of service delivery, to characterize services delivered by these programs, to compare them to general mental health programs at the same VA medical centers, and to each other. A total of 298,509 veterans received mental health services at VA medical centers that also operated a rural ACT/ICM program in FY 2012. Altogether 854 (0.29%) received ACT/ICM services for 1 year or more (long term participants) and 259 (.09%) received them for less than 1 year (new entrants). Logistic regression showed ACT/ICM patients were distinguished by diagnoses of schizophrenia, bipolar disorder, and major depression; larger numbers of psychiatric or substance abuse visits; and use of 3 or more classes of psychotropic medication. The model had a high c statistic of 0.91. Propensity scores allowed clear identification of programs most and least conforming to the profile of a “typical” rural ACT/ICM program. Low cost administrative data can be used to identify programs successfully conforming to an empirically derived rural model of ACT/ICM. Further validation of this approach is needed.

In 2007, the Veterans Health Administration (VHA) implemented a program to deliver the full array of Assertive Community Treatment services in areas with low population density using teams with small staffs. VHA administrative data were used to compare treatment and outcomes of veterans who received services from teams with only two or three staff (N = 805) and veterans served by teams with ten or more staff (N = 861). After adjusting for baseline difference, smaller teams had statistically significantly less symptom improvement and smaller declines in suicidality indices but effect sizes were small and there were no differences on 11 other outcomes. These data demonstrate the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small teams.

The pharmacological treatment of post-traumatic stress disorder (PTSD) is extremely challenging, as no specific agent has been developed exclusively to treat this disorder. Thus, there are growing concerns among the public, providers and consumers associated with its use as the efficacy of some agents is still in question. We applied a dimensional and symptom cluster-based approach to better understand how the heterogeneous phenotypic presentation of PTSD may relate to the initiation of pharmacotherapy for PTSD initial episode. US veterans who served in the conflicts in Iraq and Afghanistan and received an initial PTSD diagnosis at the US Veterans Health Administration between 2008 and 2011 were included in this study. Veterans were followed for 365 days from initial PTSD diagnosis to identify initiation for antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics and prazosin. Multivariable analyses were used to assess the relationship between the severity of unique PTSD symptom clusters and receiving prescriptions from each medication class, as well as the time from diagnosis to first prescription. Increased severity of emotional numbing symptoms was independently associated with the prescription of antidepressants, and they were prescribed after a substantially shorter period of time than other medications. Anxiolytics/sedatives/hypnotics prescription was associated with heightened re-experiencing symptoms and sleep difficulties. Antipsychotics were associated with elevated re-experiencing and numbing symptoms and prazosin with reported nightmares. Prescribing practices for military-related PTSD appear to follow US VA/DoD clinical guidelines. Results of this study suggest that a novel dimensional and symptom cluster-based approach to classifying the phenotypic presentation of military-related PTSD symptoms may help inform prescribing patterns for PTSD. None. © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Despite increasing numbers of older veterans diagnosed with posttraumatic stress disorder (PTSD) in veterans administration (VA), limited research has focused on pharmacotherapy of PTSD among the elderly. The authors examined pharmacotherapy provided to patients carrying a clinical diagnosis of PTSD in VA. Data on outpatients treated at VA nationally were utilized. Patients were veterans over 45 years of age diagnosed with PTSD in FY 2004 (N = 244,947) grouped into five age cohorts with patients 45–55 as the reference group. Psychotropic prescriptions were examined. Descriptive statistics and multivariable logistic regression adjusting for confounding characteristics, including receipt of VA service connected disability benefits which may create incentives to artificially maintain historical diagnoses, were used to identify the relationship of age to receipt of psychotropic medications net of these factors. All analyses were repeated using data only from nonservice connected veterans. Most older veterans received psychotropic medication and among these, 88.3% were prescribed antidepressants, 61.2% anxiolytics/sedative hypnotics, and 32.9% antipsychotics. A pronounced monotonic trend showed decrease use of any psychotropic medication and of each subclass with age. Medication use was higher among those treated in specialty mental health clinics than among those treated exclusively in primary care or medical clinics and interaction analysis of age by clinic type showed significantly more steeply declining use of medications with age among patients treated in specialty mental health clinics. Data from nonservice connected veterans revealed the same patterns. Diverse psychotropic medication classes are used to treat veterans diagnosed with PTSD in VA with declining use among older veterans. Medication utilization is greater in mental health clinics but declined more steeply with age, perhaps reflecting the greater sensitivity of specialists to the risks of elderly veterans. Older veterans diagnosed with PTSD appear to receive conservative, cautious treatment although observed patterns of care may reflect some degree of undertreatment.

There has been increasing concern in recent years about the availability of mental health services for people with serious mental illness in rural areas. To meet these needs the Department of Veterans Affairs (VA) implemented the Rural Access Networks for Growth Enhancement (RANGE) program, in 2007, modeled on the Assertive Community Treatment (ACT) model. This study uses VA administrative data from the RANGE program ( N  = 343) to compare client characteristics at program entry, patterns of service delivery, and outcomes with those of Veterans who received services from the general VA ACT-like program (Mental Health Intensive Case Management (MHICM) ( N  = 3,077). Veterans in the rural program entered treatment with similar symptom severity, less likelihood of being diagnosed with schizophrenia and having had long-term hospitalization, but significantly higher suicidality index scores and greater likelihood of being dually diagnosed compared with those in the general program. RANGE Veterans live further away from their treatment teams but did not differ significantly in measures of face-to-face treatment intensity. Similar proportions of RANGE and MHICM Veterans were reported to have received rehabilitation services, crisis intervention and substance abuse treatment. The rural programs had higher scores on overall satisfaction with VA mental health care than general programs, slightly poorer outcomes on quality of life and on the suicidality index but no significant difference on other outcomes. These data demonstrate the clinical need, practical feasibility and potential effectiveness of providing intensive case management through small specialized case management teams in rural areas.