VA Research: UAMS, VA Mental Health Research Takes National Role

David Robinson

UAMS VA Campus

More than half-a-million veterans enrolled in the U.S. Department of Veterans Affairs health care system are diagnosed with post-traumatic stress disorder (PTSD), and with suicide claiming the lives of an estimated 22 veterans every day, the pressure is on to find solutions.

Mental health researchers at UAMS and the Central Arkansas Veterans Healthcare System (CAVHS) have joined forces to take a prominent role in this national effort.

The research is led by some of the best minds in psychiatry and psychology as well as experts in geography, anthropology, nursing, pharmacy, religion and community engagement. Their laboratory extends across the country, including communities across Arkansas, which has more than 250,000 veterans, placing it among states with the most veterans per capita at 10.4 percent.

If researchers prove a treatment or program works, the VA will put it into practice.John Fortney, Ph.D.

On the UAMS side, the effort is led by John Fortney, Ph.D., director of the Division of Health Services Research in the Department of Psychiatry in the College of Medicine. The division has more than 20 faculty members, and about 90 percent of them have joint appointments with CAVHS. Their work is augmented by other College of Medicine departments, the colleges of Nursing and Pharmacy, and the UAMS Translational Research Institute.

The majority of the research is in developing, testing and implementing interventions for mental health and substance use disorders. Their discoveries and innovations have been adopted nationally by the VA.

The CAVHS Eugene J. Towbin Healthcare Center in North Little Rock is home to three mental health research centers, more than any VA site in the country.

“We’re having a national impact, but in many ways it’s kind of a secret in Arkansas,” said Jo Ann Kirchner, M.D., a UAMS professor of psychiatry and director of one of those centers, the Mental Health Quality Enhancement Research Initiative (QUERI).

Established in 1998, Mental Health QUERI is responsible for research on finding and implementing best clinical practices to improve treatment and outcomes for veterans with mental illness.

Other mental health centers run by CAVHS in partnership with UAMS are:

  • Mental Illness Research, Education and Clinical Centers (MIRECC), established by Congress in 1996. The South Central MIRECC covers the Florida panhandle to the panhandle of Oklahoma and includes 10 medical centers and 80 satellite clinics. The center focuses on improving access to mental health care for veterans in rural areas. Fortney is the South Central MIRECC’s associate director for research.
  • Center for Mental Healthcare and Outcomes Research (CeMHOR), directed by Richared Owen, M.D, a UAMS professor of psychiatry. Established in 1990, it conducts translational research to move findings into development of new treatments and find ways to ensure the best treatments are reaching veterans who need them.

Kirchner said having all three programs in central Arkansas is a tribute to the vision of College of Medicine Dean G. Richard Smith, M.D., former chair of the Department of Psychiatry and founding director of the UAMS Psychiatric Research Institute.

“Dr. Smith was the founding director of CeMHOR and strongly encouraged and supported the application for the VA South Central MIRECC and Mental Health QUERI,” she said.

Models of Success

Fortney and Kirchner are behind one of the biggest success stories for mental health research at CAVHS. They developed ways to implement models of delivering mental health care in primary care clinics, and their work is being used by VA policy makers across the nation.

With mental health providers co-located in the same clinic as veterans’ primary care physicians, patients may be referred on the spot without need of an appointment and without requiring a lengthy mental health evaluation. This is a change from patients being referred to mental health providers in a different building in a potentially stigmatized setting.

“In many cases the patient has a specific problem that we can help them address immediately without having to go through a full psychosocial evaluation,” Fortney said. “It is very patient-centered and problem-focused.”

Fortney and Kirchner consulted with front-line VA providers and staff in implementing the models, which they say has been key to its success.

Care managers have been added to follow up with patients, such as making sure they understand their treatment plan, promoting medication and counseling adherence, and assessing treatment response.

The biggest challenge has been in smaller medical centers and community-based outpatient clinics. Fortney adapted the integrated care model using telemedicine for smaller clinics that allows patients to speak with a mental health professional by telephone or interactive video.

Kirchner has led the development of a strategy in which specially trained facilitators work with the clinics to develop and conduct implementation plans for integrated care models.

The strategy was so effective that Kirchner was still analyzing the research data when VA leadership in Washington, D.C., requested that she start training VA staff as facilitators.

“Ultimately, that’s the measure of success,” she said. Fortney agreed. “If researchers prove a treatment or program works, the VA will put it into practice.”


The Pew Versus the Couch

The first and second meetings between local clergy and mental health providers in Russellville did not go well. Motivated by the suicide of a local veteran, they had gathered for lunch, invited by Chaplain Steve Sullivan from the Central Arkansas Veterans Healthcare System (CAVHS) and UAMS mental health researchers.

By the second meeting, a mental health social worker said she didn’t plan on referring patients to the pastors she didn’t know or trust. At the same time, a pastor complained that he went to visit a parishioner in the hospital’s intensive care unit and wasn’t allowed in the room.

The meetings were an outgrowth of the “VA/Clergy Partnership for Rural Veterans” project, a U.S. Department of Veterans Affairs-supported effort to increase communication and understanding between local clergy and mental health providers.

“Mental health providers tend to shy away from spirituality matters even though that integrates with mental health,” said Jeffrey Pyne, M.D., a professor of psychiatry and researcher for UAMS and CAVHS, “And the clergy tend to be suspicious of psychotropic medications as being the solution to what ails you.”

Despite the rocky start, the project that started four years ago in El Dorado, Pine Bluff, Searcy and Russellville has been deemed by the VA’s Office of Rural Health as its most successful project, said John Fortney, Ph.D., who leads the Division of Health Services Research in the Department of Psychiatry in the UAMS College of Medicine and also has a research leadership position at CAVHS. It is now being replicated in five other states.

“Eventually, Arkansas will be the hub resource for VA clergy partnerships that will then begin to spread to other parts of the country,” said Sullivan, also a member of the UAMS Translational Research Institute’s Community Advisory Board.

VA Chaplain Steve SullivanWhen the project wasn’t getting much traction with Russellville clergy, Sullivan gathered five local clergy and five mental health providers. The meetings began to bear fruit after a veteran told the mental health social worker that his post-traumatic stress disorder (PTSD) was a spiritual matter and he wanted to speak to a pastor.

“She was able to look around the room and identify two or three pastors who she felt could help,” Sullivan said.

About the same time, a pastor skeptical of the mental health community confided that a family member was battling depression, and he developed a trusting relationship with the same mental health social worker.

The project was strengthened when Pyne spoke to the group, Sullivan said.

Pyne noted that many veterans aren’t experiencing fear-based PTSD, but rather guilt and shame. The concept known as moral injury is a result of experiences or things veterans may have done that are not consistent with their moral upbringing and the way they understand the world.

“Dr. Pyne said, ‘Look, we’re frustrated; we’re seeing a lot of guilt and shame and our PTSD interventions are not touching this. You guys are the experts on these kinds of things. Can you help us?’”

“That totally changed the dynamic,” Sullivan said. “Pastors said they finally felt respected and they very much appreciated it.”

Local clergy are now becoming vital partners in veterans’ mental health treatment, he said.

The VA/Clergy Partnership project is sponsored and supported by the VA South Central Mental Illness, Research, Education, and Clinical Center (MIRECC).