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Anxiety

Library of Research Articles on Veterans and CIH Therapies

January 2021 Edition

Anxiety

Buttner MM, Bormann JE, Weingart K, Andrews T, Ferguson M, Afari N. Multi-site evaluation of a complementary, spiritually-based intervention for Veterans: The Mantram Repetition Program. Complement Ther Clin Pract. 2016 Feb;22:74-9. doi: 10.1016/j.ctcp.2015.12.008. Epub 2015 Dec 19.

BACKGROUND

Mental and physical symptoms affect Veterans' quality of life. Despite available conventional treatments, an increasing number of Veterans are seeking complementary approaches to symptom management. Research on the Mantram Repetition Program (MRP), a spiritually-based intervention, has shown significant improvements in psychological distress and spiritual well-being in randomized trials. However, these findings have not been replicated in real-world settings.

METHODS

In this naturalistic study, we analyzed outcomes from 273 Veterans who participated in MRP at six sites and explored outcomes based on facilitator training methods. Measures included satisfaction and symptoms of anxiety, depression, and somatization using the Brief Symptom Inventory-18; Functional Assessment of Chronic Illness Therapy-Spiritual Well-being questionnaire; and the Mindfulness Attention Awareness Scale.

RESULTS

There were significant improvements in all outcomes (p's < .001) regardless of how facilitators were trained. Patient satisfaction was high.

CONCLUSION

The MRP was disseminated successfully yielding improvements in psychological distress, spiritual well-being, and mindfulness.

Chang BH, Sommers E.  Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder. Am J Addict. 2014 Mar-Apr;23(2):129-36. doi: 10.1111/j.1521-0391.2013.12079.x. Epub 2013 Aug 30.

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) is a major health issue, especially among military veterans. We previously reported the effects of auricular acupuncture and the relaxation response (RR) on reducing craving and anxiety following 10-week interventions among veterans who were in recovery from SUDs. Our current analysis examines effects following each intervention session and RR daily practice.

METHODS

We conducted a three-arm randomized controlled trial on residents of a homeless veteran rehabilitation program. Sixty-Seven enroled participants were randomly assigned to acupuncture (n=23), RR (n=23), or usual care (n=21). Participants in the two intervention groups rated their degree of craving for substance on a scale of 1-10 and anxiety levels on a scale of 1-4 (total score 20-80) before and after each intervention session. Mixed effects regression models were used for analysis.

RESULTS

Craving and anxiety levels decreased significantly following one session of acupuncture (-1.04, p=.0001; -8.83, p<.0001) or RR intervention (-.43, p=.02; -4.64, p=.03). The level of craving continued to drop with additional intervention sessions (regression coefficient b=-.10, p=.01, and b=-.10, p=.02 for acupuncture and RR groups, respectively). Number of daily practice days of RR-eliciting techniques is also associated with reduction in craving ratings (b=-.02, p=.008).

CONCLUSIONS

Findings demonstrate the value of attending regular acupuncture and RR-eliciting intervention sessions, as well as the daily practice of RR-eliciting techniques.

SCIENTIFIC SIGNIFICANCE

Substance addiction is a complex disease and effective treatment remains a challenge. Our study findings add to the scientific evidence of these two non-pharmaceutical approaches for SUD.

Cosio D, Swaroop S. The Use of Mind-body Medicine in Chronic Pain Management: Differential Trends and Session-by-Session Changes in Anxiety. J Pain Manag Med. 2016 Mar

The evidence to date suggests that the use of mind-body medicine in chronic pain management can improve physical and psychological symptoms. However, past research evidence has largely relied on global measures of distress at pre- and post-intervention. Even though it is plausible that reported anxiety occurs in the context of pain, there is also evidence to suggest a reciprocal relationship. Thus, the purpose of the current study was to determine the differential impact that mind-body medical interventions have on anxiety among Veterans with chronic, non-cancer pain. The current study utilized multiple, repeated assessments of anxiety to better understand changes made over time between two mind-body interventions (Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT)) used for chronic pain management. Ninety-six Veterans elected to participate in either intervention following the completion of a pain health education program at a Midwestern VA Medical Center between November 3, 2009-November 4, 2010. A 2 × 7 repeated measures multivariate analyses of variance indicated significantly lower levels of global distress by the end of both the ACT and CBT interventions. Trend analysis revealed differential patterns of change in levels of anxiety over time. Helmert contrast analyses found several modules of ACT were statistically different than the overall mean of previous sessions. Implications related to timing and patterns of change for the interventions are discussed.

Duan-Porter W, Coeytaux RR, McDuffie JR, Goode AP, Sharma P, Mennella H, Nagi A, Williams JW Jr. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016 Mar;13(3):281-8. doi: 10.1123/jpah.2015-0027. PubMed PMID: 26181774.

BACKGROUND

This study describes evidence of yoga's effectiveness for depressive disorders, general anxiety disorder (GAD), panic disorder (PD), and posttraumatic stress disorder (PTSD) in adults. We also address adverse events associated with yoga.

METHODS

We searched multiple electronic databases for systematic reviews (SRs) published between 2008 and July 2014, randomized controlled trials (RCTs) not identified in eligible SRs, and ongoing RCTs registered with ClincalTrials.gov.

RESULTS

We identified 1 SR on depression, 1 for adverse events, and 3 addressing multiple conditions. The high-quality depression SR included 12 RCTs (n = 619) that showed improved short-term depressive symptoms (standardized mean difference, -0.69, 95% confidence interval, -0.99 to -0.39), but there was substantial variability (I2 = 86%) and a high risk of bias for 9 studies. Three SRs addressing multiple conditions identified 4 nonrandomized studies (n = 174) for GAD/PD and 1 RCT (n = 8) and 2 nonrandomized studies (n = 22) for PTSD. We separately found 1 RCT (n = 13) for GAD and 2 RCTs (n = 102) for PTSD. Collectively, these studies were inconclusive for the effectiveness of yoga in treating GAD/PD and PTSD. The high-quality SR for adverse events included 37 primary reports (n = 76) in which inversion postures were most often implicated. We found 5 ongoing trials (3 for PTSD).

CONCLUSIONS

Yoga may improve short-term depressive symptoms, but evidence for GAD, PD, and PTSD remain inconclusive.

Goldberg S, Zeliadt S, Hoggatt K, Simpson T, Fortney J, Taylor SL. Utilization and Perceived Effectiveness of Mindfulness Meditation in Veterans: Results from a National Survey. Mindfulness. Sep 2019: 1-10.

Objectives

Complementary and integrative health (CIH) approaches are increasingly utilized in health care, and mindfulness meditation is one such evidence-based CIH practice. More information is needed about veterans' utilization of mindfulness to inform integration within the Veterans Health Administration (VHA).

Methods

This study involved secondary data analysis of a national survey to evaluate utilization and perceived effectiveness of mindfulness relative to other CIH approaches among military veterans. Military veterans (n = 1230) enrolled in VHA reported CIH utilization rates, reasons for use, perceived effectiveness, treatment barriers, and demographics.

Results

Approximately 18% of veterans reported using mindfulness meditation in the past year, exceeding the proportion using all other CIH approaches (p < .001), with the exception of massage and chiropractic care. Mindfulness was most commonly used for stress reduction and addressing symptoms of depression and anxiety. Among mindfulness users, veterans rated mindfulness with a mean score of 3.18 out of 5 (SD = 0.82) in terms of effectiveness, reflecting a response in the "somewhat helpful" to "moderately helpful" range. This was similar to ratings of other CIH approaches (mean = 3.20, p = .391). Of those who used mindfulness, nearly all (78%) reported only using it outside the VHA. Veterans identified not knowing if the VHA offered mindfulness as the most common reason for using mindfulness outside VHA.

Conclusions

In summary, veterans use mindfulness for a range of reasons and report receiving benefit from its use. Low awareness and potentially low availability of VHA's mindfulness programs need to be addressed to increase access.

Schulz-Heik RJ, Meyer H, Mahoney L, Stanton MV, Cho RH, Moore-Downing DP, Avery TJ, Lazzeroni LC, Varni JM, Collery LM, Bayley PJ. Results from a clinical yoga program for veterans: yoga via telehealth provides comparable satisfaction and health improvements to in-person yoga. BMC Complement Altern Med. 2017 Apr 4;17(1):198. doi: 10.1186/s12906-017-1705-4. PubMed PMID: 28376861; PubMed Central PMCID: PMC5381127.

BACKGROUND

Yoga is increasingly popular, though little data regarding its implementation in healthcare settings is available. Similarly, telehealth is being utilized more frequently to increase access to healthcare; however we know of no research on the acceptability or effectiveness of yoga delivered through telehealth. Therefore, we evaluated the feasibility, acceptability, and patient-reported effectiveness of a clinical yoga program at a Veterans Affairs Medical Center and assessed whether these outcomes differed between those participating in-person and those participating via telehealth.

METHODS

Veterans who attended a yoga class at the VA Palo Alto Health Care System were invited to complete an anonymous program evaluation survey.

RESULTS

64 Veterans completed the survey. Participants reported high satisfaction with the classes and the instructors. More than 80% of participants who endorsed a problem with pain, energy level, depression, or anxiety reported improvement in these symptoms. Those who participated via telehealth did not differ from those who participated in-person in any measure of satisfaction, overall improvement (p = .40), or improvement in any of 16 specific health problems.

CONCLUSIONS

Delivering yoga to a wide range of patients within a healthcare setting appears to be feasible and acceptable, both when delivered in-person and via telehealth. Patients in this clinical yoga program reported high levels of satisfaction and improvement in multiple problem areas. This preliminary evidence for the effectiveness of a clinical yoga program complements prior evidence for the efficacy of yoga and supports the use of yoga in healthcare settings.

Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014 Dec;52(12 Suppl 5):S19-24. doi: 10.1097/MLR.0000000000000202. PubMed PMID: 25397818.

INTRODUCTION

Anxiety, depression, and pain are major problems among veterans, despite the availability of standard medical options within the Veterans Health Administration. Complementary and alternative approaches for these symptoms have been shown to be appealing to veterans. One such complementary and alternative approach is mindfulness-based stress reduction (MBSR), a brief course that teaches mindfulness meditation with demonstrated benefits for mood disorders and pain.

METHODS

We prospectively collected data on MBSR's effectiveness among 79 veterans at an urban Veterans Health Administration medical facility. The MBSR course had 9 weekly sessions that included seated and walking meditations, gentle yoga, body scans, and discussions of pain, stress, and mindfulness. Pre-MBSR and post-MBSR questionnaires investigating pain, anxiety, depression, suicidal ideation, and physical and mental health functioning were obtained and compared for individuals. We also conducted a mediation analysis to determine whether changes in mindfulness were related to changes in the other outcomes.

RESULTS

Significant reductions in anxiety, depression, and suicidal ideation were observed after MBSR training. Mental health functioning scores were improved. Also, mindfulness interacted with other outcomes such that increases in mindfulness were related to improvements in anxiety, depression, and mental health functionality. Pain intensity and physical health functionality did not show improvements.

DISCUSSION

This naturalistic study in veterans shows that completing an MBSR program can improve symptoms of anxiety and depression, in addition to reducing suicidal ideations, all of which are of critical importance to the overall health of the patients.

Shepardson RL, Funderburk JS. Likelihood of Attending Treatment for Anxiety Among Veteran Primary Care Patients: Patient Preferences for Treatment Attributes. J Clin Psychol Med Settings. 2016 Sep;23(3):225-39. doi: 10.1007/s10880-016-9462-y.

Anxiety is common, but under-treated, in primary care. Behavioral health providers embedded in primary care can help address this treatment gap. Guidance on anxiety treatment preferences would help inform tailoring of clinical practice and new interventions to be more patient-centered and increase treatment engagement. We surveyed 144 non-treatment seeking Veteran primary care patients (82.6 % male, 85.4 % White, age M = 59.8 years, SD = 13.9) reporting current anxiety symptoms (M = 13.87, SD = 3.66, on the Generalized Anxiety Disorder-7 Questionnaire) on their likelihood of attending anxiety treatment featuring various levels of 11 attributes (modality, type, location, format, provider, visit frequency, visit length, treatment duration, type of psychotherapy, symptom focus, and topic/skill). Participants indicated clear preferences for individual, face-to-face treatment in primary care, occurring once a month for at least 30 min and lasting at least three sessions. They also tended to prefer a stress management approach focused on trouble sleeping or fatigue, but all topics/skills were rated equivalently. For most attributes, the highest rated options were consistent with characteristics of integrated care. Implications for research and practice are discussed.

Smeeding SJ, Bradshaw DH, Kumpfer K, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complement Med. 2010

OBJECTIVES

The purpose of this longitudinal outcome research study was to determine the effectiveness of the Integrative Health Clinic and Program (IHCP) and to perform a subgroup analysis investigating patient benefit. The IHCP is an innovative clinical service within the Veterans Affairs Health Care System designed for nonpharmacologic biopsychosocial management of chronic nonmalignant pain and stress-related depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) utilizing complementary and alternative medicine and mind-body skills.

METHODS

A post-hoc quasi-experimental design was used and combined with subgroup analysis to determine who benefited the most from the program. Data were collected at intake and up to four follow-up visits over a 2-year time period. Hierarchical linear modeling was used for the statistical analysis. The outcome measures included: Health-Related Quality of Life (SF-36), the Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subgroup comparisons included low anxiety (BAI < 19, n = 82), low depression (BDI < 19, n = 93), and absence of PTSD (n = 102) compared to veterans with high anxiety (BAI > or = 19, n = 77), high depression (BDI > 19, n = 67), and presence of PTSD (n = 63).

RESULTS

All of the comparison groups demonstrated an improvement in depression and anxiety scores, as well as in some SF-36 categories. The subgroups with the greatest improvement, seen at 6 months, were found in the high anxiety group (Cohen's d = 0.52), the high-depression group (Cohen's d = 0.46), and the PTSD group (Cohen's d = 0.41).

CONCLUSIONS

The results suggest IHCP is an effective program, improving chronic pain and stress-related depression, anxiety, and health-related quality of life. Of particular interest was a significant improvement in anxiety in the PTSD group. The IHCP model offers innovative treatment options that are low risk, low cost, and acceptable to patients and providers.

Williams JW Jr, Gierisch JM, McDuffie J, Strauss JL, Nagi A.  An Overview of Complementary and Alternative Medicine Therapies for Anxiety and Depressive Disorders: Supplement to Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder.  Washington (DC): Department of Veterans Affairs (US); 2011 Aug.

BACKGROUND

VA is committed to expanding the breadth of posttraumatic stress disorder (PTSD)-related services available to Veterans. Since depressive and anxiety disorders share common features with PTSD, this report was commissioned to examine the efficacy of complementary and alternative medicine (CAM) therapies for the treatment of depressive and anxiety disorders as a means to detect treatments that might be applicable to PTSD.

METHODS

The key questions (KQs) were adapted from the parent report, Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder. We searched MEDLINE® (via PubMed®) and the Cochrane Database of Systematic Reviews for recent English-language systematic reviews (SRs) that examined the literature on mind-body medicine, manipulative and body-based practices, and movement or energy therapies, excluding nutritionals, herbal remedies and other supplements. To be included, SRs had to be published within the past five years and be evaluated as a "fair" or "good" quality. Titles, abstracts, and articles were reviewed in duplicate, and relevant data were abstracted by authors trained in the critical analysis of literature.

KEY FINDINGS

We identified five relevant SRs on mind-body CAM therapies, but none on manipulative and body-based, movement-based, or energy therapies. Most primary studies were small trials that did not provide descriptions of CAM strategies adequate to permit replication. Dose, duration, and frequency of interventions sometimes varied widely.