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Principal Investigator: ANOUK L GRUBAUGH
Organization: RALPH H JOHNSON VA MEDICAL CENTER
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: Severe mental illnesses are consistently ranked as some of the most debilitating health conditions
worldwide due to their early age of onset, chronicity, and impact on functioning. Fortunately, a number of
antipsychotic medications have been found to be effective for managing the symptoms of severe mental illness
(SMI) and for preventing relapse and rehospitalization. Despite their efficacy, treatment non-compliance for
individuals on these medications is high due to a number of factors including poor insight into illness, negative
attitudes about medication, and medication related side effects. Further complicating care and outcomes for this
clinical population, providers must maintain close oversight of patients on antipsychotics due to the impact of
these medications on metabolic and cardiac functioning which confer an increased risk of obesity, diabetes,
heart problems, and other chronic illnesses. This oversight includes regular monitoring of weight, blood pressure,
fasting blood glucose, and lipid levels. Additionally, clozapine, indicated for treatment-resistant schizophrenia,
requires weekly-to-monthly monitoring of absolute neutrophil counts to prevent potentially fatal clozapine-
induced agranulocytosis. Significance: The proposed project has significant and immediate relevance to
Veterans and the VHA in that it seeks to better understand if and to what extent COVID-19 related care
disruptions impacted care and outcomes for Veterans with SMI prescribed antipsychotic medications. Given pre-
existing challenges in the treatment of this Veteran population, this is an important area of inquiry as well as one
for which little is known. Added strengths of the proposed study include the use of a mixed methods approach
that includes national level data from multiple sources. Aside from addressing a critical knowledge gap, the
proposed study targets what is unarguably one of the most vulnerable patient populations within the VA and
other healthcare systems—patients with SMI prescribed antipsychotic medications. Specific Aims: Aim 1: To
assess the impact of COVID-19 related care disruptions on healthcare use and outcomes for Veterans on
antipsychotic medications using robust statistical methods and national level data; Aim 2: To assess whether the
impact of COVID-19 related care disruptions differ by race/ethnicity, gender, age, and rural/urban status using
national level data; Aim 3: To conduct thematic interviews with provider and patient stakeholder groups at the
national level to better understand COVID-19 related care disruptions. Provider stakeholders (e.g., psychiatrists,
advanced nurse practitioners) will be interviewed to better understand COVID-19 related changes in practice
behaviors, the perceived impact of these changes on care continuity and outcomes, and to solicit suggestions
to mitigate the impact of interrupted care in the future; Veterans prescribed antipsychotic medication
prescriptions in the pre COVID-19 window will be interviewed to better understand the impact of COVID-19
related care disruptions on treatment seeking behaviors, obstacles encountered with regard to access, and to
explore other factors potentially impacting outcomes in this patient group. Methodology: The proposed study
will employ a mixed-methods (quantitative/qualitative) approach. For Aims 1 & 2 we will employ retrospective,
observational analyses using a national cohort of Veterans (N>250,000) with an ICD-CM-10 diagnostic code for
schizophrenia or bipolar disorder prescribed a first-generation or second-generation antipsychotic [1/19-12/21].
Veterans of all ages, genders, racial groups, military eras will be included in the cohort. Aim 3 will involve
individual thematic interviews with provider (n=35-45) and patient stakeholders (n=50-60). Next
Steps/Implementation: Findings from this 2-year project will be of immediate relevance and impact for local,
regional, and national level administrators and mental health providers as well as the VA Office of Mental Health
and Suicide Prevention and VA Pharmacy Benefits Management Services. Collectively, data from this project
will serve to identify potential strategies to further mitigate the impact of COVID-19 on the care and outcomes of
Veterans with SMI as well as prepare for future public health and/or other national emergencies.
Terms: <Address><Adherence><Administrator><Admission><Admission activity><Age><Age of Onset><Agranulocytosis><Antipsychotic Agents><Antipsychotic Drugs><Antipsychotics><Area><Armed Forces Personnel><Attitude><Behavior><Bipolar Affective Psychosis><Bipolar Disorder><Blood Glucose><Blood Neutrophil><Blood Polymorphonuclear Neutrophil><Blood Pressure><Blood Sugar><COVID-19><COVID-19 affected><COVID-19 consequence><COVID-19 effect><COVID-19 impact><COVID-19 impacted><CV-19><Cancers><Cardiac Diseases><Cardiac Disorders><Caring><Chronic><Chronic Disease><Chronic Illness><Clinical><Clozapine><Code><Coding System><Continuity of Care><Continuity of Patient Care><Continuum of Care><Coronavirus Infectious Disease 2019><Data><Data Sources><Diabetes Mellitus><Diagnostic><Disease><Disorder><Drug Prescribing><Drug Prescriptions><Drugs><ED care><ER care><Emergencies><Emergency Care><Emergency Department care><Emergency Room care><Emergency Situation><Emergency health care><Emergency healthcare><Emergency medical care><Ethnic Origin><Ethnicity><Event><Fasting><Future><Gender><Generations><Granulocytopenia><Guidelines><Health><Health Care Providers><Health Care Systems><Health Care Utilization><Health Personnel><Healthcare><Healthcare Delivery><Healthcare Providers><Healthcare Systems><Healthcare worker><Heart><Heart Diseases><Individual><Interruption><Interview><Knowledge><Lipids><Major Tranquilizers><Major Tranquilizing Agents><Malignant Neoplasms><Malignant Tumor><Manic-Depressive Psychosis><Marrow Neutrophil><Medication><Mental Health><Mental Hygiene><Mental disorders><Mental health disorders><Metabolic><Methodology><Methods><Military><Military Personnel><Monitor><Neuroleptic Agents><Neuroleptic Drugs><Neuroleptics><Neutrophilic Granulocyte><Neutrophilic Leukocyte><Nurse Practitioners><Out-patients><Outcome><Outpatients><Patients><Pharmaceutical Preparations><Pharmacists><Polymorphonuclear Cell><Polymorphonuclear Leukocytes><Polymorphonuclear Neutrophils><Population><Provider><Psychiatric Disease><Psychiatric Disorder><Psychiatrist><Psychological Health><Public Health><Racial Group><Research Design><Resistance><Rural><Safety><Schizophrenia><Schizophrenic Disorders><Services><Statistical Methods><Study Type><Suggestion><Suicide><Suicide precaution><Suicide prevention><System><Testing><Veterans><Visit><Weight><Woman><access to health care><access to healthcare><accessibility of health care><accessibility to health care><accessibility to healthcare><ages><bipolar affective disorder><bipolar disease><bipolar illness><bipolar mood disorder><cardiac function><care outcomes><chronic disorder><chronic mental illness><cohort><coronavirus disease 2019><coronavirus disease 2019 consequence><coronavirus disease 2019 effect><coronavirus disease 2019 impact><coronavirus disease-19><coronavirus disease-19 impact><coronavirus infectious disease-19><cost><dementia praecox><diabetes><differences due to race><differences in race><differs by race><differs in race><drug/agent><economic impact><ethnic minority><experience><fasted><fasts><fatal attempt><fatal suicide><function of the heart><health and care delivery><health care><health care access><health care availability><health care delivery><health care outcomes><health care personnel><health care service access><health care service availability><health care service use><health care service utilization><health care worker><health delivery systems><health provider><health services delivery><health workforce><healthcare access><healthcare accessibility><healthcare availability><healthcare outcomes><healthcare personnel><healthcare service access><healthcare service availability><healthcare service use><healthcare service utilization><healthcare utilization><heart disorder><heart function><hospital re-admission><hospital readmission><insight><intent to die><malignancy><manage symptom><manic depressive disorder><manic depressive illness><medical personnel><medication prescription><mental illness><military population><military veteran><mortality><multiple data sources><neoplasm/cancer><neutrophil><non-compliance><non-compliant><noncompliance><noncompliant><obesity risk><patient population><persistent mental illness><pharmacy benefit><post-COVID><post-COVID-19><post-coronavirus disease 2019><prescribed medication><prevent><prevent relapse><prevent suicidality><prevent suicide><preventing><psychiatric illness><psychiatric inpatient><psychological disorder><race based differences><race differences><race related differences><racial difference><racial minority><racial population><racial subgroup><racially different><re-admission><re-hospitalization><readmission><rehospitalization><relapse prevention><resistant><risk for obesity><risk of obesity><rural area><rural location><rural region><schizophrenic><serious mental disorder><serious mental illness><severe mental disorder><severe mental illness><side effect><statistic methods><study design><suicidality prevention><suicide intervention><suicides><symptom management><treatment provider><urban dwelling><veteran population><weights>