A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Academy for Health Services Research

and Health Policy

continued on page 2

Mental Health Care: Using Research to

Inform “Best Practices” in the VA

By Frederic C. Blow, Ph.D., Serious Mental Illness Treatment Research 

and Evaluation Center and HSR&D Center of Excellence, Ann Arbor 

FORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT JUNE 2002

Mental illness exacts enormous

costs — both financial and human

— on this country. The 1999

Surgeon General’s report on mental

health documents ample evidence

of these costs. Approximately 28

percent of the U.S. population has

a mental illness, but only 15 percent uses any mental health care

services. 

People with mental illness suffer

in very real terms. Four of the 10

leading causes of disability in the

U.S. are mental disorders: major

depression, bipolar disorder, schizophrenia, and obsessive-compulsive

disorder. Mental illnesses frequently

strike more vulnerable members of

our society. Post-traumatic stress

disorder (PTSD), for example, is

common among war veterans and

victims of rape, mugging, domestic

violence, terrorism, and natural

disasters. Approximately 5.2 million Americans ages 18 to 54 —

about 3.6 percent of people in this

age group — have PTSD. Alzheimer’s

disease, the most common cause of

dementia among people 65 and

older, affects an estimated 4 million Americans. The duration of

the illness from onset of symptoms

to death averages eight to 10 years.

Mental illness also plays a huge

role in suicide: More than 90 percent of people who kill themselves

have a diagnosable mental disorder.

This terrible level of human suffering also carries a huge price tag.

In 1996, direct costs of mental

health care totaled $69 billion. The

indirect costs of mental health care

were not measured at that time,

but were later measured in 1990

totaling $78.6 billion. Most indirect

costs were due to disability, as

opposed to mortality. 

The care of veterans with mental

illnesses is of great concern to the

VA. According to the VA’s North

East Program Evaluation Center

(NEPEC), in FY00 452,890 veterans had a service-connected psychiatric disorder and 677,519 veterans

received some type of mental health

treatment in the system. Total

mental health care costs in the VA

for FY00 exceeded $1.5 billion. 

Given the magnitude of the

problem and the costs associated

with it, mental health services

research has become a priority for

the VA. To help address this priority, the VA’s Serious Mental Illness

Treatment Research and Evaluation

Center (SMITREC) has developed

the ongoing National Psychosis

Registry (NPR) to monitor the care

of veterans with these debilitating

conditions and provide information

to help answer a variety of questions related to practice and policy.

SMITREC reported that 192,982

patients with psychosis were treated in the system in FY00, with $2.8

billion spent on their medical and

mental health care combined. 

In addition to their financial

C DIRECTOR’S LETTER OMMENTARY

“Celebrating the Past, Shaping the

Future” was the theme of this year’s

Health Services Research & Development Service (HSR&D) National

Meeting held February 13-15 in

Washington, DC. Hosted by

HSR&D’s Midwest Center for

Health Services and Policy

Research, the meeting celebrated 25

years of HSR&D funding, featuring a retrospective exhibit and

video and several honored guests,

including past HSR&D directors

and VHA Chief Research and

Development Officer John R.

Feussner, M.D., M.P.H. 

The national meeting brought

together more than 550 researchers,

clinicians, and policy makers who

participated in presentations, paper

sessions, workshops, and a poster

and exhibit session. There were

many highlights, such as Secretary

for Veterans Affairs Anthony J.

Principi’s address, in which he

emphasized VA’s commitment to

providing the best possible care. 

In addition, the prestigious Under

Secretary’s Award for Outstanding

Achievement in Health Services

Research was presented to Stephan

Fihn, M.D., M.P.H. 

I would be remiss if I did not

acknowledge the sadness we feel

about Dr. Feussner’s retirement in

August. Jack has had a dramatic

impact on VA research as a whole,

and on HSR&D in particular.

Along with increasing resources for

VA research, he focused HSR&D

on integrating research into practice,

while always emphasizing the need

for measurable impact of our work.

He will be moving to Charleston, SC,

where he will become chair of the

Department of Medicine of the

Medical University of South Carolina.

All of HSR&D wishes Jack the

very best in his future position. 

John G. Demakis, M.D.

Director, HSR&D
2

costs, mental illnesses carry high

personal, family, and societal costs.

All these costs underscore the

importance to the VA of many

issues, including: access to both

medical and mental health care,

the quality of mental health care,

morbidity and mortality, migration

in and out of the VHA system, the

effectiveness of specialized intensive community-based programs for

veterans with serious mental illnesses, psychosocial rehabilitation

interventions, community-based

care versus care in other settings

(domiciliaries, residential care facilities, nursing homes), effective

treatments for post-traumatic

stress syndrome, appropriate care

for veterans with depression, innovative approaches to treating substance abuse, optimal translation of

mental health treatment guidelines,

medication prescribing and adherence, treatment outcomes, and

costs of care.

“Best Practice” Guidelines

Improve Treatment

Results of studies on these and

other pertinent issues provide “best

practice” guidelines that affect policy and clinical care decisions for the

population of veterans in need of

mental health services. For example, a long-term mental health evaluation of three innovative care

models at 14 VHA facilities has produced information about the functional status of veterans with

serious mental illnesses (SMI) during and after treatment, and suggested best practices for treating

such veterans. Studies of the costeffectiveness of innovative, specialized treatment options for veterans

with SMI have found that, in

weighing both patient outcomes

and costs, specialized outpatientoriented treatment programs are a

significant improvement over standard care, and have led to an

emphasis on these outpatient treatment models. 

Commentary

continued from page 1

C OMMENTARY

Best practice guidelines have

been developed for the treatment of

veterans with schizophrenia and

for the treatment of those with

major depressive disorder. Recommendations center on issues of

access to care; specialized treatments providing assistance for

community-based living; the treatment of veterans with co-occurring

disorders, such as mental illness

and substance abuse; and the optimal use of psychoactive medications. These best practice

guidelines are being augmented by

work evaluating the treatment of

aging veterans with SMI, use of

antipsychotic medications and

provider compliance with psychosis

guidelines, use of community residential care facilities with these

veterans, and care for veterans suffering from PTSD. 

New guideline research is focusing on methods to provide optimal

mental and physical health care to

the large number of veterans with

mental health disorders, including

those with major depressive disorder, PTSD, substance abuse, and

serious mental illnesses. Other

research is exploring alternative

approaches to care and methods to

best address the needs of specific

subgroups of veterans with psychosis,

including minorities, women, and

veterans with bipolar disorder.

QUERI Seeks To Improve

Mental Health Care 

As part of the VA’s mission to monitor, evaluate, and implement best

practices, the Mental Health

Quality Enhancement Research

Initiative (QUERI) was established

to translate innovative research

into the real world of clinical practice. Among other projects, the

Mental Health QUERI initiatives

are studying the challenges in

implementing mental health guidelines for the VA system, determining methods to integrate VA

primary care and specialty care for

veterans with major depression or

substance abuse, and monitoring

variations in practice for veterans

with major depressive disorder or

schizophrenia. 

For many years, HSR&D has

sponsored research and evaluation

studies to identify approaches that

best meet the intense but varied

needs of veterans with mental

health disorders. Models of specialized treatment that effectively target the needs of these veterans are

urgently needed to address the concerns highlighted by the Surgeon

General’s report on mental health. 

More research is needed to

answer key questions, including:

What are the best methods to

improve access to mental and physical health care for veterans with

mental and substance use disorders? What programs will best

assist in preventing morbidity and

premature mortality in veterans

with serious mental illnesses?

What are the determinants of best

practices that optimize the costeffectiveness of mental health and

substance abuse care? What

strategies can be employed to better treat underserved populations,

including women, minorities, and

veterans with co-occurring mental

and physical health disorders? 

Answering these questions will

provide critically needed treatment

and policy information that can

improve care for a particularly vulnerable population of veterans,

those with mental and substance

use disorders.

N ew guideline research

is focusing on methods to

provide optimal mental

and physical health care

to the large number of 

veterans with mental

health disorders, including

those with major depressive disorder, PTSD, and

substance abuse.
3

R ESPONSE TO COMMENTARY

HSR&D Researchers Explore Links Between 

Mental Health Research and Clinical Care

By Richard R. Owen, M.D., Director

HSR&D Center for Mental Healthcare and Outcomes Research

Mental illnesses and their treatment are important areas for VA

research. As Dr. Blow observes,

these disorders are associated with

impaired health-related quality of

life, substantial disability, excess

mortality, and high health care

costs. There is good news, however, for veterans who suffer from

these illnesses: Efficacious treatments have been developed involving psychopharmacologic,

psychotherapeutic, and psychosocial approaches. 

Evidence-based recommendations have been incorporated into

VHA’s clinical practice guidelines

for major depressive disorder

(MDD), psychotic disorders, and

substance use disorders. The challenge for VA mental health care

providers and managers in the next

decade will be how to incorporate

“best practices” for assessing and

treating mental disorders into routine practice. HSR&D investigators are off to a great start, with

projects examining mental health

guideline implementation strategies and innovative models for

delivering mental health services

to primary care patients.

In addition, the Office of

Research and Development funded

two Quality Enhancement

Research Initiative (QUERI)

groups for mental health and substance use disorders, respectively.

Mental Health QUERI focuses on

both MDD and schizophrenia. The

QUERI groups identify gaps in

knowledge, recommend solicitations for projects to close these

gaps, and work to translate

research findings into clinical practice. The ultimate goal is to

improve patient outcomes and

health-related quality of life. 

But how do we translate

research findings? The word

“translation” suggests a change in

language; perhaps some interpretation of research results will help

clinicians understand how to apply

findings to their own patient populations. However, translation

involves much more than simple

dissemination of results. Research

has shown that multiple strategies

targeted at key participants are

needed to change clinical practice.

These approaches need to go beyond

standard educational methods, to

remind and reinforce to providers

and patients to “do the right thing”

at “the right time.” Moreover,

organizational change may be necessary to promote translation.

Ongoing monitoring and feedback

of performance may be employed

both for accountability and quality

improvement. 

The Substance Abuse QUERI

group, with funding from QUERI’s

Service Directed Project (SDP)

mechanism, is conducting a translation project aimed at increasing

access to opioid agonist treatment

and at implementing evidencebased practices for opioid agonist

therapy using facilitated quality

improvement methods. Mental

Health QUERI is using SDP funding to study the effectiveness of a

multi-component quality improvement intervention to improve

antipsychotic prescribing practices

for schizophrenia. In addition,

Lisa Rubenstein, M.D., M.S.P.H., is

conducting a study of evidencebased quality improvement for

implementing collaborative care for

MDD in primary care settings. 

These projects, with their

emphasis on translating evidencebased practice into real-world clinical care, will likely have a major

impact on the delivery of mental

health and substance abuse services, as well as on patient outcomes and quality of life. They will

also enrich a relatively new field,

“translation science.”

More research is needed — 

interested investigators can refer

to the HSR&D web site at

www.hsrd.research.va.gov/ for

ongoing HSR&D and QUERI solicitations.

Under Secretary’s Award for Health Services

Research Presented to Stephan Fihn

Stephan D. Fihn, M.D., M.P.H., director of the highly

successful Northwest VA HSR&D Center for Outcomes

Research in Older Adults, has received the Under

Secretary’s Award for Outstanding Achievement in

Health Services Research. Acting Under Secretary for

Health Frances Murphy, M.D., presented the award

at the 20th HSR&D National Meeting, held Feb. 13-15

in Washington, DC.

Dr. Fihn also heads the University of Washington’s

Division of General Internal Medicine and is the

research coordinator for the Ischemic Heart Disease (IHD) QUERI

group that works to improve the care and outcomes of veterans with

IHD. In addition, Dr. Fihn leads the Seattle VA’s HSR Fellowship

Program and has mentored numerous VA fellows and Career

Development awardees. 
4

O RGANIZATIONAL PROFILE

CeMHOR Investigates Ways to Improve 

Veterans’ Mental Health and Care

By Richard R. Owen, M.D., Director

HSR&D Center for Mental Healthcare and Outcomes Research

CeMHOR, the Center for Mental

Healthcare and Outcomes Research,

has as its mission the development,

implementation, and dissemination

of policy-relevant health services

research that will improve the mental health and care of veterans. Its

goals are to:

■ Examine variations in service

delivery to identify best practices

and policies.

■ Develop and test innovations to

enhance the quality, outcomes, and

value of patient care within complex health care systems.

■ Promote and effect the translation of research discoveries, and

innovations into routine practice.

■ Increase capacity in the mental

health services research field

through training, recruitment, and

collaboration.

CeMHOR was founded in 1990

as an HSR&D Field Program.

Today it is an HSR&D Center of

Excellence housed at the North

Little Rock campus of the Central

Arkansas Veterans Healthcare

System and a collaborative effort

with the University of Arkansas for

Medical Sciences (UAMS). CeMHOR

investigators contribute to knowledge on mental health treatment,

outcomes, and stakeholder issues

through research projects funded

by VA and non-VA sources. The

investigators collaborate and hold

dual positions with UAMS and VA

entities, including the South Central

Mental Illness, Research, and

Education Clinical Center (MIRECC).

In CeMHOR’s first year,

researchers started developing diseasespecific outcome measures, prepared

proposals for schizophrenia and

substance abuse outcome modules,

studied cost-effectiveness of VA

alcohol treatments, and undertook

pilot work with the hospital’s posttraumatic stress disorder treatment

units. The budget was $1.3 million

($390,863 in HSR&D funding and

$785,076 from other sources). G.

Richard Smith, Jr., M.D., was director

and founder, with five research

health scientists. A non-VA funded

project that year brought financial

support from the National Institutes

of Mental Health (NIMH) to establish the Center for Rural Mental

Health Care Research at UAMS. 

CeMHOR continues to grow and

expand, pursuing research aimed at

improving access to care, quality of

care, and outcomes of care for veterans with prevalent and serious

mental disorders. In 2001,

CeMHOR’s 13 core investigators

received almost $5.5 million in

funding (30 percent from the VA)

for 27 projects. The Center’s total

budget was $6.3 million. 

The Work of the Mental

Health QUERI

Since 1998, CeMHOR has been the

headquarters for the Mental Health

QUERI, one of eight HSR&D

groups nationwide that target

high-risk conditions prevalent

among veterans. MH QUERI’s

goal is to improve the quality of

care and health outcomes of veterans with major depressive disorder

(MDD) and schizophrenia. These

two disorders were chosen because

of their prevalence, significant

impact on the lives of patients, and

the substantial cost to society. In

addition, gaps between known best

practices and usual clinical care are

significant. Despite the availability

of efficacious treatments for both

disorders, individuals with MDD or

continued on page 8

AHRQ Director John Eisenberg, M.D., Dies

VA mourns the loss of John Eisenberg, M.D., who

died March 10 at age 55. Dr. Eisenberg served as

director of the Department of Health and Human

Services (HHS) Agency for Healthcare Research and

Quality (AHRQ) since 1997. A former president of

both the Association for Health Services Research

and the Society of General Internal Medicine, Dr.

Eisenberg also served five years at Georgetown

University, where he was chairman of the department of medicine and physician-in-chief.

As head of AHRQ, Dr. Eisenberg played a key role in government

efforts to use health services research to reduce medical errors, improve

patient safety, and enhance the effectiveness of health care services

while containing costs and expanding access to care. While leading

AHRQ, Dr. Eisenberg also served as the senior adviser to the HHS secretary and as principal deputy assistant secretary for health.

Dr. Eisenberg was founding commissioner and past chairman of the

Congressional Physician Payment Review Commission and was elected

to the Institute of Medicine. The author of more than 275 articles, he

wrote the book Doctors’ Decisions and the Cost of Medical Care.

Dr. Eisenberg was a 1968 magna cum laude graduate of Princeton

University and of Washington University’s medical school in St. Louis. 
5

D IALOGUE

Treating Depression in Primary Care Settings: 

No Simple Guarantee for Success

By Joann E. Kirchner, M.D., HSR&D Career Development Awardee

HSR&D Center for Mental Healthcare and Outcomes Research

What is the best way to 

integrate care for depression

in primary care settings? 

— James J. Nocks, M.D., of

Veterans Integrated Service

Network 5

The easy answer to this 

question is that there is no

best way. Rather, key elements

must be considered before attempting integration to ensure a stable

integration model. 

Depression, frequently unrecognized and untreated, is the most

common, persistent, and reoccurring mental health disorder afflicting primary care patients. Fewer

than half of individuals with major

depression seek professional help

for their disorder, and, of those

that do, most seek treatment from

a primary care provider rather

than from a mental health specialist.

A great deal of professional and

research interest has focused

recently on integrating mental

health into primary care clinics

and settings. Integrated primary

care has been defined as “a service

that combines medical and behavioral health services to more fully

address the spectrum of problems

that patients bring to their primary medical care providers. It allows

patients to feel that, for almost any

problem, they have come to the

right place.” 

Integrating mental health and

substance abuse services into primary care may improve management, communication, and patient

outcomes and help hold costs

down. For patients, the benefits of

integrated care may include early

identification of mental health or

substance abuse disorders,

improved health status, relapse

prevention, easier access to care,

enhanced adherence, reduced stigma, and better continuity of care.

There are several potentially

effective models for integrating

mental health and substance abuse

services in primary care settings,

mostly for depression. These include

consultation and case management

models. With consultation models,

mental health professionals provide specialty services within the

primary care setting. Case management models designate primary

care staff to coordinate patient 

care for mental health problems.

Implementation of these types of

models has improved the quality of

depression treatment, outcomes,

and patient satisfaction.

Within the VHA, interest in

integrating mental health services

with primary care has accompanied

VHA’s transformation from a primarily inpatient, hospital-based

institution into a more efficient,

primary care-based health care 

system. As part of this process,

community-based outpatient clinics (CBOCs) have been established

as one way to provide health care

to veterans living in rural areas.

Integrating mental health and 

substance abuse services in rural

primary care settings may help

improve access to care, but few

definitive answers or solutions

have been offered regarding what

might work best in routine settings. 

Although many health care systems have been experimenting

with integrated approaches, the

knowledge base in many ways is

still in its infancy. To date, the

research and professional literature addressing barriers to integrating mental health services in

primary care has shown that lack

of space, differences in professional

orientation (culture clash), and

administrative issues are inherent

challenges. Simply adding mental

health care to an already overburdened primary health care service

is likely to be met with negative

attitudes by service providers. 

In addition, there are unique

issues and challenges to integrating mental health services in rural

primary care settings, such as a

lack of qualified providers or services, patient resistance to seeking

mental health care because of stigma, or provider awareness of the

importance of treating mental

health problems. 

Several factors facilitate the

integration of mental health services within primary care settings,

including:

■ Teamwork, particularly across

disciplines. 

■ Infrastructure and systems that

support collaboration among mental

health and primary care providers,

such as physical proximity, joint

medical records, and patient care

protocols. 

■ Long-term commitment by staff

to improving service quality.

■ Multidisciplinary training to

educate providers. 

A “one-size-fits-all” approach

will not work. Even VHA’s primary care clinics operate within heterogeneous communities where

patients’ preferences, workforce

issues, and the availability of nonVA resources all differ. 

In summary, integrating mental

health and substance abuse treatment services into primary care

settings is not simple, but it can

be done. To succeed, system

administrators and providers must

know the needs and organizational structure of their clinics, engage

clinic staff and assess the fit of the

model they develop with the culture of their patients’ communities and the available community

resources.

Q.

A.
6

R ESEARCH HIGHLIGHTS

HSR&D Studies Explore Ways to Improve Depression 

Treatment in Primary Care Settings

Depression is the second most

prevalent medical condition in VA

and has an impact on function and

quality of life that is worse than that

of many other chronic physical conditions. Although there are effective

treatments for this disorder, significant gaps remain between best

practices and routine care.

HSR&D funds a number of studies exploring ways to improve

depression treatment, as well as

treatment outcomes for VA

patients. Following are summaries

of three of those studies.

Collaborative Care Improves

Depression Outcomes

This study of depression treatment

adapted a successful collaborative

care model for managing chronic

illness in non-VA managed care settings to the VA primary care setting and compared this approach

with traditional consult-liaison

treatment. 

In collaborative care, a mental

health specialist team consisting of

a psychiatrist, psychologists, and

social workers developed a treatment plan based on the initial

assessment and provided the plan

to the primary care provider.

Primary care provider efforts were

reinforced by patient education

materials and brief social work

phone calls to support patient

adherence, address treatment barriers, and monitor symptoms.

Treatment results were systematically reviewed and suggestions for

treatment modification were fed

back to the primary providers. In

the traditional consult-liaison model,

primary care providers were

informed of the diagnosis and the

study clinicians facilitated referrals

to psychiatry residents in the primary care clinic as requested. 

Collaborative care resulted in

significantly greater improvement

in depressive symptoms and psychosocial function than the more

traditional consult-liaison treatment. Collaborative care also significantly increased the proportion

of patients given prescriptions and

engaging in cognitive behavioral

therapy. Collaborative care also

resulted in fewer mental health

treatment visits and only slightly

more total primary care visits (8.9

versus 8.5 per patient per year)

than in consult-liaison usual care.

As more chronic conditions are

treated in the primary care setting,

using this model may improve

patient outcomes. If the collaborative care model continues to

demonstrate improved patient outcomes at reasonable cost, its potential impact on care and outcomes

for depression and other chronic

conditions could be great. 

Team-Based Quality

Improvement for 

Veterans with Depression

Primary care practices are searching for effective ways to improve

quality of care for depression.

Team-based quality improvement

(QI) methods, such as continuous

quality improvement, are attractive

options. These methods place a

high value on having the health

care organization’s own health care

professionals and staff participate

in QI design and implementation.

But clinical QI for complex problems such as depression requires

substantial technical knowledge

and resources. Thus, in practice,

health care organizations often

turn to experts to design QI interventions.

Investigators from the VA

Center for the Study of Healthcare

Provider Behavior, an HSR&D

Center of Excellence, participated

in an important new study that set

out to assess the impacts of QI

teams and their environments on

team success in designing and

implementing high-quality depression care improvement programs in

primary care practices. In particular, this study compares how local

clinician participation in QI procontinued on page 7

Rudolf Moos Steps Down as CHCE Director

Rudolf Moos, Ph.D., stepped down this year as director of the HSR&D Center for Health Care Evaluation

(CHCE) in Palo Alto, CA, a position he held since the

Center was established in 1985.

Dr. Moos led the CHCE in its mission to conduct

and disseminate health services research that results

in more effective and cost-effective care for veterans.

He also served as co-chair of the Executive

Committee for the Quality Enhancement Research

Initiative’s Substance Abuse Module (QSAM) from its

inception in 1998 through 2000. 

Dr. Moos retains his position as an HSR&D senior research career scientist, and will continue his exemplary work as an HSR&D investigator,

including his involvement with QSAM. He will also pursue his interests

in areas such as the process and outcome of substance abuse and psychiatric care; the influence of life stressors, social resources, and coping on

health and well-being; and the impact of health care work environments

on the quality of care. 
7

Research Highlights

continued from page 6

gram design versus delegating

design to regional experts affects

the quality of intervention programs for depression in primary

care. The investigators also identified other characteristics of QI

teams and their organizational

environments that predict implementation of a high-quality, enduring depression intervention

program.

Over the last decade, health care

organizations in the U.S. have used

team-based QI methods to address

specific quality-of-care problems.

Better understanding of how QI

teams function and of how to structure these teams to promote their

success can promote evidence-based

models for improving depression

care in primary care practices. 

Results from this important

study will be published later this

year.

Treating Depression in 

Patients with PTSD

Post-traumatic stress disorder

(PTSD) is a serious mental health

problem among both male and

female veterans. Patients with

PTSD often have co-morbid illnesses, most commonly alcohol or substance abuse disorders, anxiety

disorders, personality disorders,

major affective disorders, and

depression. The 40 percent of veterans with PTSD and concurrent,

clinically significant depression are

particularly difficult to treat. In

addition, well-validated treatments

of PTSD and its complications are

rare. 

Male veterans suffering from

both depression and combat-related

PTSD and female veterans with

depression and trauma related to

sexual assault participated in an

HSR&D study. This ongoing study

is the first to evaluate the impact of

two psychosocial interventions on

clinical outcomes and the use of

hospital resources by veterans 

with these co-existing disorders.

Veterans in the study were randomly assigned to either self-management therapy (SMT), a cognitivebehavioral treatment program for

depression, or to a psychoeducational group therapy (PGT). Both

programs involved short-term, 14-

week group therapies designed to

teach veterans about their disorders

and to provide new strategies and

skills for overcoming the disorders. 

Preliminary findings show that

nearly 80 percent of the male veterans in the study completed the

therapy regimen, and felt that the

course of therapy was beneficial

and clear. Preliminary results on

standardized measures indicated a

significant improvement in depression in the SMT condition only and

a significant difference between the

conditions at post-test. Therapy

appears to be less effective for

severely depressed veterans.

Female veterans have completed

therapy and their assessments will

be available soon. 

John Feussner, M.D., M.P.H., Retires From VA

John R. Feussner, M.D., M.P.H., VA’s Chief

Research and Development Officer, recently

announced his retirement from VA. Dr. Feussner

has held this position since 1996 and has been a

strong leader and advocate of VA research. In

August, he will leave VA to become chair of the

Department of Medicine at the Medical University

of South Carolina in Charleston. 

In a VA career that spanned more than 25 years,

Dr. Feussner held a number of important roles and

made many contributions to veteran health care. Notably, he served as

director of the Center for Health Services Research in Primary Care in

Durham, NC (1983-1996). His academic appointments include serving

as a professor of medicine at Duke University and as chief of the

Division of General Internal Medicine at Duke University Medical

Center (1988-1996). 

Dr. Feussner has received continuous funding for research since 1982

and is the author of numerous publications. He has received a number

of prestigious awards, including the 2001 John D. Chase Award from

AMSUS (American Military Surgeons of the United States), an award

for Sustained Excellence in Executive Leadership. Most recently, he

became the second recipient of the John Eisenberg National Award for

Career Achievement in Research in General Medicine, presented at the

25th annual meeting of the Society of General Internal Medicine this year. 

During his tenure as Chief Research and Development Officer, Dr.

Feussner worked diligently with VA leadership to provide the highest

quality, most cost-effective and efficient health care for veterans. A

strong advocate for patient-centered care and evidence-based medicine,

he oversaw research in biomedicine, rehabilitation, health services, and

clinical trials. Together with then Under Secretary for Health, Kenneth

Kizer, M.D., he developed the concept of VA’s Quality Enhancement

Research Initiative (QUERI), a nationally recognized program that

focuses on translating research findings into practice. His dedication to

keeping VA at the forefront of science and medicine led to a renewed

concentration on the discovery of new knowledge that advances the

health and care of veterans and the nation. 

HSR&D thanks Dr. Feussner for his contributions to VA research

and congratulates him on his achievements, with best wishes for continued success in all his future endeavors. 
8

Martin P. Charns, D.B.A., Editor-in-Chief

Mary Darby, Editor

Geraldine McGlynn, Co-editor

ADVISORY COMMITTEE

John G. Demakis, M.D., Director, VA HSR&D

Rodney A. Hayward, M.D., VA HSR&D

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, M.H.A., FACHE, VA Medical

Center, Fresno, CA

Robert M. Roswell, M.D., VA Network #8,

Bay Pines, FL (now VA’s USH)

Hanna B. Rubins, M.D., M.P.H., VA HSR&D

Center of Excellence, Minneapolis

FORUM is a publication of the VA Office of Research &

Development, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Academy for Health Services Research

and Health Policy.

F O R U M

CeMHOR

continued from page 4

schizophrenia often receive less

than effective care. 

MH QUERI hopes to make an

impact on quality of care for veterans

with these two disorders through

the translation of research knowledge into clinical and organizational practice. Research focuses on

closing gaps in the knowledge of

best treatment practices and developing effective strategies to implement clinical guidelines. These

efforts center on two translation

initiatives: increasing the appropriate use of antipsychotics and incorporating—into routine VA practice

settings—the collaborative care

model for treating depression in

primary care.

Research shows that prescribing

rates vary for the newer antipsychotic agents (such as risperidone,

olanzapine, and quetiapine) and for

clozapine, reserved for treating

refractory patients. Moreover, both

traditional and newer antipsychotics

are often prescribed at doses outside

guideline-recommended ranges.

MH QUERI’s translation goal is

to increase the guideline-concordant use of antipsychotics, switch

refractory patients (when appropriate)

to newer medications, and reduce

the frequency of antipsychotic prescribing outside guideline-recommended dose ranges. The translation

effort has included a multi-site

demonstration project in one VISN

that demonstrates the effectiveness

of an intensive implementation

strategy. This strategy was effective

at decreasing the proportion of

patients who are prescribed very

high doses. MH QUERI plans to

disseminate its materials and programs and to expand this translation effort to include improving the

use of clozapine and side effect

management.

The goal of the collaborative care

model project, headed by Lisa

Rubenstein, M.D., is to translate,

across multiple VISNs, a previously

tested model for improving the

quality of depression care. The team

of researchers is conducting a

process evaluation of evidence-based

quality improvement, a dissemination method that relies on expert

design and local implementation.

Other Research at CeMHOR

Here is a sampling of other CeMHOR

research initiatives currently under

way:

■ Integrating primary and mental

health care for alcohol disorders

and depression, and evaluating an

intervention to provide mental

health and substance use services

in VA community-based outpatient

clinics (CBOCs).

■ Studying stakeholder perspectives on sustaining involvement in

schizophrenia care, looking at what

factors influence or motivate people with schizophrenia to seek

treatment and stay in long-term

care.

■ Examining how a shift from

inpatient to outpatient treatment

has affected the care of veterans

diagnosed with psychotic disorders

(with Frederic C. Blow, Ph.D., Ann

Arbor, principal investigator).

For more information, please visit

http://vaww.va.gov/cemhor/, or contact Dr. Owen: phone 501/257-1710;

fax 501/257-1707; e-mail

Richard.Owen2@med.va.gov.