Group Motivational Interviewing (GMI) For Homeless Veterans In VA Services
Condition: Alcoholism; Substance-related Disorders; Dual Diagnosis
MeSH terms: Alcoholism; Substance-Related Disorders
Study type: Interventional

Summary: 
      Homeless Veterans with substance use disorders (SUDs) are a major group served by VA and are
      heavily represented in VA housing. VA recently adopted a 'Housing First' approach emphasizing
      rapid housing placement to initiate recovery without requiring sobriety and will necessitate
      SUD interventions that are efficient and easily layered onto existing services. The proposed
      study will investigate the effectiveness, implementation process, and cost estimate of Group
      Motivational Interviewing (GMI) for Veterans with SUDs in VA housing (Housing Urban
      Development-VA Support Housing [HUD-VASH] and Grant and per Diem [GPD]). Outcomes will be
      assessed at multiple time points using a multi-modal approach. The ultimate goal of this
      research is to establish the basis of a GMI dissemination and implementation course of action
      for highly vulnerable homeless Veterans in VA housing for achieving their greatest success in
      attaining housing stability.
    

Detailed description: 
      Anticipated Impacts on Veterans Health Care:

      VA set an ambitious goal for ending homelessness among Veterans by 2015. Housing Urban
      Development-VA Support Housing [HUD-VASH] and Grant and per Diem [GPD] are two primary VA
      housing programs to help Veterans exit homelessness. Substance abuse among Veterans in VA
      housing is a major risk factor for worsening psychopathology and housing instability. Despite
      recent adoption of a Housing First approach, many VA housing programs lack the staff
      infrastructure to manage substance use disorders (SUDs). This is a significant problem as 60%
      (conservative estimate) of Veterans in VA housing have SUDs and these Veterans show greater
      psychopathology compared to their counterparts without SUDs. These issues warrant substantial
      need for SUD programs in VA housing that are efficient to deploy, easily layered onto
      existing services, and require minimal staff to operate. The current study addresses this
      current void in VA treatment services in that it investigates the effectiveness,
      implementation process, and cost estimate of treatment of an adaptation of motivational
      interviewing, an empirically supported intervention with strong impact on reducing substance
      use and enhancing treatment engagement, in a group format, referred to as Group Motivational
      Interviewing (GMI) for Veterans with SUDs in VA housing. Data from this project, if shown to
      be promising, will establish the basis of a GMI dissemination and implementation course of
      action for highly vulnerable homeless Veterans in VA housing for achieving their greatest
      success in attaining housing stability.

      Background:

      There is a significant need for 'wraparound' treatment services in VA housing for addressing
      SUDs. Homeless Veterans with SUDs are vulnerable to treatment dropout, rendering them
      susceptible to relapse, while their continuation in outpatient care during their
      participation in VA housing leads to improved clinical outcomes. According to systematic
      reviews, individual motivational interviewing reduces the incidence of substance use
      disorders, when compared to no treatment, but is labor intensive. As VA moves toward a
      'Housing First' paradigm where greater numbers of homeless Veterans will continue to use
      substances while in VA housing, delivery of GMI (which may be less labor intensive) to these
      patients will be important for initiating and maintaining their recovery as well as enhancing
      their psychosocial integration and quality of life. In a prior controlled trial conducted by
      the Principal Investigator, GMI resulted in significantly higher outpatient treatment
      engagement and lower substance use compared to treatment-as-usual among dually diagnosed
      Veterans.

      Objectives:

      Study objectives are consistent with VA housing recommendations focusing on patient recovery,
      health services promotion, and treatment implementation evaluation. GMI will be compared to a
      control treatment condition (CT) on (Specific Aim I; Five outcomes: (Primary Hypothesis 1):
      treatment engagement; (Primary Hypothesis 1): substance use; (Secondary H2): psychosocial
      integration (e.g., social support, community participation); (Secondary H3) quality of
      life/psychiatric indices; and (Secondary H4): number of days engaging in
      structured/productive work activities in the 6-month follow up. Specific Aim II involves a
      process evaluation for documenting (A) formative (e.g., developmental), (B) process, and (C)
      summative outcomes; and Specific Aim III involves estimation of cost of intervention in terms
      of direct costs, indirect costs of staff, costs of capital and workload measures for future
      implementation and dissemination research.

      Methods:

      Randomized controlled trial comparing GMI to control treatment (CT) across five critical
      outcomes. 186 Veterans in VA housing services (93 per treatment arm) will be enrolled with a
      diagnosis of alcohol or drug abuse/dependence. Recruitment will take place in Charleston VA
      Medical Center HUD-VASH & GPD. Participants will be randomly assigned to (1) GMI or (2) CT,
      each consisting of 4 sessions, and will be evaluated at 1, 3, and 6 months. Participants with
      a non-substance related DSM-V disorder (e.g., major depressive disorder, PTSD) will be
      eligible for the study. Analyses will be conducted using generalized linear mixed models
      (GLMM) approach.

      Significance to Veterans:

      Homeless Veterans with SUDs represent one of the largest and most chronic groups of
      psychiatric patients treated in the VA Healthcare System. With the ongoing execution of VA's
      "Plan to End Veteran Homelessness," Veterans entering housing require interventions that can
      be feasibly implemented with minimal reorganization of existing services. GMI is based on
      motivational interviewing, an empirically valid treatment that aligns with Veteran-centered
      recovery models including Harm Reduction and more traditional treatment philosophies. The
      investment in GMI for VA housing may be minimal as it requires only a few staff to operate in
      relatively short time (e.g., 4 sessions, 90-min each) with modest (20 hours) staff training.
      It can be layered onto existing services with little interruption or reorganization of staff,
      and it has potential to be offered to larger numbers of Veterans with SUDs in VA housing who
      would otherwise not receive this intervention.
    

Intervention name(s): Group Motivational Interviewing (GMI); Control Treatment Condition (CT)
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants randomized to Group Motivational Interviewing (GMI) will receive four structured, back-to-back, 90-minute sessions consistent with the central principles and spirit of Motivational Interviewing (MI). GMI, which is based on a manualized protocol, is specifically designed for dually diagnosed Veterans. A focus of the intervention creates awareness of the relationship between the substance use and co-existing psychiatric disorder and the importance of treating both.; Control Treatment Condition (CT): Participants in CT will attend four sessions equal in time and length to GMI (i.e., 90 minutes) and will involve the following topics: A popular 'box activity': participants will anonymously write evocative questions on slips of paper involving their personal concerns that are placed in a box and, when randomly selected, opened for group discussion (e.g., "How do I talk to my family about my alcohol problem?"), money management with feedback (2 sessions), and cooking-home maintenance.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Alcoholism; Substance-related disorders; Dual Diagnosis