Joseph Goulet - Academia.edu (original) (raw)

Papers by Joseph Goulet

Social Service Review, 1999

Journal of Affective Disorders, 2013

We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation En... more We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder. We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments. Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively). Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment. SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden.

Journal of Pain and Symptom Management, May 1, 2005

Desire for hastened death (DHD) is reported in the literature as being common in patients with ca... more Desire for hastened death (DHD) is reported in the literature as being common in patients with cancer pain. However, there is currently little evidence to suggest that improvement in pain results in improvement in DHD. Our objectives were to assess 1) the impact of improvements in cancer pain severity and pain's interference with daily functioning and depression on DHD, and 2) the role of factors such as social and spiritual well-being, educational level, and patient age in moderating the impact of pain and depression on DHD. This observational study included patient-rated and clinician-rated scales administered twice at 4-week intervals. We enrolled 131 newly-referred patients to the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center or newly-admitted patients to Calvary Hospital in New York. One hundred and sixteen patients completed the baseline measures and 64 patients completed both baseline and follow-up measures. The main outcome measures included the Brief Pain Inventory (BPI), Beck Depression Inventory (BDI), and the Desire for Hastened Death Scale (DHD). Sixty-six percent of patients had no DHD at baseline and 45% of patients had BDI scores of 14 or greater ('mild' depression). Only 40% of patients with moderate/severe depression were receiving antidepressants. BPI scores improved significantly from baseline to follow-up (6.36 vs. 4.86, P Ͻ 0.01). DHD scores increased significantly from baseline to follow-up (0.84 to 1.38, P ϭ 0.03). All other measures including depression were stable. DHD scores were moderately correlated with depression (r ϭ 0.43), low social support (r ϭ 0.38), poor spiritual well-being (r ϭ Ϫ0.38), religious well being (r ϭ Ϫ0.25), pain interference (r ϭ 0.27), higher educational level (F ϭ 4.50, P ϭ 0.02) and lower physical functioning Address reprint requests to: Sean O'Mahony, MB, BCH, BAO,

Schizophrenia Research, Oct 1, 2008

Most research establishing the relationship between cognition and functioning in schizophrenia ha... more Most research establishing the relationship between cognition and functioning in schizophrenia has been conducted crosssectionally, leaving unanswered the question of whether there is a predictive relationship between temporal change in cognition and temporal change in functioning. In the present study, we used longitudinal mixed models to examine the relationship between change in cognition and change in Quality of Life (QLS), as measured over three time-points spanning a 12-month period, for 151 schizophrenia outpatients participating in work therapy with or without cognitive remediation. Memory and executive function changes were significant predictors of improved QLS total. Whereas the relationship between memory and QLS total was in the expected direction, with improvements in memory associated with improvements in QLS, the relationship between executive function and QLS was negative, with QLS improvements associated with declines in executive function. Similar patterns were found for individual QLS domains. Finally, there were positive cross-sectional relationships between QLS and hours worked as well as gender (female gender associated with better QLS). Lag models supported these results. Differences between these findings and previous studies are discussed along with functional assessment issues and the potential moderators of the relationship between cognitive change and functioning. Published by Elsevier B.V.

The American Journal of Managed Care, Sep 1, 2005

To determine the relationship between provider type (eg, resident, mid-level practitioner, attend... more To determine the relationship between provider type (eg, resident, mid-level practitioner, attending physician) and attainment of clinical goals with respect to the treatment of dyslipidemia, diabetes mellitus, and hypertension. Using electronic medical records, we identified all patients seen in the Veterans Affairs Connecticut Health Care System in a 6-month period with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code corresponding to a diagnosis of coronary artery disease, diabetes mellitus, or hypertension. We recorded the most recent low-density lipoprotein cholesterol level for patients with diabetes or coronary artery disease, glycosylated hemoglobin level for patients with diabetes, and blood pressure for patients with hypertension. We then examined the relationship between these measures and provider type. After controlling for patient age and practice site, no significant differences were noted between attending physicians and residents in attaining treatment goals for dyslipidemia (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.96-1.38) or diabetes (OR 1.05, 95% CI 0.82-1.33). However, attending physicians were significantly more likely to attain blood pressure goals than were residents (59% vs 54%, P = .002; OR 1.23, 95% CI 1.08-1.39). Controlling for additional patient characteristics did not alter the findings. Internal medicine residents may quickly develop expertise in managing dyslipidemia and diabetes mellitus. Residents in our sample, however, were less likely than attending physicians to reach goal blood pressure for patients with hypertension. Educational efforts aimed at house staff to improve the treatment of hypertension are warranted.

Pain Medicine, Oct 1, 2009

Journal of general internal medicine, Jan 3, 2016

For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care o... more For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes-notably mortality-is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95%...

BMC Musculoskeletal Disorders, 2016

Background: The Institute of Medicine report "Relieving Pain in America" recommends the promotion... more Background: The Institute of Medicine report "Relieving Pain in America" recommends the promotion of patient self-management of pain for all people with pain. Given the high prevalence of chronic pain in the US, new strategies are needed to enhance access to cognitive behavioral therapy (CBT) and other evidencebased treatments designed to facilitate self-management of chronic pain conditions. Although CBT is efficacious, many patients have limited or no access to CBT. Technology-assisted delivery of CBT may improve access while maintaining efficacy.

Psychiatric Services, Oct 7, 2014

Substance Abuse, 2015

As antiretroviral treatments prolong life in HIV-infected patients, smoking cessation is now a to... more As antiretroviral treatments prolong life in HIV-infected patients, smoking cessation is now a top priority. However, studies of HIV-infected smokers have not been conducted with uninfected controls. We determined factors associated with contemplating smoking cessation and making a prior quit attempt among HIV-infected and uninfected smoking Veterans. Between 2005 and 2007, we identified 1027 HIV-infected and 794 uninfected smokers enrolled in the Veterans Aging Cohort Study (VACS). Stratifying by HIV status, we calculated adjusted odd ratios using logistic regression to identify factors associated with contemplating smoking cessation and making a prior quit attempt. Most participants (66% of HIV-infected vs. 68% of uninfected, p=0.46) were contemplating cessation, and 56% of both groups (p=0.99) had attempted to quit in the last year. In stratified multivariable analyses, HIV-infected smokers with recent pulmonary disease diagnoses were more likely to have made a quit attempt (AOR 4.93, 95% CI=1.41-17.17). Both HIV-infected and uninfected patients with unhealthy alcohol use were less likely to be contemplating cessation (AOR 0.66, 95% CI=0.49-0.90 and 0.71, 95% CI=0.50-1.00). HIV-infected smokers who reported unhealthy alcohol use were also less likely to have made a quit attempt in the last year (AOR 0.68, 95% CI=0.51-0.91). Patient-level interest and motivation are not major barriers to smoking cessation among HIV-infected Veterans. Targeting HIV-infected smokers with a recent pulmonary disease diagnosis may improve sustained smoking cessation. Unhealthy alcohol use appears to be a key modifiable risk factor. Smoking cessation rates may be improved by combining interventions for smoking and alcohol use for HIV-infected patients.

The Journal of Pain, Jan 4, 2015

AIDS and behavior, Mar 18, 2015

Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and... more Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need f...

Journal of General Internal Medicine, 2014

Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain ... more Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. Our aim was to examine changes in care for Veterans receiving long-term OT for management of chronic pain over a four-year study period. As part of a comprehensive implementation evaluation of performance improvements, the current evaluation reports performance improvement outcomes related to pain management and OT over a four-year period. We studied Veterans receiving long-term (90+ consecutive days) OT through primary care. We engaged an interdisciplinary clinical-research team to develop and implement a multifaceted performance improvement approach that included interactive educational strategies and other organizational initiatives. We measured the proportion of patients receiving long-term OT; use of opioid risk mitigation strategies; referrals to pain-related specialty services; and use of non-opioid analgesics. The proportion of patients receiving high-dose opioids decreased over four years (27.7 % to 24.7 %). The use of opioid risk mitigation strategies increased significantly. Referrals to physical therapy and chiropractic care and prescriptions for topical analgesics increased significantly, while referrals to the pain medicine specialty clinic decreased. We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.

Objectives: We compared factors affecting postwar healthcare utilization among women and men vete... more Objectives: We compared factors affecting postwar healthcare utilization among women and men veterans receiving care at VA Connecticut clinics who participated in Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF). Methods: We abstracted clinic utilization data from the VA's electronic medical record (EMR) on returning OEF/OIF veterans who used the VA CT healthcare system. Results: We identified 141 women and 690 men veterans who had at least one outpatient visit in primary care or women's health clinic (p<0.05) in the past 3 years. The mean age of veterans utilizing VA health care services was 31 years for women and 34 years for men (p<0.00). Twenty-six percent of women using VA CT healthcare services identified as African-American compared to 13% of men (p<0.00). Women veterans seeking healthcare were less likely to be married (23%) as compared to men (39%) (p=0.00). Forty-nine percent of the women veterans with a history of combat exposure utilized ...

The Journal of Pain, 2015

Open Access Journal of Contraception, 2015

Background: While extensive research has explored pharmacokinetic interactions between antiretrov... more Background: While extensive research has explored pharmacokinetic interactions between antiretroviral therapy (ART) and hormonal contraception, few studies have examined whether these interactions affect clinical outcomes. To address this gap, we conducted a systematic review of the literature that describes hormonal contraceptive use among HIV-infected women who also use ART, focusing on papers that address clinically important outcomes such as pregnancy or ovulation. Methods/design: An electronic literature search was conducted of PubMed and Ovid to identify all articles that addressed hormonal contraception co-administered with ART published in English between January 1, 1990 and October 30, 2014. In addition, manual reference checks of all articles of interest were conducted to identify articles not captured in the electronic search. Our search criteria identified 405 records. The title and abstract of data reports retrieved via the search were reviewed to identify potential articles of interest. Those with any indication of the main outcomes of interest were considered for inclusion (N=162). Abstracts were then reviewed to identify those manuscripts that would merit a review of the full-text version (N=64). Eight articles that addressed the outcomes of interest were identified. The Newcastle-Ottawa Scale was used to assess the quality of these articles.

Public health reports (Washington, D.C. : 1974)

Food insecurity may be a modifiable and independent risk factor for worse control of medical cond... more Food insecurity may be a modifiable and independent risk factor for worse control of medical conditions, but it has not been explored among veterans. We determined the prevalence of, and factors independently associated with, food insecurity among veterans in the Veterans Aging Cohort Study (VACS). Using data from VACS from 2002-2008, we determined the prevalence of food insecurity among veterans who have accessed health care in the Veterans Health Administration (VA) as defined by "concern about having enough food for you or your family in the past month." We used multivariable logistic regression to determine factors independently associated with food insecurity and tests of trend to measure the association between food insecurity and control of hypertension, diabetes, HIV, and depression. Of the 6,709 veterans enrolled in VACS, 1,624 (24%) reported being food insecure. Food insecurity was independently associated with being African American, earning <$25,000/year, re...

Pain Medicine, 2015

Objective. Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran popula-ti... more Objective. Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran popula-tions have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND).

Military medicine, 2008

The growing presence of female veterans within the Department of Veterans Affairs (VA) health car... more The growing presence of female veterans within the Department of Veterans Affairs (VA) health care system highlights the need to assess the quality of and access to gender-specific care for menopause. We assessed the use of hormone therapy (HT) among female veterans before and after the release of the Women's Health Initiative clinical trial results and evaluated whether the structure of women's health care services within the VA system affects the use of HT. We identified all female veterans using HT in 2001 by using the VA pharmacy benefits management database and administrative data. Subjects identified as using HT in 2001 were evaluated to determine estrogen use status in 2003 and 2004. We calculated the change in HT use over time and performed multivariate analyses to identify patient and utilization determinants of HT discontinuation. In 2001, 36,222 female veterans used HT. By 2004, 23,924 (66%) had discontinued HT. Subjects who had used a VA women's clinic or wer...