Serving Those Who Have Served: Treatments to Help Veterans With Their Transitions: Physical and Mental Health Outcomes Associated With Acupuncture Utilization in Military Veterans Presenter: Christine Eickhoff, MA Coauthors: Holliday, S.B., Sullivan, P., Reinhard, M., Duncan, A., Courtney, R.E., Sossin, K., Hull, A. Integrative Health and Wellness Program War Related Illness and Injury Study Center Washington DC VA Medical Center, August 6th 2015

Why acupuncture for Veterans? How do Veterans access acupuncture? This presentation will focus on the following topics: Why are we investigating acupuncture for Veterans? How is this service accessible at the DC VAMC and how are we able to measure health outcomes of those participating in acupuncture? What health domains are improved with acupuncture utilization? What future research topics should be addressed and what more can we do to improve Veteran’s well being with Complementary and integrative health (CIH) services like acupuncture? Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Why acupuncture for Veterans? How do Veterans access acupuncture? Improvement is seen in what domains? What more can we do?

Number of Veterans enrolling at VA is increasing1 Military Personnel go through many transitions throughout their careers, including the transition from active duty to veteran or reserve status. The number of Veterans enrolling in VA facilities is increasing. According to the National Center for Veterans Analysis and Statistics, between FY 2009 and FY 2013, each fiscal year the number of Veterans enrolling in VA facilities increased by 1 to 3 thousand Veterans. Veterans with chronic multi-symptom illness, referred to as CMI, may have increased difficulty with transition due to health complications that impact their quality of life. Wellness activities, such as acupuncture, address CMI and support Veterans’ physical and emotional wellbeing. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Number of Veterans enrolling at VA is increasing1 Many Veterans have chronic multisymptom illnesses (CMI) affecting both physical and psychological health2 Evidence supporting the use of acupuncture to treat chronic pain3, PTSD4, and depression5 in the Veteran population is growing6.

CIH Services at the DC VAMC The DC VAMC offers many complementary and integrative health services for Veterans of all eras and ages. Through the Integrative Health and Wellness program , Veterans can access CIH services at the facility. To take part in these services, Veterans must be referred to the program by their provider. After a brief program orientation, Veterans are able to participate in the services they choose at a frequency they decide. This veteran-centric approach to whole health is discussed between the Veteran and their provider and facilitated by the Integrative Health and Wellness program. This patient-driven approach is growing in popularity with increasing numbers of Veterans referred by their providers each fiscal year. Acupuncture is one of the most sought-after services in the IHW program. CIH Services at the DC VAMC Facility-Wide Complementary and Integrative Health Integrative Medicine IM Physician IM Fellow Partnerships with Primary Care Wellness Services Yoga Meditation Qigong/T’ai Chi Acupuncture Massage Nutrition Workshops Biofield Health Education Healing Spaces Meditation Room Teaching Kitchen Outdoor Garden

A Pilot Study of the Integrative Healthcare and Wellness (IHW) Program Prior to 2012, acupuncture was available at the DCVAMC, but it was not occurring within a coordinated clinic setting. Starting in 2012, Veterans could be referred to the IHW program through a consult. Services such as iRest Yoga Nidra Meditation, individual acupuncture, group acupuncture, and health education were available in 2012. Since then the number of available services has grown. The IHW program began a research initiative in 2012 to examine the health outcomes and satisfaction of Veterans participating in all of the IHW CIH services. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? A Pilot Study of the Integrative Healthcare and Wellness (IHW) Program Examined the impact of acupuncture participation on aspects of physical and mental health.

63.7% participated in the first 12 weeks Between 2012 and 2014, over 700 Veterans were referred to the IHW program 336 Veterans enrolled in the program and 226 participated in the pilot study. 66.9% of participants were male with a mean age of 50. The age ranged from 23 to 86. 63.7% of research participants attended at least one CIH service in the first 12 weeks following their program orientation. 72.1% attended within the first 6 months. 100% of participants reported mental health or pain as their primary symptom of concern, regardless of the reason for referral. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Participants N=226 Veterans 66.9% male Mean age = 50 63.7% participated in the first 12 weeks 100% reported mental health or pain as their primary symptoms of concern, regardless of reason for referral.

Measures Perceived Stress Scale (PSS) Participants completed several self-report measures of mental and physical health, including the Perceived Stress Scale Medical Outcomes Study ShortForm36, both the Physical and Mental Health Component Summaries Insomnia Severity Index Beck Depression Inventory-II Pain Disability Questionnaire and the Measure Yourself Medical Outcome Profile2, referred to in this presentation as the “My-mop 2”. On the MYMOP2, participants identified two symptoms they consider to be their most significant health concerns and reported the degree of severity for each. They also reported the degree to which an activity they enjoy was impacted by these symptoms, in addition to their overall wellbeing. This patient-centered measure provides an opportunity for participants to identify their specific health concerns. Lower scores on the MYMOP-2 reflect less severe symptom reporting, greater ability to be active, and greater self-reported well-being. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Measures Perceived Stress Scale (PSS) Medical Outcomes Study ShortForm36 Physical and Mental Health Component Summary (SF 36 PCS and MCS) Insomnia Severity Index (ISI) Beck Depression Inventory II (BDIII) Pain Disability Questionnaire (PDQ) Measure Yourself Medical Outcome Profile 2 (MYMOP-2).

Methods Baseline assessment prior to any service utilization. Baseline assessment was administered during the program orientation prior to any service utilization. Follow up assessment was administered at 12 weeks from baseline. Service utilization is discussed between Veterans and their providers and ultimately decided on by the Veteran. Therefore, not all research participants enrolled in the study utilized acupuncture services. The analysis we performed focused on Veterans who participated in individual and group acupuncture. Veterans could participate in both services; therefore, a larger group of Veterans who participated in both individual and group acupuncture was also examined. Please see the handout for complete tables and details of the research findings. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Methods Baseline assessment prior to any service utilization. Follow up assessment administered at 12 weeks. 3 Groups Analyzed: Individual acupuncture (n=24) Group acupuncture (n=27) Combined individual + group (n = 39)

Individual Acupuncture (n=24) A series of paired sample t-tests were conducted to examine change from baseline to follow-up. Veterans who participated in individual acupuncture reported significant improvements. Decreased mean scores on the PSS and increased mean scores on the SF 36 PCS indicate improvement in the domains of perceived stress and physical health. Decreased mean scores on the MYMOP2 symptom #2, as well the MYMOP activity level and wellbeing indicate significant improvements in the domains of pain, mental health, activity level, and perceived wellbeing. Individual Acupuncture (n=24) Significant Findings Measure Baseline M (SD) 12 Weeks M (SD) PSS* 23.83 (7.57) 22.09 (9.20) SF36 PCS** 33.38 (8.52) 37.10 (9.37) MYMOP-2 Symptom 2* 4.88 (1.03) 4.29 (1.00) MYMOP-2 Activity* 5.09 (0.81) 4.32 (1.39) MYMOP-2 Wellbeing* 4.43 (0.95) 3.91 (1.24) *p < .05, **p < .01; Note: all analyses are one-tailed paired-sample t-tests

Individual Acupuncture (n=24) These results indicate Veterans who participated in individual acupuncture reported significant improvements in physical health, mental health, and pain. Their perceived stress decreased, they experienced less difficulty being active, and their perceived wellbeing increased. For this group, the number of sessions attended was significantly correlated with change on the PDQ and change on MYMOP2 symptom #1, with more sessions attended associated with greater improvements in the domains of pain and mental health. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Individual Acupuncture (n=24) Participation correlated with significant improvements on: Perceived Stress Physical Health Pain/Mental Health Activity level Perceived Wellbeing Number of sessions attended positively associated with greater improvement in pain PDQ and mental health (PDQ & MYMOP-2 Symptom #1).

Group Acupuncture (n=27) Veterans who participated in group acupuncture also reported significant improvements on the PSS, their primary symptom on the MYMOP2, as well as improvement in their activity level and wellbeing. In addition, decreased mean scores on the ISI, BDI, and PSS indicate improvement on these measures. Group Acupuncture (n=27) Significant Findings Measure Baseline M (SD) 12 Weeks M (SD) MYMOP-2 Symptom 1** 4.85 (1.05) 4.04 (1.34) MYMOP-2 Activity* 4.46 (0.86) 3.92 (1.47) MYMOP-2 Wellbeing* 3.96 (0.91) 3.42 (1.14) ISI* 17.62 (7.84) 16.00 (8.66) BDI-II* 25.28 (14.29) 21.68 (15.53) PSS** 24.37 (6.57) 21.15 (8.75) *p < .05, **p < .01; Note: all analyses are one-tailed paired-sample t-tests

Group Acupuncture (n=27) Study data shows that Veterans who participated in group acupuncture reported significant improvements on their primary symptom of concern (which was related to pain or mental health) as well as their quality of sleep and level of depression. Their perceived stress decreased, they experienced less difficulty being active, and their perceived wellbeing increased. For this group, There were no significant correlations between the number of services attended and symptom change. Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Group Acupuncture (n=27) Participation correlated with significant improvements on: Perceived Stress Sleep Depression Pain/Mental Health Activity level Perceived Wellbeing

Individual + Group Acupuncture (n=39) Significant Findings Measure Baseline M (SD) 12 Weeks M (SD) MYMOP-2 Symptom 1** 4.97 (0.97) 4.42 (1.31) MYMOP-2 Symptom 2* 4.64 (1.05) 4.11 (1.17) MYMOP-2 Activity** 4.75 (0.94) 4.00 (1.55) MYMOP-2 Wellbeing** 4.19 (0.97) 3.62 (1.28) PSS** 23.63 (7.19) 20.97 (8.90) SF-36 PCS* 36.31 (9.83) 38.12 (10.01) *p < .05, **p < .01; Note: all analyses are one-tailed paired-sample t-tests The combined group of veterans who participated in any acupuncture service (both group and individual) reported significant improvements on both symptoms 1 and 2 of the MYMOP2 as well as improvement in their activity and wellbeing. Additionally, this group also reported significant improvement on the PSS and SF-36 PCS.

Individual + Group Acupuncture (n=39) Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Individual + Group Acupuncture (n=39) Participation correlated with significant improvements on: Pain/Mental Health Perceived Stress Physical Health Activity level Perceived Wellbeing Number of sessions attended positively associated with greater improvement in depression. These results indicate Veterans who participated in any acupuncture service reported significant improvements on both of their self-reported symptoms of concern (which were related to pain or mental health) as well as their physical health. Their perceived stress decreased, they experienced less difficulty being active, and their perceived wellbeing increased. In addition, within this group, a greater number of sessions attended was associated with greater improvements on the BDI-II.

Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Results Summary 100% reported mental health or pain as primary health concern. Veterans who participated in any acupuncture (group and/or individual) reported significant improvements in multiple domains Improvement was positively correlated with increased service utilization. In sum 100% of participants reported mental health or pain as their primary health concern. Veterans who participated in any acupuncture (group and/or individual) reported significant improvements in multiple domains Improvement was positively correlated with increased service utilization.

Limitations Small Sample of Convenience Overlapping Groups Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Limitations Small Sample of Convenience Overlapping Groups Self Assessment Study limitations include: Limited generalizability of these findings due to the size, convenience, and homogeneity of the sample. Also, the sole use of self report measures may limit the validity of the data Additionally, the groups overlapped on service utilization thus making it difficult to associate improvement with a specific acupuncture use condition. Because of the observational nature of this study and ethical considerations, it was not possible to limit the participants’ utilization of services. Investigators are in process of publishing on the results of analysis of these individual cohorts. The results generally suggest that there were no between-group differences across the three groups but general improvements were observed.

Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Future Questions What are the longitudinal outcomes of service utilization? How do these outcomes compare to results from care as usual? What are the benefits of integrating acupuncture into a standard treatment plan? What are the barriers of access? We are currently enrolling participants in a study of health outcomes of Veterans participating in CIH services throughout the DC VAMC, as well as a substudy on acupuncture outcomes for Veterans with chronic pain. This expanded study examining a larger cohort will help us answer questions pertaining to long-term and lasting effects of CIH service utilization. An important question for future research is, “How do these outcomes compare to results from care as usual?” Control groups are necessary in future studies to compare outcomes from acupuncture to outcomes of standard allopathic treatment plans, as well as the combination of standard treatment and CIH services. To increase the sample size of future research and include a more representative sample of the general population of Veterans, it will be important to identify barriers to access for acupuncture and other CIH services. It is imperative we identify how to make evidence-backed CIH services more accessible to Veterans to meet the needs of the growing Veteran population.

Why acupuncture for Veterans? How do Veterans access acupuncture? In what domains do we see improvement? What more can we do? Conclusion Wellness activities, such as acupuncture, support Veterans mental and physical wellbeing. Participation in acupuncture may be associated with improvements in physical and psychological health, activity levels, and overall wellbeing Improvements positively correlated with acupuncture service utilization. More research is required to investigate barriers, integration with standard practice, and long-term outcomes. In conclusion, There is a growing body of evidence that complementary and integrative health services, such as acupuncture, support Veterans mental and physical wellbeing. Participation in acupuncture may be associated with improvements in physical and psychological health, activity levels, and overall wellbeing. Improvements may be positively correlated with acupuncture service utilization. More research is required to investigate barriers, integration with standard practice, and long-term outcomes.

Special Thanks Coauthors Holliday, S.B., Sullivan, P., Reinhard, M., Duncan, A., Courtney, R.E., Sossin, K., Hull, A. War Related Illness and Injury Study Center (WRIISC) Washington, DC Department of Veterans Affairs Please see handout for full references used in this presentation Stephanie B. Holliday, PhD Rena E. Courtney, BA Patrick Sullivan, MA Kayla Sossin, BA Matthew Reinhard, PsyD Amanda Hull, PhD Alaine Duncan, LAc

Christine.Eickhoff@va.gov (202) 745-8000 x55370 Christine Eickhoff, MS Research Coordinator Integrative Health and Wellness Program War Related Illness and Injury Study Center Washington, DC VA Medical Center Christine.Eickhoff@va.gov (202) 745-8000 x55370 This material is the result of work supported with resources and the use of facilities at the Washington, DC Veteran’s Affairs Medical Center. The contents of this presentation do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.