US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.¹ Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.

The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.

METHODS

The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.

A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.

RESULTS

A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).

DISCUSSION

The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.^2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.

Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,² while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.³ Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.⁴

Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.^5,6

Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.⁷ The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.⁸

Patient transfers are a known risk for both patient and staff injuries.^9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.

The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.

Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.^11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.

Strengths and Limitations

A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.

CONCLUSIONS

Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.

US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.¹ Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.

The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.

METHODS

The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.

A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.

RESULTS

A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).

DISCUSSION

The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.^2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.

Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,² while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.³ Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.⁴

Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.^5,6

Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.⁷ The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.⁸

Patient transfers are a known risk for both patient and staff injuries.^9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.

The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.

Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.^11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.

Strengths and Limitations

A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.

CONCLUSIONS

Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.

US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.¹ Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.

The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.

METHODS

The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.

A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.

RESULTS

A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).

DISCUSSION

The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.^2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.

Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,² while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.³ Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.⁴

Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.^5,6

Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.⁷ The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.⁸

Patient transfers are a known risk for both patient and staff injuries.^9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.

The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.

Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.^11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.

Strengths and Limitations

A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.

CONCLUSIONS

Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.

Long-term use of statins may delay or deflect the development of hepatocellular carcinoma in adults with chronic liver disease, as well as in the general population, emerging research, including several large cohort studies, suggested.

The most recent study, published in JAMA Internal Medicine, showed a lower incidence of hepatic decompensation among statin users in a registry for adults aged 40 years or older with baseline chronic liver disease.

“Our findings support the idea that statins may offer benefits beyond lipid-lowering in patients with [chronic liver disease], and clinicians may be more confident in prescribing statins when indicated,” even in these patients, said corresponding Co-author Raymond T. Chung, MD, gastroenterology investigator at Mass General Research Institute, Boston, in an interview. 

“While prior studies have suggested an association between statin use and reduced hepatocellular carcinoma risk, our study aimed to build on that evidence by using a large, real-world, hospital-based cohort inclusive of all etiologies of chronic liver disease,” Chung told GI & Hepatology News.

Chung, along with Jonggi Choi, MD, of the University of Ulsan College of Medicine, Seoul, South Korea, and colleagues, reviewed data from the Research Patient Data Registry from 2000 to 2023 for 16,501 participantsaged 40 years or older with baseline chronic liver disease and baseline Fibrosis-4 (FIB-4) scores ≥ 1.3.

The study population had a mean age of 59.7 years, and 40.9% were women. The researchers divided the population into statin users (n = 3610) and nonusers (n = 12,891). Statin use was defined as a cumulative defined daily dose ≥ 30 mg.

The primary outcome was the cumulative incidence of hepatocellular carcinoma and hepatic decompensation.

At 10 years follow-up, statin users showed a significantly reduced incidence of hepatocellular carcinoma vs nonusers (3.8% vs 8.0%; P < .001) as well as a significantly reduced incidence of hepatic decompensation (10.6% vs 19.5%; P < .001).

Incorporating FIB-4 scores, a surrogate marker for liver fibrosis, also showed that statin users were less likely to experience fibrosis progression, offering a potential mechanism of action for the observed reduction in adverse liver outcomes, Chung told GI & Hepatology News.

“Similar trends have been observed in prior observational studies, but our findings now support a real effect of statin use on fibrosis progression,” he said. “However, what strengthened our study was that the association remained consistent across multiple subgroups and sensitivity analyses.”

Another study published in Clinical Gastroenterology and Hepatology showed a reduced risk of developing severe liver disease in a Swedish cohort of noncirrhotic adults with chronic liver disease who used statins (n = 3862) compared with control patients with chronic liver disease (matched 1:1) and who did not use statins (hazard ratio [HR], 0.60). 

In that study, Rajani Sharma, MD, and colleagues found a protective association in both prefibrosis and fibrosis stages at diagnosis, and statin use was associated with reduced rates of progression to both cirrhosis and hepatocellular carcinoma (HR, 0.62 and 0.44, respectively).

 

Exciting and Necessary Research

The research by Choi and colleagues is “exciting,” said Bubu Banini, MD, PhD, an assistant professor in digestive diseases at Yale School of Medicine, New Haven, Connecticut, in an interview.

Liver cancer prevalence has risen over the past few decades in the United States and worldwide, and the 5-year overall survival rate of liver cancer is less than 20%, Banini told GI & Hepatology News.

Clinicians often withhold statins out of fear of liver injury in persons with chronic liver disease; however, a takeaway from this study is that for persons with chronic liver disease who have indications for statin use, the medication should not be withheld, she said.

Of course, prospective studies are needed to replicate the results, Banini added.

The study findings were limited by several factors, including the inability to adjust for all potential confounding variables, lack of data on post-index treatments, and the use of wide, cumulative, defined daily dose categories to ensure statistical power, the researchers noted.

“Moving forward, randomized controlled trials are essential to establish a causal relationship and clarify the molecular and clinical pathways through which statins exert hepatoprotective effects,” Chung added.

Randomized controlled trials are also needed to determine whether statins can actually reduce the risk for hepatocellular carcinoma and hepatic decompensation in patients with chronic liver disease, and cost-effectiveness analyses may be essential for translating this evidence into clinical guidelines, he added.

 

Statins and HCC Risk in the General Population

A large cohort study, published in JAMA Network Open by Mara Sophie Vell, PhD, and colleagues, showed an association between reduced risk for hepatocellular carcinoma and statin use in the general population and in those at increased risk for liver disease.

The study, which included data for individuals aged 37-73 years from the UK Biobank, found a 15% reduced risk for new-onset liver disease and a 28% reduced risk for liver-related death among regular statin users than among nonusers (HR, 0.85 and 0.72, respectively). 

In addition, regular statin users showed a 74% reduced risk (P = .003) of developing hepatocellular carcinoma compared with those not using statins. The researchers identified a particular impact on liver disease risk reduction among men, individuals with diabetes, and patients with high levels of liver scarring at baseline based on the FIB-4 index.

A meta-analysis of 24 studies, previously published in the journal Cancers, showed a significant reduction of 46% in hepatocellular carcinoma risk among statins users compared with nonusers.

The researchers found this risk reduction was significant in subgroups of patients with diabetes, liver cirrhosis, and those on antiviral therapy, and they suggested that the antiangiogenic, immunomodulatory, antiproliferative, and antifibrotic properties of statins may contribute to their potential to reduce tumor growth or hepatocellular carcinoma development.

The meta-analysis authors noted that although most studies have reported a low risk for statin-induced hepatotoxicity, clinicians should proceed with caution in some patients with existing cirrhosis.

“If the patients are diagnosed with decompensated cirrhosis, then statins should be prescribed with caution at low doses,” they wrote.

Advocating statin use solely for chemoprevention may be premature based on observational data, Chung told GI & Hepatology News.

“However, in patients with [chronic liver disease] who already meet indications for statin therapy, the potential added benefit of reducing liver-related complications strengthens the rationale for their use,” he said. Future randomized clinical trials will be key to defining the risk-benefit profile in this context.

The study by Choi and colleagues was supported by the National Institutes of Health.

The study by Sharma and colleagues was supported by the Karolinska Institutet, Stockholm, Sweden, and the Columbia University Irving Medical Center, New York City; researchers were supported by grants from the Swedish Research Council, Center for Innovative Medicine, the Swedish Cancer Society, and the National Institutes of Health.

The study by Vell and colleagues had no outside funding.

The study by Mohaimenul Islam and colleagues was supported by the Ministry of Education and Ministry of Science and Technology, Taiwan.

Chung and Banini had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

Long-term use of statins may delay or deflect the development of hepatocellular carcinoma in adults with chronic liver disease, as well as in the general population, emerging research, including several large cohort studies, suggested.

The most recent study, published in JAMA Internal Medicine, showed a lower incidence of hepatic decompensation among statin users in a registry for adults aged 40 years or older with baseline chronic liver disease.

“Our findings support the idea that statins may offer benefits beyond lipid-lowering in patients with [chronic liver disease], and clinicians may be more confident in prescribing statins when indicated,” even in these patients, said corresponding Co-author Raymond T. Chung, MD, gastroenterology investigator at Mass General Research Institute, Boston, in an interview. 

“While prior studies have suggested an association between statin use and reduced hepatocellular carcinoma risk, our study aimed to build on that evidence by using a large, real-world, hospital-based cohort inclusive of all etiologies of chronic liver disease,” Chung told GI & Hepatology News.

Chung, along with Jonggi Choi, MD, of the University of Ulsan College of Medicine, Seoul, South Korea, and colleagues, reviewed data from the Research Patient Data Registry from 2000 to 2023 for 16,501 participantsaged 40 years or older with baseline chronic liver disease and baseline Fibrosis-4 (FIB-4) scores ≥ 1.3.

The study population had a mean age of 59.7 years, and 40.9% were women. The researchers divided the population into statin users (n = 3610) and nonusers (n = 12,891). Statin use was defined as a cumulative defined daily dose ≥ 30 mg.

The primary outcome was the cumulative incidence of hepatocellular carcinoma and hepatic decompensation.

At 10 years follow-up, statin users showed a significantly reduced incidence of hepatocellular carcinoma vs nonusers (3.8% vs 8.0%; P < .001) as well as a significantly reduced incidence of hepatic decompensation (10.6% vs 19.5%; P < .001).

Incorporating FIB-4 scores, a surrogate marker for liver fibrosis, also showed that statin users were less likely to experience fibrosis progression, offering a potential mechanism of action for the observed reduction in adverse liver outcomes, Chung told GI & Hepatology News.

“Similar trends have been observed in prior observational studies, but our findings now support a real effect of statin use on fibrosis progression,” he said. “However, what strengthened our study was that the association remained consistent across multiple subgroups and sensitivity analyses.”

Another study published in Clinical Gastroenterology and Hepatology showed a reduced risk of developing severe liver disease in a Swedish cohort of noncirrhotic adults with chronic liver disease who used statins (n = 3862) compared with control patients with chronic liver disease (matched 1:1) and who did not use statins (hazard ratio [HR], 0.60). 

In that study, Rajani Sharma, MD, and colleagues found a protective association in both prefibrosis and fibrosis stages at diagnosis, and statin use was associated with reduced rates of progression to both cirrhosis and hepatocellular carcinoma (HR, 0.62 and 0.44, respectively).

 

Exciting and Necessary Research

The research by Choi and colleagues is “exciting,” said Bubu Banini, MD, PhD, an assistant professor in digestive diseases at Yale School of Medicine, New Haven, Connecticut, in an interview.

Liver cancer prevalence has risen over the past few decades in the United States and worldwide, and the 5-year overall survival rate of liver cancer is less than 20%, Banini told GI & Hepatology News.

Clinicians often withhold statins out of fear of liver injury in persons with chronic liver disease; however, a takeaway from this study is that for persons with chronic liver disease who have indications for statin use, the medication should not be withheld, she said.

Of course, prospective studies are needed to replicate the results, Banini added.

The study findings were limited by several factors, including the inability to adjust for all potential confounding variables, lack of data on post-index treatments, and the use of wide, cumulative, defined daily dose categories to ensure statistical power, the researchers noted.

“Moving forward, randomized controlled trials are essential to establish a causal relationship and clarify the molecular and clinical pathways through which statins exert hepatoprotective effects,” Chung added.

Randomized controlled trials are also needed to determine whether statins can actually reduce the risk for hepatocellular carcinoma and hepatic decompensation in patients with chronic liver disease, and cost-effectiveness analyses may be essential for translating this evidence into clinical guidelines, he added.

 

Statins and HCC Risk in the General Population

A large cohort study, published in JAMA Network Open by Mara Sophie Vell, PhD, and colleagues, showed an association between reduced risk for hepatocellular carcinoma and statin use in the general population and in those at increased risk for liver disease.

The study, which included data for individuals aged 37-73 years from the UK Biobank, found a 15% reduced risk for new-onset liver disease and a 28% reduced risk for liver-related death among regular statin users than among nonusers (HR, 0.85 and 0.72, respectively). 

In addition, regular statin users showed a 74% reduced risk (P = .003) of developing hepatocellular carcinoma compared with those not using statins. The researchers identified a particular impact on liver disease risk reduction among men, individuals with diabetes, and patients with high levels of liver scarring at baseline based on the FIB-4 index.

A meta-analysis of 24 studies, previously published in the journal Cancers, showed a significant reduction of 46% in hepatocellular carcinoma risk among statins users compared with nonusers.

The researchers found this risk reduction was significant in subgroups of patients with diabetes, liver cirrhosis, and those on antiviral therapy, and they suggested that the antiangiogenic, immunomodulatory, antiproliferative, and antifibrotic properties of statins may contribute to their potential to reduce tumor growth or hepatocellular carcinoma development.

The meta-analysis authors noted that although most studies have reported a low risk for statin-induced hepatotoxicity, clinicians should proceed with caution in some patients with existing cirrhosis.

“If the patients are diagnosed with decompensated cirrhosis, then statins should be prescribed with caution at low doses,” they wrote.

Advocating statin use solely for chemoprevention may be premature based on observational data, Chung told GI & Hepatology News.

“However, in patients with [chronic liver disease] who already meet indications for statin therapy, the potential added benefit of reducing liver-related complications strengthens the rationale for their use,” he said. Future randomized clinical trials will be key to defining the risk-benefit profile in this context.

The study by Choi and colleagues was supported by the National Institutes of Health.

The study by Sharma and colleagues was supported by the Karolinska Institutet, Stockholm, Sweden, and the Columbia University Irving Medical Center, New York City; researchers were supported by grants from the Swedish Research Council, Center for Innovative Medicine, the Swedish Cancer Society, and the National Institutes of Health.

The study by Vell and colleagues had no outside funding.

The study by Mohaimenul Islam and colleagues was supported by the Ministry of Education and Ministry of Science and Technology, Taiwan.

Chung and Banini had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

Long-term use of statins may delay or deflect the development of hepatocellular carcinoma in adults with chronic liver disease, as well as in the general population, emerging research, including several large cohort studies, suggested.

The most recent study, published in JAMA Internal Medicine, showed a lower incidence of hepatic decompensation among statin users in a registry for adults aged 40 years or older with baseline chronic liver disease.

“Our findings support the idea that statins may offer benefits beyond lipid-lowering in patients with [chronic liver disease], and clinicians may be more confident in prescribing statins when indicated,” even in these patients, said corresponding Co-author Raymond T. Chung, MD, gastroenterology investigator at Mass General Research Institute, Boston, in an interview. 

“While prior studies have suggested an association between statin use and reduced hepatocellular carcinoma risk, our study aimed to build on that evidence by using a large, real-world, hospital-based cohort inclusive of all etiologies of chronic liver disease,” Chung told GI & Hepatology News.

Chung, along with Jonggi Choi, MD, of the University of Ulsan College of Medicine, Seoul, South Korea, and colleagues, reviewed data from the Research Patient Data Registry from 2000 to 2023 for 16,501 participantsaged 40 years or older with baseline chronic liver disease and baseline Fibrosis-4 (FIB-4) scores ≥ 1.3.

The study population had a mean age of 59.7 years, and 40.9% were women. The researchers divided the population into statin users (n = 3610) and nonusers (n = 12,891). Statin use was defined as a cumulative defined daily dose ≥ 30 mg.

The primary outcome was the cumulative incidence of hepatocellular carcinoma and hepatic decompensation.

At 10 years follow-up, statin users showed a significantly reduced incidence of hepatocellular carcinoma vs nonusers (3.8% vs 8.0%; P < .001) as well as a significantly reduced incidence of hepatic decompensation (10.6% vs 19.5%; P < .001).

Incorporating FIB-4 scores, a surrogate marker for liver fibrosis, also showed that statin users were less likely to experience fibrosis progression, offering a potential mechanism of action for the observed reduction in adverse liver outcomes, Chung told GI & Hepatology News.

“Similar trends have been observed in prior observational studies, but our findings now support a real effect of statin use on fibrosis progression,” he said. “However, what strengthened our study was that the association remained consistent across multiple subgroups and sensitivity analyses.”

Another study published in Clinical Gastroenterology and Hepatology showed a reduced risk of developing severe liver disease in a Swedish cohort of noncirrhotic adults with chronic liver disease who used statins (n = 3862) compared with control patients with chronic liver disease (matched 1:1) and who did not use statins (hazard ratio [HR], 0.60). 

In that study, Rajani Sharma, MD, and colleagues found a protective association in both prefibrosis and fibrosis stages at diagnosis, and statin use was associated with reduced rates of progression to both cirrhosis and hepatocellular carcinoma (HR, 0.62 and 0.44, respectively).

 

Exciting and Necessary Research

The research by Choi and colleagues is “exciting,” said Bubu Banini, MD, PhD, an assistant professor in digestive diseases at Yale School of Medicine, New Haven, Connecticut, in an interview.

Liver cancer prevalence has risen over the past few decades in the United States and worldwide, and the 5-year overall survival rate of liver cancer is less than 20%, Banini told GI & Hepatology News.

Clinicians often withhold statins out of fear of liver injury in persons with chronic liver disease; however, a takeaway from this study is that for persons with chronic liver disease who have indications for statin use, the medication should not be withheld, she said.

Of course, prospective studies are needed to replicate the results, Banini added.

The study findings were limited by several factors, including the inability to adjust for all potential confounding variables, lack of data on post-index treatments, and the use of wide, cumulative, defined daily dose categories to ensure statistical power, the researchers noted.

“Moving forward, randomized controlled trials are essential to establish a causal relationship and clarify the molecular and clinical pathways through which statins exert hepatoprotective effects,” Chung added.

Randomized controlled trials are also needed to determine whether statins can actually reduce the risk for hepatocellular carcinoma and hepatic decompensation in patients with chronic liver disease, and cost-effectiveness analyses may be essential for translating this evidence into clinical guidelines, he added.

 

Statins and HCC Risk in the General Population

A large cohort study, published in JAMA Network Open by Mara Sophie Vell, PhD, and colleagues, showed an association between reduced risk for hepatocellular carcinoma and statin use in the general population and in those at increased risk for liver disease.

The study, which included data for individuals aged 37-73 years from the UK Biobank, found a 15% reduced risk for new-onset liver disease and a 28% reduced risk for liver-related death among regular statin users than among nonusers (HR, 0.85 and 0.72, respectively). 

In addition, regular statin users showed a 74% reduced risk (P = .003) of developing hepatocellular carcinoma compared with those not using statins. The researchers identified a particular impact on liver disease risk reduction among men, individuals with diabetes, and patients with high levels of liver scarring at baseline based on the FIB-4 index.

A meta-analysis of 24 studies, previously published in the journal Cancers, showed a significant reduction of 46% in hepatocellular carcinoma risk among statins users compared with nonusers.

The researchers found this risk reduction was significant in subgroups of patients with diabetes, liver cirrhosis, and those on antiviral therapy, and they suggested that the antiangiogenic, immunomodulatory, antiproliferative, and antifibrotic properties of statins may contribute to their potential to reduce tumor growth or hepatocellular carcinoma development.

The meta-analysis authors noted that although most studies have reported a low risk for statin-induced hepatotoxicity, clinicians should proceed with caution in some patients with existing cirrhosis.

“If the patients are diagnosed with decompensated cirrhosis, then statins should be prescribed with caution at low doses,” they wrote.

Advocating statin use solely for chemoprevention may be premature based on observational data, Chung told GI & Hepatology News.

“However, in patients with [chronic liver disease] who already meet indications for statin therapy, the potential added benefit of reducing liver-related complications strengthens the rationale for their use,” he said. Future randomized clinical trials will be key to defining the risk-benefit profile in this context.

The study by Choi and colleagues was supported by the National Institutes of Health.

The study by Sharma and colleagues was supported by the Karolinska Institutet, Stockholm, Sweden, and the Columbia University Irving Medical Center, New York City; researchers were supported by grants from the Swedish Research Council, Center for Innovative Medicine, the Swedish Cancer Society, and the National Institutes of Health.

The study by Vell and colleagues had no outside funding.

The study by Mohaimenul Islam and colleagues was supported by the Ministry of Education and Ministry of Science and Technology, Taiwan.

Chung and Banini had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

WASHINGTON, DC — Age-related neurodegenerative disorders — motor neuron diseases, demyelinating diseases, Alzheimer’s disease, and other proteinopathies — are at an “inflection point,” said researcher Andrea R. Merchak, PhD, with a fuller understanding of disease pathophysiology but an overall dearth of effective disease-modifying treatments.

And this, Merchak said at the Gut Microbiota for Health (GMFH) World Summit 2025, is where the gut microbiome comes in. “The gut-brain axis is important to take into consideration,” she urged, both for gut microbiome researchers — whose collaboration with neurologists and neuroscientists is essential — and for practicing gastroenterologists.

“We are the sum of our environmental exposures,” said Merchak, assistant research professor of neurology at the Indiana University School of Medicine, in Indianapolis. “So for your patient populations, remember you’re not only treating the diseases they’re coming to you with, you’re also treating them for a lifetime of healthy [brain] aging.”

At the center of a healthy aging brain are the brain-residing microglia and peripheral monocytes, she said. These immune cell populations are directly influenced by blood-brain barrier breakdown, inflammation, and gut permeability — and indirectly influenced by microbial products, gastrointestinal (GI) function, and bacterial diversity, Merchak said at the meeting, which was convened by AGA and the European Society of Neurogastroenterology and Motility.

“Many of us grew up learning that the brain is an immune-privileged site, but we’ve been establishing that this is fundamentally not true,” she said. “While the brain does have a privileged status, there are interactions with the blood, with the peripheral immune cells.”

Merchak coauthored a 2024 review in Neurotherapeutics in which she and her colleagues explained that the brain is “heavily connected with peripheral immune dynamics,” and that the gut — as the largest immune organ in the body — is a critical place for peripheral immune development, “thus influencing brain health.”

Gut microbiota interact with the brain via several mechanisms including microbiota-derived metabolites that enter circulation, direct communication via the vagus nerve, and modulation of the immune system, Merchak and her coauthors wrote. Leaky gut, they noted, can lead to an accumulation of inflammatory signals and cells that can exacerbate or induce the onset of neurodegenerative conditions.

As researchers better understand the role that GI dysfunction plays in neurodegenerative disease — as they identify microbiome signatures for predicting risk, for instance — there will be “opportunities to target the microbiome to prevent or reverse dysbiosis as a way to delay, arrest or prevent the onset and progression of neurodegenerative diseases,” they wrote.

At the GMFH meeting, Merchak described both ongoing preclinical research that is dissecting gut-brain communication, and preliminary clinical evidence for the use of gut microbiota-modulating therapies in neurodegenerative disease.

 

Support for a Gut-Focused Approach

Research on bile acid metabolism in multiple sclerosis (MS) and on peripheral inflammation in dementia exemplify the ongoing preclinical research uncovering the mechanisms of gut-brain communication, Merchak said.

The finding that bile acid metabolism modulates MS autoimmunity comes from research done by Merchak and a team at the University of Virginia, Charlottesville, Virginia, several years ago in which mice with experimental autoimmune encephalomyelitis (EAE) — an animal model of MS — were engineered for T cell specific knockout of the aryl hydrocarbon receptor (AHR). The AHR has been directly tied to MS, and T lymphocytes are known to play a central role in MS pathophysiology.

Blocking the activity of AHR in CD4-positive T cells significantly affected the production of bile acids and other metabolites in the microbiome — and the outcome of central nervous system autoimmunity. “Mice with high levels of bile acids, both primary and secondary, actually recovered from this EAE” and regained motor function, Merchak said at the GMFH meeting.

The potential impact of genetic manipulation on recovery was ruled out — and the role of bile acids confirmed — when, using the EAE model, gut bacteria from mice without AHR were transplanted into mice with AHR. The mice with AHR were able to recover, confirming that AHR can reprogram the gut microbiome and that “high levels of bile acid can lead to reduced autoimmunity in an MS model,” she said.

Other elements and stages of the research, which was published in PLOS Biology in 2023, showed increased apoptosis of CD4-positive immune cells in AHR-deficient mice and the ability of oral taurocholic acid — a bile acid that was especially high in mice without AHR — to reduce the severity of EAE, Merchak said.

Evidence for the role of gut and peripheral inflammation on neurodegeneration is building on numerous fronts, Merchak said. Unpublished research using spatial transcriptomics of colon biopsies from patients with inflammatory bowel disease (IBD), patients with Parkinson’s disease (PD), and neurologically healthy control individuals, for instance, showed similar cell communication patterns in patients with IBD or PD (and no history of IBD) compared with healthy control individuals.

And in research using a single-cell genomics approach and a mouse model of lipopolysaccharide (LPS)-induced system neuroinflammation, microglia were found to preferentially communicate with peripheral myeloid cells rather than other microglia after peripheral LPS exposure.

“In saline-treated mice, the microglia are talking primarily to microglia, but in LPS-treated mice, microglia spend more time communicating with monocytes and T cells,” Merchak explained. “We see communication going from inside the brain to cells coming in from the periphery.”

In another experiment, 2 months of a high-fat, high-sugar diet in mice with an engineered predisposition to frontotemporal dementia led to significant upregulation of major histocompatibility complex class II (MHC II) expression on monocytes in the brain, she said, describing unpublished research. Because MHC II handles antigen presentation in the brain, the change signals increased central-peripheral immune crosstalk and increased brain inflammation.

 

State of Clinical Research

On the clinical side, Merchak said studies of gut microbiome-modulating therapies are currently not longitudinal enough to accurately study neurodegenerative diseases that may develop over decades. Still, her review of the literature — part of her 2024 article — suggests there is at least some preliminary clinical evidence for the use of probiotics/prebiotics/diet and fecal microbiota transplant (FMT) in several diseases.

• Parkinson’s Disease: “There has been some evidence,” Merchak said at the meeting, “for the treatment [with probiotics, prebiotics and diet] of nonmotor symptoms — things like gastrointestinal distress and mood changes — but no real evidence that such treatments can help with the motor symptoms we see in Parkinson’s.” Over 60 patients with PD have been treated with FMT, she said, with reduced GI distress and mixed results with motor symptoms.
• Alzheimer’s and related dementias: “Diet shows promise for cognitive outcomes, but there hasn’t been much evidence for probiotics,” she said. Her review found 17 patients diagnosed with dementia who were treated with FMT, “and for many of them, maintenance of cognitive function was reported — so no further decline — which is excellent.”
• Multiple Sclerosis: “We see higher quality-of-life measures in patients getting probiotics, prebiotics, and changes in diet,” Merchak said. “Again, most of this [relates to] mood and digestion, but some studies show a slowing of neurological damage as measured by MRI.” 

There are reports of 15 patients treated with FMT, and “three of these document full functional recovery,” she said, noting that longer follow-up is necessary as MS is characterized by relapsed and periods of recovery.

Merchak reported no financial disclosures.

A version of this article appeared on Medscape.com.

WASHINGTON, DC — Age-related neurodegenerative disorders — motor neuron diseases, demyelinating diseases, Alzheimer’s disease, and other proteinopathies — are at an “inflection point,” said researcher Andrea R. Merchak, PhD, with a fuller understanding of disease pathophysiology but an overall dearth of effective disease-modifying treatments.

And this, Merchak said at the Gut Microbiota for Health (GMFH) World Summit 2025, is where the gut microbiome comes in. “The gut-brain axis is important to take into consideration,” she urged, both for gut microbiome researchers — whose collaboration with neurologists and neuroscientists is essential — and for practicing gastroenterologists.

“We are the sum of our environmental exposures,” said Merchak, assistant research professor of neurology at the Indiana University School of Medicine, in Indianapolis. “So for your patient populations, remember you’re not only treating the diseases they’re coming to you with, you’re also treating them for a lifetime of healthy [brain] aging.”

At the center of a healthy aging brain are the brain-residing microglia and peripheral monocytes, she said. These immune cell populations are directly influenced by blood-brain barrier breakdown, inflammation, and gut permeability — and indirectly influenced by microbial products, gastrointestinal (GI) function, and bacterial diversity, Merchak said at the meeting, which was convened by AGA and the European Society of Neurogastroenterology and Motility.

“Many of us grew up learning that the brain is an immune-privileged site, but we’ve been establishing that this is fundamentally not true,” she said. “While the brain does have a privileged status, there are interactions with the blood, with the peripheral immune cells.”

Merchak coauthored a 2024 review in Neurotherapeutics in which she and her colleagues explained that the brain is “heavily connected with peripheral immune dynamics,” and that the gut — as the largest immune organ in the body — is a critical place for peripheral immune development, “thus influencing brain health.”

Gut microbiota interact with the brain via several mechanisms including microbiota-derived metabolites that enter circulation, direct communication via the vagus nerve, and modulation of the immune system, Merchak and her coauthors wrote. Leaky gut, they noted, can lead to an accumulation of inflammatory signals and cells that can exacerbate or induce the onset of neurodegenerative conditions.

As researchers better understand the role that GI dysfunction plays in neurodegenerative disease — as they identify microbiome signatures for predicting risk, for instance — there will be “opportunities to target the microbiome to prevent or reverse dysbiosis as a way to delay, arrest or prevent the onset and progression of neurodegenerative diseases,” they wrote.

At the GMFH meeting, Merchak described both ongoing preclinical research that is dissecting gut-brain communication, and preliminary clinical evidence for the use of gut microbiota-modulating therapies in neurodegenerative disease.

 

Support for a Gut-Focused Approach

Research on bile acid metabolism in multiple sclerosis (MS) and on peripheral inflammation in dementia exemplify the ongoing preclinical research uncovering the mechanisms of gut-brain communication, Merchak said.

The finding that bile acid metabolism modulates MS autoimmunity comes from research done by Merchak and a team at the University of Virginia, Charlottesville, Virginia, several years ago in which mice with experimental autoimmune encephalomyelitis (EAE) — an animal model of MS — were engineered for T cell specific knockout of the aryl hydrocarbon receptor (AHR). The AHR has been directly tied to MS, and T lymphocytes are known to play a central role in MS pathophysiology.

Blocking the activity of AHR in CD4-positive T cells significantly affected the production of bile acids and other metabolites in the microbiome — and the outcome of central nervous system autoimmunity. “Mice with high levels of bile acids, both primary and secondary, actually recovered from this EAE” and regained motor function, Merchak said at the GMFH meeting.

The potential impact of genetic manipulation on recovery was ruled out — and the role of bile acids confirmed — when, using the EAE model, gut bacteria from mice without AHR were transplanted into mice with AHR. The mice with AHR were able to recover, confirming that AHR can reprogram the gut microbiome and that “high levels of bile acid can lead to reduced autoimmunity in an MS model,” she said.

Other elements and stages of the research, which was published in PLOS Biology in 2023, showed increased apoptosis of CD4-positive immune cells in AHR-deficient mice and the ability of oral taurocholic acid — a bile acid that was especially high in mice without AHR — to reduce the severity of EAE, Merchak said.

Evidence for the role of gut and peripheral inflammation on neurodegeneration is building on numerous fronts, Merchak said. Unpublished research using spatial transcriptomics of colon biopsies from patients with inflammatory bowel disease (IBD), patients with Parkinson’s disease (PD), and neurologically healthy control individuals, for instance, showed similar cell communication patterns in patients with IBD or PD (and no history of IBD) compared with healthy control individuals.

And in research using a single-cell genomics approach and a mouse model of lipopolysaccharide (LPS)-induced system neuroinflammation, microglia were found to preferentially communicate with peripheral myeloid cells rather than other microglia after peripheral LPS exposure.

“In saline-treated mice, the microglia are talking primarily to microglia, but in LPS-treated mice, microglia spend more time communicating with monocytes and T cells,” Merchak explained. “We see communication going from inside the brain to cells coming in from the periphery.”

In another experiment, 2 months of a high-fat, high-sugar diet in mice with an engineered predisposition to frontotemporal dementia led to significant upregulation of major histocompatibility complex class II (MHC II) expression on monocytes in the brain, she said, describing unpublished research. Because MHC II handles antigen presentation in the brain, the change signals increased central-peripheral immune crosstalk and increased brain inflammation.

 

State of Clinical Research

On the clinical side, Merchak said studies of gut microbiome-modulating therapies are currently not longitudinal enough to accurately study neurodegenerative diseases that may develop over decades. Still, her review of the literature — part of her 2024 article — suggests there is at least some preliminary clinical evidence for the use of probiotics/prebiotics/diet and fecal microbiota transplant (FMT) in several diseases.

• Parkinson’s Disease: “There has been some evidence,” Merchak said at the meeting, “for the treatment [with probiotics, prebiotics and diet] of nonmotor symptoms — things like gastrointestinal distress and mood changes — but no real evidence that such treatments can help with the motor symptoms we see in Parkinson’s.” Over 60 patients with PD have been treated with FMT, she said, with reduced GI distress and mixed results with motor symptoms.
• Alzheimer’s and related dementias: “Diet shows promise for cognitive outcomes, but there hasn’t been much evidence for probiotics,” she said. Her review found 17 patients diagnosed with dementia who were treated with FMT, “and for many of them, maintenance of cognitive function was reported — so no further decline — which is excellent.”
• Multiple Sclerosis: “We see higher quality-of-life measures in patients getting probiotics, prebiotics, and changes in diet,” Merchak said. “Again, most of this [relates to] mood and digestion, but some studies show a slowing of neurological damage as measured by MRI.” 

There are reports of 15 patients treated with FMT, and “three of these document full functional recovery,” she said, noting that longer follow-up is necessary as MS is characterized by relapsed and periods of recovery.

Merchak reported no financial disclosures.

A version of this article appeared on Medscape.com.

WASHINGTON, DC — Age-related neurodegenerative disorders — motor neuron diseases, demyelinating diseases, Alzheimer’s disease, and other proteinopathies — are at an “inflection point,” said researcher Andrea R. Merchak, PhD, with a fuller understanding of disease pathophysiology but an overall dearth of effective disease-modifying treatments.

And this, Merchak said at the Gut Microbiota for Health (GMFH) World Summit 2025, is where the gut microbiome comes in. “The gut-brain axis is important to take into consideration,” she urged, both for gut microbiome researchers — whose collaboration with neurologists and neuroscientists is essential — and for practicing gastroenterologists.

“We are the sum of our environmental exposures,” said Merchak, assistant research professor of neurology at the Indiana University School of Medicine, in Indianapolis. “So for your patient populations, remember you’re not only treating the diseases they’re coming to you with, you’re also treating them for a lifetime of healthy [brain] aging.”

At the center of a healthy aging brain are the brain-residing microglia and peripheral monocytes, she said. These immune cell populations are directly influenced by blood-brain barrier breakdown, inflammation, and gut permeability — and indirectly influenced by microbial products, gastrointestinal (GI) function, and bacterial diversity, Merchak said at the meeting, which was convened by AGA and the European Society of Neurogastroenterology and Motility.

“Many of us grew up learning that the brain is an immune-privileged site, but we’ve been establishing that this is fundamentally not true,” she said. “While the brain does have a privileged status, there are interactions with the blood, with the peripheral immune cells.”

Merchak coauthored a 2024 review in Neurotherapeutics in which she and her colleagues explained that the brain is “heavily connected with peripheral immune dynamics,” and that the gut — as the largest immune organ in the body — is a critical place for peripheral immune development, “thus influencing brain health.”

Gut microbiota interact with the brain via several mechanisms including microbiota-derived metabolites that enter circulation, direct communication via the vagus nerve, and modulation of the immune system, Merchak and her coauthors wrote. Leaky gut, they noted, can lead to an accumulation of inflammatory signals and cells that can exacerbate or induce the onset of neurodegenerative conditions.

As researchers better understand the role that GI dysfunction plays in neurodegenerative disease — as they identify microbiome signatures for predicting risk, for instance — there will be “opportunities to target the microbiome to prevent or reverse dysbiosis as a way to delay, arrest or prevent the onset and progression of neurodegenerative diseases,” they wrote.

At the GMFH meeting, Merchak described both ongoing preclinical research that is dissecting gut-brain communication, and preliminary clinical evidence for the use of gut microbiota-modulating therapies in neurodegenerative disease.

 

Support for a Gut-Focused Approach

Research on bile acid metabolism in multiple sclerosis (MS) and on peripheral inflammation in dementia exemplify the ongoing preclinical research uncovering the mechanisms of gut-brain communication, Merchak said.

The finding that bile acid metabolism modulates MS autoimmunity comes from research done by Merchak and a team at the University of Virginia, Charlottesville, Virginia, several years ago in which mice with experimental autoimmune encephalomyelitis (EAE) — an animal model of MS — were engineered for T cell specific knockout of the aryl hydrocarbon receptor (AHR). The AHR has been directly tied to MS, and T lymphocytes are known to play a central role in MS pathophysiology.

Blocking the activity of AHR in CD4-positive T cells significantly affected the production of bile acids and other metabolites in the microbiome — and the outcome of central nervous system autoimmunity. “Mice with high levels of bile acids, both primary and secondary, actually recovered from this EAE” and regained motor function, Merchak said at the GMFH meeting.

The potential impact of genetic manipulation on recovery was ruled out — and the role of bile acids confirmed — when, using the EAE model, gut bacteria from mice without AHR were transplanted into mice with AHR. The mice with AHR were able to recover, confirming that AHR can reprogram the gut microbiome and that “high levels of bile acid can lead to reduced autoimmunity in an MS model,” she said.

Other elements and stages of the research, which was published in PLOS Biology in 2023, showed increased apoptosis of CD4-positive immune cells in AHR-deficient mice and the ability of oral taurocholic acid — a bile acid that was especially high in mice without AHR — to reduce the severity of EAE, Merchak said.

Evidence for the role of gut and peripheral inflammation on neurodegeneration is building on numerous fronts, Merchak said. Unpublished research using spatial transcriptomics of colon biopsies from patients with inflammatory bowel disease (IBD), patients with Parkinson’s disease (PD), and neurologically healthy control individuals, for instance, showed similar cell communication patterns in patients with IBD or PD (and no history of IBD) compared with healthy control individuals.

And in research using a single-cell genomics approach and a mouse model of lipopolysaccharide (LPS)-induced system neuroinflammation, microglia were found to preferentially communicate with peripheral myeloid cells rather than other microglia after peripheral LPS exposure.

“In saline-treated mice, the microglia are talking primarily to microglia, but in LPS-treated mice, microglia spend more time communicating with monocytes and T cells,” Merchak explained. “We see communication going from inside the brain to cells coming in from the periphery.”

In another experiment, 2 months of a high-fat, high-sugar diet in mice with an engineered predisposition to frontotemporal dementia led to significant upregulation of major histocompatibility complex class II (MHC II) expression on monocytes in the brain, she said, describing unpublished research. Because MHC II handles antigen presentation in the brain, the change signals increased central-peripheral immune crosstalk and increased brain inflammation.

 

State of Clinical Research

On the clinical side, Merchak said studies of gut microbiome-modulating therapies are currently not longitudinal enough to accurately study neurodegenerative diseases that may develop over decades. Still, her review of the literature — part of her 2024 article — suggests there is at least some preliminary clinical evidence for the use of probiotics/prebiotics/diet and fecal microbiota transplant (FMT) in several diseases.

• Parkinson’s Disease: “There has been some evidence,” Merchak said at the meeting, “for the treatment [with probiotics, prebiotics and diet] of nonmotor symptoms — things like gastrointestinal distress and mood changes — but no real evidence that such treatments can help with the motor symptoms we see in Parkinson’s.” Over 60 patients with PD have been treated with FMT, she said, with reduced GI distress and mixed results with motor symptoms.
• Alzheimer’s and related dementias: “Diet shows promise for cognitive outcomes, but there hasn’t been much evidence for probiotics,” she said. Her review found 17 patients diagnosed with dementia who were treated with FMT, “and for many of them, maintenance of cognitive function was reported — so no further decline — which is excellent.”
• Multiple Sclerosis: “We see higher quality-of-life measures in patients getting probiotics, prebiotics, and changes in diet,” Merchak said. “Again, most of this [relates to] mood and digestion, but some studies show a slowing of neurological damage as measured by MRI.” 

There are reports of 15 patients treated with FMT, and “three of these document full functional recovery,” she said, noting that longer follow-up is necessary as MS is characterized by relapsed and periods of recovery.

Merchak reported no financial disclosures.

A version of this article appeared on Medscape.com.

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good.

Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will. 

 

1. Family Changes

If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

2. Relocating to a New State

The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

3. Tax Law Changes

Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

4. You Want to Support a Favorite Cause

If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

5. Changes in Your Estate’s Value

When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good.

Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will. 

 

1. Family Changes

If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

2. Relocating to a New State

The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

3. Tax Law Changes

Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

4. You Want to Support a Favorite Cause

If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

5. Changes in Your Estate’s Value

When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good.

Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will. 

 

1. Family Changes

If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

2. Relocating to a New State

The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

3. Tax Law Changes

Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

4. You Want to Support a Favorite Cause

If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

5. Changes in Your Estate’s Value

When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

Researchers have developed and internally validated a simple score using clinical factors that can help estimate the likelihood of advanced colorectal neoplasia in adults younger than age 45 years.

While colorectal cancer (CRC) incidence has declined overall due to screening, early-onset CRC is on the rise, particularly in individuals younger than 45 years — an age group not currently recommended for CRC screening.

Studies have shown that the risk for early-onset advanced neoplasia varies based on several factors, including sex, race, family history of CRC, smoking, alcohol consumption, diabetes, hyperlipidemia, obesity, and diet.

A score that incorporates some of these factors to identify which younger adults are at higher risk for advanced neoplasia, a precursor to CRC, could support earlier, more targeted screening interventions.

The simple clinical score can be easily calculated by primary care providers in the office, Carole Macaron, MD, lead author of the study and a gastroenterologist at Cleveland Clinic, told GI & Hepatology News. “Patients with a high-risk score would be referred for colorectal cancer screening.”

The study was published in Digestive Diseases and Sciences.

To develop and validate their risk score, Macaron and colleagues did a retrospective cross-sectional analysis of 9446 individuals aged 18-44 years (mean age, 36.8 years; 61% women) who underwent colonoscopy at their center.

Advanced neoplasia was defined as a tubular adenoma ≥ 10 mm or any adenoma with villous features or high-grade dysplasia, sessile serrated polyp ≥ 10 mm, sessile serrated polyp with dysplasia, traditional serrated adenoma, or invasive adenocarcinoma.

The 346 (3.7%) individuals found to have advanced neoplasia served as the case group, and the remainder with normal colonoscopy or non-advanced neoplasia served as controls.

A multivariate logistic regression model identified three independent risk factors significantly associated with advanced neoplasia: Higher body mass index (BMI; P = .0157), former and current tobacco use (P = .0009 and P = .0015, respectively), and having a first-degree relative with CRC < 60 years (P < .0001) or other family history of CRC (P = .0117).

The researchers used these risk factors to develop a risk prediction score to estimate the likelihood of detecting advanced neoplasia, which ranged from a risk of 1.8% for patients with a score of 1 to 22.2% for those with a score of 12. Individuals with a score of ≥ 9 had a 14% or higher risk for advanced neoplasia.

Based on the risk model, the likelihood of detecting advanced neoplasia in an asymptomatic 32-year-old overweight individual, with a history of previous tobacco use and a first-degree relative younger than age 60 with CRC would be 20.3%, Macaron and colleagues noted.

The model demonstrated “moderate” discriminatory power in the validation set (C-statistic: 0.645), indicating that it can effectively differentiate between individuals at a higher and lower risk for advanced neoplasia.

Additionally, the authors are exploring ways to improve the discriminatory power of the score, possibly by including additional risk factors.

Given the score is calculated using easily obtainable risk factors for individuals younger than 45 who are at risk for early-onset colorectal neoplasia, it could help guide individualized screening decisions for those in whom screening is not currently offered, Macaron said. It could also serve as a tool for risk communication and shared decision-making.

Integration into electronic health records or online calculators may enhance its accessibility and clinical utility.

The authors noted that this retrospective study was conducted at a single center caring mainly for White non-Hispanic adults, limiting generalizability to the general population and to other races and ethnicities.

 

Validation in Real-World Setting Needed

“There are no currently accepted advanced colorectal neoplasia risk scores that are used in general practice,” said Steven H. Itzkowitz, MD, AGAF, professor of medicine, oncological sciences, and medical education, Icahn School of Medicine at Mount Sinai in New York City. “If these lesions can be predicted, it would enable these young individuals to undergo screening colonoscopy, which could detect and remove these lesions, thereby preventing CRC.”

Many of the known risk factors (family history, high BMI, or smoking) for CRC development at any age are incorporated within this tool, so it should be feasible to collect these data,” said Itzkowitz, who was not involved with the study.

But he cautioned that accurate and adequate family histories are not always performed. Clinicians also may not have considered combining these factors into an actionable risk score.

“If this score can be externally validated in a real-world setting, it could be a useful addition in our efforts to lower CRC rates among young individuals,” Itzkowitz said.

The study did not receive any funding. Macaron and Itzkowitz reported no competing interests.

A version of this article first appeared on Medscape.com.

Researchers have developed and internally validated a simple score using clinical factors that can help estimate the likelihood of advanced colorectal neoplasia in adults younger than age 45 years.

While colorectal cancer (CRC) incidence has declined overall due to screening, early-onset CRC is on the rise, particularly in individuals younger than 45 years — an age group not currently recommended for CRC screening.

Studies have shown that the risk for early-onset advanced neoplasia varies based on several factors, including sex, race, family history of CRC, smoking, alcohol consumption, diabetes, hyperlipidemia, obesity, and diet.

A score that incorporates some of these factors to identify which younger adults are at higher risk for advanced neoplasia, a precursor to CRC, could support earlier, more targeted screening interventions.

The simple clinical score can be easily calculated by primary care providers in the office, Carole Macaron, MD, lead author of the study and a gastroenterologist at Cleveland Clinic, told GI & Hepatology News. “Patients with a high-risk score would be referred for colorectal cancer screening.”

The study was published in Digestive Diseases and Sciences.

To develop and validate their risk score, Macaron and colleagues did a retrospective cross-sectional analysis of 9446 individuals aged 18-44 years (mean age, 36.8 years; 61% women) who underwent colonoscopy at their center.

Advanced neoplasia was defined as a tubular adenoma ≥ 10 mm or any adenoma with villous features or high-grade dysplasia, sessile serrated polyp ≥ 10 mm, sessile serrated polyp with dysplasia, traditional serrated adenoma, or invasive adenocarcinoma.

The 346 (3.7%) individuals found to have advanced neoplasia served as the case group, and the remainder with normal colonoscopy or non-advanced neoplasia served as controls.

A multivariate logistic regression model identified three independent risk factors significantly associated with advanced neoplasia: Higher body mass index (BMI; P = .0157), former and current tobacco use (P = .0009 and P = .0015, respectively), and having a first-degree relative with CRC < 60 years (P < .0001) or other family history of CRC (P = .0117).

The researchers used these risk factors to develop a risk prediction score to estimate the likelihood of detecting advanced neoplasia, which ranged from a risk of 1.8% for patients with a score of 1 to 22.2% for those with a score of 12. Individuals with a score of ≥ 9 had a 14% or higher risk for advanced neoplasia.

Based on the risk model, the likelihood of detecting advanced neoplasia in an asymptomatic 32-year-old overweight individual, with a history of previous tobacco use and a first-degree relative younger than age 60 with CRC would be 20.3%, Macaron and colleagues noted.

The model demonstrated “moderate” discriminatory power in the validation set (C-statistic: 0.645), indicating that it can effectively differentiate between individuals at a higher and lower risk for advanced neoplasia.

Additionally, the authors are exploring ways to improve the discriminatory power of the score, possibly by including additional risk factors.

Given the score is calculated using easily obtainable risk factors for individuals younger than 45 who are at risk for early-onset colorectal neoplasia, it could help guide individualized screening decisions for those in whom screening is not currently offered, Macaron said. It could also serve as a tool for risk communication and shared decision-making.

Integration into electronic health records or online calculators may enhance its accessibility and clinical utility.

The authors noted that this retrospective study was conducted at a single center caring mainly for White non-Hispanic adults, limiting generalizability to the general population and to other races and ethnicities.

 

Validation in Real-World Setting Needed

“There are no currently accepted advanced colorectal neoplasia risk scores that are used in general practice,” said Steven H. Itzkowitz, MD, AGAF, professor of medicine, oncological sciences, and medical education, Icahn School of Medicine at Mount Sinai in New York City. “If these lesions can be predicted, it would enable these young individuals to undergo screening colonoscopy, which could detect and remove these lesions, thereby preventing CRC.”

Many of the known risk factors (family history, high BMI, or smoking) for CRC development at any age are incorporated within this tool, so it should be feasible to collect these data,” said Itzkowitz, who was not involved with the study.

But he cautioned that accurate and adequate family histories are not always performed. Clinicians also may not have considered combining these factors into an actionable risk score.

“If this score can be externally validated in a real-world setting, it could be a useful addition in our efforts to lower CRC rates among young individuals,” Itzkowitz said.

The study did not receive any funding. Macaron and Itzkowitz reported no competing interests.

A version of this article first appeared on Medscape.com.

Researchers have developed and internally validated a simple score using clinical factors that can help estimate the likelihood of advanced colorectal neoplasia in adults younger than age 45 years.

While colorectal cancer (CRC) incidence has declined overall due to screening, early-onset CRC is on the rise, particularly in individuals younger than 45 years — an age group not currently recommended for CRC screening.

Studies have shown that the risk for early-onset advanced neoplasia varies based on several factors, including sex, race, family history of CRC, smoking, alcohol consumption, diabetes, hyperlipidemia, obesity, and diet.

A score that incorporates some of these factors to identify which younger adults are at higher risk for advanced neoplasia, a precursor to CRC, could support earlier, more targeted screening interventions.

The simple clinical score can be easily calculated by primary care providers in the office, Carole Macaron, MD, lead author of the study and a gastroenterologist at Cleveland Clinic, told GI & Hepatology News. “Patients with a high-risk score would be referred for colorectal cancer screening.”

The study was published in Digestive Diseases and Sciences.

To develop and validate their risk score, Macaron and colleagues did a retrospective cross-sectional analysis of 9446 individuals aged 18-44 years (mean age, 36.8 years; 61% women) who underwent colonoscopy at their center.

Advanced neoplasia was defined as a tubular adenoma ≥ 10 mm or any adenoma with villous features or high-grade dysplasia, sessile serrated polyp ≥ 10 mm, sessile serrated polyp with dysplasia, traditional serrated adenoma, or invasive adenocarcinoma.

The 346 (3.7%) individuals found to have advanced neoplasia served as the case group, and the remainder with normal colonoscopy or non-advanced neoplasia served as controls.

A multivariate logistic regression model identified three independent risk factors significantly associated with advanced neoplasia: Higher body mass index (BMI; P = .0157), former and current tobacco use (P = .0009 and P = .0015, respectively), and having a first-degree relative with CRC < 60 years (P < .0001) or other family history of CRC (P = .0117).

The researchers used these risk factors to develop a risk prediction score to estimate the likelihood of detecting advanced neoplasia, which ranged from a risk of 1.8% for patients with a score of 1 to 22.2% for those with a score of 12. Individuals with a score of ≥ 9 had a 14% or higher risk for advanced neoplasia.

Based on the risk model, the likelihood of detecting advanced neoplasia in an asymptomatic 32-year-old overweight individual, with a history of previous tobacco use and a first-degree relative younger than age 60 with CRC would be 20.3%, Macaron and colleagues noted.

The model demonstrated “moderate” discriminatory power in the validation set (C-statistic: 0.645), indicating that it can effectively differentiate between individuals at a higher and lower risk for advanced neoplasia.

Additionally, the authors are exploring ways to improve the discriminatory power of the score, possibly by including additional risk factors.

Given the score is calculated using easily obtainable risk factors for individuals younger than 45 who are at risk for early-onset colorectal neoplasia, it could help guide individualized screening decisions for those in whom screening is not currently offered, Macaron said. It could also serve as a tool for risk communication and shared decision-making.

Integration into electronic health records or online calculators may enhance its accessibility and clinical utility.

The authors noted that this retrospective study was conducted at a single center caring mainly for White non-Hispanic adults, limiting generalizability to the general population and to other races and ethnicities.

 

Validation in Real-World Setting Needed

“There are no currently accepted advanced colorectal neoplasia risk scores that are used in general practice,” said Steven H. Itzkowitz, MD, AGAF, professor of medicine, oncological sciences, and medical education, Icahn School of Medicine at Mount Sinai in New York City. “If these lesions can be predicted, it would enable these young individuals to undergo screening colonoscopy, which could detect and remove these lesions, thereby preventing CRC.”

Many of the known risk factors (family history, high BMI, or smoking) for CRC development at any age are incorporated within this tool, so it should be feasible to collect these data,” said Itzkowitz, who was not involved with the study.

But he cautioned that accurate and adequate family histories are not always performed. Clinicians also may not have considered combining these factors into an actionable risk score.

“If this score can be externally validated in a real-world setting, it could be a useful addition in our efforts to lower CRC rates among young individuals,” Itzkowitz said.

The study did not receive any funding. Macaron and Itzkowitz reported no competing interests.

A version of this article first appeared on Medscape.com.