Trial interventionists were 2 veterans of the armed forces with some prior exposure to counseling, hereafter referred to as “veteran peers.” Of note, in this study, veteran peers were different from VA-employed Veteran Peer Specialists, who are also considered peers, not only because of their prior military service, but also because they are in MH recovery themselves. Veteran peers for this study were trained by psychologists at their respective study sites to use MI techniques, such as open-ended questions, affirmations, reflections, and summary statements, as well as key MI principles, such as expressing empathy and rolling with resistance with the goal of having veteran peers conduct MI-informed coaching rather than formal MI. Veteran peers were encouraged to relate to study participants as veteran peers and potentially disclose more personal information than is typical when using manualized MI. Psychologist supervisors also trained the veteran peers in how to address potential suicidal and homicidal ideation and race/ethnic and sexual orientation and identity issues. During the trial, with participant consent, motivational coaching sessions were audio recorded for fidelity monitoring . Psychologist supervisors reviewed the audio-recordings and provided feedback to veteran peers at weekly group supervision meetings. For participants assigned to the intervention arm, veteran peers started by providing participants feedback on each of their baseline MH screens and used MI-informed, open-ended questions to elicit participants’ reactions to their MH screen results. For example, a veteran peer coach would inform a veteran participant of their PHQ-9 score and explain the meaning of a positive score for depression as either mild, moderate, or severe, flood drain tray asking veterans to share their thoughts or feelings on hearing this information, using psychoeducation and normalizing data as appropriate.

Veteran peers then explored participants’ readiness for MH treatment, reminded veterans that they themselves were not licensed practitioners and, based on their location and preferences, asked permission to provide a customized list of MH treatment and self-care options. Subsequently, participants received up to 3 additional 20- to 30-min motivational coaching calls at 2, 4, and 8 weeks to encourage MH treatment initiation using MI principles as described above. For example, a veteran peer coach attempting to elicit change talk and motivation for MH treatment might use the Readiness Ruler to ask a participant how ready they were to receive MH treatment and would reflect back to them, “You gave yourself a 4 out of 10, why not a lower number? What would need to happen to move you up one or two numbers?” Because veteran peers were trained in coaching in addition to MI, they might add additional coaching language, such as: “If you decided to start receiving outside help, what kind of help do you think would work the best for you?” and, “If we take a step back and think about the big picture, what really matters in your life?” During the 8-week motivational coaching intervention, if a participant scheduled or engaged in clinician-directed MH treatment , the peer-delivered coaching intervention shifted to treatment retention. Treatment retention calls consisted of 20- to 30-min calls at 2 and 6 weeks after MH treatment initiation. During retention calls, veteran peers focused on eliciting the benefits of sustained MH treatment engagement, that is, “Now that you are receiving outside help, how do you see your life getting better?”VA and non-VA community MH services in Northern California and Louisiana were identified and vetted to create a comprehensive annotated list of MH treatment referrals for veterans. As described above, MH treatment referrals were provided to veterans with positive MH screens in both study arms following the baseline assessment and were grouped as follows: clinician-directed MH treatment either within VA or in the community reimbursed by VA, or through a non-VA community MH facility; non-clinician-directed MH care either through VA or in the community ; and self care .

For participants in both arms, veteran peers provided contact information for referrals by phone and letter but did not schedule referrals for veterans.All primary and secondary study outcomes were assessed by blinded research staff at 8 and 16 weeks using the same battery of items administered at baseline and only MH treatment engagement was assessed at 32 weeks. The primary outcome was initiation of clinician-directed MH treatment, and among participants who initiated treatment, retention in MH treatment for ≥ 2 visit, as determined by self-report, VA administrative data, or both . Any new VA or non-VA MH appointment during follow-up between participants’ baseline assessment to 60 days after the final 32-week time point was counted as MH treatment engagement. An MH treatment experiences self-report questionnaire was used to identify categories of clinician-directed VA or non-VA MH treatment. Only MH treatment encounters at VA or in non-VA community settings reimbursed by VA are included in VA administrative data. Secondary outcomes included: non-clinician-directed MH care at VA or in the community and engagement in self-care activities , defined as activities that reduce stress and promote well-being, which can be particularly important for rural veterans and influenced by location. Other secondary outcomes included MH symptoms and quality of life domains .At baseline , following randomization, the 135 controls and 137 telephone motivational coaching participants did not differ in terms of sociodemographics. Overall, the majority was male and middle-aged . Although most participants were White, racial minorities were over represented compared to the US population. The majority earned < $50,000/year; 72% had a military service-connected disability ; 14%- 26% enrolled in VA health care had used private insurance or Medicaid/Medicare within the past 6 months; and the majority received care at rural VA health care facilities. As shown in Table 2, the 2 groups also did not differ at baseline in terms of quality of life measures, MH symptoms , as well as most substance use scores .

Overall, most participants screened positive for MH symptoms, including depression and anxiety , followed by PTSD , and roughly one-quarter screened positive for high-risk drinking. Controls demonstrated significantly higher baseline opioid and amphetamine use than intervention participants , although use of both was extremely low. The 2 groups did not differ in terms of barriers to MH care, but at baseline, controls were significantly more ready than intervention participants to obtain MH treatment. At baseline, the 2 arms did not differ regarding past 5-year MH treatment or self-care activities . In the intervention arm, of 4 possible motivational coaching sessions for MH treatment initiation, participants competed a mean of 2.6 sessions, and of 2 possible MH treatment retention sessions , a mean of 1.72 sessions were completed. As shown in Table 4, a similar number of controls and intervention participants initiated clinician-directed MH treatment during follow-up . Of those initiating MH treatment, a similar proportion reported ≥ 2 MH visits: 41% of controls reported a mean of 6.6 visits, SD = 9.6, and 37% of intervention participants reported a mean of 4.4 visits, SD = 4.6. While there were no between-group differences in type of clinician-directedMH treatment, in this largely rural veteran sample, most MH care was within primary care, followed by MH clinics and receiving “psychiatric medication.” Adjusted Cox proportional hazards regression confirmed no independent differences between the 2 arms with regard to MH treatment initiation , after adjusting for site, MH treatment history, baseline MH symptom severity, baseline opioid and amphetamine scores, and readiness for MH treatment. Of note, the only positive independent association with MH treatment initiation was greater MH symptom severity. Table 6 shows that there were also no significant between group differences regarding engagement in nonclinician-directed MH treatment. Figure 3 summarizes the proportion of participants in each arm initiating self-care activities during follow-up. Compared with controls, more participants in the intervention arm engaged in MH-related Internet or mobile self-help applications and MH-focused community classes . Self-reported MH screen scores and quality of life domain scores were captured at 8 and 16 weeks . Varying numbers of participants did not complete assessments at these 2 time points, resulting in missing values. Nevertheless, as shown in Table 7, compared with controls, intervention participants had significantly lower depression scores and cannabis scores . The COACH trial tested a veteran peer-delivered telephone motivational coaching intervention to improve MH treatment initiation among veterans who primarily used rural VA health care facilities and screened positive for MH symptoms but were not in MH care; which, to our knowledge, is the only study of its kind. No significant differences were found between groups in clinician-directed MH treatment initiation , nor in MH treatment retention. Notably, however, veterans randomized to the intervention were significantly more likely than controls to demonstrate modest improvements in several secondary outcomes, flood and drain tray including MH symptoms, quality of life indicators, and self-care. Qualitative findings may explain how achieving these secondary MH and quality of life outcomes in the intervention arm may have paradoxically obviated veterans’ need to engage in more formal MH treatment. Both participant- and intervention-related factors may explain the lack of difference observed between the 2 groups regarding MH treatment engagement. First, rural veterans prefer to address MH concerns on their own terms , largely influenced by geography and culture, as opposed to engaging in traditional MH treatment. 

In addition, stoicism, self-reliance, and preference for community, family, and peers may have presented barriers to MH treatment engagement among rural veterans not observed in prior similar studies of urband welling veterans. Regarding the intervention, while other studies have employed MH professionals to deliver MI, this study trained peer veterans to conduct motivational coaching. MITI scores demonstrated fair fidelity to MI, raising the question of whether the primary outcome may have been enhanced by stronger adherence to MI principles. Additionally, intervention participants received a mean of 2.6 of 4 motivational coaching sessions, suggesting that dose may have been attenuated, although other studies with fewer doses of MI have achieved treatment engagement. Nevertheless, this study achieved overall enhanced MH treatment engagement in all participants, likely through components common across both study arms, for example, multiple MH assessments, feedback of MH results, and personalized treatment referrals by veteran peers. These findings align with studies which have demonstrated that assessment of substance use alone is associated with significant reductions in use, known as “assessment reactivity.” Similar to our study, Walker et al found that repeated assessment for alcohol abuse followed by a single session of telephone-delivered MI versus psychoeducation were both associated with increased treatment seeking in soldiers with untreated alcohol abuse, pinpointing repeated assessment as a key ingredient. The between-group descriptive analyses for the secondary outcomes demonstrated that veteran peer motivational coaching resulted in improved MH symptoms, reduced cannabis use, improved quality of life scores, and encouraged self-care activities compared to controls as observed in another study. This finding may be explained by the fact that “partnership” was the highest of the peers’ MITI global ratings. Self-disclosure about their experiences may have explained the higher partnership scores, although self disclosure is not measured by the MITI.Non-clinician peers were specifically selected as study interventionists for this trial because rural veterans are known to prefer and trust insiders over “outside experts.” Qualitative exit interviews did suggest that the veteran peers achieved a therapeutic effect themselves, possibly through partnership and relatability, in their delivery of the motivational coaching intervention. For example, one study participant explained, “When she opened up that she was a veteran, I think it made me -. I let my guard down a lot more. It gave me more freedom to express myself and actually talk.” Another consideration is that greater MH symptom severity , and hence perceived need for MH treatment, is a major driver of MH treatment engagement. Thus, as veteran peers achieved secondary outcomes of improved MH symptoms, quality of life, and increased self-care through motivational coaching, they may have paradoxically reduced veterans’ need for formal MH treatment engagement, perhaps explaining our findings in this trial. For example, one participant described the veteran peer coach as helping them, “catch it quickly, without it getting so out of hand that I have to call somebody for mental health. That was—to me—the highlight of all this.” This trial had several limitations that should be considered in interpreting results. First, as evidenced by the CONSORT diagram , veterans enrolling in the trial were likely a biased sample as roughly half who were assessed for eligibility declined to participate. However, this attrition is not wholly unexpected because administrative data were used for recruitment. Second, the sample was largely White, male, and VA service-connected , so findings may not generalize to veterans of color and non-veteran populations. Third, there was large loss to follow-up among rural veterans , but reasons for drop-out are not known. Fourth, fidelity to the MI component of the intervention, intended to enhance MH treatment engagement, may have been supplanted by veteran peers’ “peerness” or relatability, which may have favored the study’s secondary outcomes.