<p> <b>BACKGROUND AND PURPOSE:</b> This study sought to examine the association of severe mental illness (SMI) among stroke survivors treated in Veteran Administration (VA) hospitals with medical (non-psychiatric) hospitalizations, recurrent stroke hospitalization and mortality risk over a five year period after the initial stroke. Additionally, this study used administrative data to explored inpatient stroke treatment differences between patients with and without SMI. </p><p> <b>METHODS:</b> This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VA medical center during fiscal year 2003. This cohort of stroke survivors was followed from discharge in 2003 through 2008 using administrative data documenting patient demographics, disease co-morbidities, subsequent VA hospital admissions, recurrent stroke admissions, and death. Multivariate Poisson regression with log link functions was used to examine the relationship between SMI status and non-psychiatric hospitalizations after stroke. Cox proportional hazards regression was used to examine the relationship between SMI status and recurrent stroke and post-stroke mortality. The differences in compliance with inpatient stroke treatment guidelines between patients with and without SMI was assessed using logistic regression. </p><p> <b>RESULTS:</b> The study cohort of 523 veterans included 100 with SMI comorbidity and 423 without SMI comorbidity. It was found that stroke survivors with SMI do not have significantly increased risk for non-psychiatric hospitalizations, recurrent stroke or mortality at any time period post-stroke after adjustment for covariates. It was also found that there was no significant difference in the delivery of guideline concordant inpatient stroke care between patients with and without SMI. </p><p> <b>CONCLUSIONS:</b> The finding that SMI had little impact on the post-stroke outcomes of hospitalization, recurrent stroke and mortality among veterans who receive their care at VA hospitals was surprising. It was hypothesized that SMI would continue to disadvantage individuals even after having survived a stroke. These findings may be partially explained by the highly integrated nature of care for the mentally ill in the VA system, which may equalize disparities associated with SMI post-stroke. This study offers preliminary evidence of this in VA hospital inpatient settings where acute stroke treatment did not significantly vary between patients with and without SMI.</p>

<p> The rural primary care provider is likely to treat patients with mental health issues in rural populations due to lack of mental health providers, comorbidity and multimorbidity of patient illness, and stigma associated with seeking mental health services. The very nature of rural primary care allows for patients to be comfortable with their PCP and therefore, rely on the strong foundational relationship they have in entrusting them with their mental health concerns. Being a primary care provider in a rural setting offers both rewards and challenges unique to the rural culture.</p><p> The main goal of the study was to explore what might enhance, diminish, or otherwise give meaning to the rural primary care provider&rsquo;s experience of engaging in discussions about mental health issues with their patients. This was achieved through identifying themes in response to two primary research questions. The primary research questions were: (a) How do rural primary care providers engage in conversations about mental health issues with their patients?; and (b) What are factors of being in a rural setting that affect and/or influence the primary care provider in having these conversations?</p><p> Data from ten participants across the three rural primary care clinics was analyzed using the qualitative method of thematic analysis to identify embedded themes. Five themes were revealed: (a) The relationship between the patient and the rural primary care provider allows for the conversation about mental health issues; (b) Rural primary care providers routinely provide mental health services; (c) Rural primary care providers experience challenges treating complex mental health issues; (d) Rural primary care providers navigate barriers in rural communities; and (e) There are benefits and drawbacks of rural living.</p><p>