The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

Needle-knife fistulotomy (NKF) is a safe and effective technique for primary biliary access during endoscopic retrograde cholangiopancreatography (ERCP), even among trainee advanced endoscopists, based on results of a randomized trial.

Across procedures conducted predominantly by trainees, safety outcomes were similar between NKF and standard cannulation, and all patients were successfully cannulated, suggesting this is a broadly accessible technique, reported lead author Aleksey Novikov, MD, of the University of Florida College of Medicine, Gainesville, and colleagues, reported.

Writing in Techniques and Innovations in Gastrointestinal Endoscopy, the investigators noted that standard cannulation fails in 5-20% of cases, which has led to development of various alternative techniques, including NKF. To perform the technique, the endoscopist makes a small incision in the intraduodenal biliary segment 3-6mm above the papillary orifice, with cephalad extension until bili-ary access is achieved.

To date, four prospective studies have evaluated NKF in the hands of expert advanced endoscopists. 

“These studies showed that NKF is a safe and useful technique that significantly reduces the risk of PEP in the hands of expert advanced endoscopists,” the investigators wrote. ‘The suggestion that NKF should be restricted to expert advanced endoscopists likely limits widespread use.”

To determine whether NKF is a suitable technique for less experienced endoscopists, the investigators conducted the present single-center, prospective randomized controlled trial at Thomas Jefferson University Hospital in Philadelphia.

Adults undergoing ERCP for biliary indications were randomly assigned in a 1:1 ratio to undergo primary cannulation via NKF or standard cannulation. Patients with prior sphincterotomy, ampullectomy, or unfavorable anatomy were excluded.

A total of 186 patients were randomized, with 137 ultimately included in the per-protocol analysis after exclusions for anatomic factors. Most procedures (72.3%) were performed by advanced endoscopy trainees under direct supervision, 26 procedures (19.0%) were performed by attending endoscopists without substantive prior NKF experience, and 12 (8.8%) by an attending endoscopist with NKF expertise.

“It is important to note that the majority of procedures performed in the context of this study were performed by an advanced endoscopy trainee with no NKF experience or an attending advanced endoscopist with minimal NKF experience,” the investigators wrote.

All patients received prophylactic rectal indomethacin, and cannulation attempts were capped at 20 minutes before crossover to another technique was permitted.

The primary endpoint was incidence of post-ERCP pancreatitis. Secondary endpoints included successful biliary access, time to access, and rates of bleeding and perforation.

Post-ERCP pancreatitis occurred at similar rate across groups: 6 cases (8.2%) in the standard cannulation arm and 5 cases (7.8%) in the NKF arm (P = .93). Rates of bleeding and perforation were also similar for both techniques.

Within the initial 20-minute window, biliary access rates were comparable between groups, at 75.3% and 82.2% for standard cannulation and NKF, respectively (P = .89). Allowing additional attempts or crossover, overall success rose to 100% in both arms.

Mean time to access was longer with NKF, averaging 380 seconds compared with 268 seconds for standard cannulation (P less than .05). 

“NKF was essentially equivalent to standard cannulation in many aspects,” the investigators wrote, calling the two techniques “complementary.”

They also suggested that the relative equivalence between techniques “carries more weight” after considering the low level of NKF experience among participating endoscopists.

“Overall, our data support teaching advanced endoscopy trainees NKF as a primary method of biliary access in patients with favorable anatomy,” the investigators concluded.

The investigators disclosed relationships with Medtronic, Boston Scientific, and Olympus.
 

Needle-knife fistulotomy (NKF) is a safe and effective technique for primary biliary access during endoscopic retrograde cholangiopancreatography (ERCP), even among trainee advanced endoscopists, based on results of a randomized trial.

Across procedures conducted predominantly by trainees, safety outcomes were similar between NKF and standard cannulation, and all patients were successfully cannulated, suggesting this is a broadly accessible technique, reported lead author Aleksey Novikov, MD, of the University of Florida College of Medicine, Gainesville, and colleagues, reported.

Writing in Techniques and Innovations in Gastrointestinal Endoscopy, the investigators noted that standard cannulation fails in 5-20% of cases, which has led to development of various alternative techniques, including NKF. To perform the technique, the endoscopist makes a small incision in the intraduodenal biliary segment 3-6mm above the papillary orifice, with cephalad extension until bili-ary access is achieved.

To date, four prospective studies have evaluated NKF in the hands of expert advanced endoscopists. 

“These studies showed that NKF is a safe and useful technique that significantly reduces the risk of PEP in the hands of expert advanced endoscopists,” the investigators wrote. ‘The suggestion that NKF should be restricted to expert advanced endoscopists likely limits widespread use.”

To determine whether NKF is a suitable technique for less experienced endoscopists, the investigators conducted the present single-center, prospective randomized controlled trial at Thomas Jefferson University Hospital in Philadelphia.

Adults undergoing ERCP for biliary indications were randomly assigned in a 1:1 ratio to undergo primary cannulation via NKF or standard cannulation. Patients with prior sphincterotomy, ampullectomy, or unfavorable anatomy were excluded.

A total of 186 patients were randomized, with 137 ultimately included in the per-protocol analysis after exclusions for anatomic factors. Most procedures (72.3%) were performed by advanced endoscopy trainees under direct supervision, 26 procedures (19.0%) were performed by attending endoscopists without substantive prior NKF experience, and 12 (8.8%) by an attending endoscopist with NKF expertise.

“It is important to note that the majority of procedures performed in the context of this study were performed by an advanced endoscopy trainee with no NKF experience or an attending advanced endoscopist with minimal NKF experience,” the investigators wrote.

All patients received prophylactic rectal indomethacin, and cannulation attempts were capped at 20 minutes before crossover to another technique was permitted.

The primary endpoint was incidence of post-ERCP pancreatitis. Secondary endpoints included successful biliary access, time to access, and rates of bleeding and perforation.

Post-ERCP pancreatitis occurred at similar rate across groups: 6 cases (8.2%) in the standard cannulation arm and 5 cases (7.8%) in the NKF arm (P = .93). Rates of bleeding and perforation were also similar for both techniques.

Within the initial 20-minute window, biliary access rates were comparable between groups, at 75.3% and 82.2% for standard cannulation and NKF, respectively (P = .89). Allowing additional attempts or crossover, overall success rose to 100% in both arms.

Mean time to access was longer with NKF, averaging 380 seconds compared with 268 seconds for standard cannulation (P less than .05). 

“NKF was essentially equivalent to standard cannulation in many aspects,” the investigators wrote, calling the two techniques “complementary.”

They also suggested that the relative equivalence between techniques “carries more weight” after considering the low level of NKF experience among participating endoscopists.

“Overall, our data support teaching advanced endoscopy trainees NKF as a primary method of biliary access in patients with favorable anatomy,” the investigators concluded.

The investigators disclosed relationships with Medtronic, Boston Scientific, and Olympus.
 

Needle-knife fistulotomy (NKF) is a safe and effective technique for primary biliary access during endoscopic retrograde cholangiopancreatography (ERCP), even among trainee advanced endoscopists, based on results of a randomized trial.

Across procedures conducted predominantly by trainees, safety outcomes were similar between NKF and standard cannulation, and all patients were successfully cannulated, suggesting this is a broadly accessible technique, reported lead author Aleksey Novikov, MD, of the University of Florida College of Medicine, Gainesville, and colleagues, reported.

Writing in Techniques and Innovations in Gastrointestinal Endoscopy, the investigators noted that standard cannulation fails in 5-20% of cases, which has led to development of various alternative techniques, including NKF. To perform the technique, the endoscopist makes a small incision in the intraduodenal biliary segment 3-6mm above the papillary orifice, with cephalad extension until bili-ary access is achieved.

To date, four prospective studies have evaluated NKF in the hands of expert advanced endoscopists. 

“These studies showed that NKF is a safe and useful technique that significantly reduces the risk of PEP in the hands of expert advanced endoscopists,” the investigators wrote. ‘The suggestion that NKF should be restricted to expert advanced endoscopists likely limits widespread use.”

To determine whether NKF is a suitable technique for less experienced endoscopists, the investigators conducted the present single-center, prospective randomized controlled trial at Thomas Jefferson University Hospital in Philadelphia.

Adults undergoing ERCP for biliary indications were randomly assigned in a 1:1 ratio to undergo primary cannulation via NKF or standard cannulation. Patients with prior sphincterotomy, ampullectomy, or unfavorable anatomy were excluded.

A total of 186 patients were randomized, with 137 ultimately included in the per-protocol analysis after exclusions for anatomic factors. Most procedures (72.3%) were performed by advanced endoscopy trainees under direct supervision, 26 procedures (19.0%) were performed by attending endoscopists without substantive prior NKF experience, and 12 (8.8%) by an attending endoscopist with NKF expertise.

“It is important to note that the majority of procedures performed in the context of this study were performed by an advanced endoscopy trainee with no NKF experience or an attending advanced endoscopist with minimal NKF experience,” the investigators wrote.

All patients received prophylactic rectal indomethacin, and cannulation attempts were capped at 20 minutes before crossover to another technique was permitted.

The primary endpoint was incidence of post-ERCP pancreatitis. Secondary endpoints included successful biliary access, time to access, and rates of bleeding and perforation.

Post-ERCP pancreatitis occurred at similar rate across groups: 6 cases (8.2%) in the standard cannulation arm and 5 cases (7.8%) in the NKF arm (P = .93). Rates of bleeding and perforation were also similar for both techniques.

Within the initial 20-minute window, biliary access rates were comparable between groups, at 75.3% and 82.2% for standard cannulation and NKF, respectively (P = .89). Allowing additional attempts or crossover, overall success rose to 100% in both arms.

Mean time to access was longer with NKF, averaging 380 seconds compared with 268 seconds for standard cannulation (P less than .05). 

“NKF was essentially equivalent to standard cannulation in many aspects,” the investigators wrote, calling the two techniques “complementary.”

They also suggested that the relative equivalence between techniques “carries more weight” after considering the low level of NKF experience among participating endoscopists.

“Overall, our data support teaching advanced endoscopy trainees NKF as a primary method of biliary access in patients with favorable anatomy,” the investigators concluded.

The investigators disclosed relationships with Medtronic, Boston Scientific, and Olympus.
 

New pharmacologic options approved by the FDA are set to alter the treatment landscape of metabolic dysfunction-associated steatotic liver disease (MASLD), according to the authors of clinical reviews who offered guidance on the pros and cons of resmetirom and semaglutide.

MASLD has become one of the most common causes of chronic liver disease due to the increased prevalence of diabetes, obesity, and other metabolic disorders, Joanne Lin, DO, an internist in the Division of Gastroenterology and Hepatology at the University of California, San Francisco, and colleagues wrote, in a review published in the Journal of Clinical Gastroenterology.

Its complexity makes MASLD challenging to manage. Metabolic, genetic, and environmental factors are involved in the disease, so patients require multidisciplinary and individualized care, Lin told GI & Hepatology News.

Weight loss, dietary changes, and exercise had long been the only treatment approach clinicians could offer patients. But the approval of two drugs — the thyroid hormone receptor-beta agonist resmetirom and the GLP-1 receptor agonist (RA) semaglutide — for patients whose MASLD has advanced to metabolic dysfunction-associated steatohepatitis (MASH) gives physicians new options for patients with severe disease.

In the review, published online before the official approval of semaglutide, Lin and colleagues proposed an algorithm to guide clinicians in choosing a pharmacological therapy for MASLD. “Resmetirom should be primarily used to reverse fibrosis for patients with MASLD and F2-F3 stages, while GLP-1 RAs are beneficial in managing metabolic comorbidities and weight loss in patients with MASLD,” the researchers concluded.

 

GLP-1 Power and Potential

In August 2025, the FDA approved semaglutide for MASH and cited evidence from the ESSENCE trial in its decision.

The ESSENCE study, published in The New England Journal of Medicine, showed significantly higher rates of resolution of steatohepatitis without worsening of fibrosis and reduction in liver fibrosis without worsening steatohepatitis in patients with MASH and moderate or advanced liver fibrosis who received 2.4 mg of once-weekly semaglutide compared with patients who received placebo.

The most common adverse events reported with GLP-1 RAs are gastrointestinal-related, including nausea, diarrhea, vomiting, and constipation, and are mainly mild-to-moderate and dose dependent, Lin and colleagues noted in their review.

GLP-1s have some limitations, Lin said. “GLP-1s are great for weight loss and metabolic risk reduction, but studies are still ongoing to determine their effect on liver histology and reversing fibrosis/cirrhosis,” she said. Some patients seeking these medications also have trouble obtaining them because of their popularity for weight loss, she noted.

 

Resmetirom Shows Success

Resmetirom has demonstrated ability to target hepatocytes and increase the hepatic metabolism of lipids, Lin and colleagues wrote in their review.

Several trials have examined resmetirom as a treatment for MASH, notably the landmark MAESTRO-NASH study , a randomized, placebo-controlled trial of nearly 1000 adults with biopsy-confirmed MASH and stage F2 or F3 fibrosis, which was the basis for the FDA’s approval of the drug in 2024. In the study, 25.9% of the patients treated with 80 mg of resmetirom and 29.9% treated with 100 mg resmetirom achieved MASH resolution with no increase in fibrosis compared with 9.7% of patients treated with placebo. In addition, 24.2% of the patients in the 80-mg resmetirom group and 25.9% of those in the 100-mg resmetirom group achieved fibrosis improvement by at least one stage without worsening of MASLD activity scores compared with 14.2% of patients treated with placebo.

The most common reported side effects from resmetirom are diarrhea or constipation, nausea or vomiting, and abdominal pain.

“The limitations of resmetirom include the absence of validated predictors for individual patient response, and no societal guidelines are available to determine when to stop the medication if ineffective,” Lin told GI & Hepatology News. In addition, resmetirom is currently only recommended for a subset of patients with F2-F3 fibrosis, based on the existing trial, she said.

Other limitations include its high cost, which restricts access to the drug for some patients, and lack of long-term safety and efficacy data, Lin added.

 

Weighing the Options

Comparing the emerging agents in the context of MASLD/MASH is important to help clinicians understand how different patient populations respond and guide evidence-based treatment decisions, said Hazem Ayesh, MD, an endocrinologist at Deaconess Health System, Evansville, Indiana, in an interview.

“The choice of therapy should be individualized based on comorbidities,” said Ayesh, the lead author of a 2024 review published in Biomedicines that compared resmetirom, GLP-1 agonists, and fibroblast growth factor 21 analogs.

“For example, a GLP-1 receptor agonist may be more appropriate for patients with coexisting diabetes or obesity, while resmetirom may be better suited for patients with more advanced liver disease or minimal metabolic comorbidities,” he said.

GLP-1 RAs, such as semaglutide, offer benefits for diabetes, obesity, and metabolic dysfunction in patients with MASLD/MASH and may be more accessible and cost effective, Ayesh told GI & Hepatology News. However, some patients may experience gastrointestinal side effects or be unable to tolerate GLP-1 RAs, he noted.

By contrast, resmetirom may be preferable for patients with low BMI, advanced fibrosis, or an inability to tolerate GLP-1s, as resmetirom directly targets hepatic pathways involved in MASLD/MASH progression, Ayesh said.

 

Next Steps to Inform Practice

“More research is needed to validate noninvasive biomarkers to monitor response to these medications, determine predictors of efficacy, and evaluate the additive effects, safety, and drug-drug interactions of combination therapy,” Lin said.

Studies are needed to determine both medications’ effects on patients with advanced fibrosis/cirrhosis and special populations, such as individuals with advanced renal disease or posttransplant patients, she added. More studies are expected to inform clinical practice and proper guidelines for the treatment of MASLD, as has been the case with chronic diseases such as hypertension and diabetes, Lin said.

Long-term safety and efficacy data are critical, as most trials of the newly approved medications have had relatively short follow-up periods of approximately 1 year, Ayesh said. “We need real-world evidence and longitudinal studies spanning 3-5 years to confirm sustained efficacy and safety,” he said. Research on cost effectiveness and health-system impacts will be essential to guide policy and ensure equitable access to the medications, he added.

The study by Lin and colleagues received no outside funding. The researchers had no financial conflicts to disclose. Ayesh had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

New pharmacologic options approved by the FDA are set to alter the treatment landscape of metabolic dysfunction-associated steatotic liver disease (MASLD), according to the authors of clinical reviews who offered guidance on the pros and cons of resmetirom and semaglutide.

MASLD has become one of the most common causes of chronic liver disease due to the increased prevalence of diabetes, obesity, and other metabolic disorders, Joanne Lin, DO, an internist in the Division of Gastroenterology and Hepatology at the University of California, San Francisco, and colleagues wrote, in a review published in the Journal of Clinical Gastroenterology.

Its complexity makes MASLD challenging to manage. Metabolic, genetic, and environmental factors are involved in the disease, so patients require multidisciplinary and individualized care, Lin told GI & Hepatology News.

Weight loss, dietary changes, and exercise had long been the only treatment approach clinicians could offer patients. But the approval of two drugs — the thyroid hormone receptor-beta agonist resmetirom and the GLP-1 receptor agonist (RA) semaglutide — for patients whose MASLD has advanced to metabolic dysfunction-associated steatohepatitis (MASH) gives physicians new options for patients with severe disease.

In the review, published online before the official approval of semaglutide, Lin and colleagues proposed an algorithm to guide clinicians in choosing a pharmacological therapy for MASLD. “Resmetirom should be primarily used to reverse fibrosis for patients with MASLD and F2-F3 stages, while GLP-1 RAs are beneficial in managing metabolic comorbidities and weight loss in patients with MASLD,” the researchers concluded.

 

GLP-1 Power and Potential

In August 2025, the FDA approved semaglutide for MASH and cited evidence from the ESSENCE trial in its decision.

The ESSENCE study, published in The New England Journal of Medicine, showed significantly higher rates of resolution of steatohepatitis without worsening of fibrosis and reduction in liver fibrosis without worsening steatohepatitis in patients with MASH and moderate or advanced liver fibrosis who received 2.4 mg of once-weekly semaglutide compared with patients who received placebo.

The most common adverse events reported with GLP-1 RAs are gastrointestinal-related, including nausea, diarrhea, vomiting, and constipation, and are mainly mild-to-moderate and dose dependent, Lin and colleagues noted in their review.

GLP-1s have some limitations, Lin said. “GLP-1s are great for weight loss and metabolic risk reduction, but studies are still ongoing to determine their effect on liver histology and reversing fibrosis/cirrhosis,” she said. Some patients seeking these medications also have trouble obtaining them because of their popularity for weight loss, she noted.

 

Resmetirom Shows Success

Resmetirom has demonstrated ability to target hepatocytes and increase the hepatic metabolism of lipids, Lin and colleagues wrote in their review.

Several trials have examined resmetirom as a treatment for MASH, notably the landmark MAESTRO-NASH study , a randomized, placebo-controlled trial of nearly 1000 adults with biopsy-confirmed MASH and stage F2 or F3 fibrosis, which was the basis for the FDA’s approval of the drug in 2024. In the study, 25.9% of the patients treated with 80 mg of resmetirom and 29.9% treated with 100 mg resmetirom achieved MASH resolution with no increase in fibrosis compared with 9.7% of patients treated with placebo. In addition, 24.2% of the patients in the 80-mg resmetirom group and 25.9% of those in the 100-mg resmetirom group achieved fibrosis improvement by at least one stage without worsening of MASLD activity scores compared with 14.2% of patients treated with placebo.

The most common reported side effects from resmetirom are diarrhea or constipation, nausea or vomiting, and abdominal pain.

“The limitations of resmetirom include the absence of validated predictors for individual patient response, and no societal guidelines are available to determine when to stop the medication if ineffective,” Lin told GI & Hepatology News. In addition, resmetirom is currently only recommended for a subset of patients with F2-F3 fibrosis, based on the existing trial, she said.

Other limitations include its high cost, which restricts access to the drug for some patients, and lack of long-term safety and efficacy data, Lin added.

 

Weighing the Options

Comparing the emerging agents in the context of MASLD/MASH is important to help clinicians understand how different patient populations respond and guide evidence-based treatment decisions, said Hazem Ayesh, MD, an endocrinologist at Deaconess Health System, Evansville, Indiana, in an interview.

“The choice of therapy should be individualized based on comorbidities,” said Ayesh, the lead author of a 2024 review published in Biomedicines that compared resmetirom, GLP-1 agonists, and fibroblast growth factor 21 analogs.

“For example, a GLP-1 receptor agonist may be more appropriate for patients with coexisting diabetes or obesity, while resmetirom may be better suited for patients with more advanced liver disease or minimal metabolic comorbidities,” he said.

GLP-1 RAs, such as semaglutide, offer benefits for diabetes, obesity, and metabolic dysfunction in patients with MASLD/MASH and may be more accessible and cost effective, Ayesh told GI & Hepatology News. However, some patients may experience gastrointestinal side effects or be unable to tolerate GLP-1 RAs, he noted.

By contrast, resmetirom may be preferable for patients with low BMI, advanced fibrosis, or an inability to tolerate GLP-1s, as resmetirom directly targets hepatic pathways involved in MASLD/MASH progression, Ayesh said.

 

Next Steps to Inform Practice

“More research is needed to validate noninvasive biomarkers to monitor response to these medications, determine predictors of efficacy, and evaluate the additive effects, safety, and drug-drug interactions of combination therapy,” Lin said.

Studies are needed to determine both medications’ effects on patients with advanced fibrosis/cirrhosis and special populations, such as individuals with advanced renal disease or posttransplant patients, she added. More studies are expected to inform clinical practice and proper guidelines for the treatment of MASLD, as has been the case with chronic diseases such as hypertension and diabetes, Lin said.

Long-term safety and efficacy data are critical, as most trials of the newly approved medications have had relatively short follow-up periods of approximately 1 year, Ayesh said. “We need real-world evidence and longitudinal studies spanning 3-5 years to confirm sustained efficacy and safety,” he said. Research on cost effectiveness and health-system impacts will be essential to guide policy and ensure equitable access to the medications, he added.

The study by Lin and colleagues received no outside funding. The researchers had no financial conflicts to disclose. Ayesh had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

New pharmacologic options approved by the FDA are set to alter the treatment landscape of metabolic dysfunction-associated steatotic liver disease (MASLD), according to the authors of clinical reviews who offered guidance on the pros and cons of resmetirom and semaglutide.

MASLD has become one of the most common causes of chronic liver disease due to the increased prevalence of diabetes, obesity, and other metabolic disorders, Joanne Lin, DO, an internist in the Division of Gastroenterology and Hepatology at the University of California, San Francisco, and colleagues wrote, in a review published in the Journal of Clinical Gastroenterology.

Its complexity makes MASLD challenging to manage. Metabolic, genetic, and environmental factors are involved in the disease, so patients require multidisciplinary and individualized care, Lin told GI & Hepatology News.

Weight loss, dietary changes, and exercise had long been the only treatment approach clinicians could offer patients. But the approval of two drugs — the thyroid hormone receptor-beta agonist resmetirom and the GLP-1 receptor agonist (RA) semaglutide — for patients whose MASLD has advanced to metabolic dysfunction-associated steatohepatitis (MASH) gives physicians new options for patients with severe disease.

In the review, published online before the official approval of semaglutide, Lin and colleagues proposed an algorithm to guide clinicians in choosing a pharmacological therapy for MASLD. “Resmetirom should be primarily used to reverse fibrosis for patients with MASLD and F2-F3 stages, while GLP-1 RAs are beneficial in managing metabolic comorbidities and weight loss in patients with MASLD,” the researchers concluded.

 

GLP-1 Power and Potential

In August 2025, the FDA approved semaglutide for MASH and cited evidence from the ESSENCE trial in its decision.

The ESSENCE study, published in The New England Journal of Medicine, showed significantly higher rates of resolution of steatohepatitis without worsening of fibrosis and reduction in liver fibrosis without worsening steatohepatitis in patients with MASH and moderate or advanced liver fibrosis who received 2.4 mg of once-weekly semaglutide compared with patients who received placebo.

The most common adverse events reported with GLP-1 RAs are gastrointestinal-related, including nausea, diarrhea, vomiting, and constipation, and are mainly mild-to-moderate and dose dependent, Lin and colleagues noted in their review.

GLP-1s have some limitations, Lin said. “GLP-1s are great for weight loss and metabolic risk reduction, but studies are still ongoing to determine their effect on liver histology and reversing fibrosis/cirrhosis,” she said. Some patients seeking these medications also have trouble obtaining them because of their popularity for weight loss, she noted.

 

Resmetirom Shows Success

Resmetirom has demonstrated ability to target hepatocytes and increase the hepatic metabolism of lipids, Lin and colleagues wrote in their review.

Several trials have examined resmetirom as a treatment for MASH, notably the landmark MAESTRO-NASH study , a randomized, placebo-controlled trial of nearly 1000 adults with biopsy-confirmed MASH and stage F2 or F3 fibrosis, which was the basis for the FDA’s approval of the drug in 2024. In the study, 25.9% of the patients treated with 80 mg of resmetirom and 29.9% treated with 100 mg resmetirom achieved MASH resolution with no increase in fibrosis compared with 9.7% of patients treated with placebo. In addition, 24.2% of the patients in the 80-mg resmetirom group and 25.9% of those in the 100-mg resmetirom group achieved fibrosis improvement by at least one stage without worsening of MASLD activity scores compared with 14.2% of patients treated with placebo.

The most common reported side effects from resmetirom are diarrhea or constipation, nausea or vomiting, and abdominal pain.

“The limitations of resmetirom include the absence of validated predictors for individual patient response, and no societal guidelines are available to determine when to stop the medication if ineffective,” Lin told GI & Hepatology News. In addition, resmetirom is currently only recommended for a subset of patients with F2-F3 fibrosis, based on the existing trial, she said.

Other limitations include its high cost, which restricts access to the drug for some patients, and lack of long-term safety and efficacy data, Lin added.

 

Weighing the Options

Comparing the emerging agents in the context of MASLD/MASH is important to help clinicians understand how different patient populations respond and guide evidence-based treatment decisions, said Hazem Ayesh, MD, an endocrinologist at Deaconess Health System, Evansville, Indiana, in an interview.

“The choice of therapy should be individualized based on comorbidities,” said Ayesh, the lead author of a 2024 review published in Biomedicines that compared resmetirom, GLP-1 agonists, and fibroblast growth factor 21 analogs.

“For example, a GLP-1 receptor agonist may be more appropriate for patients with coexisting diabetes or obesity, while resmetirom may be better suited for patients with more advanced liver disease or minimal metabolic comorbidities,” he said.

GLP-1 RAs, such as semaglutide, offer benefits for diabetes, obesity, and metabolic dysfunction in patients with MASLD/MASH and may be more accessible and cost effective, Ayesh told GI & Hepatology News. However, some patients may experience gastrointestinal side effects or be unable to tolerate GLP-1 RAs, he noted.

By contrast, resmetirom may be preferable for patients with low BMI, advanced fibrosis, or an inability to tolerate GLP-1s, as resmetirom directly targets hepatic pathways involved in MASLD/MASH progression, Ayesh said.

 

Next Steps to Inform Practice

“More research is needed to validate noninvasive biomarkers to monitor response to these medications, determine predictors of efficacy, and evaluate the additive effects, safety, and drug-drug interactions of combination therapy,” Lin said.

Studies are needed to determine both medications’ effects on patients with advanced fibrosis/cirrhosis and special populations, such as individuals with advanced renal disease or posttransplant patients, she added. More studies are expected to inform clinical practice and proper guidelines for the treatment of MASLD, as has been the case with chronic diseases such as hypertension and diabetes, Lin said.

Long-term safety and efficacy data are critical, as most trials of the newly approved medications have had relatively short follow-up periods of approximately 1 year, Ayesh said. “We need real-world evidence and longitudinal studies spanning 3-5 years to confirm sustained efficacy and safety,” he said. Research on cost effectiveness and health-system impacts will be essential to guide policy and ensure equitable access to the medications, he added.

The study by Lin and colleagues received no outside funding. The researchers had no financial conflicts to disclose. Ayesh had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

PHOENIX — Users of e-cigarettes had increased odds of peptic ulcer disease (PUD) compared to those who have never used them, a cross-sectional study found.

The study also found increased risk of PUD among former users of e-cigarettes, reported Albert E. Ohrin, MBChB, MHS, of Ascension Saint Agnes Hospital, Baltimore, Maryland, who presented the study here at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting. 

While cigarette smoking is a known risk factor for PUD, there was little in the literature investigating whether vaping has a similar risk profile, said Ohrin, a first-year internal medicine resident. He told GI & Hepatology News he found e-cigarette users on Reddit discussing worsening PUD and decided to investigate further, especially since vaping is so popular among young people.

E-cigarettes are the most-used tobacco product among middle and high school students. The National Youth Tobacco Survey in the US reported that 1.6 million students (5.9%) vaped in 2024, a decline from 7.7% in 2023. And the number of adults using e-cigarettes is increasing, according to the US CDC. In 2023, 6.5% of adults over age 18 used e-cigarettes, up from 3.7% in 2020. 

Ohrin and colleagues conducted a cross-sectional analysis of adults enrolled in the National Institutes of Health All of Us Research Program. Participants self-reported e-cigarette use. PUD was defined using validated electronic health record diagnosis codes.

Among the 371,398 participants, 29,373 (8%) reported using e-cigarettes, including 21,277 current users and 8096 former users. E-cigarette users were significantly younger (mean age 45.3 vs 59.3 years; P < .001), more likely to be female, and more likely to report lower education and income (P < .001). 

Current e-cigarette users had 27% higher odds of PUD (adjusted odds ratio [aOR], 1.27; 95% CI, 1.12-1.45), compared to never-users. This was greater than the risk with traditional combustible cigarettes (aOR, 1.19) that was seen in the study.

Former e-cig users had 13% higher odds (aOR, 1.13; 95% CI, 1.04-1.24) compared to never-users, and any e-cigarette use was associated with higher odds of PUD (aOR, 1.17; 95% CI, 1.09-1.26) compared to never-use. 

Use of non-steroidal anti-inflammatories (aOR, 2.15) and having gastroesophageal reflux disease (aOR, 4.45) presented the most significant PUD risk.

Ohrin said he and his colleagues were surprised to see that people who had stopped using e-cigarettes still had higher odds of PUD, although he pointed out that the researchers did not know the frequency of use or how long users had stopped. 

“Now that we know there’s an association, we are going to do more studies on e-cigarettes” to see what the potential harms are, especially on the gastrointestinal system, he told GI & Hepatology News. 

“One of the things we are looking to elicit is — is there a dose response?” he said, noting it would take a prospective trial to determine that effect.

 

‘Opens a Door’ to Looking at the GI System

Laura Crotty Alexander, MD, a professor of medicine and associate division chief of pulmonary, critical care, sleep medicine, and physiology at the University of California, San Diego, said she found the study novel and interesting. 

“It’s the first I’ve heard of an association between e-cigarette vaping and peptic ulcer disease,” said Crotty Alexander, who has studied the health effects of e-cigarettes for a decade. 

Previous studies have shown that nicotine itself can drive an increase in gastric acid production and decrease healing, which can contribute to PUD, Crotty Alexander told GI & Hepatology News. With combustible cigarettes, it is thought that “the larger drivers of that association are the other things in tobacco smoke, such as tar and carbon monoxide and a million other horrible chemicals,” she said. 

Crotty Alexander and her colleagues have conducted studies in vitro and in mice that show that e-cigarette aerosols are irritants and cause oxidative stress, which can drive PUD. 

While many studies have shown vaping impacts various organs, Ohrin’s study “opens a door” to start looking at the gastrointestinal system, she said. 

The study is also a signal to clinicians to “take an accurate inhalant history,” which means asking about vaping, she added.

Ohrin and Crotty Alexander reported no conflicts.

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

PHOENIX — Users of e-cigarettes had increased odds of peptic ulcer disease (PUD) compared to those who have never used them, a cross-sectional study found.

The study also found increased risk of PUD among former users of e-cigarettes, reported Albert E. Ohrin, MBChB, MHS, of Ascension Saint Agnes Hospital, Baltimore, Maryland, who presented the study here at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting. 

While cigarette smoking is a known risk factor for PUD, there was little in the literature investigating whether vaping has a similar risk profile, said Ohrin, a first-year internal medicine resident. He told GI & Hepatology News he found e-cigarette users on Reddit discussing worsening PUD and decided to investigate further, especially since vaping is so popular among young people.

E-cigarettes are the most-used tobacco product among middle and high school students. The National Youth Tobacco Survey in the US reported that 1.6 million students (5.9%) vaped in 2024, a decline from 7.7% in 2023. And the number of adults using e-cigarettes is increasing, according to the US CDC. In 2023, 6.5% of adults over age 18 used e-cigarettes, up from 3.7% in 2020. 

Ohrin and colleagues conducted a cross-sectional analysis of adults enrolled in the National Institutes of Health All of Us Research Program. Participants self-reported e-cigarette use. PUD was defined using validated electronic health record diagnosis codes.

Among the 371,398 participants, 29,373 (8%) reported using e-cigarettes, including 21,277 current users and 8096 former users. E-cigarette users were significantly younger (mean age 45.3 vs 59.3 years; P < .001), more likely to be female, and more likely to report lower education and income (P < .001). 

Current e-cigarette users had 27% higher odds of PUD (adjusted odds ratio [aOR], 1.27; 95% CI, 1.12-1.45), compared to never-users. This was greater than the risk with traditional combustible cigarettes (aOR, 1.19) that was seen in the study.

Former e-cig users had 13% higher odds (aOR, 1.13; 95% CI, 1.04-1.24) compared to never-users, and any e-cigarette use was associated with higher odds of PUD (aOR, 1.17; 95% CI, 1.09-1.26) compared to never-use. 

Use of non-steroidal anti-inflammatories (aOR, 2.15) and having gastroesophageal reflux disease (aOR, 4.45) presented the most significant PUD risk.

Ohrin said he and his colleagues were surprised to see that people who had stopped using e-cigarettes still had higher odds of PUD, although he pointed out that the researchers did not know the frequency of use or how long users had stopped. 

“Now that we know there’s an association, we are going to do more studies on e-cigarettes” to see what the potential harms are, especially on the gastrointestinal system, he told GI & Hepatology News. 

“One of the things we are looking to elicit is — is there a dose response?” he said, noting it would take a prospective trial to determine that effect.

 

‘Opens a Door’ to Looking at the GI System

Laura Crotty Alexander, MD, a professor of medicine and associate division chief of pulmonary, critical care, sleep medicine, and physiology at the University of California, San Diego, said she found the study novel and interesting. 

“It’s the first I’ve heard of an association between e-cigarette vaping and peptic ulcer disease,” said Crotty Alexander, who has studied the health effects of e-cigarettes for a decade. 

Previous studies have shown that nicotine itself can drive an increase in gastric acid production and decrease healing, which can contribute to PUD, Crotty Alexander told GI & Hepatology News. With combustible cigarettes, it is thought that “the larger drivers of that association are the other things in tobacco smoke, such as tar and carbon monoxide and a million other horrible chemicals,” she said. 

Crotty Alexander and her colleagues have conducted studies in vitro and in mice that show that e-cigarette aerosols are irritants and cause oxidative stress, which can drive PUD. 

While many studies have shown vaping impacts various organs, Ohrin’s study “opens a door” to start looking at the gastrointestinal system, she said. 

The study is also a signal to clinicians to “take an accurate inhalant history,” which means asking about vaping, she added.

Ohrin and Crotty Alexander reported no conflicts.

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

PHOENIX — Users of e-cigarettes had increased odds of peptic ulcer disease (PUD) compared to those who have never used them, a cross-sectional study found.

The study also found increased risk of PUD among former users of e-cigarettes, reported Albert E. Ohrin, MBChB, MHS, of Ascension Saint Agnes Hospital, Baltimore, Maryland, who presented the study here at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting. 

While cigarette smoking is a known risk factor for PUD, there was little in the literature investigating whether vaping has a similar risk profile, said Ohrin, a first-year internal medicine resident. He told GI & Hepatology News he found e-cigarette users on Reddit discussing worsening PUD and decided to investigate further, especially since vaping is so popular among young people.

E-cigarettes are the most-used tobacco product among middle and high school students. The National Youth Tobacco Survey in the US reported that 1.6 million students (5.9%) vaped in 2024, a decline from 7.7% in 2023. And the number of adults using e-cigarettes is increasing, according to the US CDC. In 2023, 6.5% of adults over age 18 used e-cigarettes, up from 3.7% in 2020. 

Ohrin and colleagues conducted a cross-sectional analysis of adults enrolled in the National Institutes of Health All of Us Research Program. Participants self-reported e-cigarette use. PUD was defined using validated electronic health record diagnosis codes.

Among the 371,398 participants, 29,373 (8%) reported using e-cigarettes, including 21,277 current users and 8096 former users. E-cigarette users were significantly younger (mean age 45.3 vs 59.3 years; P < .001), more likely to be female, and more likely to report lower education and income (P < .001). 

Current e-cigarette users had 27% higher odds of PUD (adjusted odds ratio [aOR], 1.27; 95% CI, 1.12-1.45), compared to never-users. This was greater than the risk with traditional combustible cigarettes (aOR, 1.19) that was seen in the study.

Former e-cig users had 13% higher odds (aOR, 1.13; 95% CI, 1.04-1.24) compared to never-users, and any e-cigarette use was associated with higher odds of PUD (aOR, 1.17; 95% CI, 1.09-1.26) compared to never-use. 

Use of non-steroidal anti-inflammatories (aOR, 2.15) and having gastroesophageal reflux disease (aOR, 4.45) presented the most significant PUD risk.

Ohrin said he and his colleagues were surprised to see that people who had stopped using e-cigarettes still had higher odds of PUD, although he pointed out that the researchers did not know the frequency of use or how long users had stopped. 

“Now that we know there’s an association, we are going to do more studies on e-cigarettes” to see what the potential harms are, especially on the gastrointestinal system, he told GI & Hepatology News. 

“One of the things we are looking to elicit is — is there a dose response?” he said, noting it would take a prospective trial to determine that effect.

 

‘Opens a Door’ to Looking at the GI System

Laura Crotty Alexander, MD, a professor of medicine and associate division chief of pulmonary, critical care, sleep medicine, and physiology at the University of California, San Diego, said she found the study novel and interesting. 

“It’s the first I’ve heard of an association between e-cigarette vaping and peptic ulcer disease,” said Crotty Alexander, who has studied the health effects of e-cigarettes for a decade. 

Previous studies have shown that nicotine itself can drive an increase in gastric acid production and decrease healing, which can contribute to PUD, Crotty Alexander told GI & Hepatology News. With combustible cigarettes, it is thought that “the larger drivers of that association are the other things in tobacco smoke, such as tar and carbon monoxide and a million other horrible chemicals,” she said. 

Crotty Alexander and her colleagues have conducted studies in vitro and in mice that show that e-cigarette aerosols are irritants and cause oxidative stress, which can drive PUD. 

While many studies have shown vaping impacts various organs, Ohrin’s study “opens a door” to start looking at the gastrointestinal system, she said. 

The study is also a signal to clinicians to “take an accurate inhalant history,” which means asking about vaping, she added.

Ohrin and Crotty Alexander reported no conflicts.

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

PHOENIX -- Patients with or without polyp removal in an index colonoscopy commonly receive follow-up surveillance with a fecal immunochemical test (FIT), yet many of these patients do not receive a recommended colonoscopy after a positive FIT.

"In this large US study, we found interval FITs are frequently performed in patients with and without prior polypectomy," said first author Natalie J. Wilson, MD, of the University of Minnesota in Minneapolis, while presenting the findings this week at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting.

"These findings reinforce the importance of colonoscopy following positive interval FIT, given the high risk of advanced neoplasia and colorectal cancer, regardless of polypectomy history," Wilson said.

Guideline recommendations stress the need for follow-up surveillance with a colonoscopy, particularly in patients who have had a prior polypectomy, due to the higher risk.

Reasons patients may instead turn to FIT include cost or other factors.

To determine just how often that happens, how having a previous polypectomy affects FIT results, and how adherent patients are to follow up if a FIT result is positive, Wilson and her colleagues evaluated data from nearly 4.8 million individuals in the Veterans Health Administration Corporate Data Warehouse who underwent colonoscopy between 2000 and 2004.

Of the patients, 10.9% were found to have subsequently received interval FIT within 10 years of the index colonoscopy, and of those patients, nearly half (49.9%) had received a polypectomy at the index colonoscopy.

The average time from the colonoscopy/polypectomy to the interval FIT was 5.9 years (5.6 years in the polypectomy group vs 6.2 years in the nonpolypectomy group).

Among the FIT screenings, results were positive in 17.2% of postpolypectomy patients and 14.1% of patients who no prior polypectomy, indicating a history of polypectomy to be predictive of positive interval FIT (odds ratio [OR], 1.12; P < .0001).

Notably, while a follow-up colonoscopy is considered essential following a positive FIT result -- and having a previous polypectomy should add further emergency to the matter -- the study showed only 50.4% of those who had an earlier polypectomy went on to receive the recommended follow-up colonoscopy after a positive follow-up FIT, and the rate was 49.3% among those who had not received a polypectomy (P = .001).

For those who did receive a follow-up colonoscopy after a positive FIT, the duration of time to receiving the colonoscopy was longer among those who had a prior polypectomy, at 2.9 months compared with 2.5 months in the nonpolypectomy group (P < .001).

Colonoscopy results following a positive FIT showed higher rates of detections among patients who had prior polypectomies than among those with no prior polypectomy, including tubular adenomas (54.7% vs 45.8%), tubulovillous adenomas (5.6% vs 4.7%), adenomas with high-grade dysplasia (0.8% vs 0.7%), sessile serrated lesions (3.52% vs 2.4%), advanced colorectal neoplasia (9.2% vs 7.9%), and colorectal cancer (3.3% vs 3.0%).

However, a prior polypectomy was not independently predictive of colorectal cancer (OR, 0.96; P = .65) or advanced colorectal neoplasia (OR, 0.97; P = .57) in the postcolonoscopy interval FIT.

The findings underscore that "positive results carried a high risk of advanced neoplasia or cancer, irrespective or prior polypectomy history," Wilson said.

Commenting on the study, William D. Chey, MD, chief of the Division of Gastroenterology & Hepatology at the University of Michigan in Ann Arbor, Michigan, noted that the study "addresses one of the biggest challenges we face as a profession, which is making sure that patients who have a positive stool test get a colonoscopy."

He noted that the low rate of just 50% of recipients of positive FITs going on to receive a colonoscopy is consistent with what is observed in other trials.

"Other data suggest that the rate might even be significantly higher -- at 70% to 80%, depending upon the population and the test," Chey told Medscape Medical News.

Reasons for the failure to receive the follow-up testing range from income restrictions (due to the high cost of a colonoscopy, especially if not covered by insurance), education, speaking a foreign language, and other factors, he said.

The relatively high rates of colon cancers detected by FIT in the study, in those with and without a prior polypectomy, along with findings from other studies "should raise questions about whether there might be a role for FIT testing in addition to colonoscopy." However, much stronger evidence would be needed, Chey noted.

In the meantime, a key issue is "how do we do a better job of making sure that individuals who have a positive FIT test get a colonoscopy," he said.

"I think a lot of this is going to come down to how it's down at the primary care level."

Chey added that in that, and any other setting, "the main message that needs to get out to people who are undergoing stool-based screening is that the stool test is only the first part of the screening process, and if it's positive, a follow-up colonoscopy must be performed.

"Otherwise, the stool-based test is of no value."

Wilson had no disclosures to report. Chey's disclosures include consulting and/or other relationships with Ardelyx, Atmo, Biomerica, Commonwealth Diagnostics International, Corprata, Dieta, Evinature, Food Marble, Gemelli, Kiwi BioScience, Modify Health, Nestle, Phathom, Redhill, Salix/Valean, Takeda, and Vibrant.

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

PHOENIX -- Patients with or without polyp removal in an index colonoscopy commonly receive follow-up surveillance with a fecal immunochemical test (FIT), yet many of these patients do not receive a recommended colonoscopy after a positive FIT.

"In this large US study, we found interval FITs are frequently performed in patients with and without prior polypectomy," said first author Natalie J. Wilson, MD, of the University of Minnesota in Minneapolis, while presenting the findings this week at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting.

"These findings reinforce the importance of colonoscopy following positive interval FIT, given the high risk of advanced neoplasia and colorectal cancer, regardless of polypectomy history," Wilson said.

Guideline recommendations stress the need for follow-up surveillance with a colonoscopy, particularly in patients who have had a prior polypectomy, due to the higher risk.

Reasons patients may instead turn to FIT include cost or other factors.

To determine just how often that happens, how having a previous polypectomy affects FIT results, and how adherent patients are to follow up if a FIT result is positive, Wilson and her colleagues evaluated data from nearly 4.8 million individuals in the Veterans Health Administration Corporate Data Warehouse who underwent colonoscopy between 2000 and 2004.

Of the patients, 10.9% were found to have subsequently received interval FIT within 10 years of the index colonoscopy, and of those patients, nearly half (49.9%) had received a polypectomy at the index colonoscopy.

The average time from the colonoscopy/polypectomy to the interval FIT was 5.9 years (5.6 years in the polypectomy group vs 6.2 years in the nonpolypectomy group).

Among the FIT screenings, results were positive in 17.2% of postpolypectomy patients and 14.1% of patients who no prior polypectomy, indicating a history of polypectomy to be predictive of positive interval FIT (odds ratio [OR], 1.12; P < .0001).

Notably, while a follow-up colonoscopy is considered essential following a positive FIT result -- and having a previous polypectomy should add further emergency to the matter -- the study showed only 50.4% of those who had an earlier polypectomy went on to receive the recommended follow-up colonoscopy after a positive follow-up FIT, and the rate was 49.3% among those who had not received a polypectomy (P = .001).

For those who did receive a follow-up colonoscopy after a positive FIT, the duration of time to receiving the colonoscopy was longer among those who had a prior polypectomy, at 2.9 months compared with 2.5 months in the nonpolypectomy group (P < .001).

Colonoscopy results following a positive FIT showed higher rates of detections among patients who had prior polypectomies than among those with no prior polypectomy, including tubular adenomas (54.7% vs 45.8%), tubulovillous adenomas (5.6% vs 4.7%), adenomas with high-grade dysplasia (0.8% vs 0.7%), sessile serrated lesions (3.52% vs 2.4%), advanced colorectal neoplasia (9.2% vs 7.9%), and colorectal cancer (3.3% vs 3.0%).

However, a prior polypectomy was not independently predictive of colorectal cancer (OR, 0.96; P = .65) or advanced colorectal neoplasia (OR, 0.97; P = .57) in the postcolonoscopy interval FIT.

The findings underscore that "positive results carried a high risk of advanced neoplasia or cancer, irrespective or prior polypectomy history," Wilson said.

Commenting on the study, William D. Chey, MD, chief of the Division of Gastroenterology & Hepatology at the University of Michigan in Ann Arbor, Michigan, noted that the study "addresses one of the biggest challenges we face as a profession, which is making sure that patients who have a positive stool test get a colonoscopy."

He noted that the low rate of just 50% of recipients of positive FITs going on to receive a colonoscopy is consistent with what is observed in other trials.

"Other data suggest that the rate might even be significantly higher -- at 70% to 80%, depending upon the population and the test," Chey told Medscape Medical News.

Reasons for the failure to receive the follow-up testing range from income restrictions (due to the high cost of a colonoscopy, especially if not covered by insurance), education, speaking a foreign language, and other factors, he said.

The relatively high rates of colon cancers detected by FIT in the study, in those with and without a prior polypectomy, along with findings from other studies "should raise questions about whether there might be a role for FIT testing in addition to colonoscopy." However, much stronger evidence would be needed, Chey noted.

In the meantime, a key issue is "how do we do a better job of making sure that individuals who have a positive FIT test get a colonoscopy," he said.

"I think a lot of this is going to come down to how it's down at the primary care level."

Chey added that in that, and any other setting, "the main message that needs to get out to people who are undergoing stool-based screening is that the stool test is only the first part of the screening process, and if it's positive, a follow-up colonoscopy must be performed.

"Otherwise, the stool-based test is of no value."

Wilson had no disclosures to report. Chey's disclosures include consulting and/or other relationships with Ardelyx, Atmo, Biomerica, Commonwealth Diagnostics International, Corprata, Dieta, Evinature, Food Marble, Gemelli, Kiwi BioScience, Modify Health, Nestle, Phathom, Redhill, Salix/Valean, Takeda, and Vibrant.

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

PHOENIX -- Patients with or without polyp removal in an index colonoscopy commonly receive follow-up surveillance with a fecal immunochemical test (FIT), yet many of these patients do not receive a recommended colonoscopy after a positive FIT.

"In this large US study, we found interval FITs are frequently performed in patients with and without prior polypectomy," said first author Natalie J. Wilson, MD, of the University of Minnesota in Minneapolis, while presenting the findings this week at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting.

"These findings reinforce the importance of colonoscopy following positive interval FIT, given the high risk of advanced neoplasia and colorectal cancer, regardless of polypectomy history," Wilson said.

Guideline recommendations stress the need for follow-up surveillance with a colonoscopy, particularly in patients who have had a prior polypectomy, due to the higher risk.

Reasons patients may instead turn to FIT include cost or other factors.

To determine just how often that happens, how having a previous polypectomy affects FIT results, and how adherent patients are to follow up if a FIT result is positive, Wilson and her colleagues evaluated data from nearly 4.8 million individuals in the Veterans Health Administration Corporate Data Warehouse who underwent colonoscopy between 2000 and 2004.

Of the patients, 10.9% were found to have subsequently received interval FIT within 10 years of the index colonoscopy, and of those patients, nearly half (49.9%) had received a polypectomy at the index colonoscopy.

The average time from the colonoscopy/polypectomy to the interval FIT was 5.9 years (5.6 years in the polypectomy group vs 6.2 years in the nonpolypectomy group).

Among the FIT screenings, results were positive in 17.2% of postpolypectomy patients and 14.1% of patients who no prior polypectomy, indicating a history of polypectomy to be predictive of positive interval FIT (odds ratio [OR], 1.12; P < .0001).

Notably, while a follow-up colonoscopy is considered essential following a positive FIT result -- and having a previous polypectomy should add further emergency to the matter -- the study showed only 50.4% of those who had an earlier polypectomy went on to receive the recommended follow-up colonoscopy after a positive follow-up FIT, and the rate was 49.3% among those who had not received a polypectomy (P = .001).

For those who did receive a follow-up colonoscopy after a positive FIT, the duration of time to receiving the colonoscopy was longer among those who had a prior polypectomy, at 2.9 months compared with 2.5 months in the nonpolypectomy group (P < .001).

Colonoscopy results following a positive FIT showed higher rates of detections among patients who had prior polypectomies than among those with no prior polypectomy, including tubular adenomas (54.7% vs 45.8%), tubulovillous adenomas (5.6% vs 4.7%), adenomas with high-grade dysplasia (0.8% vs 0.7%), sessile serrated lesions (3.52% vs 2.4%), advanced colorectal neoplasia (9.2% vs 7.9%), and colorectal cancer (3.3% vs 3.0%).

However, a prior polypectomy was not independently predictive of colorectal cancer (OR, 0.96; P = .65) or advanced colorectal neoplasia (OR, 0.97; P = .57) in the postcolonoscopy interval FIT.

The findings underscore that "positive results carried a high risk of advanced neoplasia or cancer, irrespective or prior polypectomy history," Wilson said.

Commenting on the study, William D. Chey, MD, chief of the Division of Gastroenterology & Hepatology at the University of Michigan in Ann Arbor, Michigan, noted that the study "addresses one of the biggest challenges we face as a profession, which is making sure that patients who have a positive stool test get a colonoscopy."

He noted that the low rate of just 50% of recipients of positive FITs going on to receive a colonoscopy is consistent with what is observed in other trials.

"Other data suggest that the rate might even be significantly higher -- at 70% to 80%, depending upon the population and the test," Chey told Medscape Medical News.

Reasons for the failure to receive the follow-up testing range from income restrictions (due to the high cost of a colonoscopy, especially if not covered by insurance), education, speaking a foreign language, and other factors, he said.

The relatively high rates of colon cancers detected by FIT in the study, in those with and without a prior polypectomy, along with findings from other studies "should raise questions about whether there might be a role for FIT testing in addition to colonoscopy." However, much stronger evidence would be needed, Chey noted.

In the meantime, a key issue is "how do we do a better job of making sure that individuals who have a positive FIT test get a colonoscopy," he said.

"I think a lot of this is going to come down to how it's down at the primary care level."

Chey added that in that, and any other setting, "the main message that needs to get out to people who are undergoing stool-based screening is that the stool test is only the first part of the screening process, and if it's positive, a follow-up colonoscopy must be performed.

"Otherwise, the stool-based test is of no value."

Wilson had no disclosures to report. Chey's disclosures include consulting and/or other relationships with Ardelyx, Atmo, Biomerica, Commonwealth Diagnostics International, Corprata, Dieta, Evinature, Food Marble, Gemelli, Kiwi BioScience, Modify Health, Nestle, Phathom, Redhill, Salix/Valean, Takeda, and Vibrant.

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

It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.

Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.

"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."

Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.

Budget Cuts Reach Far and Wide

Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.

"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.

The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.

"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."

All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.

"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."

Foundations Take Emergency Measures

Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.

We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.

"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."

The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.

"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."

At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.

"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."

Some See Hope in Raised Voices

Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.

"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."

As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.

"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."

Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.

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

It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.

Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.

"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."

Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.

Budget Cuts Reach Far and Wide

Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.

"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.

The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.

"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."

All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.

"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."

Foundations Take Emergency Measures

Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.

We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.

"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."

The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.

"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."

At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.

"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."

Some See Hope in Raised Voices

Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.

"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."

As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.

"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."

Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.

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

It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.

Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.

"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."

Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.

Budget Cuts Reach Far and Wide

Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.

"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.

The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.

"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."

All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.

"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."

Foundations Take Emergency Measures

Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.

We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.

"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."

The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.

"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."

At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.

"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."

Some See Hope in Raised Voices

Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.

"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."

As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.

"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."

Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.

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

For Kelly, a retired Navy operations specialist, coping with depression and anxiety hindered her ability to enjoy everyday life. Then she elected to enter therapy, a decision she calls “transformative.”

“When I started doing therapy, it was like releasing the toxins, releasing the buildup of the fear or the rage or the overwhelming feelings of shame,” she says. “We can’t just hold on to it. Just telling the truth, it helps me every single day. It is so worth it.”

Kurt, an Army veteran, tried to power through his anxiety, depression, and survivor guilt. He didn’t have much faith in mental health therapy, thinking no one could relate to him. He was surprised, though, once he started treatment, how much his life improved. He now encourages other veterans to face their own mental health challenges, be it through virtual/mental health apps or in-person care.

“From getting help, every day of my life is better,” he says, “and I couldn’t be more grateful for it.”

Stories from Kelly and Kurt are 2 of 7 the US Department of Veterans Affairs (VA) highlighted during National Recovery Month, outlining how their lives were forever changed with the support of mental health care.

But for every Kelly and Kurt, there are thousands of individuals reluctant to seek mental health care. A analysis of 2019-2020 data from the National Health and Resilience in Veterans Study found that 924 (26%) of 4069 veterans met criteria for ≥ 1 psychological disorders, but only 12% reported engagement in mental health care. The researchers considered the role of protective psychosocial characteristics, such as grit (ie, “trait perseverance that extends to one’s decision or commitment to address mental health needs on one’s own; dispositional optimism; and purpose in life”). Veterans who reported mental dysfunction but scored highly on grit were less likely to be engaged in treatment. This pattern suggests higher levels of grit may reduce the likelihood of seeking treatment, “even in the presence of clinically meaningful distress.”

A 2004 study found only 23% to 40% of service members who screened positive for a mental disorder sought care. They often believed they would be seen as weak, or their unit leadership might treat them differently, and unit members would have less confidence in them. 

Given that military members and veterans are at increased risk of posttraumatic stress disorder (PTSD) in addition to mood, anxiety, and substance use disorders, any alternatives that increase their access to support and services are crucial. For those who aren’t disposed to office visits and group therapy, the answer may lie in mobile apps. 

In a recent randomized controlled trial, 201 veterans who screened positive for PTSD and alcohol use disorder were divided into 2 groups: a mobile mindfulness-based intervention group enhanced with brief alcohol intervention content (Mind Guide), and an active stress management program group. Mind Guide engagement was excellent, according to the study, with averages of > 31 logins and 5 hours of app use. At 16 weeks, the Mind Guide group showed significant reductions in PTSD symptoms (no differences emerged for alcohol use frequency). Mind Guide may be a valuable adjunct to more intensive in-person PTSD treatment by facilitating interest in services, integration into care, and/or sustainment of posttreatment improvements. The VA currently offers 16 apps, including MHA for Veterans, an app designed for patients to complete mental health assessments after their clinician assigned them. Other apps address a variety of issues, such as anger management, insomnia, chronic pain, and PTSD. 

Two apps were created with an eye toward specific communities. One, Veterans Wellness Path, was designed for American Indians and Alaska Natives with input from those veterans, their family members, and health care practitioners. It supports the transition from military service to home and encourages balance and connection with self, family, community, and environment. Similarly, WellWithin Coach was designed by the VA National Center for PTSD with input from women veterans and subject matter experts in women’s mental health.

Whatever form it takes—in-person or virtual—finding support that works can make all the difference for veterans. Kelly founded and serves as the executive director of Acta Non Verba: Youth Urban Farm Project, an organization that brings together > 3000 low-income youth and families annually to learn about urban farming, aiming to fill a gap in an area known as a food desert: “We do have the power and the right to wake up the next day and try to do something different,” she said.

For Kelly, a retired Navy operations specialist, coping with depression and anxiety hindered her ability to enjoy everyday life. Then she elected to enter therapy, a decision she calls “transformative.”

“When I started doing therapy, it was like releasing the toxins, releasing the buildup of the fear or the rage or the overwhelming feelings of shame,” she says. “We can’t just hold on to it. Just telling the truth, it helps me every single day. It is so worth it.”

Kurt, an Army veteran, tried to power through his anxiety, depression, and survivor guilt. He didn’t have much faith in mental health therapy, thinking no one could relate to him. He was surprised, though, once he started treatment, how much his life improved. He now encourages other veterans to face their own mental health challenges, be it through virtual/mental health apps or in-person care.

“From getting help, every day of my life is better,” he says, “and I couldn’t be more grateful for it.”

Stories from Kelly and Kurt are 2 of 7 the US Department of Veterans Affairs (VA) highlighted during National Recovery Month, outlining how their lives were forever changed with the support of mental health care.

But for every Kelly and Kurt, there are thousands of individuals reluctant to seek mental health care. A analysis of 2019-2020 data from the National Health and Resilience in Veterans Study found that 924 (26%) of 4069 veterans met criteria for ≥ 1 psychological disorders, but only 12% reported engagement in mental health care. The researchers considered the role of protective psychosocial characteristics, such as grit (ie, “trait perseverance that extends to one’s decision or commitment to address mental health needs on one’s own; dispositional optimism; and purpose in life”). Veterans who reported mental dysfunction but scored highly on grit were less likely to be engaged in treatment. This pattern suggests higher levels of grit may reduce the likelihood of seeking treatment, “even in the presence of clinically meaningful distress.”

A 2004 study found only 23% to 40% of service members who screened positive for a mental disorder sought care. They often believed they would be seen as weak, or their unit leadership might treat them differently, and unit members would have less confidence in them. 

Given that military members and veterans are at increased risk of posttraumatic stress disorder (PTSD) in addition to mood, anxiety, and substance use disorders, any alternatives that increase their access to support and services are crucial. For those who aren’t disposed to office visits and group therapy, the answer may lie in mobile apps. 

In a recent randomized controlled trial, 201 veterans who screened positive for PTSD and alcohol use disorder were divided into 2 groups: a mobile mindfulness-based intervention group enhanced with brief alcohol intervention content (Mind Guide), and an active stress management program group. Mind Guide engagement was excellent, according to the study, with averages of > 31 logins and 5 hours of app use. At 16 weeks, the Mind Guide group showed significant reductions in PTSD symptoms (no differences emerged for alcohol use frequency). Mind Guide may be a valuable adjunct to more intensive in-person PTSD treatment by facilitating interest in services, integration into care, and/or sustainment of posttreatment improvements. The VA currently offers 16 apps, including MHA for Veterans, an app designed for patients to complete mental health assessments after their clinician assigned them. Other apps address a variety of issues, such as anger management, insomnia, chronic pain, and PTSD. 

Two apps were created with an eye toward specific communities. One, Veterans Wellness Path, was designed for American Indians and Alaska Natives with input from those veterans, their family members, and health care practitioners. It supports the transition from military service to home and encourages balance and connection with self, family, community, and environment. Similarly, WellWithin Coach was designed by the VA National Center for PTSD with input from women veterans and subject matter experts in women’s mental health.

Whatever form it takes—in-person or virtual—finding support that works can make all the difference for veterans. Kelly founded and serves as the executive director of Acta Non Verba: Youth Urban Farm Project, an organization that brings together > 3000 low-income youth and families annually to learn about urban farming, aiming to fill a gap in an area known as a food desert: “We do have the power and the right to wake up the next day and try to do something different,” she said.

For Kelly, a retired Navy operations specialist, coping with depression and anxiety hindered her ability to enjoy everyday life. Then she elected to enter therapy, a decision she calls “transformative.”

“When I started doing therapy, it was like releasing the toxins, releasing the buildup of the fear or the rage or the overwhelming feelings of shame,” she says. “We can’t just hold on to it. Just telling the truth, it helps me every single day. It is so worth it.”

Kurt, an Army veteran, tried to power through his anxiety, depression, and survivor guilt. He didn’t have much faith in mental health therapy, thinking no one could relate to him. He was surprised, though, once he started treatment, how much his life improved. He now encourages other veterans to face their own mental health challenges, be it through virtual/mental health apps or in-person care.

“From getting help, every day of my life is better,” he says, “and I couldn’t be more grateful for it.”

Stories from Kelly and Kurt are 2 of 7 the US Department of Veterans Affairs (VA) highlighted during National Recovery Month, outlining how their lives were forever changed with the support of mental health care.

But for every Kelly and Kurt, there are thousands of individuals reluctant to seek mental health care. A analysis of 2019-2020 data from the National Health and Resilience in Veterans Study found that 924 (26%) of 4069 veterans met criteria for ≥ 1 psychological disorders, but only 12% reported engagement in mental health care. The researchers considered the role of protective psychosocial characteristics, such as grit (ie, “trait perseverance that extends to one’s decision or commitment to address mental health needs on one’s own; dispositional optimism; and purpose in life”). Veterans who reported mental dysfunction but scored highly on grit were less likely to be engaged in treatment. This pattern suggests higher levels of grit may reduce the likelihood of seeking treatment, “even in the presence of clinically meaningful distress.”

A 2004 study found only 23% to 40% of service members who screened positive for a mental disorder sought care. They often believed they would be seen as weak, or their unit leadership might treat them differently, and unit members would have less confidence in them. 

Given that military members and veterans are at increased risk of posttraumatic stress disorder (PTSD) in addition to mood, anxiety, and substance use disorders, any alternatives that increase their access to support and services are crucial. For those who aren’t disposed to office visits and group therapy, the answer may lie in mobile apps. 

In a recent randomized controlled trial, 201 veterans who screened positive for PTSD and alcohol use disorder were divided into 2 groups: a mobile mindfulness-based intervention group enhanced with brief alcohol intervention content (Mind Guide), and an active stress management program group. Mind Guide engagement was excellent, according to the study, with averages of > 31 logins and 5 hours of app use. At 16 weeks, the Mind Guide group showed significant reductions in PTSD symptoms (no differences emerged for alcohol use frequency). Mind Guide may be a valuable adjunct to more intensive in-person PTSD treatment by facilitating interest in services, integration into care, and/or sustainment of posttreatment improvements. The VA currently offers 16 apps, including MHA for Veterans, an app designed for patients to complete mental health assessments after their clinician assigned them. Other apps address a variety of issues, such as anger management, insomnia, chronic pain, and PTSD. 

Two apps were created with an eye toward specific communities. One, Veterans Wellness Path, was designed for American Indians and Alaska Natives with input from those veterans, their family members, and health care practitioners. It supports the transition from military service to home and encourages balance and connection with self, family, community, and environment. Similarly, WellWithin Coach was designed by the VA National Center for PTSD with input from women veterans and subject matter experts in women’s mental health.

Whatever form it takes—in-person or virtual—finding support that works can make all the difference for veterans. Kelly founded and serves as the executive director of Acta Non Verba: Youth Urban Farm Project, an organization that brings together > 3000 low-income youth and families annually to learn about urban farming, aiming to fill a gap in an area known as a food desert: “We do have the power and the right to wake up the next day and try to do something different,” she said.