Treatment of Nightmares in Psychiatric Inpatients With Imagery Rehearsal Therapy: An Open Trial and Case Series.

Objectives: This study sought to assess the utility of Imagery Rehearsal Therapy (IRT) for nightmares in an inpatient psychiatric setting. Although IRT enjoys a substantial evidence base for efficacy in various populations, data with psychiatric inpatients are lacking. Participants: Participants were 20 adult psychiatric inpatients (11 male, 9 female; mean age=43.4), in an extended stay psychiatric inpatient facility. All participants were diagnosed with multiple, treatment resistant, comorbid conditions, including mood disorders, anxiety disorders, personality disorders, and substance-related disorders. Patients with active psychosis or significant cognitive impairment were excluded. Methods: This was an open trial utilizing a case series design. In addition to routine hospital treatment that included psychotherapeutic and pharmacological interventions, participants received IRT over a span of 3 weeks in 4 small group sessions. Included were education about sleep and nightmares, instruction in writing new dream narratives and practicing guided imagery, and support via further consultation and trouble-shooting. Patients were referred by their psychiatrist or were self-referred, with approval from their treatment teams. Results: Results showed significant aggregate reductions in nightmare frequency and intensity, as well as improvement in sleep overall. Patients also improved on a variety of other symptom measures, including suicidal ideation. No adverse reactions were observed. The present report includes a sampling of individual case vignettes to illustrate variability in treatment response. Conclusions: This study provides preliminary evidence that IRT can be used safely and effectively in a hospital environment to benefit patients suffering from serious mental illnesses, often in the midst of significant life crises. It is not possible in this preliminary study to conclude that IRT specifically (as opposed to other aspects of hospital treatment) produced these outcomes. Larger, controlled trials are needed to establish a causal connection between IRT and nightmare reduction.

Further evidence that suicide risk is categorical: A taxometric analysis of data from an inpatient sample.

Recent research by Witte and colleagues (2017) revealed a taxonic structure for classifying suicide risk using a sample of predominantly military outpatients. The authors sought to replicate the Witte et al. (2017) findings using data from a sample of 2,385 psychiatric inpatients who completed measures of suicidal ideation and behavior upon admission to the hospital. The comparison curve fit index values for means above minus below a cut (.80), maximum eigenvalue (.71), and latent mode (.52) showed a similar taxonic structure (i.e., dichotomous rather than continuous). Consistent with Witte et al. (2017), differences between the taxon and complement groups were larger for variables conceptually directly related to suicide risk than to broader constructs such as hopelessness or depression. Support for this categorical distinction among a sample of long-term psychiatric inpatients, who are uniformly high in symptom severity, emphasizes the need for additional research on this high-risk group and development of further assessment methods. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Word count as an indicator of suicide risk in an inpatient setting.

The current study replicates a previously used methodology with a suicidal inpatient sample regarding word counts generated by participants writing about suicidal constructs. Word counts (i.e., the number of written words) on the Suicide Status Form from initial sessions with suicidal inpatients were compared to self-rated suicide risk scores as well as to continuous and repeated measures of hopelessness and suicide ideation assessed over the course of inpatient care. Results showed that higher word counts were associated with initially higher suicide ideation scores that steadily declined over the course of treatment. Lower word counts were associated with lower initial hopelessness scores that increased during treatment before ultimately decreasing. In addition, word count was not found to be a significant predictor of self-rated suicide risk. Clinical implications of these data and future directions are discussed.

Contributions of Cognitions, Psychological Flexibility, and Therapeutic Alliance to Suicidal Ideation in Psychiatric Inpatients.

Although suicide treatment is an expanding area of research, there is relatively less in the literature with respect to how specific vulnerabilities to suicide are addressed by treatment. Utilizing measures of suicide cognitions, therapeutic alliance, and psychological flexibility, we compared their relative contributions to suicidal ideation during and posttreatment among a group of adult psychiatric inpatients (N = 434). Results revealed that cognitions contributed considerably more unique variance to suicidal ideation than alliance and flexibility at discharge and at 2 weeks postdischarge, and to change in suicidal ideation over the course of treatment. Psychological flexibility explained a small amount of variance at the 6-month time point. Factor level analyses also were conducted, with the unsolvability factor within suicide cognitions accounting for the largest portion of variance at both discharge and 2 weeks postdischarge. Study limitations, implications, and future directions are discussed.

Variations of emotion dysregulation in borderline personality disorder: a latent profile analysis approach with adult psychiatric inpatients.

BACKGROUND: The purpose of the present study was to identify variations in emotional dysregulation patterns among adults diagnosed with borderline personality disorder (BPD), with an eye toward implications for treatment. METHODS: Latent profile analysis (LPA) was utilized to classify 156 inpatients with BPD, based on patterns of Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, J Psychopathol Behav Assess 26: 41-54, 2004) subscale scores. RESULTS: Results revealed that a three class solution best fit the sample (Low Impairment, Global Dysregulation, and Emotionally Aware). Further analysis of the classes at admission revealed that the Global Dysregulation group reported significantly higher suicidal ideation than either the Low Impairment or Emotionally Aware groups, and that the Global Dysregulation group reported significantly higher functional impairment than the Low Impairment group. CONCLUSIONS: All three groups improved greatly over the course of hospital treatment, although they remained distinguishable at discharge, retaining their positions symptomatically relative to one another. Limitations, implications, and future directions are discussed.

Discovering the impact of psychotherapeutic hospital treatment for adults with serious mental illness.

The authors summarize findings from a multiyear research project designed primarily to investigate outcomes of intensive, psychotherapeutic hospital treatment lasting several weeks. Patients are assessed with well-established measures at admission, and their progress is reassessed biweekly up to discharge. A follow-up component was added recently to track outcomes for 1 year after discharge. All inpatient assessments are integrated with clinical care by providing individual results for each time point to the patient and the treatment team. In addition to reporting findings from inpatient treatment, the authors summarize what has been learned about the measures and methodology as well as what the assessments have revealed about psychopathology in these patients. More recently, the outcomes project has included a neuroscience initiative with findings from neuroimaging, genetics, and the microbiome; initial findings are also summarized. The authors conclude with a discussion of their understanding of the basis of the effectiveness of this increasingly rare form of inpatient treatment.

Recognizing and addressing unique vulnerabilities of suicidal patients: Suicide research at The Menninger Clinic.

Suicide risk is an inescapable presence in the treatment of people with psychiatric disorders, a fact that applies especially in inpatient psychiatric settings. This article summarizes a several-year research initiative at The Menninger Clinic aimed at better understanding psychological contributors to suicidality and developing more effective clinical interventions. Two areas of research are described, an outcomes arm focused on assessing the feasibility and effectiveness of a suicide-specific intervention (The Collaborative Assessment and Management of Suicidality) and an exploratory arm whose objective is to learn about psychological vulnerabilities that distinguish suicidal from nonsuicidal patients, with an eye toward developing interventions that address such vulnerabilities. The author concludes that, combined with other developments in the field, this body of work strongly supports the view that suicidal patients should be treated with interventions that specifically target vulnerabilities that seem to set the stage for suicidal episodes.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up.

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Psychometric Reevaluation of the Columbia-Suicide Severity Rating Scale: Findings From a Prospective, Inpatient Cohort of Severely Mentally Ill Adults.

OBJECTIVE: Accurate prediction of suicide remains elusive due to lack of predictive measures. Given the Columbia-Suicide Severity Rating Scale's (C-SSRS) emerging "gold-standard" status for risk assessment, studies are needed to assess its psychometric properties, particularly predictive validity. The current study adds to the limited literature by assessing the C-SSRS's internal consistency, factor structure, concurrent validity, and predictive validity. METHODS: In this longitudinal study of 1,055 adults with DSM-IV diagnoses consecutively admitted to a specialized psychiatric hospital between July 1, 2012, and June 30, 2014, patients completed standardized assessments, including the C-SSRS, at admission and 2, 12, and 24 weeks postdischarge. RESULTS: The C-SSRS evidenced excellent internal consistency (ordinal α = .95). Principal components analysis (PCA) revealed a 2-factor solution, accounting for 65.3% of the variance across items. The severity of ideation and behavioral items loaded onto the first factor, and the intensity of ideation items loaded onto the second factor. The total score, factors, and the most severe ideation single item were moderately correlated with other measures of suicidality (0.27 ≤ r ≤ 0.58; P < .0001). The summary score from the ideation/behavior factor was found to be modestly correlated with any suicide-related behavior within the 6 months following hospitalization. Receiver operator characteristics indicated that the C-SSRS performed adequately in correctly classifying any suicide-related behavior within 6 months of discharge from the hospital (AUC = 0.757, P < .001) with the total score and summary score from the ideation/behavior factor providing the best balance between sensitivity (0.694) and specificity (0.652-0.674). CONCLUSIONS: This study is the first to assess the factor structure of the C-SSRS in a large, high-risk sample. The measure has solid psychometric properties and merits use as a suicide risk assessment measure.

Acute Suicidal Affective Disturbance (ASAD): A confirmatory factor analysis with 1442 psychiatric inpatients.

Acute Suicidal Affective Disturbance (ASAD) is a newly proposed diagnostic entity that characterizes rapid onset suicidal intent. This study aims to confirm the factor structure of ASAD among psychiatric inpatients, and to determine the clinical utility of ASAD in predicting suicide attempt status. Overall, 1442 psychiatric inpatients completed a battery of self-report questionnaires assessing symptoms theorized to comprise the ASAD construct. Utilizing these data, a confirmatory factor analysis with a one-factor solution was performed. Regression analyses were employed to determine if the ASAD construct predicted past suicide attempts, and analyses of variance (ANOVAs) were employed to determine if ASAD symptoms differed by the presence and number of past suicide attempts. The one-factor solution indicated good fit: χ(2)(77) = 309.1, p < 0.001, Tucker-Lewis Index (TLI) = 0.96, comparative fit index (CFI) = 0.97, root-mean-square error of approximation (RMSEA) = 0.05. Controlling for depressive disorders and current symptoms, the ASAD construct significantly predicted the presence of a past suicide attempt. Moreover, ASAD differentiated in the expected directions between individuals with a history of multiple suicide attempts, individuals with a single suicide attempt, and individuals with no history of a suicide attempt. Acute Suicidal Affective Disturbance (ASAD) appears to be a unified construct that predicts suicidal behavior and is distinct from an already-defined mood disorder.

Change in Experiential Avoidance is Associated with Reduced Suicidal Ideation over the Course of Psychiatric Hospitalization.

Growing empirical literature in recent years indicates that experiential avoidance plays a role in a wide variety of psychological disorders and psychotherapeutic interventions. This study explored the view of suicidal ideation as a form of experiential avoidance by examining the association between suicidal ideation and therapeutic change in a sample of 189 adult psychiatric inpatients. Results were consistent with predictions, showing a statistically significant association between scores on the Beck Scale for Suicidal Ideation and the Acceptance and Action Questionnaire-II (AAQ-II). It was further shown that change in AAQ-II scores over the course of hospitalization was associated with change in suicidality, independent of changes in depression severity and hopelessness. Moreover, treatment responders (patients whose suicidal ideation scores dropped significantly over the course of treatment) showed greater drops in experiential avoidance relative to nonresponders. These results are consistent with a view of suicidal ideation (and, by extension, suicide) as a form of experiential avoidance and potentially a therapeutic approach that specifically seeks to reduce experiential avoidance.

Implicit Measure of Life/Death Orientation Predicts Response of Suicidal Ideation to Treatment in Psychiatric Inpatients.

In this study, we set out to extend empirical research on the Life-Death Implicit Association Test (IAT) by administering the measure to an adult psychiatric inpatient population with suicidal ideation. We sought to examine its association with other suicide-relevant measures and to determine whether it adds predictive utility beyond that offered by other measures of suicide risk. The IAT was administered (N = 124) at biweekly intervals as part of an assessment battery at an inpatient facility for complex, treatment resistant psychiatric disorders (average length of stay: approximately 6 weeks). Multiple regression procedures were utilized to examine relationships among the measures and their predictive utility with respect to suicidal ideation at discharge. Consistent with prior research with other populations, significant associations were found between IAT performance and explicit (self-report and interview) measures of suicide risk. Moreover, the IAT was found to predict suicidal ideation at discharge above and beyond number of prior suicide attempts and admission scores on measures of depression, suicidal ideation, and hopelessness. Change in IAT performance over the course of treatment was observed. The IAT shows promise as an addition to explicit measures conventionally used to estimate suicide risk in psychiatric patients. These findings are consistent with a cognitive vulnerability model of suicide risk.

Erratum to: intensive inpatient treatment improves emotion-regulation capacities among adults with severe mental illness.

[This corrects the article DOI: 10.1186/2051-6673-1-19.].

Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality.

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

A psychometric study of the Suicide Cognitions Scale with psychiatric inpatients.

The cognitive model of suicide makes specific predictions about the role of cognition in suicide risk. This study examined psychometric properties of the Suicide Cognitions Scale (SCS), an instrument designed to measure suicide-specific cognitions, in a sample of 150 patients (age range, 18-75 years, SD = 14.42; 56% female, 94% White) hospitalized for suicide risk associated with multiple, treatment-resistant psychiatric conditions. Findings revealed strong psychometric properties, including internal consistency and test-retest reliability. Incremental validity beyond depression and hopelessness was demonstrated in the prediction of suicidal ideation. Confirmatory factor analysis examining previously reported factor solutions suggested more consistency with a three-factor solution (Unlovability, Unbearability, and Unsolvability) relative to a two-factor solution. Good sensitivity to treatment response over the course of hospitalization also was demonstrated. The hypothesis of residual risk, derived from cognitive theory and predicting that lack of change in suicide schemas would be associated with higher suicide risk at discharge, was supported. Overall, these findings suggest considerable promise for the SCS as a measure of suicide risk that adds predictive utility to measures of depression and hopelessness, with potential usefulness in planning and monitoring treatment for suicidal individuals.

Presence and persistence of sleep-related symptoms and suicidal ideation in psychiatric inpatients.

BACKGROUND: Although sleep is an important risk factor for suicidal behavior, research has yet to examine the association between sleep problems and suicidality across the course of inpatient treatment. This study examined the relationship among sleep-related symptoms and suicidal ideation across inpatient treatment. AIMS: To examine whether poor sleep at admission longitudinally predicts less improvement in suicidal ideation over the course of treatment. Further, to examine whether suicidal ideation is reduced in patients whose sleep does not improve. METHOD: The study utilized the Beck Depression Inventory (BDI)-II, which contains items measuring depressive symptoms, sleep-related symptoms, and suicidal ideation. The study sample consisted of 1,529 adult psychiatric inpatients. Patients were assessed at admission, biweekly, and at treatment termination. RESULTS: Admission fatigue, loss of energy, and change in sleep pattern were associated with higher levels of suicidal ideation at admission and discharge. Fatigue at admission predicted suicidal ideation at termination independent of admission depression and suicidal ideation. Individuals whose sleep did not improve over the course of treatment had significantly higher suicidal ideation scores at termination relative to those whose sleep symptoms improved, after controlling for sleep, depression, and suicidal ideation scores at admission. CONCLUSION: These findings suggest that persistence of sleep-related symptoms warrants clinical attention in the treatment of suicidal patients.

Assessing and addressing patient satisfaction in a longer-term inpatient psychiatric hospital: preliminary findings on the Menninger Quality of Care measure and methodology.

Patient satisfaction is increasingly used as an indicator of health care quality. Few measures are available to assess characteristics unique to inpatient psychiatric hospitals, especially those that provide longer-term care. Furthermore, there is limited guidance on how to utilize patient satisfaction data to guide quality improvement initiatives. The authors developed the 20-item, Menninger Quality of Care measure at The Menninger Clinic in Houston, Texas. Psychometric analyses were based on responses from 337 adult inpatients. The measure has excellent internal reliability (Cronbach α=0.92) with adequate concurrent and construct validity. We present a methodology to identify targeted quality improvement efforts by (1) highlighting the perspective of patients who are generally satisfied but had at least some reservations regarding the care they received and (2) highlighting areas of concern that are most associated with overall quality of care. We discuss our findings in light of national health care quality trends.

Anhedonia predicts suicidal ideation in a large psychiatric inpatient sample.

This study examined the relationship among symptoms of anhedonia and suicidal ideation at baseline, at termination, and over time in 1529 adult psychiatric inpatients. Anhedonia was associated with suicidality cross-sectionally at baseline and at termination. In addition, change in anhedonia from baseline to termination predicted change in suicidality from baseline to termination, as well as level of suicidality at termination; moreover, anhedonia remained a robust predictor of suicidal ideation independent of cognitive/affective symptoms of depression. Symptom-level analyses also revealed that, even after accounting for the physical aspect of anhedonia (e.g., loss of energy), loss of interest and loss of pleasure were independently associated with higher levels of suicidal ideation at baseline, over time, and at discharge. Loss of interest was most highly predictive of suicidal ideation, providing support for recent differential conceptualizations of anhedonia. Taken together, these findings indicate that the manner in which anhedonia is conceptualized is important in predicting suicidal ideation, and that anhedonia symptoms warrant particular clinical attention in the treatment of suicidal patients.

Intensive inpatient treatment improves emotion-regulation capacities among adults with severe mental illness.

BACKGROUND: Impaired capacity for emotion regulation is associated with a broad spectrum of psychiatric disturbances; however, little is known about treatment response in emotion regulation functioning among patients with severe mental illness. This study examined treatment response and the role that experiential avoidance plays in mediating the relationship between attachment anxiety/avoidance and change in emotion regulation. METHODS: Difficulties in emotion regulation were assessed at admission and at discharge, and rates of improvement and deterioration in emotion regulation were calculated. Attachment anxiety and avoidance were assessed in conjunction with experiential avoidance at baseline in a large cohort (N = 493) of adults admitted to a specialized adult psychiatric hospital. RESULTS: Inpatient treatment was associated with clinically significant improvement in emotion-regulation capacities for 49 percent of patients completing at least four weeks of treatment. Fifty-six percent of patients attained a status of recovery. Greater attachment avoidance and anxiety were related to positive change in emotion regulation at discharge. Experiential avoidance fully mediated the relationship between insecure attachment and change in emotion-regulation capacities. CONCLUSIONS: Contrary to expectation, greater attachment insecurity (anxiety and avoidance) as well as greater experiential avoidance predicted improvement in emotion regulation. These counterintuitive findings add to a growing evidence base indicating that severity of psychopathology is associated with greater improvement in hospitalized patients. Results of the mediation analysis suggest that targeting experiential avoidance may be an effective augmentation in the treatment of impaired emotion regulation functioning.