Innovations in Practice: Dissemination and implementation of child-parent psychotherapy in rural public health agencies.

BACKGROUND: Early trauma exposure can have long-term negative health effects. Few young children receive evidence-based trauma treatment. This article explores the feasibility of implementing Child-Parent Psychotherapy (CPP), an evidence-based intervention, in rural public health agencies. METHOD: Twenty-three clinicians across four agencies were trained. Training outcomes and implementation barriers and facilitators were assessed. RESULTS: One hundred twelve client-caregiver dyads began the year-long treatment; 50% are currently enrolled or have completed treatment. Barriers and facilitators to implementation were identified. CONCLUSIONS: CPP is feasible to implement in rural community mental health agencies. Important lessons were learned related to planning, implementation, and sustainability.

Medial temporal lobe BOLD activity at rest predicts individual differences in memory ability in healthy young adults.

Human beings differ in their ability to form and retrieve lasting long-term memories. To explore the source of these individual differences, we used functional magnetic resonance imaging to measure blood-oxygen-level-dependent (BOLD) activity in healthy young adults (n = 50) during periods of resting fixation that were interleaved with periods of simple cognitive tasks. We report that medial temporal lobe BOLD activity during periods of rest predicts individual differences in memory ability. Specifically, individuals who exhibited greater magnitudes of task-induced deactivations in medial temporal lobe BOLD signal (as compared to periods of rest) demonstrated superior memory during offline testing. This relationship was independent of differences in general cognitive function and persisted across different control tasks (i.e., number judgment versus checkerboard detection) and experimental designs (i.e., blocked versus event-related). These results offer a neurophysiological basis for the variability in mnemonic ability that is present amongst healthy young adults and may help to guide strategies aimed at early detection and intervention of neurological and mnemonic impairment.

Unique and persistent individual patterns of brain activity across different memory retrieval tasks.

Fourteen subjects were scanned in two fMRI sessions separated by several months. During each session, subjects performed an episodic retrieval task, a semantic retrieval task, and a working memory task. We found that 1) despite extensive intersubject variability in the pattern of activity across the whole brain, individual activity patterns were stable over time, 2) activity patterns of the same individual performing different tasks were more similar than activity patterns of different individuals performing the same task, and 3) that individual differences in decision criterion on a recognition test predicted the degree of similarity between any two individuals' patterns of brain activity, but individual differences in memory accuracy or similarity in structural anatomy did not. These results imply that the exclusive use of group maps may be ineffective in profiling the pattern of activations for a given task. This may be particularly true for a task like episodic retrieval, which is relatively strategic and can involve widely distributed specialized processes that are peripheral to the actual retrieval of stored information. Further, these processes may be differentially engaged depending on individual differences in cognitive processing and/or physiology.

Shared decision-making preferences of people with severe mental illness.

OBJECTIVE: Perceived roles and preferences were explored for shared decision making among persons with severe mental illnesses. METHODS: In this pilot study, 30 adult clients with severe mental illness in a community mental health center were surveyed about decision making regarding psychiatric medications, rehabilitation, and general medical care. RESULTS: Clients generally expressed a desire for greater participation in decisions about psychiatric care than they currently experienced. Regarding use of new psychiatric medications, 23 persons (77%) preferred autonomous or shared roles, but only 11 (37%) rated their current roles as more than passive (z=-2.83, p=.005). Clients were less likely to prefer a passive role in medication decisions about psychiatric care than about general medical care (seven persons, or 23%, versus 23 persons, or 77%; z=-3.01, p=.003). CONCLUSIONS: Most clients with severe mental illnesses prefer shared decision making, particularly in relation to their mental health care.

A Mathematical Model Captures the Structure of Subjective Affect.

Although it is possible to observe when another person is having an emotional moment, we also derive information about the affective states of others from what they tell us they are feeling. In an effort to distill the complexity of affective experience, psychologists routinely focus on a simplified subset of subjective rating scales (i.e., dimensions) that capture considerable variability in reported affect: reported valence (i.e., how good or bad?) and reported arousal (e.g., how strong is the emotion you are feeling?). Still, existing theoretical approaches address the basic organization and measurement of these affective dimensions differently. Some approaches organize affect around the dimensions of bipolar valence and arousal (e.g., the circumplex model), whereas alternative approaches organize affect around the dimensions of unipolar positivity and unipolar negativity (e.g., the bivariate evaluative model). In this report, we (a) replicate the data structure observed when collected according to the two approaches described above, and reinterpret these data to suggest that the relationship between each pair of affective dimensions is conditional on valence ambiguity, and (b) formalize this structure with a mathematical model depicting a valence ambiguity dimension that decreases in range as arousal decreases (a triangle). This model captures variability in affective ratings better than alternative approaches, increasing variance explained from ~60% to over 90% without adding parameters.

A Randomized Implementation Study of Trauma-Focused Cognitive Behavioral Therapy for Adjudicated Teens in Residential Treatment Facilities.

Adjudicated youth in residential treatment facilities (RTFs) have high rates of trauma exposure and post-traumatic stress disorder (PTSD). This study evaluated strategies for implementing trauma-focused cognitive behavioral therapy (TF-CBT) in RTF. Therapists (N = 129) treating adjudicated youth were randomized by RTF program (N = 18) to receive one of the two TF-CBT implementation strategies: (1) web-based TF-CBT training + consultation (W) or (2) W + 2 day live TF-CBT workshop + twice monthly phone consultation (W + L). Youth trauma screening and PTSD symptoms were assessed via online dashboard data entry using the University of California at Los Angeles PTSD Reaction Index. Youth depressive symptoms were assessed with the Mood and Feelings Questionnaire-Short Version. Outcomes were therapist screening; TF-CBT engagement, completion, and fidelity; and youth improvement in PTSD and depressive symptoms. The W + L condition resulted in significantly more therapists conducting trauma screening (p = .0005), completing treatment (p = .03), and completing TF-CBT with fidelity (p = .001) than the W condition. Therapist licensure significantly impacted several outcomes. Adjudicated RTF youth receiving TF-CBT across conditions experienced statistically and clinically significant improvement in PTSD (p = .001) and depressive (p = .018) symptoms. W + L is generally superior to W for implementing TF-CBT in RTF. TF-CBT is effective for improving trauma-related symptoms in adjudicated RTF youth. Implementation barriers are discussed.

Hepatitis C virus and HIV co-infection in people with severe mental illness and substance use disorders.

OBJECTIVES: The 5-7% of adults in the United States with severe mental illness (SMI), especially the 50% who are 'dually diagnosed' with co-occurring substance use disorders (SUD), are at an elevated risk of HIV and hepatitis C virus (HCV). However, little is known about HIV/HCV co-infection in this population. This paper examines the prevalence and correlates of HIV, hepatitis C, and HIV/HCV co-infection in a large, multisite sample of SMI clients. DESIGN: We conducted a re-analysis of data on prevalence and correlates of blood-borne infections in a multisite sample of SMI clients. METHODS: In 1997-1998, 755 SMI clients were tested for HIV, hepatitis B virus and HCV, and assessed for demographic, illness-related and other behavioral risk factors for blood-borne infections. The prevalence and correlates of co-infection were examined, as well as the knowledge, attitudes and risk behaviors of individuals with HCV mono-infection. RESULTS: Of the 755 participants, 623 (82.5%) were negative for both HIV and HCV, 23 (3.0%) were positive for HIV, 109 (14.4%) were positive for HCV, and 13 (1.7%) were co-infected with HIV and HCV. Overall, 2.5% of dually diagnosed participants were co-infected, whereas only 0.6% of SMI participants without a comorbid SUD diagnosis were co-infected. Co-infection was associated with psychiatric illness severity, ongoing drug abuse, poverty, homelessness, incarceration, urban residence and minority status. HCV-mono-infected clients continued to engage in high levels of risk behavior for HIV. CONCLUSION: In addition to efforts to identify and treat SMI patients with HIV/HCV co-infection, HCV-mono-infected clients should be targeted for prevention interventions.

Single and multiple suicide attempts and associated health risk factors in New Hampshire adolescents.

In this study we examined self-reported suicide attempts and their relationship to other health risk factors in a community sample of 16,644 adolescents. Fifteen percent endorsed suicide attempts (10% single; 5% multiple attempts) We hypothesized that multiple attempters would show higher prevalence of comorbid health risks than single or non-attempters. The three groups showed significant differences in ten health risk domains, on factors such as depressed mood, sexual assault, weight problems, and drug and alcohol use (ORs: 3.26-13.57). Repeated suicide attempts appear to be related to increased vulnerability and likelihood of harm in multiple domains of health risk.

The five-site health and risk study of blood-borne infections among persons with severe mental illness.

This article outlines the history and rationale of a multisite study of blood-borne infections among persons with severe mental illness reported in this special section of Psychiatric Services. The general problem of blood-borne diseases in the United States is reviewed, particularly as it affects people with severe mental illness and those with comorbid substance use disorders. The epidemiology and natural history of three of the most important infections are reviewed: the human immunodeficiency virus (HIV), the hepatitis B virus, and the hepatitis C virus. Current knowledge about blood-borne diseases among people with severe mental illness as well as information on current treatment advances for hepatitis C are summarized. A heuristic model, based on the pragmatic, empirical, and conceptual issues that influenced the final study design, is presented. The specific rationale of the five-site collaborative design is discussed, as well as the sampling frames, measures, and procedures used at the participating sites. Alternative strategies for analyzing data deriving from multisite studies that use nonrandomized designs are described and compared. Finally, each of the articles in this special section is briefly outlined, with reference to the overall hypotheses of the studies.

Costs of a public health model to increase receipt of hepatitis-related services for persons with mental illness.

OBJECTIVE: This study examined the costs and impact on receipt of hepatitis and HIV testing and hepatitis immunization services of a public health intervention model that was designed for use by persons with serious mental illness and co-occurring substance use disorders. METHODS: Between 2006 and 2008, a random sample of 202 nonelderly, predominantly African-American males with a psychotic or major depressive disorder and a co-occurring substance use disorder was recruited at four community mental health outpatient programs in a large metropolitan area. Participants were randomly assigned at each site to enhanced treatment as usual (N=97), including education about blood-borne diseases and referrals for testing and vaccinations, or to an experimental intervention (N=105) that provided on-site infectious disease education, screening of risk level, pretest counseling, testing for HIV and hepatitis B and C, vaccination for hepatitis A and B, and personalized risk-reduction counseling. The authors compared the two study groups to assess the average costs of improving hepatitis and HIV testing and hepatitis A and B vaccination in this population. RESULTS: The average cost per participant was $423 for the intervention and $24 for the comparison condition (t=52.7, df=201, p<.001). The costs per additional person tested was $706 for hepatitis C, $776 for hepatitis B, and $3,630 for HIV, and the cost per additional person vaccinated for hepatitis was $561. CONCLUSIONS: Delivery of hepatitis and HIV public health services to persons with serious mental illness in outpatient mental health settings can be as cost-effective as similar interventions for other at-risk populations.

The strategic nature of false recognition in the DRM paradigm.

The false memory effect produced by the Deese/Roediger & McDermott (DRM) paradigm is reportedly impervious to warnings to avoid false alarming to the critical lures (D. A. Gallo, H. L. Roediger III, & K. B. McDermott, 2001). This finding has been used as strong evidence against models that attribute the false alarms to a decision process (e.g., M. B. Miller & G. L. Wolford, 1999). In this report, the authors clarify their earlier article and suggest that subjects establish only 2 underlying criteria for a recognition judgment, a liberal criterion for items that seem to be related to 1 of the study list themes and a conservative criterion for items that do not seem to be related. They demonstrate that warnings designed on the basis of these underlying criteria are effective in significantly suppressing the false recognition effect, suggesting that strategic control of the retrieval response does play a role in the DRM paradigm.

Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness.

OBJECTIVES: People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), but they generally do not receive basic recommended screening or preventive and treatment services. Barriers to services include lack of programs offered by mental health providers and client refusal of available services. Clients from racial-ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings and to increase acceptance of such services among clients. METHODS: A randomized controlled trial (N=236) compared enhanced treatment as usual (control) with a brief intervention to deliver best-practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups. The "STIRR" intervention included Screening for HIV and HCV risk factors, Testing for HIV and hepatitis, Immunization against hepatitis A and B, Risk reduction counseling, and medical treatment Referral and support at the site of mental health care. RESULTS: Clients randomly assigned to the STIRR intervention had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV, to be immunized against hepatitis A virus and HBV, and to increase their knowledge about hepatitis and reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care, and showed no increase in HIV knowledge. Intervention costs were $541 per client (including $234 for blood tests). CONCLUSIONS: STIRR appears to be efficacious in providing a basic, best-practice package of interventions for clients with co-occurring disorders.

The principled control of false positives in neuroimaging.

An incredible amount of data is generated in the course of a functional neuroimaging experiment. The quantity of data gives us improved temporal and spatial resolution with which to evaluate our results. It also creates a staggering multiple testing problem. A number of methods have been created that address the multiple testing problem in neuroimaging in a principled fashion. These methods place limits on either the familywise error rate (FWER) or the false discovery rate (FDR) of the results. These principled approaches are well established in the literature and are known to properly limit the amount of false positives across the whole brain. However, a minority of papers are still published every month using methods that are improperly corrected for the number of tests conducted. These latter methods place limits on the voxelwise probability of a false positive and yield no information on the global rate of false positives in the results. In this commentary, we argue in favor of a principled approach to the multiple testing problem--one that places appropriate limits on the rate of false positives across the whole brain gives readers the information they need to properly evaluate the results.

Development of a screening tool to identify adolescents engaged in multiple problem behaviors: the Adolescent Risk Behavior Screen (ARBS).

PURPOSE: To describe the development of a new, brief screening tool to identify teenagers engaged in multiple, co-occurring high-risk behaviors, and to create a screen that bypasses problems associated with assessment of sensitive and potentially stigmatizing behaviors by including questions that are minimally threatening and less transparent than purely face valid items. METHODS: This study utilizes a large, cross-sectional data set consisting of self-report responses to questions about high-risk teen health behaviors such as substance use, sexual risk-taking, and suicidality. Data were collected from 16,664 predominantly Caucasian public high school students, aged 14-18 years, participating in the 2001 New Hampshire Youth Risk Behavior Survey. High-risk status was defined by endorsement of five or more high-risk behaviors. Nine items were chosen for the screen, covering multiple risk domains. The screen's predictive accuracy was then tested on additional holdout subsets of the total sample and separately by gender using receiver operating characteristic (ROC) curves. RESULTS: Approximately 10% of the sample met criteria for "high-risk" status. High ROC areas were found for the initial sample and subsequent holdout samples. The screen was found to be accurate for both girls and boys in identifying multi-problem, high-risk adolescents. CONCLUSIONS: The Adolescent Risk Behavior Screen (ARBS) holds promise as a useful clinical tool for adolescent health care providers. It can quickly and accurately identify multi-problem teens, engaged in dangerous high-risk activities, who are likely in need of more comprehensive evaluation and intervention.

Extensive individual differences in brain activations associated with episodic retrieval are reliable over time.

The localization of brain functions using neuroimaging techniques is commonly dependent on statistical analyses of groups of subjects in order to identify sites of activation, particularly in studies of episodic memory. Exclusive reliance on group analysis may be to the detriment of understanding the true underlying cognitive nature of brain activations. In the present study, we found that the patterns of brain activity associated with episodic retrieval are very distinct for individual subjects from the patterns of brain activity at the group level. These differences go beyond the relatively small variations due to cyctoarchitectonic differences or spatial normalization. We quantify this individual variability by cross-correlating volumes of brain images. We demonstrate that individual patterns of brain activity are reliable over time despite their extensive variability. We suggest that varied but reliable individual patterns of significant brain activity may be indicative of different cognitive strategies used to produce a recognition response. We believe that individual analysis in conjunction with group analysis may be critical to fully understanding the relationship between retrieval processes and underlying brain regions.

Expressive disclosure and health outcomes in a prostate cancer population.

OBJECTIVE: This pilot study explored the feasibility and the efficacy of a brief, well-defined psychosocial intervention (expressive disclosure) in improving behavioral, medical, immunological, and emotional health outcomes in men with diagnosed prostate cancer. METHOD: Thirty prostate cancer patients receiving outpatient oncology care were randomized into experimental (disclosure) and control (non-disclosure) groups. All had been previously treated by surgery or radiation within the last 4 years and were being monitored without further intervention for change in PSA levels. Psychological and physical health surveys were administered and peripheral blood for PSA levels and immune assays was obtained upon study enrollment and again at 3 and 6 months post enrollment. Multivariate analyses were used to examine how the expressive disclosure impacted the hypothesized domains of functioning: physical and psychological symptoms; health care utilization; and immunocompetence. RESULTS: Compared to controls, patients in the expressive disclosure condition showed improvements in the domains of physical symptoms and health care utilization, but not in psychological variables nor in disease relevant aspects of immunocompetence. CONCLUSIONS: Study results support the feasibility of an expressive disclosure intervention for men with prostate cancer. The intervention was well accepted by this population, and participation/adherence was quite high. Results provide only limited support for the hypothesis that a written emotional disclosure task can positively impact health outcomes in a cancer population. However, this pilot study may have lacked adequate power to detect possible intervention benefits. Further studies with larger samples are needed to better assess the intervention's impact on psychological well-being and immunocompetence.