Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study.

OBJECTIVES: To determine whether sharing of routinely collected health service performance data could have predicted a critical safety failure at an Australian maternity service. DESIGN: Observational quantitative descriptive study. SETTING: A public hospital maternity service in Victoria, Australia. DATA SOURCES: A public health service; the Victorian state health quality and safety office-Safer Care Victoria; the Health Complaints Commission; Victorian Managed Insurance Authority; Consultative Council on Obstetric and Paediatric Mortality and Morbidity; Paediatric Infant Perinatal Emergency Retrieval; Australian Health Practitioner Regulation Agency. MAIN OUTCOME MEASURES: Numbers and rates for events (activity, deaths, complaints, litigation, practitioner notifications). Correlation coefficients. RESULTS: Between 2000 and 2014 annual birth numbers at the index hospital more than doubled with no change in bed capacity, to be significantly busier than similar services as determined using an independent samples t-test (p<0.001). There were 36 newborn deaths, 11 of which were considered avoidable. Pearson correlations revealed a weak but significant relationship between number of births per birth suite room birth and perinatal mortality (r2 =0.18, p=0.003). Independent samples t-tests demonstrated that the rates of emergency neonatal and perinatal transfer were both significantly lower than similar services (both p<0.001). Direct-to-service patient complaints increased ahead of recognised excess perinatal mortality. CONCLUSION: While clinical activity data and direct-to-service patient complaints appear to offer promise as potential predictors of health service stress, complaints to regulators and medicolegal activity are less promising as predictors of system failure. Significant changes to how all data are handled would be required to progress such an approach to predicting health service failure.

Criminal justice involvement, behavioral health service use, and costs of forensic assertive community treatment: a randomized trial.

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.

Therapist fidelity with an exposure-based treatment of PTSD in adults with schizophrenia or schizoaffective disorder.

This study examined therapists' fidelity to a manualized, multicomponent cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Independent raters assessed therapists' competence and adherence, rating 20% of randomly selected audio taped sessions (n=57 sessions, coded by two raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged "very good" or higher (6 on 7-point Likert scale). Findings suggest that therapists can effectively deliver a manualized cognitive-behavioral intervention for PTSD, with exposure therapy, to patients with severe mental illness without compromise to the structure of sessions and/or the therapeutic relationship.

Integrated Behavioral Treatment for Veterans With Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial.

Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PERSPECTIVE: Opioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.

Diagnostic practices for traumatized youths: do clinicians incorporate symptom scale results?

Clinician generated diagnoses are subject to heuristic biases, and structured diagnostic interviews are useful but costly diagnostic aids. Because dimensional rating scales may hold potential to improve diagnostic practices in community mental health settings, we examined how community clinicians incorporate the results of the Trauma Symptom Checklist for Children (TSCC; Briere 1996) into their diagnostic practices. Results suggest clinicians may attend to the TSCC anxiety and depression scores, but most scales agreed poorly with diagnoses assigned. While dimensional rating scales do hold potential as diagnostic aids, additional work on how to increase their utility to clinicians is needed.

How many forensic assertive community treatment teams do we need?

Despite the growing interest in forensic assertive community treatment (FACT), there is no standardized definition of FACT eligibility and no guidelines for how many FACT teams communities may need. In this brief report a definition for FACT eligibility is proposed-severe and persistent mental illness and three jail detentions in a one-year period-and modeled by using 5.5 years of administrative data (July 1, 1993, through December 31, 1998) from a large, urban county in the western United States. Findings suggest that large, urban communities should develop enough FACT teams to serve approximately 44% of their populations of persons with severe mental illness, or roughly .05% of their adult populations. Developing standardized eligibility criteria for FACT is an important first step toward developing its evidence base.

Workshop-based training in trauma-focused CBT: an in-depth analysis of impact on provider practices.

Despite evidence that more intensive methods are more effective, many clinical settings continue to train practitioners using workshops. To more fully understand the strengths and limitations of workshops, the present investigation studied changes in practitioner behavior following a workshop in trauma-focused cognitive-behavioral therapy (TF-CBT). A chart review indicated no changes in TF-CBT use following the training, although therapists indicated that CBT was the most effective treatment for traumatized youths and was their primary approach to treating trauma. Analysis of client factors indicated weak relationships between technique use and treatment need. Implications of these findings for future training efforts are discussed.

An update on the South Carolina trauma initiative.

Seven years ago the South Carolina Department of Mental Health developed a statewide effort to improve its response to consumers who are trauma survivors. The initiative's goals included sensitizing stakeholders to the impact of trauma, influencing policies, educating and training clinicians, addressing concerns about the safety and dignity of psychiatric settings (for example, sanctuary trauma), and increasing knowledge by supporting a strong empirical research platform. In the brief report presented here, the authors describe the past seven years in terms of obstacles encountered, progress, and future directions of this initiative in the hope of providing information and guidance to other state systems.

Clinicians' perspectives on cognitive-behavioral treatment for PTSD among persons with severe mental illness.

OBJECTIVE: As an intermediate step in the development of a cognitive-behavioral posttraumatic stress disorder (PTSD) treatment program for persons with severe mental illness, a focus group gathered feedback from clinicians and clinical supervisors within a public-sector mental health system. METHODS: Five qualitative focus group discussions were held with 33 clinicians and clinical supervisors within a state-funded community mental health center system. RESULTS: Clinicians perceived trauma to be a significant adverse factor in the lives of their mental health services consumers, were reluctant to address trauma with them, and yet believed that cognitive-behavioral treatments for PTSD may be effective and appropriate for them. Clinicians also offered practical suggestions to improve the feasibility and acceptability of the proposed cognitive-behavioral treatment program. Examples include creating gender-specific treatment groups; ensuring that trust and rapport with clients are established before the discussion of traumatic experiences; developing careful safety precautions for clients, especially for the exposure therapy component; preparing for the possibility that some consumers will lack the cognitive ability to understand treatment; and collaborating with other care providers to ensure optimal integration with other aspects of care and minimize clinic disruptions. CONCLUSIONS: These findings provide information relevant to the development and implementation of PTSD interventions for patients with severe mental illness treated in public-sector settings.

Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis.

Numerous guidelines have been developed over the past decade regarding treatments for Posttraumatic stress disorder (PTSD). However, given differences in guideline recommendations, some uncertainty exists regarding the selection of effective PTSD therapies. The current manuscript assessed the efficacy, comparative effectiveness, and adverse effects of psychological treatments for adults with PTSD. We searched MEDLINE, Cochrane Library, PILOTS, Embase, CINAHL, PsycINFO, and the Web of Science. Two reviewers independently selected trials. Two reviewers assessed risk of bias and graded strength of evidence (SOE). We included 64 trials; patients generally had severe PTSD. Evidence supports efficacy of exposure therapy (high SOE) including the manualized version Prolonged Exposure (PE); cognitive therapy (CT), cognitive processing therapy (CPT), cognitive behavioral therapy (CBT)-mixed therapies (moderate SOE); eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (low-moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., Cohen's d ~-1.0 or more compared with controls). Numbers needed to treat (NNTs) were <4 to achieve loss of PTSD diagnosis for exposure therapy, CPT, CT, CBT-mixed, and EMDR. Several psychological treatments are effective for adults with PTSD. Head-to-head evidence was insufficient to determine these treatments' comparative effectiveness, and data regarding adverse events was absent from most studies.

Consumers' perceptions of negative experiences and "sanctuary harm" in psychiatric settings.

OBJECTIVE: Recent studies show a high prevalence of trauma symptoms among people with serious mental illness who are treated in public-sector mental health systems. Unfortunately, growing evidence suggests that many consumers have had traumatic or harmful experiences while being treated in various psychiatric settings. This study explores consumers' perceptions of such harmful inpatient experiences, events that the authors place under the rubric of "sanctuary harm." METHODS: The authors conducted semistructured qualitative interviews with 27 randomly selected mental health consumers to hear their descriptions of adverse events that they experienced while receiving psychiatric care. Our analysis of interview transcriptions focused on understanding consumers' narratives of harmful experiences-events that would not meet DSM-IV criteria for trauma but that nevertheless resulted in significant distress. RESULTS: Eighteen of 27 interviewees described harmful incidents that they had witnessed or experienced directly, many of which evoked strong emotional responses by consumers during their narration. Nearly all incidents described were hospital based and were clustered around two sets of themes. The first set related to the hospital setting, including the fear of physical violence and the arbitrary nature of the rules. The second set related to the narrators' interactions with clinical staff, including depersonalization, lack of fairness, and disrespect. CONCLUSIONS: The findings suggest that many mental health consumers have had a lifetime sanctuary experience that they perceived as harmful. They also offered suggestions for how the mental health service delivery system might reduce the potential for sanctuary harm experiences.

Patients' reports of traumatic or harmful experiences within the psychiatric setting.

OBJECTIVE: This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector mental health system. METHODS: Participants were 142 randomly selected adult psychiatric patients who were recruited through a day hospital program. Participants completed a battery of self-report measures to assess traumatic and harmful events that occurred during the course of their mental health care, lifetime trauma exposure, and symptoms of posttraumatic stress disorder. RESULTS: Data revealed high rates of reported lifetime trauma that occurred within psychiatric settings, including physical assault (31 percent), sexual assault (8 percent), and witnessing traumatic events (63 percent). The reported rates of potentially harmful experiences, such as being around frightening or violent patients (54 percent), were also high. Finally, reported rates of institutional measures of last resort, such as seclusion (59 percent), restraint (34 percent), takedowns (29 percent), and handcuffed transport (65 percent), were also high. Having medications used as a threat or punishment, unwanted sexual advances in a psychiatric setting, inadequate privacy, and sexual assault by a staff member were associated with a history of exposure to sexual assault as an adult. CONCLUSIONS: Findings suggest that traumatic and harmful experiences within psychiatric settings warrant increased attention.

Trauma history screening in a community mental health center.

OBJECTIVE: This study assessed the lifetime prevalence of traumatic events among consumers of a community mental health center by using a brief trauma screening instrument. This study also examined the relationship between trauma exposure and physical and mental health sequelae and determined whether the routine administration of a trauma screening measure at intake would result in increased diagnoses of posttraumatic stress disorder (PTSD) and in changes in treatment planning in a practice setting. METHODS: A 13-item self-report trauma screening instrument, a shortened version of the Trauma Assessment of Adults instrument, was incorporated into the intake assessment process at a community mental health center (CMHC). A total of 505 out of 515 consumers who presented to the CMHC consecutively were surveyed from May 1, 2001, to January 31, 2002. Data from the initial assessment on trauma exposure and on rate of PTSD diagnosis were examined, and a chart review was conducted on 97 cases (19 percent) to determine the extent to which CMHC services addressed trauma-related problems. RESULTS: Data indicated that 460 consumers (91 percent) had been exposed to one or more traumatic life experiences. The number of traumatic events was negatively correlated with physical and mental health functioning on the 12-item Short-Form Health Survey (SF-12). Subjects with a history of sexual abuse scored significantly higher on the SF-12, reflecting poorer physical and mental health. Although the rate of PTSD diagnosis increased after implementation of the trauma screening instrument, the rates of actual PTSD treatment services provided did not change. CONCLUSIONS: This study strongly suggests that screening for trauma history should be a routine part of mental health assessment and may significantly improve the recognition rate of PTSD. However, much work remains to be done in implementing appropriate treatment.

Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model.

The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, "homework" assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.

PTSD as a mediator between lifetime sexual abuse and substance use among jail diversion participants.

OBJECTIVE: Many of the individuals with serious mental illness involved in the criminal justice system have experienced interpersonal victimization, such as sexual abuse, and have high rates of alcohol and drug use disorders. Little attention has been paid to the prevalence of posttraumatic stress disorder (PTSD) and its potential role in the substance misuse of offenders with mental illness. METHODS: The study used a path analytic framework to test the hypothesis that PTSD mediates the relationship between sexual abuse and level of alcohol and drug use among individuals (N=386) with mental illness enrolled in a multisite (N=7) jail diversion project. RESULTS: Sexual abuse was strongly associated with PTSD, which was in turn associated with both heavy drug use and heavy drinking. CONCLUSIONS: These findings suggest that PTSD may be an important target for jail diversion programs.

Perceived coercion among jail diversion participants in a multisite study.

OBJECTIVE: Although jail diversion is considered an appropriate and humane response to the disproportionately high volume of people with mental illness who are incarcerated, little is known regarding the perceptions of jail diversion participants, the extent to which they feel coerced into participating, and whether perceived coercion reduces involvement in mental health services. This study addressed perceived coercion among participants in postbooking jail diversion programs in a multisite study and examined characteristics associated with the perception of coercion. METHODS: Data collected in interviews with 905 jail diversion participants from 2003 to 2005 were analyzed with random-effects proportional odds models. RESULTS: Ten percent of participants reported a high level of coercion, and another 26% reported a moderate level of coercion. Having a drug charge was associated with lower perceived coercion to enter the program. In addition, an interaction between sexual abuse and substance abuse indicated that recent sexual abuse was associated with higher levels of perceived coercion, but only among those without current substance abuse. At the 12-month follow-up (N=398), variables associated with higher perceived coercion to receive behavioral health services included spending more time in jail and higher perceived coercion at baseline. The amount of behavioral health service use was not predicted by perceived coercion at baseline. Rather, being older, having greater symptom severity, and having a history of sexual abuse but no substance abuse and no history of physical abuse were associated with higher levels of outpatient service use. CONCLUSIONS: Overall, one-third of jail diversion participants reported some level of perceived coercion. Important determinants of perceived coercion included charge type, length of time in jail, and sexual abuse history. Engagement in treatment was not affected by perceived coercion.

Disseminating evidence-based practices for adults with PTSD and severe mental illness in public-sector mental health agencies.

Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care. Yet few public-sector mental health agencies routinely provide specialized services for PTSD. The purpose of the article is to describe strategies and efforts to disseminate trauma-focused empirically based practices in a public-sector mental health system. Identified challenges include limited resources and commitment; knowledge deficits, attitudes, and biases; and limited practice accountability at provider, facility, and system levels. Proposed strategies for overcoming these challenges are to set clear goals, nurture broad-based organizational commitment and key stakeholder involvement, implement specialty training efforts to provide information and change attitudes, provide ongoing supervision, conduct fidelity monitoring, and ensure accountability to the extent possible.

Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study.

In an open trial design, adults (n=20) with posttraumatic stress disorder (PTSD) and either schizophrenia or schizoaffective disorder were treated via an 11-week cognitive-behavioral intervention for PTSD that consisted of education, anxiety management therapy, social skills training, and exposure therapy, provided at community mental health centers. Results offer preliminary hope for effective treatment of PTSD among adults with schizophrenia or schizoaffective disorder, especially among treatment completers (n=13). Data showed significant PTSD symptom improvement, maintained at 3-month follow-up. Further, 12 of 13 completers no longer met criteria for PTSD or were considered treatment responders. Clinical outcomes for other targeted domains (e.g., anger, general mental health) also improved and were maintained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no adverse events. Significant improvements were not noted on depression, general anxiety, or physical health status. Future directions include the need for randomized controlled trials and dissemination efforts.

Targeting trauma-related interventions and improving outcomes for women with co-occurring disorders.

National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.