Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness.

BACKGROUND: A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS: To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD: In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS: There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS: Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Undocumented PTSD among African American clients with serious mental illness in a statewide mental health system.

OBJECTIVES: African Americans are at increased risk for trauma exposure and the development of posttraumatic stress disorder (PTSD) relative to other racial groups. Among African Americans with Serious Mental Illness (SMI), PTSD is frequently underdiagnosed and untreated. The primary objective of this study was to investigate trauma exposure, PTSD symptom severity, and the rate of undocumented PTSD in medical records among African Americans diagnosed with SMI. METHODS: Screening for trauma exposure and PTSD symptoms was implemented among 404 clients receiving community mental health services. Participants endorsed at least 1 traumatic event, had a score of at least 45 on the DSM-IV PTSD Checklist indicating probable PTSD, and had a chart diagnosis of an Axis I disorder. RESULTS: Around 18.3% of participants had PTSD diagnosed in their medical chart. A diagnosis of schizophrenia/schizoaffective disorder was inversely related to the detection of PTSD in the chart. Client age and gender did not adversely affect the detection of PTSD, and detection rates remained low overall. Childhood sexual abuse was the most commonly endorsed index trauma, followed closely by sudden death of a loved one (including violent death). Participants typically experienced an average of 8 types of traumatic events in their lifetime. Cumulative total trauma exposure significantly predicted PTSD severity. Clients with mood disorders reported more severe PTSD. CONCLUSION: Findings highlight the low detection rate of PTSD and related symptoms in African American clients with SMI. There is a need for early intervention, grief counseling, culturally sensitive trauma screening, and culturally informed treatment options for this population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Partial hospitalization: compatible with evidence-based and recovery-oriented treatment?

Partial hospitalization is a service modality that some have suggested is incompatible with both evidence-based and recovery-oriented treatment. The purpose of this study was to examine the accuracy of this assumption. Toward this end, a specific partial hospitalization program was examined using administrative data, self-reports regarding recovery orientation, and fidelity ratings from independent assessors. Findings support that the partial hospitalization program studied has reasonable lengths of stay, provides recovery-oriented services, and has implemented evidence-based practices. We conclude that partial hospitalization programs have the potential to become part of an evidence-based and recovery-oriented system.

A Naturalistic Study of Racial Disparities in Diagnoses at an Outpatient Behavioral Health Clinic.

OBJECTIVE: The authors examined electronic medical record (EMR) outpatient data to determine whether African Americans with schizophrenia or schizoaffective disorder were more likely than non-Latino whites to screen positive for major depression. METHODS: EMR data for 1,657 patients at Rutgers University Behavioral Health Care certified community outpatient clinics were deidentified and accrued for 9 months starting July 1, 2017. A Fisher's exact test was used to compare differences in the proportion of patients with positive screens for major depression (cutoff score of ≥15 on the nine-item Patient Health Questionnaire) among African-American and non-Latino white patients diagnosed as having schizophrenia or schizoaffective disorder. RESULTS: Among patients diagnosed as having schizophrenia, African Americans were more likely than non-Latino whites (p<.003) to screen positive for major depression. The between-group difference in positive screens was not significant among patients diagnosed as having schizoaffective disorder. CONCLUSIONS: The results are consistent with findings from a large body of literature suggesting that racial differences in the diagnosis of schizophrenia in the United States result in part from clinicians underemphasizing the relevance of mood symptoms among African Americans compared with other racial-ethnic groups. If the results are replicated, a case could be made that routine screening for major depression in community mental health settings could reduce racial disparities in schizophrenia diagnoses.

Cost-Effectiveness of a PTSD Intervention Tailored for Individuals With Severe Mental Illness.

OBJECTIVE: This study examined the cost-effectiveness of a cognitive-behavioral therapy (CBT) intervention for posttraumatic stress disorder (PTSD) that is tailored for adults with a co-occurring severe mental illness. METHODS: Data were from a randomized trial involving 183 adult clients of two outpatient clinics and three partial hospitalization programs. All had a severe mental illness diagnosis (major mood disorder, schizophrenia, or schizoaffective disorder) and severe PTSD. Participants were randomly assigned to the tailored 12- to 16-session CBT intervention for PTSD (CBT-P) or a three-session breathing retraining and psychoeducation intervention (BRF). Cost estimates included intervention costs for training, supervision, fidelity assessment, personnel, and overhead and related mental health care costs for outpatient, inpatient, and emergency department services and for medications. The incremental cost-effectiveness ratio comparing CBT-P with BRF measured the added cost or savings per remission from PTSD at 12 months postintervention. Generalized linear models were used to estimate intervention effects on annual mental health care costs and the likelihood of a remission from PTSD. Ten thousand bootstrap replications were used to assess uncertainty. RESULTS: Annual mean mental health care costs were $25,539 per client (in 2010 dollars) for BRF participants and $29,530 per client for CBT-P participants, a nonsignificant difference. The mean incremental cost-effectiveness ratio was $36,893 per additional PTSD remission yielded by CBT-P compared with BRF (95% confidence interval=-$33,523 to $158,914). Remissions were associated with improvements in quality of life and functioning. CONCLUSIONS: An effective CBT intervention tailored for adults with severe mental illness and PTSD was not found to be more cost-effective than a brief three-session intervention.

Efficacy of the team solutions program for educating patients about illness management and treatment.

OBJECTIVE: Despite the demonstrated efficacy of psychosocial approaches to schizophrenia treatment that include a psychoeducational component, such as illness management, the implementation of these approaches into routine mental health treatment has been slow. The authors sought to examine the efficacy of a comprehensive, modularized, psychoeducational program called Team Solutions, which was designed to educate patients with major mental illnesses about their illness and how to manage it. Team Solutions was chosen for study because it is available over the Internet and other venues at no cost and is used by mental health agencies across the United States and Canada. METHODS: Seventy-one persons with schizophrenia or schizoaffective disorder from three day treatment settings participated in this randomized, single-blind study. Participants were randomly assigned to attend one of two interventions: the Team Solutions intervention, which consisted of participating in a 24-week psychoeducational group focused on illness management, or treatment as usual. RESULTS: For participants who attended the experimental group, significant improvement was observed in knowledge about schizophrenia. In addition, client satisfaction was high. However, no changes were observed in symptoms or functioning. CONCLUSIONS: Results indicated that participation in the Team Solutions psychoeducational group improved participants' knowledge. However, participation in the program did not demonstrate superiority over treatment as usual with respect to secondary and tertiary outcomes, such as symptom severity, treatment adherence, and global functioning.

Diagnostic patterns in Latino, African American, and European American psychiatric patients.

BACKGROUND: The purpose of this study was to examine whether Latino patients presenting for behavioral health treatment showed major systematic differences in presenting symptoms, clinical severity, and psychiatric diagnosis compared with European American and African American patients. Documenting such differences should have important implications for evidence-based clinical practice. METHODS: Data were drawn from a large behavioral health service delivery system in New Jersey, and included administrative data, clinical diagnosis, a clinician-rated global level of functioning, and a self-reported symptoms and functioning scale. The study involved a clinical sample of all new admissions into the system between January 1, 2000, and August 31, 2001. To examine the main effects of ethnicity, in the context of other independent variables, logistic regression was performed for each of 3 dependent binary variables: presence or absence of major depression, a schizophrenia spectrum disorder, and bipolar disorder. RESULTS: Consistent with previous studies, we found that African Americans were diagnosed as having a disorder in the schizophrenic disorders spectrum more frequently than did Latinos and European Americans (odds ratio, 1.80; 95% confidence interval, 1.62-2.00). Latinos were disproportionately diagnosed as having major depression, despite the fact that significantly higher levels of psychotic symptoms were self-reported by Latinos (odds ratio, 1.74; 95% confidence interval, 1.56-1.93). CONCLUSIONS: Latinos in this study were more likely to be clinically diagnosed as having major depression than were other ethnic groups. Further research is needed to determine the reasons for these systematic differences. Possible explanations include (1) self-selection, (2) culturally determined expression of symptoms, (3) difficulties in the accurate application of DSM-IV diagnostic criteria to Latinos, (4) bias related to lack of clinicians' cultural competence, and (5) imprecision inherent in the use of unstructured interviews, possibly combined with clinician bias. Additional research is required to determine the generalizability, accuracy, and applicability of these findings and their possible mechanisms.

Service Use and Self-Reported Symptoms Among Persons With Positive PTSD Screens and Serious Mental Illness.

OBJECTIVE: Although many studies have reported higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness, the screening, diagnosis, and treatment of PTSD in public mental health centers remain at a suboptimal level and PTSD is often overlooked and untreated. This study used routine PTSD screening and service use data in electronic medical records to determine the association of PTSD, psychiatric symptoms, and service use in a sample of individuals with serious mental illness in a community-based treatment setting. METHODS: The sample included 1,834 active clients between January 2007 and November 2010 who were screened for PTSD and who completed the 24-item Behavior and Symptom Identification Scale (BASIS-24). Service data included services provided a year before and a year after the screening date. RESULTS: PTSD was associated with more severe psychiatric symptoms and increased no-show rates but not with increased service use or use of high-intensity services. PTSD likelihood interacted with race in accounting for elevated scores among African Americans on the psychosis domain of the BASIS-24. CONCLUSIONS: PTSD screening is feasible and recommended in service environments and may contribute significantly to better understanding of racial-ethnic and other differences in service use and diagnostic practices.

Increasing tobacco dependence treatment through continuing education training for behavioral health professionals.

OBJECTIVE: Few continuing education programs to train behavioral health professionals to deliver tobacco treatment services have been described and evaluated. METHODS: The effectiveness of two-day training on changing practice was examined by review of clinical charts from 20 clinicians who attended in 2012. Ten medical records were randomly selected for review from each clinician's outpatient practice at a large behavioral health system. Five charts from smokers seen within six months before and after training were reviewed per clinician, for a total of 200. Records were electronically searched on "cigarette," "nicotine," "tobacco," "quit," "smoking," and "smoke." RESULTS were compared via chi square tests (all p<.05). RESULTS: Almost half of the smokers indicated that they were interested in quitting, although baseline rates of tobacco use treatment were very low. Documentation of tobacco use significantly increased between baseline and posttraining, both on the problem list (35% versus 74%) and treatment plan (20% versus 60%). Also posttraining, clinicians advised significantly more outpatients to quit (9% versus 36%) or referred them to individual or group counseling. Discussion of nicotine replacement was documented more frequently in charts (10% versus 31%), and prescriptions for tobacco treatment medications increased significantly in the posttraining period, although overall prescribing remained low. The proportion of patients making quit attempts also significantly increased in the posttraining period (10% versus 39%), suggesting that providers were delivering more tobacco treatment than was reflected in charts. CONCLUSIONS: An intensive training program for behavioral health professionals increased tobacco treatment and patient quit attempts. Strategies beyond training may be needed to enhance prescribing by these practitioners.

Managing atypical antipsychotic-associated weight gain: 12-month data on a multimodal weight control program.

BACKGROUND: The purpose of this study was to test prospectively the feasibility and efficacy of a multimodal weight control program for over-weight and obese severely mentally ill adults who had gained weight while taking atypical antipsychotic medications. METHOD: Thirty-one subjects with schizophrenia or schizoaffective disorder (DSM-IV), on treatment with atypical antipsychotics, participated in a 52-week, multimodal weight control program that incorporated nutrition, exercise, and behavioral interventions. The primary outcomes were measures of body mass index (BMI) and weight. A variety of secondary outcomes, including hemoglobin A(1c) level, systolic and diastolic blood pressure, and cholesterol level, were compared from baseline to endpoint. Weight and BMI changes in the intervention group were also compared with changes in 20 nonintervention patients ("usual care" group) who were contemporaneously treated in the same clinics. RESULTS: Twenty of the 31 subjects in the intervention group completed the program. Statistically significant pre-post improvements in weight (p <.02), BMI (p <.02), hemoglobin A(1c) levels (p <.001), diastolic (p <.001) and systolic (p <.05) blood pressure, exercise level (p <.003), nutrition knowledge (p <.0001), and stage of change (exercise [p <.0001] and weight [p <.008]) were seen in the intervention group. Patients attended a mean of 69% of the sessions during the year of the program. Weight and BMI also decreased significantly (p =.01) in the intervention group compared with the "usual care" group, who gained weight during the observation period. CONCLUSIONS: Individuals with schizophrenia and schizoaffective disorder were willing to attend, and benefited from, a weight control program that focused on nutrition, exercise, and motivation. The program resulted in clinically significant reductions in weight, BMI, and other risk factors for long-term poor health, including hemoglobin A(1c). In contrast, patients who did not receive the weight control intervention continued to gain weight.

Correlates of health insurance among persons with schizophrenia in a statewide behavioral health care system.

This study explored the demographic and service use correlates of insurance status among 539 persons with schizophrenia-spectrum disorders by using the administrative data set of a statewide behavioral health care system. Lack of health insurance was prevalent in the sample (20 percent) and was associated with younger age, Latino ethnicity, and male sex. Persons who did not have insurance were less likely to use a community-based service and more likely to use only crisis or emergency services than persons who had public or private insurance. The findings are consistent with the results of previous research demonstrating that lack of insurance is associated with decreased use of community-based services among persons with severe mental illness.

A program for managing weight gain associated with atypical antipsychotics.

This study assessed the efficacy of a weight control program for patients taking atypical antipsychotics. Thirty-one patients with schizophrenia or schizoaffective disorder participated in a 12-week weight control program that incorporated nutrition, exercise, and behavioral interventions. Changes in patients' weight and in body mass index (BMI) were recorded and compared with those of 15 patients in a control group. The intervention group had a mean weight loss of 2.7 kg (six pounds) and a mean reduction of.98 BMI points, compared with a mean weight gain of 2.9 kg (6.4 pounds) and a mean gain of 1.2 BMI points in the control group. These data suggest that the intervention was effective in this group of patients. Professionals treating persons who are taking atypical antipsychotics should encourage them to engage in weight control activities.

Aging and outpatient service use among persons with schizophrenia-spectrum disorders in a statewide behavioral healthcare system.

This investigation explored the demographic and service use correlates of age among young, midlife, and older adults diagnosed with schizophrenia-spectrum disorders (N = 513), using the administrative data set of a statewide behavioral healthcare system. More African Americans persons were represented in the younger groups (age 18-35, 36-44) than in the older group (age 45 and older). Nearly two thirds of persons with schizophrenia-spectrum disorders seeking outpatient treatment were younger than 45. With the exception of crisis/emergency department services, persons in different age groups did not differ in the amount and type of outpatient service utilized and in the likelihood of dropping out of services early. However, persons aged between 18 and 44 used significantly more crisis/emergency department services than did those aged 45 and older. The findings suggest the importance of relapse prevention for persons aged 18-44 treated in outpatient settings.

Concordance between measured and self-perceived weight status of persons with serious mental illness.

OBJECTIVE: This study investigated concordance between self-perceived and measured weight status for persons with serious mental illness. METHODS: A total of 586 mental health clients assessed their weight as underweight, normal, overweight, or obese. The agreement between these self-assessments and the same categories based on measured body mass index was related to gender, ethnicity, education, age, and psychiatric diagnosis. RESULTS: Three hundred consumers (51%) underestimated their weight (they thought they weighed less than they did); only 35 (6%) overestimated it. In logistic regression analyses, gender, education, and psychiatric diagnosis showed significant effects on accuracy of self-perception, but ethnicity and age did not. CONCLUSIONS: People with serious mental illness are more likely than others to have weight problems, which contribute to higher rates of morbidity and mortality. However, they also tend to underestimate their weight. This gap between reality and self-perception must be addressed.

Service use among patients with serious mental illnesses who presented with physical symptoms at intake.

OBJECTIVE: The goal of this study was to examine relationships among serious mental illness, general physical symptoms, and use of mental health services among persons presenting for admission at a community-based mental health center. METHODS: Number and type of physical symptoms were assessed during the routine intake process. Individuals (N=1,022) were screened by phone with a modified version of the Physical Health Questionnaire-15. Diagnostic, demographic, and treatment information was tracked prospectively. Data were analyzed for 682 individuals who kept at least one appointment. Analyses examined associations among physical symptoms, diagnosis, and service use over time. RESULTS: A total of 481 patients (71%) reported three or more physical symptoms. Patients with three or more physical symptoms were significantly older (p<.013), were more likely to be female (p<.001) and Spanish speaking (p<.05), and used significantly more services (p<.001) than did those with fewer physical symptoms. Both the number and the costs of services increased with the number of physical symptoms presented at intake. Patients with major depressive disorder were as likely as patients with schizophrenia or bipolar disorder to report having three or more physical symptoms. CONCLUSIONS: Within a mental health community-based population, most incoming clients with serious mental illness reported three or more physical symptoms. The number of reported physical symptoms was a significant predictor of mental health service use and cost over the episode of care, even after analyses controlled for confounders such as gender, age, and diagnosis.

Ethnicity and clinical psychiatric diagnosis in childhood.

This paper focuses on whether a consistent difference by ethnicity existed in the clinical diagnosis of children and adolescents in two behavioral health service environments and reviews plausible explanations for such a difference. Key measures were clinical diagnosis and ethnicity, abstracted from the administrative dataset of a New Jersey behavioral health care organization during 2000-2002, and a data collection conducted for the State of Indiana during 1991-1992. Sample sizes were 5,394 and 10,437, respectively. Only primary diagnoses were used in this study, classified into externalizing versus internalizing disorders. Logistic regression was performed for the dependent variable of presence/absence of an externalizing disorder or internalizing disorder. A main effect for ethnicity was found; African American youth received more externalizing diagnoses than did European American youth (odds ratio 2.01 (CI: 1.73-2.33) in one sample and 1.67 (CI: 1.44-1.94) in the other); African American youth also received fewer internalizing diagnoses than European American youth (odds ratio 0.55 (CI: .48-.63) in one sample and 0.75 (CI:.64-.88) in the other. Potential explanations for these findings include: 1. Biopsychosocial origin; 2. Clinician bias; 3. Discordant normative behavioral expectations between parents and service providers; and 4. Interaction between differential expression of underlying pathology and tolerance for such expressions.

Managed care and clinical decision-making in child and adolescent behavioral health: provider perceptions.

This study investigated how managed care affects clinical decision-making in a behavioral health care system. Providers serving children and adolescents under both managed and unmanaged care (n = 28) were interviewed about their awareness of differences between the benefit arrangements, how benefits affect clinical decision-making, outcomes and quality of care; and satisfaction with care. Quantitative and qualitative findings indicated that providers saw both advantages and disadvantages to managed care. Although most providers recognized the advantages of managed care in increasing efficiency, many were concerned that administrative pressures associated with managed care compromise service quality.