PTSD'S mediation of the relationships between trauma, depression, substance abuse, mental health, and physical health in individuals with severe mental illness: evaluating a comprehensive model.

OBJECTIVE: Following trauma exposure and PTSD, individuals with severe mental illness (SMI) frequently suffer a complex course of recovery complicated by reduced mental and physical health and increased substance abuse. The authors evaluated a theoretical PTSD-SMI model which theorizes that trauma, PTSD, depression, substance abuse, mental health, and physical health are interrelated and that PTSD mediates these relationships. METHOD: Participants were ethnoracially diverse individuals diagnosed with SMI (N=175) who were assessed for trauma exposure, severity of PTSD and depression, substance abuse, and overall mental and physical health functioning. Pearson's correlations were utilized to examine the relationships between study domains. The mediating effects of PTSD were assessed using regression coefficients and the Sobel test for mediation. RESULTS: A majority of participants with SMI (89%) reported trauma exposure and 41% reported meeting diagnostic criteria for PTSD. On average, participants were exposed to over four types of traumatic events. Trauma, severity of PTSD and depression, substance abuse, and overall mental and physical health functioning were significantly interrelated. PTSD partially mediated the relationships between trauma and severity of depression and between trauma and overall mental health; PTSD fully mediated the trauma and overall physical health relationship. DISCUSSION: Within an ethnoracially diverse SMI sample, trauma exposure and PTSD comorbidity were high and associated with severity of depression, substance abuse, overall mental health and physical health functioning. Supporting our theoretical PTSD-SMI model, PTSD mediated the adverse effects of trauma exposure on participants' current severity of depression and overall mental and physical health functioning.

Examining the effectiveness of an intervention designed for the restoration of competency to stand trial.

This study examined the effectiveness of the Fitness Game, an intervention created for the restoration of competency to stand trial. Of 28 participants who completed either the experimental or control intervention at Hawai'i State Hospital (HSH), it was found that both groups had significant pretest to posttest improvements on Understanding and Appreciation subsets of the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA). However, there was no statistically significant difference between the groups on competency measures, indicating that the Fitness Game was not significantly more effective at restoring competency than non-legal programming. In other words, individuals committed to a psychiatric hospital for care and treatment were as likely to improve as those receiving additional specialized competency restoration treatment.

Assessment of Medicaid managed behavioral health care for persons with serious mental illness.

OBJECTIVES: This five-site study compared Medicaid managed behavioral health programs and fee-for-service programs on use and quality of services, satisfaction, and symptoms and functioning of adults with serious mental illness. METHODS: Adults with serious mental illness in managed care programs (N=958) and fee-for-service programs (N=1,011) in five states were interviewed after the implementation of managed care and six months later. After a multiple regression to standardize the groups for case mix differences, a meta-analysis using a random-effects model was conducted, and bioequivalence methods were used to determine whether differences were significant for clinical or policy purposes. RESULTS: A significantly smaller proportion of the managed care group received inpatient care (5.7 percent compared with 11.5 percent). The managed care group received significantly more hours of primary care (4.9 compared with 4.5 hours) and was significantly less healthy. However, none of these differences exceed the bioequivalence criterion of 5 percent. Managed care and fee for service were "not different but not equivalent" on 20 of 34 dependent variables. Cochrane's Q statistic, which measured intersite consistency, was significant for 20 variables. CONCLUSIONS: Managed care and fee-for-service Medicaid programs did not differ on most measures; however, a lack of sufficient power was evident for many measures. Full endorsement of managed care for vulnerable populations will require further research that assumes low penetration rates and intersite variability.

Neurocognition and long-term prediction of quality of life in outpatients with severe and persistent mental illness.

The present study examined the predictive validity of neuropsychological measures to quality of life (QOL) indicators in 30 outpatients with severe and persistent mental illness (SPMI), an average of 15 years post-testing. Outcome measures included subscale scores on the Brief Quality of Life Inventory (BQOLI). Results of several stepwise multiple regressions revealed that memory was predictive of income, satisfaction with daily activities, and general health. Executive functioning was predictive of contact with family and financial support. Motor skills were predictive of satisfaction with family contact, and working memory was predictive of victimization and satisfaction with social contacts. Discussion focused on neurocognition as a predictor of QOL, clinical implications, and the potential for improving QOL through cognitive interventions.

Neurocognition and community outcome in schizophrenia: long-term predictive validity.

The present study examined the predictive validity of neuropsychological measures to functional outcome in 26 schizophrenic patients 15-plus year post-testing. Outcome measures included score on the Resource Associated Functional Level Scale (RAFLS), number of state hospital admissions, and total duration of state hospital inpatient stay. Results of several stepwise multiple regressions revealed that verbal memory significantly predicted RAFLS score, accounting for nearly half of the variance. Trails B significantly predicted duration of state hospital inpatient status. Discussion focused on the utility of these measures for clinicians and system planners.