Barriers and Potential Solutions to Implementing Evidence-Based PTSD Treatment in Military Treatment Facilities.

INTRODUCTION: Prolonged exposure therapy is an effective treatment for posttraumatic stress disorder that is underutilized in health systems, including the military health system. Organizational barriers to prolonged exposure implementation have been hypothesized but not systematically examined. This multisite project sought to identify barriers to increasing the use of prolonged exposure across eight military treatment facilities and describe potential solutions to addressing these barriers. MATERIALS AND METHODS: As part of a larger project to increase the use of prolonged exposure therapy in the military health system, we conducted a needs assessment at eight military treatment facilities. The needs assessment included analysis of clinic administrative data and a series of stakeholder interviews with behavioral health clinic providers, leadership, and support staff. Key barriers were matched with potential solutions using a rubric developed for this project. Identified facilitators, barriers, and potential solutions were summarized in a collaboratively developed implementation plan for increasing prolonged exposure therapy tailored to each site. RESULTS: There was a greater than anticipated consistency in the barriers reported by the sites, despite variation in the size and type of facility. The identified barriers were grouped into four categories: time-related barriers, provider-related barriers, barriers related to patient education and matching patients to providers, and scheduling-related barriers. Potential solutions to each barrier are described. CONCLUSIONS: The findings highlight the numerous organizational-level barriers to implementing evidence-based psychotherapy in the military health system and offer potential solutions that may be helpful in addressing the barriers.

How well do juvenile risk assessments measure factors to target in treatment? Examining construct validity.

There has been a surge of interest in using 1 type of risk assessment instrument to tailor treatment to juveniles to reduce recidivism. Unlike prediction-oriented instruments, these reduction-oriented instruments explicitly measure variable risk factors as "needs" to be addressed in treatment. There is little evidence, however, that the instruments accurately measure specific risk factors. Based on a sample of 237 serious juvenile offenders (Mage = 18, SD = 1.6), we tested whether California Youth Assessment Inventory (CA-YASI) scores validly assess the risk factors they purport to assess. Youth were assessed by practitioners with good interrater reliability on the CA-YASI, and by research staff on a battery of validated, multimethod criterion measures of target constructs. We meta-analytically tested whether each CA-YASI risk domain score (e.g., Attitudes) related more strongly to scores on convergent measures of theoretically similar constructs (e.g., criminal thinking styles) than to scores on discriminant measures of theoretically distinct constructs (e.g., intelligence, somatization, and pubertal status). CA-YASI risk domain scores with the strongest validity support were those that assess criminal history. The only variable CA-YASI risk domain score that correlated more strongly with convergent (Zr = .35) than discriminant (Zr = .07) measures was Substance Use. There was little support for the construct validity of the remaining 6 variable CA-YASI risk domains-including those that ostensibly assess strong risk factors (e.g., "Attitudes," "Social Influence"). Our findings emphasize the need to test the construct validity of reduction-oriented instruments-and refine instruments to precisely measure their targets so they can truly inform risk reduction. (PsycINFO Database Record

Anger, hostility, and hospitalizations in patients with heart failure.

OBJECTIVE: Heart failure patients have a high hospitalization rate, and anger and hostility are associated with coronary heart disease morbidity and mortality. Using structural equation modeling, this prospective study assessed the predictive validity of anger and hostility traits for cardiovascular and all-cause rehospitalizations in patients with heart failure. METHOD: 146 heart failure patients were administered the STAXI and Cook-Medley Hostility Inventory to measure anger, hostility, and their component traits. Hospitalizations were recorded for up to 3 years following baseline. Causes of hospitalizations were categorized as heart failure, total cardiac, noncardiac, and all-cause (sum of cardiac and noncardiac). RESULTS: Measurement models were separately fit for Anger and Hostility, followed by a Confirmatory Factor Analysis to estimate the relationship between the Anger and Hostility constructs. An Anger model consisted of State Anger, Trait Anger, Anger Expression Out, and Anger Expression In, and a Hostility model included Cynicism, Hostile Affect, Aggressive Responding, and Hostile Attribution. The latent construct of Anger did not predict any of the hospitalization outcomes, but Hostility significantly predicted all-cause hospitalizations. Analyses of individual trait components of each of the 2 models indicated that Anger Expression Out predicted all-cause and noncardiac hospitalizations, and Trait Anger predicted noncardiac hospitalizations. None of the individual components of Hostility were related to rehospitalizations or death. CONCLUSION: The construct of Hostility and several components of Anger are predictive of hospitalizations that were not specific to cardiac causes. Mechanisms common to a variety of health problems, such as self-care and risky health behaviors, may be involved in these associations. (PsycINFO Database Record

Analyzing offense patterns as a function of mental illness to test the criminalization hypothesis.

OBJECTIVE: Programs for offenders with mental illness seem to be based on a hypothesis that untreated symptoms are the main source of criminal behavior and that linkage with psychiatric services is the solution. This study tested this criminalization hypothesis, which implies that these individuals have unique patterns of offending. METHODS: Participants were 220 parolees; 111 had a serious mental illness, and 109 did not. Interview data and records were used to reliably classify offenders into one of five groups, based on their lifetime pattern of offending: psychotic, disadvantaged, reactive, instrumental, or gang- or drug-related affiliation. The distributions of those with and without serious mental illness were compared. RESULTS: A small but important minority of offenders with a mental illness (7%, N=8) fit the criminalization hypothesis, in that their criminal behavior was a direct result of psychosis (5%, N=6) or comprised minor "survival" crimes related to poverty (2%, N=2). However, the reactive group contained virtually all offenders with a mental illness (90%, N=100) and the vast majority of offenders without a mental illness (68%, N=74), suggesting that criminal behavior for both groups chiefly was driven by hostility, disinhibition, and emotional reactivity. For most offenders with a mental illness in the reactive group, crime was also driven by substance dependence. CONCLUSIONS: Offenders with serious mental illness manifested heterogeneous patterns of offending that may stem from a variety of sources. Although psychiatric service linkage may reduce recidivism for a visible minority, treatment that targets impulsivity and other common criminogenic needs may be needed to prevent recidivism for the larger group.