A multicomponent approach toward understanding emotion regulation in schizophrenia.

OBJECTIVES: Emotion deficits are well documented in people with schizophrenia. Far less is known about their ability to implement emotion regulation strategies. We sought to explore whether people with schizophrenia can modify their emotion responses similar to controls. METHODS: People with (n = 25) and without (n = 21) schizophrenia were instructed to amplify positive-emotion expression, reappraise negative emotion experience, and suppress physiological response. Multiple components of emotion response were measured (experience, expression, and physiology). RESULTS: Although people with schizophrenia showed increased positive expressivity following amplification and decreased negative emotion experience following reappraisal, overall, they expressed less positive emotion and experienced more negative emotion compared with controls. Neither group was effective at physiological suppression. CONCLUSIONS: Together these findings suggest that people with schizophrenia can engage in amplification and reappraisal when explicitly instructed to do so, albeit additional practice may be necessary to modify emotion responses to levels similar to controls.

High inpatient utilization among Veterans Health Administration patients with substance-use disorders and co-occurring mental health conditions.

BACKGROUND: Substance-use disorders (SUDs) are common and costly conditions. Understanding high inpatient utilization (HIU) among patients with SUD can inform the development of treatment approaches designed to reduce healthcare expenditures and improve service quality. OBJECTIVES: To examine the prevalence, type, and predictors of HIU among patients with SUD and co-occurring mental health conditions. METHODS: Service utilization and demographic and clinical variables were extracted from a national sample of Veterans Health Administration (VA) patients with SUD-only [n = 148,960 (98.3% male)], SUD plus serious mental illness ([i.e. schizophrenia- and/or bipolar-spectrum disorders; SUD/SMI; n = 75,913 (91.6% male)], and SUD plus other mental illness [SUD/MI; n = 245,675 (94.6% male)]. Regression models were used to examine HIU during a follow-up year. RESULTS: Prevalence of HIU among the SUD-only group was 6.2% (95% confidence interval (CI): 6.1%-6.3%) compared with 22.7% (95% CI: 22.4%-23.0%) and 9.7% (95% CI: 9.6%-9.8%) among the SUD/SMI and SUD/MI groups, respectively. Patients with SUD/MI represented nearly half of the HIU sample. Primary type of inpatient service use varied by comorbidity: SUD-only = medicine; SUD/SMI = psychiatric; SUD/MI similar use of psychiatric, SUD-related, and medicine. Predictors of HIU were generally similar across groups: older age, unmarried, homelessness, suicide risk, pain diagnosis, alcohol/opioid/sedative-use disorders, and prior-year emergency department/inpatient utilization. CONCLUSIONS: Substantial reductions in HIU among an SUD population will likely require treatment approaches that target patients with less-severe mental health conditions in addition to SMI. Cross-service collaborations (e.g., integration of medical providers in SUD care) and interventions designed to target issues and/or conditions that lead to HIU (e.g., homeless care services) may be critical to reducing HIU in this population.

The relationships of posttraumatic stress disorder and depression symptoms with health-related quality of life and the role of social support among Veterans.

PURPOSE: The presence of posttraumatic stress disorder (PTSD) or depression symptoms is associated with poor quality of life. Social support buffers against developing symptoms of PTSD and depression and is associated with greater quality of life. We examined the relationships between PTSD and depression symptom severity with physical (PCS) and mental (MCS) health-related quality of life (HRQoL), and whether social support moderated these relationships. METHODS: Randomly selected Veterans with at least one Primary Care or PTSD Clinical Team visit received a mailed survey including self-report measures of health and wellness. Among the 717 respondents, we examined the association between symptom severity and HRQoL using linear regression. We included interaction terms between symptom severity and social support to examine whether social support moderated these associations. RESULTS: Social support did not moderate the association between symptom severity and mental HRQoL. Higher PTSD and depression symptom severity were associated with lower MCS scores, whereas higher social support was associated with higher MCS scores. When examining physical HRQoL, social support moderated the association with PTSD and depression symptom severity. Among individuals with high social support, there was a negative association between symptom severity and PCS scores, whereas there was no association among those with low social support. CONCLUSIONS: Although there are contexts in which social support is helpful, in some cases it may interfere with HRQoL among those with mental health conditions. Thus, it is important to educate support providers about behaviors that enhance the benefits and minimize the costs of social support.

Preliminary examination of a measure of metacognitive perspective-taking: The Interpersonal Block Assembly Task.

OBJECTIVE: People with schizophrenia experience deficits in perspective-taking and metacognition, both of which are related to social impairment in the disorder. Current measurement paradigms vary in their ability to capture the nuanced interconnection of metacognitive and perspective-taking processes during dyadic interactions. This study aimed to introduce the Interpersonal Block Assembly Task (IBAT) as a measure of metacognitive perspective-taking and to provide preliminary evidence of reliability and validity in a sample of people with schizophrenia. METHOD: Thirty-nine people with schizophrenia and 35 healthy people (without a psychiatric diagnosis) participated in this study. Participants were administered the IBAT as well as other measures of social cognition, neurocognition, and symptoms. Indices of internal consistency and interrater reliability were calculated, and convergent validity was assessed using correlational analyses. Analysis of covariance was used to test whether the IBAT could differentiate participant groups. RESULTS: The IBAT total score displayed adequate internal consistency and interrater reliability, and evidenced expected associations with social cognition, neurocognition, and negative symptoms. The IBAT also differentiated patient groups such that those with schizophrenia performed significantly worse. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This pilot study suggests potential utility of the IBAT and provides preliminary evidence of reliability and validity of this unique measure of metacognitive perspective-taking for people with schizophrenia. With further research, the IBAT may be a valuable contribution to the field of psychiatric rehabilitation, especially considering increased emphasis on social-cognitive and metacognitive intervention approaches. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A positive emotion regulation intervention for bipolar I disorder: Treatment development and initial outcomes.

OBJECTIVE: Dysfunction in positive affect is a defining symptom of bipolar I disorder (BD), both during and between mood episodes. We hypothesize that helping people with BD learn skills to create balance in their affective experiences by engaging in strategies that increase low activation positive emotion (LAP; e.g., relaxation) could help to improve well-being during periods of symptom remission. We discuss the development and preliminary outcomes of a positive emotion regulation (PER) group treatment for people with BD, designed as a supplement to pharmacological treatment. METHOD: The Learning Affective Understanding for a Rich Emotional Life (LAUREL) intervention is a group-based intervention covering 10 empirically supported skills designed to increase LAP. Sixteen people with BD enrolled in the LAUREL intervention and twelve completed baseline and post-intervention assessments. RESULTS: Participants who completed the study (n = 12) attended the majority of groups (87.96%) and reported practicing skills, on average, 16 times a week. We were unable to detect significant differences in mania symptoms following engagement in this PER intervention. Finally, participants reported increases in several areas associated with well-being post-intervention, including mindfulness, reappraisal, and self-compassion. CONCLUSION: This study provides a theoretical framework and preliminary support for a PER intervention for BD.

Feasibility of a care management approach for complex substance use disorders and high acute services utilization.

Although care management approaches have potential to improve clinical outcomes and reduce healthcare costs, little is known about the feasibility of these interventions in patients with complex substance use disorders (SUDs), which are characterized by psychosocial, psychological and/or medical needs and high acute healthcare utilization. We assessed the feasibility of recruitment, treatment engagement, compliance with follow-up assessments, and patients' use of a care management model (CMM) at one medical center. This pilot study enrolled patients with complex SUDs and high healthcare utilization in a prospective, 1-year open trial of a CMM adapted for specific needs of this patient population. Patients completed baseline assessment, monthly assessments of treatment progress and follow-up assessments at 6- and 12-months. Patients' use of CMM services were abstracted from medical records. Of 33 eligible patients approached, 23 (69.6%) men enrolled in the study. Approximately 59.1% of patients attended a CMM visit in ≥8 of 12 months enrolled. Patients completed monthly assessments in 4.9 (SD = 3.1) of 12 months enrolled, and 68.2% and 41.0% completed 6- and 12-month follow-up assessments, respectively. The most common CMM service delivered was care coordination/case management, followed by supportive counseling, motivational interviewing, and medication management. Recruitment and engagement results suggest that use of CMM for complex SUDs and high healthcare utilization is feasible. More robust outreach services may be needed to increase engagement among those who did not engage or lost contact with the CMM team. Additional research is needed to evaluate if CMM enhances retention, improves outcomes and reduces acute healthcare utilization of patients with complex SUDs.

Gender differences in service utilization among Operations Enduring Freedom, Iraqi Freedom, and New Dawn Veterans Affairs patients with severe mental illness and substance use disorders.

Severe mental illness (SMI) and substance use disorders (SUD) are among the more chronic and costly mental health conditions treated in the Department of Veterans Affairs (VA). Service use patterns of returning veterans with SMI and SUD have received little attention. We examined gender differences in the utilization of VA services among a national sample of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) VA patients with SMI, SUD, and their comorbidity (SMI/SUD) in their first year of established VA care (N = 24,166). Outpatient services and acute-residential stays were modeled using negative binomial and logistic regression, respectively. Among all diagnostic categories, men used outpatient services less often than did women, including primary care (adjusted rate ratio [ARR] = .71, 95% confidence interval CI [.68, .74]), mental health (ARR = .85, 95% CI [.80, .91]), and addiction (ARR = .91, 95% CI [.83, .99]) services. For emergency department (ED) and psychiatric inpatient services, gender interacted significantly with diagnosis. The combination of SMI/SUD compared to either SMI or SUD conferred greater risk of ED utilization among men than women (adjusted odds ratio [AOR] = 2.09, 95% CI [1.24, 3.51], and 1.95, 95% CI [1.17, 3.26], respectively). SMI versus SUD conferred greater risk of psychiatric inpatient utilization among men than women (AOR = 1.83, 95% CI [1.43, 2.34]). Our findings point to gender differences in outpatient and acute service utilization among OEF/OIF/OND VA patients with some of the more chronic and costly mental health conditions. Further investigation of health care utilization patterns is needed to understand factors driving these gender differences to ensure that veterans have appropriate access to the services they need. (PsycINFO Database Record

Patients' perspectives on care management services for complex substance use disorders.

Although care management approaches have potential to improve clinical outcomes and reduce high health care costs of patients with complex substance use disorders, characterized by high psychosocial, psychological, and/or medical needs and high acute health care utilization, little is known about patients' perspectives or experiences with these interventions. The objectives of this study were to identify barriers and facilitators to patient engagement in care management services for complex substance use disorders from patients' perspectives. This pilot study invited 22 men with complex substance use disorders and high health care utilization who were enrolled in a 1-year open trial of a Care Management Model to complete semi-structured interviews at 1- and 3-months post-baseline. Interviews were recorded, transcribed, and analyzed using template analysis. Five themes related to engagement were identified: barriers to conventional substance use disorder treatment, facilitators of care management services, patient-provider relationship, patient-related factors, and enhancements to a Care Management Model. Results highlighted the importance of the patient-provider relationship, individual visits with providers, flexible and personalized treatment, and a focus on recovery over abstinence in promoting patient engagement in care management services. Results also highlighted a need for increased outreach and assistance with housing and transit to treatment. Patients' perspectives support key elements of the care management services that are designed to facilitate patient engagement and suggest the need for additional outreach and assistance with obtaining shelter and transportation. Additional research is needed to evaluate if care management approaches enhance retention, improve outcomes, and reduce health care utilization of patients with complex and chronic substance use disorders.

Toward an understanding of anticipatory pleasure deficits in schizophrenia: Memory, prospection, and emotion experience.

Anticipatory pleasure deficits have been observed in people with schizophrenia. Less is known about the extent to which interrelated processes that comprise anticipatory pleasure, including memory, prospection, and emotion experience are disrupted. We asked people with (n = 32) and without (n = 29) schizophrenia or schizoaffective disorder to provide memory and prospection narratives in response to specific cues. Half of the prospections followed a memory task, and half followed a control task. People with schizophrenia generated memories similar in content and experience as controls even as they described them less clearly. However, people with schizophrenia were less likely to explicitly reference the past in their prospections, and their prospections were less detailed and richly experienced than controls, regardless of the task completed before prospection. People with schizophrenia reported similar levels of positive emotion (current and predicted) in positive prospections that followed the memory task, but less positive emotion than controls in positive prospections that followed the control task. Taken together, these results suggest that people with schizophrenia experience difficulties drawing from past experiences and generating detailed prospections. However, asking people with schizophrenia to recall and describe memories prior to prospection may increase the likelihood of drawing from the past in prospections, and may help boost current and predicted pleasure.

Military Sexual Trauma and Co-occurring Posttraumatic Stress Disorder, Depressive Disorders, and Substance Use Disorders among Returning Afghanistan and Iraq Veterans.

PURPOSE: Posttraumatic stress disorder (PTSD), depressive disorders (DD), and substance use disorders (SUD) are prevalent among veterans. A positive military sexual trauma (MST) screen is associated with higher likelihood of each of these disorders. The current study examined the associations between MST, gender, and co-occurring PTSD, DD, and SUD among veterans receiving services at the Department of Veterans Affairs to inform assessment and treatment. We were specifically interested in the interactions between MST and gender on co-occurring disorders. METHODS: The sample included 494,822 Department of Veterans Affairs service-seeking veterans (12.5% women) deployed to Iraq and Afghanistan who recently separated from the military and were screened for MST between 2004 and 2013. MAIN FINDINGS: Veterans with positive MST screens had higher odds than those with negative screens of individual and co-occurring PTSD, DD, and SUD. The association between positive MST screens and diagnostic outcomes, including PTSD, was stronger for women than for men, and the association between positive MST screens and some diagnostic outcomes, including DD, was stronger for men than for women. CONCLUSIONS: These results highlight the importance of assessing for and recognizing the potential MST and gender interactions in the clinical context among veterans with co-occurring PTSD, DD, and/or SUD.