A controlled examination of acute warning signs for suicide attempts among hospitalized patients.

BACKGROUND: Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. METHODS: Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). RESULTS: Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. CONCLUSIONS: The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

A Lifestyle Risk Reduction Model for Preventing High-Risk Substance Use Across the Lifespan.

While effective models of alcohol and drug prevention exist, they often focus solely on youth or young adults. This article describes the Lifestyle Risk Reduction Model (LRRM), an approach applicable across the lifespan. The intent behind the LRRM is to guide the development of prevention and treatment programs provided to individuals and small groups. The LRRM authors' goals are to help individuals reduce risk for impairment, addiction, and substance use's negative consequences. The LRRM identifies six key principles that conceptualize the development of substance-related problems by drawing parallels with health conditions, such as heart disease and diabetes, which often result from combined effects of biological risk and behavioral choices. The model also proposes five conditions that describe important steps for individuals as they progress toward greater perception of risk and lower risk behavior. One LRRM-based indicated prevention program (Prime For Life) shows positive results in cognitive outcomes and in impaired driving recidivism for people across the lifespan. The model emphasizes common elements across the lifespan, responds to contexts and challenges that change across the life course, complements other models, and is usable for universal, selective, and indicated prevention programs.

Multidimensional Evaluation of Screening Brief Intervention and Referral to Treatment Training for Medical Students.

OBJECTIVE: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying and addressing alcohol use in non-specialty settings. Many medical schools teach SBIRT, but most published evaluations of these efforts exclude rigorous skill assessments and teaching methods. METHODS: During the 2017-2018 academic year, 146 third-year medical students received classroom-based learning on SBIRT and motivational interviewing (MI) and at least two SBIRT practices with feedback as part of a 4-week psychiatry clerkship. The objective of this curriculum was to improve SBIRT knowledge, attitudes, and confidence and enable learners to skillfully deliver SBIRT. Outcomes evaluated included satisfaction, knowledge, attitudes and confidence, and clinical skill in delivering SBIRT to a standardized patient (rated by the actor, as well as an expert). RESULTS: Results indicated acceptable satisfaction at post-curriculum and significant improvements in attitudes and knowledge from pre- to post-curriculum. On the clinical skills exam, all students were rated as having mastered at least 80% of SBIRT elements by standardized patients and 91.8% were rated at this level by a faculty expert. Student attitudes and knowledge were unrelated to expert ratings, and standardized patient ratings had limited associations with expert ratings. CONCLUSIONS: These results suggest curriculum objectives were achieved and provide unique contributions to the SBIRT curricular outcome research for healthcare trainees. Other findings included that trainee knowledge and confidence may not relate to skill, and standardized patient feedback provides different information on SBIRT and MI skill than expert ratings.

Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS.

BACKGROUND AND OBJECTIVES: Research has shown that people living with HIV/AIDS (PLWHA) engage in increased rates of substance use, which has a number of potential negative health outcomes. Increased legalization of cannabis is likely to further increase the availability and use of cannabis in this population. Efforts have been made to integrate screening and intervention resources as part of an individual's routine healthcare visits. Though brief approaches such as Screening and Brief Intervention (SBIRT) have shown promise in addressing alcohol use, results are mixed in addressing cannabis use. The present study investigated how individuals reporting cannabis use responded to an invitation to engage in a brief negotiated intervention (BNI). METHODS: PLWHA participated in a self-administered tablet computer-based version of SBIRT. Patients screened as having at-risk, high-risk, or dependent substance use (N = 331) were eligible to receive the BNI. Of these patients, 101 reported cannabis-only use, with or without alcohol. RESULTS: Binary logistic regressions controlling for Alcohol Use Disorders Identification Test and Drug Abuse Screening Test score and demographics, found that cannabis-only use was significantly related to declining the BNI. DISCUSSION AND CONCLUSIONS: Cannabis-only engagement predicts lower BNI acceptance rates than other substance use profiles; inappropriate screening tools may be one reason for this discrepancy. Implications and directions for future research are discussed. SCIENTIFIC SIGNIFICANCE: Findings are relevant in modifying SBIRT for cannabis use. To our knowledge, this is the first work to evaluate acceptance of brief interventions for cannabis as compared to other substances and brief intervention acceptance in a sample of PLWHA.

Motivational interviewing training of substance use treatment professionals: A systematic review.

Background: Through evaluations of training programs, systematic reviews, and meta-analyses, advances in identifying best practices for disseminating motivational interviewing (MI) have emerged. To advance this work further, inclusion of thorough descriptions of the following is needed in research publications: study (design, trainee characteristics, setting characteristics), training and coaching methods (if applicable), trainer qualifications, and evaluation of MI skills. Methods: The purpose of this study was to systematically evaluate the research on MI training of substance use treatment professionals for the inclusion of such descriptions. Twenty-five studies were reviewed using a scoring rubric developed by the authors. Results: Just over two thirds of the studies (68%) were randomized controlled trials of MI training. The majority of studies provided information about (a) trainee characteristics (professional background = 76%, education = 60%, experience = 56%); (b) setting characteristics (80%); (c) training methods (format = 96%, length = 92%); (d) coaching (76%); and (e) evaluation of MI skills (92%). Conclusion: Findings suggest advancements in MI training studies since previous reviews, especially in regards to the inclusion of feedback and coaching. However, this review also found that inconsistencies in methods and reporting of training characteristics, as well as limited follow-up assessment of trainees' skill, continue to limit knowledge of effective training methods.

Adults with Comorbid Posttraumatic Stress Disorder, Alcohol Use Disorder, and Opioid Use Disorder: The Effectiveness of Modified Prolonged Exposure.

Opioid use disorders (OUDs) are a growing problem in the United States. When OUDs co-occur with problematic drinking and posttraumatic stress disorder (PTSD), negative drug-related mental and physical health outcomes may be exacerbated. Thus, it is important to establish whether PTSD treatments with established efficacy for dually diagnosed individuals also demonstrate efficacy in individuals who engage in problematic drinking and concurrent opioid misuse. Adults who met DSM-IV-TR criteria for PTSD and alcohol dependence were recruited from a substance use treatment facility and were randomly assigned to receive either modified prolonged exposure (mPE) therapy for PTSD or a non-trauma-focused comparison treatment. Compared to adults in a non-OUD comparison group (n = 74), adults with OUD (n = 52) were younger, reported more cravings for alcohol, were more likely to use amphetamines and sedatives, were hospitalized more frequently for drug- and alcohol-related problems, and suffered from more severe PTSD symptomatology, depressive symptoms, and anxiety, standardized mean differences = 0.36-1.81. For participants with OUD, mPE was associated with large reductions in PTSD symptomatology, sleep disturbances, and symptoms of anxiety and depression, ds = 1.08-2.56. Moreover, participants with OUD reported decreases in alcohol cravings that were significantly greater than those reported by the non-OUD comparison group, F(1, 71.42) = 6.37, p = .014. Overall, our findings support the efficacy of mPE for PTSD among individuals who engage in problematic drinking and concurrent opioid misuse, despite severe baseline symptoms.

Borderline personality disorder and related constructs as risk factors for intimate partner violence perpetration.

In this manuscript we systematically reviewed 29 articles from 2010 to 2014 that addressed the association between borderline personality disorder (BPD) and intimate partner violence (IPV) perpetration, with particular attention paid to the role of perpetrator sex. Our primary objective was to provide a summary of (1) the operationalization and measurement of BPD and IPV, (2) mechanisms of the BPD-IPV association, and (3)the current understanding of the role of perpetrator sex related to BPD and IPV. We observed three distinct operational definitions of BPD which are measured in a variety of ways. IPV measurement tends to be more consistent. Further, emotion perception, impulsivity, attachment, and substance use are proposed mechanisms to explain the BPD IPV relation. The findings regarding potential perpetrator sex differences in the BPD-IPV association are mixed. Finally, we also provide recommendations for future research and clinical practice.

Measuring Client Experiences of Motivational Interviewing during a Lifestyle Intervention.

The Client Evaluation of Motivational Interviewing was used to assess MI experiences in a predominantly female, African American sample from the Southeastern U.S. who received MI-based feedback during a multi-component lifestyle intervention. MI was experienced differently than a primarily White, male, Northeastern mental health sample.

Low-Burden Universal Substance Use Screening in a Primary Care Clinic to Lower Implementation Barriers.

Universal substance use screening in primary care can proactively identify patients for intervention, though implementation is challenging. This project developed a strategy for universal low time- and labor-cost screening, brief intervention, and referral for treatment (SBIRT) in an HIV primary care clinic at an academic medical center in the Southeastern USA. Screening was implemented using a tablet computer that calculated results in real time and suggested motivational language for provider response. A brief intervention (BNI) was conducted by a trained professional as needed, preventing the need for all clinic providers to be competent in motivational interviewing (MI). More than 1868 patients were screened in 12 months, with an MI intervention conducted for 101 patients with higher risk use. Forty-four patients were referred for in-clinic treatment, compared to nine in the previous year. Computer-based, self-administered screening with real-time linkage to a BNI can allow recommended screening with low provider burden.

College student mental health, treatment utilization, and reduced enrollment: Findings across a state university system during the COVID-19 pandemic.

Objective: This study measured the rate of college student mental health concerns and mental health service utilization. The roles of mental health and seeking treatment regarding anticipated enrollment were explored. Methods: One thousand eight hundred thirty-one randomly selected students participated in this online survey. Results: Most students reported clinically significant symptoms (88.3%), and many sought treatment in the past year (28.8%). Most students had favorable attitudes toward telemental health. Barriers to seeking care included a preference for self-management of symptoms (68.8%) and limited time (43.3%). Mental health was the most commonly reported reason for anticipating reduced enrollment (ps < .001), and these individuals were more likely to seek treatment. Conclusions: Past and anticipated use of mental health treatment likely exceeds on-campus capacity. Student mental health and retention are linked, and treatment may support retention. Nontraditional services, including telemental health, could help address increasing symptom severity and demand for services.

Predicting benzodiazepine prescriptions: A proof-of-concept machine learning approach.

Introduction: Benzodiazepines are the most commonly prescribed psychotropic medications, but they may place users at risk of serious adverse effects. Developing a method to predict benzodiazepine prescriptions could assist in prevention efforts. Methods: The present study applies machine learning methods to de-identified electronic health record data, in order to develop algorithms for predicting benzodiazepine prescription receipt (yes/no) and number of benzodiazepine prescriptions (0, 1, 2+) at a given encounter. Support-vector machine (SVM) and random forest (RF) approaches were applied to outpatient psychiatry, family medicine, and geriatric medicine data from a large academic medical center. The training sample comprised encounters taking place between January 2020 and December 2021 (N = 204,723 encounters); the testing sample comprised data from encounters taking place between January and March 2022 (N = 28,631 encounters). The following empirically-supported features were evaluated: anxiety and sleep disorders (primary anxiety diagnosis, any anxiety diagnosis, primary sleep diagnosis, any sleep diagnosis), demographic characteristics (age, gender, race), medications (opioid prescription, number of opioid prescriptions, antidepressant prescription, antipsychotic prescription), other clinical variables (mood disorder, psychotic disorder, neurocognitive disorder, prescriber specialty), and insurance status (any insurance, type of insurance). We took a step-wise approach to developing a prediction model, wherein Model 1 included only anxiety and sleep diagnoses, and each subsequent model included an additional group of features. Results: For predicting benzodiazepine prescription receipt (yes/no), all models showed good to excellent overall accuracy and area under the receiver operating characteristic curve (AUC) for both SVM (Accuracy = 0.868-0.883; AUC = 0.864-0.924) and RF (Accuracy = 0.860-0.887; AUC = 0.877-0.953). Overall accuracy was also high for predicting number of benzodiazepine prescriptions (0, 1, 2+) for both SVM (Accuracy = 0.861-0.877) and RF (Accuracy = 0.846-0.878). Discussion: Results suggest SVM and RF algorithms can accurately classify individuals who receive a benzodiazepine prescription and can separate patients by the number of benzodiazepine prescriptions received at a given encounter. If replicated, these predictive models could inform system-level interventions to reduce the public health burden of benzodiazepines.

Prolonged Exposure Therapy for PTSD among Individuals in a Residential Substance Use Treatment Program: A Case Series.

Clients with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders present a unique challenge for clinicians in substance use treatment settings. Substance dependent individuals with PTSD tend to improve less during substance use treatment and relapse more quickly following abstinence attempts compared to those without PTSD. Recent scientific efforts have focused on understanding the potential benefit of providing PTSD treatment concurrent with substance use treatment. The current case study describes 4 individuals with PTSD in a residential substance use facility who received prolonged exposure therapy for treatment of PTSD, in addition to the substance use treatment. These individuals completed 9 bi-weekly 60-minute sessions of prolonged exposure, as well as in vivo and imaginal exposure homework between sessions. None of the clients met criteria for PTSD at the end of treatment, with these gains being maintained at 3- and 6-months post-treatment. Additionally, the clients did not relapse in response to undergoing exposure therapy. Implications for delivery of PTSD treatment in substance use treatment facilities are discussed.

Treatment-resistant depression with anhedonia: Integrating clinical and preclinical approaches to investigate distinct phenotypes.

In our clinical work with treatment-resistant depressed (TRD) patients, certain patterns have emerged in terms of patients' presentations of anhedonia. Multiple studies have investigated anhedonia either as a state or a trait variable in depression, but anhedonia is a multifaceted construct and, as we better understand anhedonia, we increase our ability to measure and treat it. With the aim of personalizing medicine for more efficacious treatments, this paper focuses on clinical patterns we have seen in anhedonic TRD and argues for studies to be done in support of translational, face, and construct validity. Three representative clinical presentations of TRD with anhedonia are described: a congenital type, a stress-induced type, and a type exacerbated by medication. Each case is followed with discussion relating the clinical features to clinical and preclinical research relevant to putative mechanisms for the case. Animal models that are best suited to investigate and validate the existence of etiologies and mechanisms underlying anhedonia constructs unique to each case are proposed, as are potential directions for research in humans.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research.

PURPOSE: To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula. METHOD: The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability. RESULTS: Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula. CONCLUSIONS: SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

Predicting Posttraumatic Stress Disorder Among Survivors of Recent Interpersonal Violence.

A substantial minority of women who experience interpersonal violence will develop posttraumatic stress disorder (PTSD). One critical challenge for preventing PTSD is predicting whose acute posttraumatic stress symptoms will worsen to a clinically significant degree. This 6-month longitudinal study adopted multilevel modeling and exploratory machine learning (ML) methods to predict PTSD onset in 58 young women, ages 18 to 30, who experienced an incident of physical and/or sexual assault in the three months prior to baseline assessment. Women completed baseline assessments of theory-driven cognitive and neurobiological predictors and interview-based measures of PTSD diagnostic status and symptom severity at 1-, 3-, and 6-month follow-ups. Higher levels of self-blame, generalized anxiety disorder severity, childhood trauma exposure, and impairment across multiple domains were associated with a pattern of high and stable posttraumatic stress symptom severity over time. Predictive performance for PTSD onset was similarly strong for a gradient boosting machine learning model including all predictors and a logistic regression model including only baseline posttraumatic stress symptom severity. The present findings provide directions for future work on PTSD prediction among interpersonal violence survivors that could enhance early risk detection and potentially inform targeted prevention programs.

Affect intensity and lability: the role of posttraumatic stress disorder symptoms in borderline personality disorder.

BACKGROUND: Emotion dysregulation is likely a core psychological process underlying the heterogeneity of presentations in borderline personality disorder (BPD) and is associated with BPD symptom severity. Emotion dysregulation has also been independently associated with posttraumatic stress disorder (PTSD), a disorder that has been found to co-occur with BPD in 30.2% of cases in a nationally representative sample. However, relatively little is known about the specific relationships between emotion dysregulation and PTSD among those diagnosed with BPD. The purpose of this study was to evaluate relationships between PTSD symptom severity and negative affect intensity and affective lability among individuals with BPD. METHOD: Participants were 67 individuals diagnosed with BPD (79% women; M(age) = 38, SD = 10), who reported one or more DSM-IV PTSD Criterion A events. RESULTS: Hierarchical multiple regression analyses indicated that when examined concurrently with BPD symptom severity, PTSD symptom severity, but not BPD symptom severity, was related to negative affect intensity and affective lability. Re-experiencing symptoms uniquely predicted affective lability, and hyperarousal symptoms uniquely predicted negative affect intensity, lending additional support to emerging literature linking re-experiencing and hyperarousal symptoms with emotion dysregulation. CONCLUSIONS: PTSD symptom severity among individuals with a BPD diagnosis is related to elevations in emotion dysregulation. It is important to evaluate whether early treatment of PTSD symptoms provided concurrently with BPD treatment leads to enhanced improvements in emotion regulation among individuals with co-occurring PTSD and BPD.

Personalized feedback to improve CPAP adherence in obstructive sleep apnea.

Obstructive sleep apnea (OSA) is effectively treated with continuous positive airway pressure (CPAP). Low rates of CPAP adherence led to the development of a personalized feedback intervention requiring minimal provider burden. In a comparison of the intervention to standard information, group differences failed to reach significance. Explanations for the findings include low power, that machines were not provided, and an atypical sample. Effect sizes were medium to large at 2 weeks, suggesting that sufficiently powered studies may be warranted.

Intimate partner violence and Hurricane Katrina: predictors and associated mental health outcomes.

This study sought to establish the prevalence and correlates of intimate partner violence (IPV) victimization in the 6 months before and after Hurricane Katrina. Participants were 445 married or cohabiting persons who were living in the 23 southernmost counties of Mississippi at the time of Hurricane Katrina. Data for this study were collected as part of a larger, population-based, representative study. The percentage of women reporting psychological victimization increased from 33.6% prior to Hurricane Katrina to 45.2% following Hurricane Katrina (p < .001). The percentage of men reporting psychological victimization increased from 36.7% to 43.1% (p = .01). Reports of physical victimization increased from 4.2% to 8.3% for women (p = .01) but were unchanged for men. Significant predictors of post-Katrina victimization included pre-Katrina victimization, age, educational attainment, marital status, and hurricane-related stressors. Reports of IPV were associated with greater risk of post-Katrina depression and posttraumatic stress disorder. Data from the first population-based study to document IPV following a large-scale natural disaster suggest that IPV may be an important but often overlooked public health concern following disasters.

Using a single-item rating scale as a psychiatric behavioral management triage tool in the emergency department.

INTRODUCTION: Proper monitoring of patients' behavior is essential for effective treatment and efficient disposition of psychiatric cases in the adult emergency department. The goal of the current study was to examine an attempt to implement the Behavioral Activity Rating Scale, an existing single-item measure of behavioral activity, as part of a behavioral management triage strategy for psychiatric patients in an emergency department. METHODS: For the period beginning approximately 2 months after use of the behavioral activity measure was initiated in the emergency department, charts from 284 consecutive patients who presented to the department with a chief complaint that was psychiatric in nature were reviewed. RESULTS: Level of adoption of the measure by emergency nurses was lower than desired; only 46% of charts reviewed contained a behavioral activity rating. Ratings were less likely to be recorded during the night shift than during other shifts. As predicted, ratings indicative of elevated behavioral activity were associated with physician orders for formal behavioral management (ie, intramuscular, intravenous, or orally dissolving sedating medications or physical restraint). DISCUSSION: The findings of this study suggest that a single-item behavioral activity measure may be an efficient, effective, and discreet way for emergency nursing staff to communicate with one another and with physicians about psychiatric patients in need of behavioral management in adult emergency departments. The findings also suggest that a broad implementation approach is needed to achieve desired levels of adoption by emergency nursing staff.

Motivational interviewing quality assurance: A systematic review of assessment tools across research contexts.

The need for sustained skill development and quality assurance when executing behavioral interventions is best demonstrated in the empirical evolution of Motivational Interviewing (MI). As a brief behavioral intervention that identifies the therapeutic process as an active treatment ingredient, it is critical for researchers, trainers, and administrators to use psychometrically sound and theoretically congruent tools to evaluate provider skills and fidelity when executing MI. Yet, no prior work has evaluated the breadth of MI tools employed across research contexts. Therefore, this review identified MI fidelity and skill development tools across measurement, training and efficacy/effectiveness studies and evaluated their psychometric strength and fit with current MI theory. We identified 199 empirical studies that employed an MI fidelity/skill tool and we found 21 tools with varying degrees of empirical support and theoretical congruence. Specifically, we identified five observer-, two trainee- and one client-rated tool with strong empirical support, and nine observer- and two client-rated tools with preliminary empirical support. We detailed the empirical strength, including the extent to which tools were linked to trainee/client outcomes across research contexts and offer recommendations on which MI tools to use in training, efficacy, and effectiveness trials.