Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults.

The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Multiple family group intervention for spinal cord injury: Quantitative and qualitative comparison with standard education.

Objective: To evaluate a Multiple Family Group (MFG) education and support intervention for individuals with Spinal Cord Injury (SCI) and their primary caregivers. We hypothesized that MFG would be superior to an Education Control Group (EC) for improving patient activation and coping skills, social supports, and relationship functioning.Setting: A large free-standing inpatient and outpatient rehabilitation facility.Participants: Community dwelling adults with SCI and their caregivers living in the Northwest United States.Interventions/Methods: Nineteen individuals with SCI who had been discharged from inpatient rehabilitation within the previous three years, and their primary caregivers participated. Patient/caregiver pairs were randomized to the MFG intervention or an active SCI EC condition in a two-armed clinical trial design. Participants were assessed pre- and post-program and 6 months post-program. Qualitative and quantitative outcomes were evaluated. Focus groups were conducted with each group to determine benefits and recommendations for improvement.Results: Relative to EC, MFG reduced passive coping and increased subjective and overall social support in participants with SCI. Relative to EC, MFG also reduced passive coping in caregivers. Patient activation relative to EC was non-significantly increased. Content analysis identified four themes describing participants' experiences: enhanced sense of belonging, increased opportunities for engagement, knowledge, and team work; results that were generally congruent with quantitative measures of improved social support.Conclusions: Relative to EC, MFG assisted participants with SCI and their caregivers to manage the difficult, long-term, life adjustments by improving coping and strengthening social support.Trial registration: ClinicalTrials.gov NCT02161913. Registered 10 June 2014.

Comparison of two psycho-educational family group interventions for improving psycho-social outcomes in persons with spinal cord injury and their caregivers: a randomized-controlled trial of multi-family group intervention versus an active education control condition.

BACKGROUND: Over 12,000 individuals suffer a spinal cord injury (SCI) annually in the United States, necessitating long-term, complex adjustments and responsibilities for patients and their caregivers. Despite growing evidence that family education and support improves the management of chronic conditions for care recipients as well as caregiver outcomes, few systematic efforts have been made to involve caregivers in psycho-educational interventions for SCI. As a result, a serious gap exists in accumulated knowledge regarding effective, family-based treatment strategies for improving outcomes for individuals with SCI and their caregivers. The proposed research aims to fill this gap by evaluating the efficacy of a structured adaptation of an evidence-based psychosocial group treatment called Multi-Family Group (MFG) intervention. The objective of this study is to test, in a randomized-controlled design, an MFG intervention for the treatment of individuals with SCI and their primary caregivers. Our central hypothesis is that by providing support in an MFG format, we will improve coping skills of persons with SCI and their caregivers as well as supportive strategies employed by caregivers. METHODS: We will recruit 32 individuals with SCI who have been discharged from inpatient rehabilitation within the previous 3 years and their primary caregivers. Patient/caregiver pairs will be randomized to the MFG intervention or an active SCI education control (SCIEC) condition in a two-armed randomized trial design. Participants will be assessed pre- and post-program and 6 months post-program. Intent to treat analyses will test two a priori hypotheses: (1) MFG-SCI will be superior to SCIEC for SCI patient activation, health status, and emotion regulation, caregiver burden and health status, and relationship functioning, and (2) MFG will be more effective for individuals with SCI and their caregivers when the person with SCI is within 18 months of discharge from inpatient rehabilitation compared to when the person is between 19 and 36 months post discharge. DISCUSSION: Support for our hypotheses will indicate that MFG-SCI is superior to specific education for assisting patients and their caregivers in the management of difficult, long-term, life adjustments in the months and years after SCI, with increased efficacy closer in time to the injury. TRIAL REGISTRATION: ClinicalTrials.gov NCT02161913 . Registered 10 June 2014.

Cognitive rehabilitation multi-family group intervention for individuals with mild cognitive impairment and their care-partners.

There is increasing need for early, pro-active programs that can delay dementia diagnosis and enhance well-being of individuals with mild cognitive impairment (MCI) and their care-partners (i.e., care-dyads). This randomized controlled trial evaluated the efficacy of a combined cognitive rehabilitation and multi-family group treatment (CR-MFG) that was designed to facilitate adoption of newly learned cognitive strategies into the care-dyads everyday lives. Analyzed data included 23 care-dyads who participated in CR-MFG treatment and 23 care-dyads in standard care (SC). The 3-month intervention consisted of individual joining sessions, an educational workshop, and 20/twice weekly multifamily memory strategy training and problem-solving sessions. Everyday functioning, memory, and psychological functioning (i.e., quality-of-life, depression, coping) were assessed. The CR-MFG intervention was associated with significant post-test group differences and improved post-test performances by the MCI participants on performance-based measures of everyday functioning and neuropsychological tests of memory. There was also some suggestion that CR-MFG care-partners perceived positive change in the everyday functioning of the MCI participants. In contrast, no post-test group differences were found for either care-dyad member on the self-report psychological measures; care-partners in the treatment group did self-report improved coping behaviors at post-test. These 3-month results are preliminary but suggestive that CR-MFG may produce modest, practical everyday functional benefits for persons with MCI.

Determinants of buprenorphine treatment for opioid dependence.

This study assessed the social, demographic and clinical determinants of whether an opioid-dependent patient received buprenorphine versus an alternative therapy. A retrospective cohort analysis of opioid-dependent adults enrolled in Group Health Cooperative between January 1, 2006 and December 1, 2010 was performed. Increasing the number of physicians with DATA waivers in a region and living in a relatively-populated area increased the likelihood of being treated with buprenorphine, indicating that lack of access is a potential barrier. Comorbidity also appeared to be a factor in receipt of treatment, with the effect varying by diagnosis. Finally, patients with an insurance plan allowing health services to be sought from any provider, with increased cost sharing, were significantly more likely to receive buprenorphine, implying that patient demand is a factor. Programs integrating patient education, physician training, and support from addiction specialists would be likely facilitators of increasing access to this cost-effective treatment.

Implementation of multifamily group treatment for veterans with traumatic brain injury.

OBJECTIVE: This study evaluated the initial efficacy and feasibility of implementing multifamily group treatment for veterans with traumatic brain injury (TBI). METHODS: Veterans at two Veterans Affairs medical centers were prescreened by their providers for participation in an open trial of multifamily group treatment for TBI. Enrollment was limited to consenting veterans with a clinical diagnosis of TBI sustained during the Operation Enduring Freedom-Operation Iraqi Freedom era, a family member or partner consenting to participate, and a score ≥20 on the Mini-Mental State Examination. The nine-month (April 2010-March 2011) trial consisted of individual family sessions, an educational workshop, and bimonthly multifamily problem-solving sessions. Interpersonal functioning and symptomatic distress among veterans and family burden, empowerment, and symptomatic distress among families were assessed before and after treatment. RESULTS: Providers referred 34 (58%) of 59 veterans screened for the study; of those, 14 (41%) met criteria and consented to participate, and 11 (32%) completed the study. Severity of TBI, insufficient knowledge about the benefits of family involvement, and access problems influenced decisions to exclude veterans or refuse to participate. Treatment was associated with decreased veteran anger expression (p≤.01) and increased social support and occupational activity (p≤.05), with effect sizes ranging from .6 to 1.0. Caregivers reported decreased burden (p≤.05) and increased empowerment (p≤.01). CONCLUSIONS: The results supported implementation of a randomized controlled trial, building in education at the provider and family level.

Multifamily group treatment for veterans with traumatic brain injury: what is the value to participants?

OBJECTIVE: This study evaluated the feasibility, acceptability, and helpfulness of implementation of multifamily group treatment for traumatic brain injury (TBI) among veterans who sustained a TBI during the wars in Iraq and Afghanistan and their families or caregivers. METHODS: Veterans and their family members who participated in an open clinical trial (August 2010-March 2011) of multifamily psychoeducation for TBI at two Veterans Affairs medical centers were invited to one of three focus groups. Participants were asked about problems experienced before and during the intervention, aspects of treatment that were helpful, and improvements that would facilitate effective implementation of multifamily group treatment for TBI. Postintervention focus group transcripts were analyzed by utilizing qualitative content analysis. RESULTS: Participants included eight veterans with TBI and eight family members. Five themes emerged: exploring common struggles and reducing isolation, building skills to cope with TBI and related problems, restoring relationships through communication and understanding, increasing understanding of the interconnection between TBI and posttraumatic stress disorder, and improving the multifamily group experience and increasing treatment engagement of veterans and families. Veterans and family members found multifamily group treatment for TBI highly acceptable and offered recommendations to improve and increase access to the program. CONCLUSIONS: The results supported the feasibility and acceptability of multifamily group treatment for TBI. Specific recommendations to improve this psychoeducational intervention and its implementation are offered.

Co-occurring mood disorders among hospitalized patients and risk for subsequent medical hospitalization.

OBJECTIVE: The objective was to determine if patients hospitalized with a primary medical diagnosis and any co-occurring serious mental illness (SMI) were more likely than patients without any co-occurring SMI diagnosis to experience a subsequent medical hospitalization. METHOD: This was a longitudinal cohort study of 925,705 adult persons (aged 18+ years). Patients hospitalized in Washington State from 2004 to 2008 were followed through 2009 (for an average of 43 months). RESULTS: Compared to patients hospitalized for medical conditions without co-occurring SMI, patients with co-occurring dysthymia, bipolar and major depressive disorders were at an elevated risk for long-term subsequent hospitalization. Patients in the combined co-occurring mood disorders cohort were more likely (hazard ratio=1.13; 99% confidence interval=1.10-1.16; P<.001) than patients in the reference cohort to experience a subsequent medical hospitalization. A significant interaction between substance and mood disorders that increased risk for subsequent hospitalization was also observed. CONCLUSION: Hospitalized patients with co-occurring mood disorders are at high risk for repeat hospitalization for a medical reason. This high-risk population, including those with substance abuse, should be a focus of research efforts to identify and address ambulatory-care-sensitive conditions amenable to strategies that decrease complications and illness leading to subsequent hospitalizations.

Adapting multiple-family group treatment for brain and spinal cord injury intervention development and preliminary outcomes.

OBJECTIVE: There is a need for interventions that assist in managing the multiple adjustments of persons with spinal cord and brain injuries and their families. The purpose of the present field-initiated development project was to adapt a family psychoeducation model, multiple-family group treatment (MFGT), for persons with brain and spinal cord injury and their families. DESIGN: The experiences of survivors and caregivers in MFGT were evaluated using quantitative and qualitative methods. Twenty-seven survivors and 28 caregivers participated in MFGT for 12-18 mos. Reliable and valid quantitative measures were used to assess a variety of target outcomes. Additionally, semistructured interviews and focus groups were conducted with participants. RESULTS: Survivors reported a decrease in depressive symptoms and anger expression toward others as well as an increase in life satisfaction. Caregivers reported a significant reduction in burden. The themes derived from the qualitative analysis addressed the normalization of the caregiving experience, importance of socialization, improvement in a variety of coping skills, and education about the injuries. CONCLUSIONS: The findings support the adaptation of MFGT for brain and spinal cord injuries.

Multiple-family group treatment of outpatients with schizophrenia: impact on service utilization.

The impact of multiple-family group treatment (MFGT) on outpatient and inpatient mental health service utilization of 97 persons with schizophrenia was investigated. Participants were randomly assigned to standard care (n = 44) or standard care plus MFGT (n = 53). Service use for a year prior to randomization, the 2-year study period, and a 1-year follow-up were examined. Relative to standard care participants, the MFGT group had reduced community hospitalization during year 1 of the intervention and reduced state hospitalization at follow-up. During the intervention period, MFGT participants demonstrated a significant increase in outpatient utilization as a direct consequence of the intervention. However, when service use was summed across 3 years post-randomization, no group differences were observed. Results suggest that implementation of MFGT in a community mental health setting reduces inpatient service at specific time periods, without significantly increasing outpatient service utilization. These findings add to other outcomes from this study that demonstrate decreased psychiatric symptoms and caregiver distress.

Unlinking disability income, substance use and adverse outcomes in dually diagnosed, severely mentally ill outpatients.

The goals of the current study were to determine whether incorporating disability benefit management into combined outpatient psychiatric/addiction treatment was feasible and clinically useful for managing severely mentally ill, substance-abusing patients over time, and then if patients in this program would demonstrate the first-week-of-the-month increased substance abuse and hospitalizations shown in other studies. Forty-four patients were studied for an average of forty weeks, with little treatment or study dropout. There was no evidence in either the schizophrenic/cocaine abuser or the broader diagnostic sample of the cyclic first-of-the-month pattern of substance use and hospitalizations observed in other studies. Findings suggest that combined treatment/benefit management programs are clinically feasible and effective in stabilizing patients and keeping them in treatment.

Multiple-family group treatment as an effective intervention for children with psychological disorders.

An estimated 20% of children suffer from psychological disorders and only 10-20% receive adequate treatment. A lack of empirically supported treatments is one reason why relatively few children receive treatment for their psychological difficulties. Multiple-family group treatment (MFGT) is an empirically supported intervention for adults with chronic mental illnesses that may be an effective treatment for children with psychological disorders. This article reviewed the adult MFGT model and its empirical support. The quantity and quality of child MFGT research was then reviewed. Child MFGT models are compared with one another and to the adult MFGT model. All studies provided initial support of MFGT as an appropriate treatment for childhood disorders. However, the child literature as whole was relatively limited, unfocused, and lacked replication. Suggestions for future research are made, focusing on a structured and scientific approach to establishing MFGT as an empirically supported intervention for children.

Outcomes of managing disability benefits among patients with substance dependence and severe mental illness.

To evaluate the feasibility and efficacy of a program to manage Social Security disability benefits in a clinical sample of patients with severe mental illness and co-occurring substance dependence, 41 patients were randomly assigned to have their benefits either contingently or noncontingently managed through their mental health center. Contingent management involved adjustments to the type or frequency (not amount) of disability benefits and payments for study participation based on ratings of substance use, money management, and treatment follow-through. The patients with contingent management used significantly less alcohol and drugs and showed much better money management than those with noncontingent management. Patients and case managers who participated in the study reported that they found the management strategy to be acceptable and useful.

Impact of multiple-family groups for outpatients with schizophrenia on caregivers' distress and resources.

OBJECTIVE: The objective of this study was to evaluate the effects of multiple-family group treatment on distress and psychosocial resources among family caregivers of persons with schizophrenia. METHODS: A total of 97 consumers with schizophrenia or another psychotic disorder and their caregivers were randomly assigned to receive multiple-family group treatment (N=53) or standard psychiatric outpatient care (N=44). Reliable and valid measures were used to assess caregivers' distress, caregivers' resources, and consumers' clinical status. RESULTS: After consumers' clinical status and baseline rates of caregivers' distress and caregivers' resources were controlled for, the caregivers of consumers who received multiple-family group treatment experienced greater reductions in distress but no increases in resources compared with caregivers of consumers who received standard psychiatric care. CONCLUSIONS: Multiple-family group treatment reduced caregivers' distress but did not increase caregivers' resources relative to standard psychiatric care.

Predicting rehospitalization and outpatient services from administration and clinical databases.

The study tests whether psychiatric services utilization may be predicted from administrative databases without clinical variables equally as well as from databases with clinical variables. Persons with a psychiatric hospitalization at an urban medical center were followed for 1 year postdischarge (N = 1384.) Dependent variables included statewide rehospitalization and the number of hours of outpatient services received. Three linear and logistic regression models were developed and cross-validated: a basic model with limited administrative independent variables, an intermediate model with diagnostic and limited clinical indicators, and a full model containing additional clinical predictors. For rehospitalization, the clinical cross-validated model accounted for twice the variance accounted by the basic model (adjusted R2 = .13 and .06, respectively). For outpatient hours, the basic cross-validated model performed as well as the clinical model (adjusted R2 = .36 and .34, respectively). Clinical indicators such as assessment of functioning and co-occurring substance use disorder should be considered for inclusion in predicting rehospitalization.

Burden in schizophrenia caregivers: impact of family psychoeducation and awareness of patient suicidality.

Family caregivers of persons with schizophrenia and other psychotic disorders experience high levels of burden. Although a number of patient and caregiver predictors of burden have been identified, little research has investigated the contributions of patient depression, suicidal ideation, and substance abuse. In addition, family psychoeducation interventions have reduced patient symptoms, as well as inpatient treatment utilization; however, it is not known whether or not these interventions reduce family burden. This study investigated predictors of family burden and tested to what degree multiple family group treatment (MFGT), relative to a standard care condition, was associated with reduced family burden. Participants were 90 outpatients with a diagnosis of schizophrenia or other psychotic disorders, and their caregivers who were enrolled in a 2 year psychoeducation intervention. The best set of predictors of burden, identified by stepwise linear regression, was young patient age, awareness of patient's suicidal ideation, and family resources. These variables accounted for 32% of the total variance in burden. Findings suggest that caregiver's awareness of patient's suicidal ideation, not patient's report of suicidal ideation; and that patient age, not duration of the illness, were significant independent predictors of burden. When compared to a standard-care condition over 2 years, MFGT did not reduce family caregiver burden. Discussions focus on the relationship between burden and its predictors, and possible reasons why MFGT did not decrease burden. Modifications are proposed that may increase the impact of MFGT.

Service use among patients with schizophrenia in psychoeducational multiple-family group treatment.

OBJECTIVES: Outpatient and inpatient mental health service outcomes for outpatients with schizophrenia or schizoaffective disorder who received psychoeducational multiple-family group treatment were compared with outcomes for similar patients who received standard care. METHODS: A total of 106 outpatients with schizophrenia or schizoaffective disorder who were receiving services from a large community mental health center were randomly assigned to receive standard care or standard care plus multiple-family group treatment. The two-year multiple-family intervention consisted of weekly group sessions designed to educate patients and their family members about the biological basis of mental illness and treatment, to improve illness management and coping skills, and to provide social support. The group sessions were conducted by two clinicians using a standardized protocol. Each multiple-family group included five to eight families and consumers. Service records for the year before and after random assignment to the study groups were examined in an intent-to-treat analysis. RESULTS: During the year after random assignment to study groups, multiple-family group treatment was associated with a lower rate of psychiatric hospitalization than standard care. It was only marginally associated with lower use of crisis services, and it was not associated with the amount of outpatient service time. CONCLUSIONS: The findings suggest that implementation of multiple-family group treatment in a capitated community mental health setting improves hospitalization outcomes without increasing the overall volume of outpatient mental health services.

Use of case manager ratings and weekly urine toxicology tests among outpatients with dual diagnoses.

Use of drugs and alcohol by 43 predominantly male outpatients who had severe mental illness and a comorbid substance use disorder were assessed weekly through the ratings of experienced dual disorder case managers and through blinded research urine toxicology tests. The percentage of weeks in which drugs or alcohol were used was calculated on the basis of one or both assessments. The case managers often missed drug use over the weekends, which was detected by the urine toxicology tests. Agreement between the two methods varied widely, even when the ratings were made by highly experienced case managers. These findings have implications for monitoring patients with dual diagnoses and provide insight into the accuracy of case manager ratings.

Contributing factors to depressed mood in Multiple Sclerosis.

By applying the behavioral theory of Lewinsohn et al. [1985. An integrative theory of depression. In: S. Reiss, & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331-359). San Diego, CA: Academic Press.] to multiple sclerosis (MS), it was hypothesized that physical disability, fatigue, and psychosocial dysfunction would be significantly predictive of depressed mood in MS patients. Seventy-six MS patients completed the following measures: the Sickness Impact Profile (SIP), the Fatigue Impact Scale (FIS), and the mood subscale from the Chicago Multiscale Depression Inventory (CMDI). Structural equation modeling revealed that physical disability and fatigue were indirectly predictive of depressed mood via their effects on recreational functioning. Fatigue also had a direct effect on mood. If reductions in recreational activities actually cause decrements in mood, depressed mood in MS may be treatable by helping patients identify recreational activities that they can enjoy regardless of physical or fatigue-related difficulties.