Reconsidering research exclusion for serious mental illness: Ethical principles, current status, and recommendations.

BACKGROUND: Historically, individuals managing serious mental illness (SMI) have often been excluded from research, typically because of concern that these individuals may not be able to understand and provide truly informed consent. As treatment has improved, the assumption that individuals managing SMI may not be capable of consent needs to be re-examined. Systematic exclusion from research may limit empirically tested treatments available for people managing SMI, and may contribute to the health care disparities seen in this population. OBJECTIVES: This article examines this issue by documenting current rates of research exclusion for high disease burden conditions, based on empirical review of studies in ClinicalTrials.gov. RESEARCH DESIGN: Current rates of exclusion from studies for psychiatric conditions were assessed through systematic review of relevant clinical trials on ClinicalTrials.gov. SUBJECTS: Subjects in this inquiry are either articles accessed in the literature reviews, or descriptions of studies in public data on ClinicalTrials.gov. MEASURES: The primary measure was a previously published coding system to document the extent and types of research exclusion related to psychiatric status. RESULTS: Among studies of interventions for substance use disorders and chronic pain, individuals managing SMI were more likely to be excluded than those with other psychiatric disorders at statistically significant levels. This was not the case among studies of interventions for ischemic heart disease. In studies of substance use disorders, 9% explicitly excluded SMI and 83% could exclude people with SMI based on broader exclusion criteria. In studies of chronic pain these two categories of exclusion were 16% and 55%, and in studies of ischemic heart disease, these two categories of exclusion were 1% and 20%. CONCLUSIONS: Evidence indicates that it is ethically and scientifically more appropriate to exclude based on capacity to consent than membership in the group of individuals managing SMI. The discussion outlines techniques researchers can use for more equitable and generalizable sampling.

Developing Organizational Interventions to Address Stigma Among Mental Health Providers: A Pilot Study.

This article outlines a pilot study of "It's Just Us," an organizational intervention designed to reduce stigma among mental health providers by increasing awareness of the stigma they hold toward both clients and other providers with lived experience of mental health challenges. The targeted organization was the Mental Health Service Line in a large, Midwestern VA health care system. About 30% of the clinicians in the service provided information about their levels of stigma toward clients and providers who manage mental health challenges at baseline, 1 year later, and 2 years later. Educational and contact interventions targeting stigma are detailed; the first year included education and short-term contact interventions, while the second year included continuous contact interventions. At the end of the first year, scores on a measure of stigma toward mental health providers with lived experience were significantly lower, while scores on (a) a self-report measure of stigma toward clients and (b) self-disclosure of lived experience to professional peers were unchanged. At the end of the second year, scores for stigma toward clients had improved, and providers in the sample were more likely to share their lived experience with professional peers. Further research is necessary to validate these findings. Data provides preliminary support for the use of the "It's Just Us" curriculum as a means of reducing stigma among mental health providers. This model may also be useful in addressing stigma among other types of health care providers as well.

Provider lived experience and stigma.

Despite professional values about advocacy for people managing mental health challenges, research on mental health providers indicates that this group expresses as much or more stigma than laypeople. This article reports on a continuing education needs assessment of 101 mental health providers, including evaluation of (a) knowledge about recovery-oriented care, (b) work engagement, (c) provider lived experience with mental health challenges, and (d) stigma, measured as disidentification. In this group of providers, recovery knowledge, lived experience, and work engagement were associated with less stigma toward clients. Recovery knowledge and work engagement were associated with less stigma toward other providers with lived experience, but having lived experience was not associated with stigma toward other providers with lived experience. Findings suggest that the professional culture of nondisclosure may be a factor that increases provider stigma and should be a topic for further research. (PsycINFO Database Record

A pilot examination of the use of narrative therapy with individuals diagnosed with PTSD.

Narrative therapy is a postmodern, collaborative therapy approach based on the elaboration of personal narratives for lived experiences. Many aspects of narrative therapy suggest it may have great potential for helping people who are negatively affected by traumatic experiences, including those diagnosed with posttraumatic stress disorder (PTSD). The potential notwithstanding, narrative therapy is relatively untested in any population, and has yet to receive empirical support for treatment among survivors of trauma. A pilot investigation of the use of narrative therapy with 14 veterans with a diagnosis of PTSD (11 treatment completers) is described. Participants completed structured diagnostic interviews and self-report assessments of symptoms prior to and following 11 to 12 sessions of narrative therapy. After treatment, 3 of 11 treatment completers no longer met criteria for PTSD and 7 of 11 had clinically significant decreases in PTSD symptoms as measured by the Clinician Administered PTSD Scale. Pre- to posttreatment effect sizes on outcomes ranged from 0.57 to 0.88. These preliminary results, in conjunction with low rates of treatment dropout (21.4%) and a high level of reported satisfaction with the treatment, suggest that further study of narrative therapy is warranted as a potential alternative to existing treatments for PTSD.

Driving difficulties among military veterans: clinical needs and current intervention status.

Military personnel deployed to Iraq and Afghanistan often develop mental health difficulties, which may manifest as problematic driving behavior. Veterans may be more likely to engage in risky driving and to subsequently be involved in motor vehicle accidents and fatalities. This article reviews literature on driving difficulties among military veterans and evaluates available research on the potential pathways that underlie risky driving behavior. Current interventions for problematic driving behaviors are considered, and the necessity of modifying these interventions to address the unique difficulties encountered by military veterans is highlighted. The review concludes with a discussion of clinical implications of these findings and identification of possible avenues for future research and intervention.

Risk-taking behaviors and impulsivity among veterans with and without PTSD and mild TBI.

Military personnel commonly experience post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), both of which are associated with premature mortality. The present study examined two factors that may play a role in premature mortality--impulsivity and risk-taking behaviors--in a sample of 234 veterans screening positive for PTSD, mTBI, PTSD + mTBI, and controls. Analyses of variance demonstrated that veterans with PTSD, regardless of mTBI status, reported engaging in more frequent risky behaviors and reported a greater tendency to engage in impulsive behaviors when in a negative affective state. They also reported more premilitary delinquent behaviors and more suicide-related behaviors than controls. The present study highlights associations between impulsivity, risk-taking behaviors, and PTSD, and suggests continuity across the lifespan in terms of a predisposition to engage in impulsive and/or risky behaviors. Thorough evaluation of impulsivity and potentially risky behaviors is important in clinical settings to guide interventions and reduce the mortality and public health impact of high-risk behaviors in veterans.

Best practices: The electronic medical record is an invaluable clinical tool: let's start using it.

This column describes the potential of an enhanced electronic medical record (EMR) to advance best practices by displaying patient history, measuring progress, and facilitating clinical research. To create a graphical, single-page display of patient history, the authors examined data in the Minneapolis Department of Veterans Affairs EMR system, including 1.8 million encounters for 50,000 mental health patients. The prototype dashboard presents information on a patient's current and past providers, diagnoses, therapeutic interventions, prescriptions, dosages, and outcomes. To provide needed outcome data to monitor patient progress, the authors tested two questions with 212 patients. Patient and clinician responses to the questions provide reliable and clinically useful data that can be used in the EMR to track patient change over time. Use of EMRs can bridge gaps between science and practice to inform diagnosis and treatment decisions and permit more accurate prognoses.

Cognitive-behavioral group treatment for driving-related anger, aggression, and risky driving in combat veterans: a pilot study.

The present study examined the preliminary effects of an 8-session group cognitive-behavioral treatment (CBT) designed to reduce driving-related anger, aggression, and risky driving behaviors in veterans. Participants (N = 9) with self-reported aggressive and risky driving problems completed self-report measures at pretreatment, posttreatment, and 1-month follow-up. Of those completing the treatment, 89% demonstrated reliable change in driving-related aggression and 67% evidenced reliable change in driving-related anger. Similar changes were found for secondary treatment targets.

Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder.

This study evaluated the impact of a course of prolonged exposure or cognitive processing therapy on mental health and medical service utilization and health care service costs provided by the Department of Veterans Affairs (VA). Data on VA health service utilization and health care costs were obtained from national VA databases for 70 veterans who completed prolonged exposure or cognitive processing therapy at a Midwestern VA medical center. Utilization of services and cost data were examined for the year before and after treatment. Results demonstrated a significant decrease in the use of individual and group psychotherapy. Direct costs associated with mental health care decreased by 39.4%. Primary care and emergency department services remained unchanged.

An exploratory examination of risk-taking behavior and PTSD symptom severity in a veteran sample.

The present study conducted an exploratory examination of the relationship between self-reported symptoms of post-traumatic stress disorder and an expanded definition of risk-taking behaviors among 395 veterans at a large Midwestern Veterans Affairs Medical Center. Post-traumatic stress disorder symptoms were associated with elevated rates of substance use, thrill seeking, aggression, risky sexual practices, and firearm possession. Results indicated that suicidal ideation and aggressive driving behavior were among the most frequently reported. The present findings hold significant public health implications and highlight the need to attend to risk-taking behaviors in treatment planning.

Smoking intensity and severity of specific symptom clusters in posttraumatic stress disorder.

Smoking prevalence among patients with posttraumatic stress disorder (PTSD) is over 40%. Baseline data from the VA Cooperative Studies Program trial of integrated versus usual care for smoking cessation in veterans with PTSD (N = 863) were used in multivariate analyses of PTSD and depression severity, and 4 measures of smoking intensity: cigarettes per day (CPD), Fagerström Test for Nicotine Dependence (FTND), time to first cigarette, and expired carbon monoxide. Multivariate regression analysis showed the following significant associations: CPD with race (B = -7.16), age (B = 0.11), and emotional numbing (B =0 .16); FTND with race (B = -0.94), education (B = -0.34), emotional numbing (B = 0.04), significant distress (B = -0.12), and PHQ-9 (B = 0.04); time to first cigarette with education (B = 0.41), emotional numbing (B = -0.03), significant distress (B = 0.09), and PHQ-9 (B = -0.03); and expired carbon monoxide with race (B = -9.40). Findings suggest that among veterans with PTSD, White race and emotional numbing were most consistently related to increased smoking intensity and had more explanatory power than total PTSD symptom score. Results suggest specific PTSD symptom clusters are important to understanding smoking behavior in patients with PTSD.

The effect of pegylated interferon-alpha2b and ribavirin on posttraumatic stress disorder symptoms.

BACKGROUND: Patients with chronic psychiatric diagnoses have a prevalence of chronic hepatitis C (HCV) approximately 11 times higher than the general American population. Posttraumatic stress disorder (PTSD) is particularly common among HCV patients. OBJECTIVE: The authors describe the effect of treatment with pegylated-interferon-alpha(2b) (IFN) and ribavirin for patients with HCV on their posttraumatic stress disorder (PTSD) symptoms. METHOD: Sixteen patients with HCV and combat-related PTSD were followed for 24 weeks and assessed with self-report measures of PTSD, hostility, and depression. RESULTS: Depression and Resentment scores significantly increased in five patients treated with IFN and ribavirin, but no significant differences were found in PTSD scores when compared with 11 control patients. CONCLUSION: The results suggest that patients with PTSD and HCV can be safely treated with anti-viral therapies when they are given appropriate psychiatric care.

Comparison of treatment for post-traumatic stress disorder among three Department of Veterans Affairs medical centers.

The objective of the present study was to compare three specialized treatment programs for post-traumatic stress disorder (PTSD) in different Veterans Affairs medical centers, in terms of the format of therapeutic services and the medications prescribed for PTSD. Chart review methods were used to examine medical records for 50 patients from each facility over a 6-month period. Results indicated that the medications prescribed were fairly consistent across sites, although they were not always consistent with treatment recommendations. Therapy formats for two of the facilities were quite different, with one offering more case management services and the other offering more intensive individual and group therapy services. Additional research is needed to broaden our knowledge of how PTSD is being treated currently and to study the effectiveness of the treatment strategies being used.

Proverb interpretation in schizophrenia: the significance of symptomatology and cognitive processes.

Although clinicians have patients interpret proverbs in mental status exams for psychosis, there are few empirical studies investigating the significance of proverb interpretation. In schizophrenia patients, we found abstraction positively correlated with overall intelligence but no symptom measures, concreteness negatively correlated with overall intelligence, executive functioning, attention, and memory, and bizarre-idiosyncratic responses associated with positive formal thought disorder but no cognitive functions.

Shame and posttraumatic stress disorder.

Guilt about surviving a traumatic event is thought to be an associated feature of posttraumatic stress disorder (PTSD). Shame is an emotion closely related to guilt but is a distinct affective state. Little is known regarding the role of shame in PTSD and there are no studies of PTSD where shame and guilt are examined simultaneously. We used a measure of shame- and guilt-proneness in 107 community residing former prisoner of war veterans all of whom had been exposed to trauma. The measure of shame-proneness was positively correlated with PTSD symptom severity whereas guilt-proneness was not. This study provides the first empirical data regarding a possible role for shame in PTSD and may have important therapeutic and theoretical implications.