START NOW: a cognitive behavioral skills training for adolescent girls with conduct or oppositional defiant disorder - a randomized clinical trial.

BACKGROUND: Conduct disorder (CD) and oppositional defiant disorder (ODD) both convey a high risk for maladjustment later in life and are understudied in girls. Here, we aimed at confirming the efficacy of START NOW, a cognitive-behavioral, dialectical behavior therapy-oriented skills training program aiming to enhance emotion regulation skills, interpersonal and psychosocial adjustment, adapted for female adolescents with CD or ODD. METHODS: A total of 127 girls were included in this prospective, cluster randomized, multi-center, parallel group, quasi-randomized, controlled phase III trial, which tested the efficacy of START NOW (n = 72) compared with standard care (treatment as usual, TAU, n = 55). All female adolescents had a clinical diagnosis of CD or ODD, were 15.6 (±1.5) years on average (range: 12-20 years), and were institutionalized in youth welfare institutions. The two primary endpoints were the change in number of CD/ODD symptoms between (1) baseline (T1) and post-treatment (T3), and (2) between T1 and 12-week follow-up (T4). RESULTS: Both treatment groups showed reduced CD/ODD symptoms at T3 compared with T1 (95% CI: START NOW = -4.87, -2.49; TAU = -4.94, -2.30). There was no significant mean difference in CD/ODD symptom reduction from T1 to T3 between START NOW and TAU (-0.056; 95% CI = -1.860, 1.749; Hedge's g = -0.011). However, the START NOW group showed greater mean symptom reduction from T1 to T4 (-2.326; 95% CI = -4.274, -0.378; Hedge's g = -0.563). Additionally, secondary endpoint results revealed a reduction in staff reported aggression and parent-reported irritability at post assessment. CONCLUSIONS: Although START NOW did not result in greater symptom reduction from baseline to post-treatment compared with TAU, the START NOW group showed greater symptom reduction from baseline to follow-up with a medium effect size, which indicates a clinically meaningful delayed treatment effect.

Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US.

OBJECTIVE: To identify potential barriers to care, this study examined the general psychiatry outpatient new appointment availability in the US, including in-person and telepsychiatry appointments, comparing results between insurance types (Medicaid vs. private insurance), states, and urbanization levels. METHOD: This mystery shopper study investigated 5 US states selected according to Mental Health America Adult Ranking and geography to represent the US mental health care system. Clinics across five selected states were stratified sampled by county urbanization levels. Calls were made during 05/2022-07/2022. Collected data included contact information accuracy, appointment availability, wait time (days), and related information. RESULTS: Altogether, 948 psychiatrists were sampled in New York, California, North Dakota, Virginia, and Wyoming. Overall contact information accuracy averaged 85.3%. Altogether, 18.5% of psychiatrists were available to see new patients with a significantly longer wait time for in-person than telepsychiatry appointments (median = 67.0 days vs median = 43.0 days, p < 0.01). The most frequent reason for unavailability was provider not taking new patients (53.9%). Mental health resources were unevenly distributed, favoring urban areas. CONCLUSION: Psychiatric care has been severely restricted in the US with low accessibility and long wait times. Transitioning to telepsychiatry represents a potential solution for rural disparities in access.

New-Onset Psychotic Symptoms Following Abrupt Buprenorphine/Naloxone Discontinuation in a Female Patient with Bipolar Disorder: A Case Report.

Buprenorphine and naloxone (Suboxone) is a combination medication-assisted treatment (MAT) for opioid use disorder. MAT withdrawal-induced psychosis is a rare clinical presentation. To our best knowledge, only three reports have summarized the characteristic manifestations of buprenorphine withdrawal psychosis, yet all of them were male. In this case report, we present a 41-year-old female patient with bipolar disorder and comorbid substance use disorder who developed new-onset psychosis and relapse of manic symptoms following abrupt discontinuation of Suboxone. Manic and psychotic symptoms remitted after a short-term hospitalization with the treatment of an antipsychotic and a mood stabilizer. In addition to discussing this case presentation and treatment approach, we review existing literature and discuss possible underlying mechanisms to enhance understanding of this clinical phenomenon.

How Should Clinicians Execute Critical Force Interventions With Compassion, Not Just Harm Minimization, as a Clinical and Ethical Goal?

Responsibly determining whether and when to use potentially lifesaving force when caring for patients who are acutely mentally ill typically requires carefully applying 2 key ethical standards. First, short-term morbidity or mortality risk must be minimized. Second, potential long-term harm to a patient who is traumatized during a forcibly performed intervention and potential long-term consequences to a patient's trust in clinicians must be seriously considered. This article suggests these minimum standards in mental health care decision making are necessary but insufficient. It is proposed that clinicians' intentions and motivations should not be grounded merely in harm minimization; rather, they should be grounded in compassion maximization. The article then proposes criteria for what compassion maximization would look like in response to a case.

Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder.

BACKGROUND: Clinical trials provide consistent evidence for buprenorphine's efficacy in treating opioid use disorder (OUD). While the Drug Addiction Treatment Act of 2000 requires physicians to combine medication-assisted treatment (MAT) with behavioral intervention, there is no clear evidence for what form or elements of psychotherapy are most effective when coupled with MAT to treat OUD. This investigation involves focus groups designed to collect patient opinions about a specific psychotherapy, called START NOW, as well as general beliefs about various elements of psychotherapy for treating OUD. Our analysis reveals trends about patient preferences and strategies for improving OUD treatment. METHODS: Subjects included patients enrolled in buprenorphine/naloxone MAT at our institution's office-based opioid treatment program. All subjects participated in a single START NOW group session, which was led by a provider (physician or nurse practitioner trained and standardized in delivering START NOW). Consented subjects participated in satisfaction surveys and audio-recorded focus groups assessing individual beliefs about various elements of psychotherapy for treating OUD. RESULTS: Overall, 38 different focus groups, 92 participation events, and 44 unique subjects participated in 1-to-6 different START NOW session/audio-recorded focus group sessions led by a certified moderator. Demographic data from 36/44 subjects was collected. Seventy-five percent (33/44) completed the START NOW Assessment Protocol, which revealed self-reported behavioral trends. Analysis of all 92 START NOW Satisfaction Questionnaire results suggests that subjects' opinions about START NOW improved with increased participation. Our analysis of audio-recorded focus groups is divided into three subsections: content strategies for new psychotherapies, implementation strategies, and other observations. For example, participants request psychotherapies to target impulsivity and to teach future planning and build positive relationships. CONCLUSIONS: The results of this study may guide implementation of psychotherapy and improve the treatment of OUD, especially as it relates to improving the modified START NOW program for treating OUD. Our study also reveals a favorable outlook of START NOW with increased participation, suggesting that any initial reticence to this program can be overcome to allow for effective implementation.

Functional disability, depression, and suicidal ideation in older prisoners.

BACKGROUND: The population of older prisoners (age ≥50), a group with high suicide rates, is growing. We sought to explore the associations among functional disability, depression, and suicidal ideation (SI) among older prisoners, focusing on the mediating role of depression. METHODS: Study participants were 220 sentenced male inmates age ≥50 who were incarcerated in 8 prisons. Face-to-face interviews were conducted following consent. Functional disability was assessed objectively, using the Short Physical Performance Battery (SPPB), and via self-report by asking participants their level of difficulty climbing stairs and completing activities necessary for daily living in prison (PADLS) such as standing in line for medications. The PHQ-9 and the Geriatric Suicide Ideation Scale assessed depressive symptoms and SI, respectively. Data were analyzed using linear regression models and causal mediation models. RESULTS: Participants were racially diverse and ranged from age 50 to 79 years. Whereas each functional disability measure was significantly associated with depressive symptoms, difficulty climbing stairs and PADL disability, but not SPPB score, were independently associated with SI. Depressive symptoms mediated the relationship between functional disability, assessed both objectively and via self-report, and SI. LIMITATIONS: Cross-sectional study design; possible under-sampling of participants with depressive symptoms and SI. CONCLUSIONS: Our findings have implications for suicide prevention in older prisoners. As this population continues to grow, prevention efforts should target those with depression, including but not limited to those with functional disability. Furthermore, assessing functional disability may offer a means of identifying those who should be screened for depression and suicidal ideation.

Rural Assertive Community Treatment and Telepsychiatry.

Assertive community treatment (ACT) is an evidence-based treatment for patients with severe and persistent mental illness. ACT has been shown to reduce inpatient hospitalization and is increasingly being used as a mainstay of evidence-based psychiatric practice for these clinical populations. The increasing implementation of evidence-based practices has led to the expansion of ACT in rural areas. Variability in the adaptation of ACT in rural areas has included accommodation by teams to multiple barriers. One way to increase psychiatric professional efficiency in rural areas is with telepsychiatry and possibly with rural ACT, but with unknown effects on fidelity and outcomes. Telepsychiatry has been considered a means of expanding the reach of and access to ACT. Concerns about the use of telepsychiatry by ACT teams include the psychiatrist's ability to develop a relationship with patients and staff and difficulties observing the patient's entire living environment via telemedicine. The Piedmont Community Services Board (CSB) Program for Assertive Community Treatment (PACT) serves patients in southwestern Virginia in collaboration with the Virginia Tech Carilion School of Medicine. The Piedmont CSB PACT uses telemedicine to expand the treating psychiatrist's reach and contact with PACT patients, increasing the efficiency of the psychiatrist's PACT time. Telemedicine is used for crisis intervention and augmentation of regular ongoing visits. The goals of this project were to measure patient, staff, and psychiatrist comfort and satisfaction with the use of telepsychiatry in ACT in addition to monitoring routine outcome measures.

Treating Aggression in Forensic Psychiatric Settings.

Forensic psychiatric units are high-risk environments for aggressive behavior. Many elements are necessary for the successful reduction or elimination of aggression in the process of creating a safe treatment environment. Many specific interventions have been attempted over the years with various degrees of, usually limited, success. Tolisano et al. present an integrated behavioral approach with solid theoretical underpinnings and opportunities to support significant safety improvements for select patients, albeit with several caveats.

Disability in prison activities of daily living and likelihood of depression and suicidal ideation in older prisoners.

OBJECTIVE: The study objective was to determine if disability in activities of daily living specific to prison, prison activities of daily living (PADLs), is associated with depression and severity of suicidal ideation (SI) in older prisoners, a rapidly growing population at high risk of suicide. METHODS: Cross-sectional design using data from a study of prisoners age ≥50 years (N = 167). Depression was operationalized as a score of ≥15 on the 9-item Physician Health Questionnaire (PHQ-9). SI severity was assessed using the Geriatric Suicide Ideation Scale (GSIS). Participants were considered to have PADL disability if they reported any of the following as "very difficult" or "cannot do:" dropping to the floor for alarms, climbing on/off the top bunk, hearing orders, walking while wearing handcuffs, standing in line for medications, and walking to chow. Associations were examined with bivariate tests and with multivariable logistic and linear regression models, and the interaction term gender × PADL disability was tested. RESULTS: PADL disability was associated with depression and SI severity. There was no main effect of gender on either depression or SI, yet the association between PADL disability and depression was considerably stronger in male than in female older prisoners. CONCLUSIONS: Identifying older prisoners who have difficulty performing PADLs may help distinguish prisoners who may also be likely to be depressed or experience more severe SI. Furthermore, the association between PADL disability and depression may be particularly salient in older male prisoners. Longitudinal studies are needed as causal inferences are limited by the cross-sectional design. Copyright © 2016 John Wiley & Sons, Ltd.

START NOW - a comprehensive skills training programme for female adolescents with oppositional defiant and conduct disorders: study protocol for a cluster-randomised controlled trial.

BACKGROUND: In Europe, the number of females exhibiting oppositional defiant disorder (ODD) and conduct disorder (CD) is growing. Many of these females live in youth welfare institutions. Consequently, there is a great need for evidence-based interventions within youth welfare settings. A recently developed approach targeting the specific needs of girls with ODD and CD in residential care is START NOW. The aim of this group-based behavioural skills training programme is to specifically enhance emotional regulation capacities to enable females with CD or ODD to appropriately deal with daily-life demands. It is intended to enhance psychosocial adjustment and well-being as well as reduce oppositional and aggressive behaviour. We present the study protocol (version 4.1; 10 February 2016) of the FemNAT-CD intervention trial titled 'Group-Based Treatment of Adolescent Female Conduct Disorders: The Central Role of Emotion Regulation'. METHODS/DESIGN: The study is a prospective, confirmatory, cluster-randomised, parallel-group, multi-centre, randomised controlled trial with 128 institutionalised female adolescents who fulfil the diagnostic criteria of ODD and/or CD. Institutions/wards will be randomised either to provide the 12-week skills training as an add-on intervention or to provide treatment as usual. Once the first cycle is completed, each institution will run a second cycle with the opposite condition. Primary endpoints are the pre-post change in number of CD/ODD symptoms as assessed by a standardised, semi-structured psychiatric interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime, CD/ODD section) between baseline and the end of intervention, as well as between baseline and a 3-month follow-up point. Secondary objectives include pre-post change in CD/ODD-related outcome measures, most notably emotional regulation on a behavioural and neurobiological level after completion of START NOW compared with treatment as usual. DISCUSSION: To our knowledge, this study is the first to date to systematically investigate the effectiveness of an adapted integrative psychosocial intervention designed for female adolescents with ODD and CD in youth welfare settings. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) identifier: DRKS00007524 . Registered on 18 December 2015 and with the World Health Organisation International Clinical Trials Registry Platform.

A Call to Action: A Blueprint for Academic Health Sciences in the Era of Mass Incarceration.

Over 100 million Americans have criminal records, and the U.S. incarcerates seven times more citizens than most developed countries. The burden of incarceration disproportionately affects people of color and ethnic minorities, and those living in poverty. While 95% of incarcerated people return to society, recidivism rates are high with nearly 75% arrested again within five years of release. Criminal records impede access to employment and other social services such as shelter and health care. Justice-involved people have higher rates of substance, mental health, and some chronic medical disorders than the general population; furthermore, the incarcerated population is rapidly aging. Only a minority of academic health science centers are engaged in health services research, workforce training, or correctional health care. This commentary provides rationale and a blueprint for engagement of academic health science institutions to harness their capabilities to tackle one of the country's most vexing public health crises.

Active and Passive Suicidal Ideation in Older Prisoners.

BACKGROUND: Older prisoners are the fastest growing incarcerated population with high suicide rates, yet limited information is available to inform best practices for their early risk detection and suicide prevention. AIMS: The present study sought to determine the current prevalence of and factors associated with active suicidal ideation (ASI) and passive suicidal ideation (PSI) in older prisoners, and to determine if ASI and PSI were similarly associated with depression and lifetime suicide attempt - markers of subsequent suicide. METHOD: ASI, PSI, current major depressive episode (MDE), lifetime suicide attempt, and participant characteristics were assessed during interviews with 124 prisoners aged 50 years and older. Participants were assigned to one of three mutually exclusive groups: no SI, PSI only, and ASI. RESULTS: Past alcohol dependence and fair/poor self-rated health were associated with SI. Compared with those with no SI, older prisoners with PSI (10%) and ASI (11%) were more likely to have a lifetime suicide attempt and/or MDE. However, the likelihood of experiencing either MDE or a suicide attempt did not differ between those with ASI or PSI. CONCLUSIONS: Among older prisoners, PSI and ASI may be similarly associated with markers of subsequent suicide. PSI should not be considered inconsequential and may distinguish older prisoners with elevated suicide risk.

Evaluating START NOW: A Skills-Based Psychotherapy for Inmates of Correctional Systems.

OBJECTIVE: This study investigated whether higher attendance in a skills-based group therapy program designed for inmates was associated with fewer rule infractions as reflected in the number of disciplinary reports received in a state correctional system. METHODS: Administrative data were provided by the Connecticut Department of Correction and Correctional Managed Health Care at UConn Health, the system's health care organization. This was a retrospective cohort analysis of START NOW program participation events from 2010 through 2013 (N=946). Participants were adult male and female inmates, both sentenced and unsentenced, with and without recorded psychiatric diagnoses. The number of disciplinary reports was documented for up to six months after program participation. Incident rate ratios are presented from zero-inflated negative binomial regression models. Predictive margins examined variation in the effect of sessions attended on disciplinary reports in the postprogram period across security risk groups and primary psychiatric diagnosis groups. RESULTS: For each additional session of START NOW completed, a 5% reduction was noted in the incident rate of disciplinary reports. The effect of program participation was robust to all model considerations. Inmates with higher overall security scores appear to benefit most from program participation. The program was also found to be effective across primary psychiatric diagnosis classifications. CONCLUSIONS: START NOW was shown to be an effective treatment option for reducing disciplinary infractions by inmates.