Specific Associations Between Type of Childhood Abuse and Elevated C-Reactive Protein in Young Adult Psychiatric Rehabilitation Participants.

BACKGROUND: Early-life adversity such as childhood emotional, physical, and sexual trauma is associated with later-life psychiatric and chronic medical conditions, including elevated inflammatory markers. Although previous research suggests a role for chronic inflammatory dysfunctions in several disease etiologies, specific associations between childhood trauma types and later-life inflammation and health status are poorly understood. METHODS: We studied patients (n = 280) admitted to a psychiatric rehabilitation center. Self-reported histories of childhood emotional, physical, and sexual trauma were collected with a standard instrument. At the time of admission, we also assessed individuals' body mass index and collected blood samples used to examine inflammatory marker C-reactive protein (CRP) levels. RESULTS: The prevalence of all 3 types of abuse was relatively high at 21% or more. Fifty percent of the sample had elevations in CRP, with clinically significant elevations in 26%. We found that compared with a history of emotional or physical abuse, a history of childhood sexual trauma was more specifically associated with elevated CRP. This result held up when using linear regressions to examine the contribution of body mass index. LIMITATION: Our sample was relatively young, with an average age of 27.2 years and minimal representation of ethnic and racial minority participants. CONCLUSION: Relative to childhood emotional and physical trauma, childhood sexual trauma may lead to elevated inflammatory responses, as confirmed in our finding of an association between CRP and sexual abuse. Future studies need to assess the causal link between childhood sexual trauma and poorer health outcomes later in life.

Measuring and Facilitating Client Engagement with Financial Incentives: Implications for Improving Clinical Outcomes in a Mental Health Setting.

Significant numbers of individuals with severe mental illnesses are difficult to engage in treatment services, presenting challenges for care. To be able to assess the relationship between engagement and discharge outcomes, we modified the "Milestones of Recovery Scale". This scale was modified for content to match the current clinical setting, evaluated for inter-rater reliability after modification in a sample of 233 cases receiving psychiatric rehabilitation, and then was administered to 423 additional psychiatric rehabilitation clients over a 24-month study period. In an effort to determine whether provision of financial incentives lead to sustained increases in client engagement, a cut off for client eligibility for financial incentives was evaluated on the basis of the reliability study and the course of engagement was related to receipt of this incentive and successful completion of treatment in a new sample of 423 patients. Of this sample, 78 % received an initial financial incentive during treatment (were initially engaged), and 93.3 % of that subgroup sustained this level of engagement it over their entire course of treatment. Of the 22 % of cases not receiving an initial incentive, only 5.4 % improved in their engagement to levels required for the incentive. Longitudinal analysis demonstrated that individuals who maintained or increased their level of engagement over time were more likely to complete treatment in accordance with planned treatment goals. The initial engagement and the course of engagement in treatment predicted successful completion, but incentives did not lead to increased engagement in initially poorly engaged patients. These data are interpreted in terms of the likely success of extrinsic rewards to increase engagement in mental health services.

Parental relationships and behavioral approach system dysregulation in young adults with bipolar disorder.

OBJECTIVES: Expressed emotion (EE), or the presence of criticism/hostility/emotional overinvolvement in a family relationship, predicts poorer outcomes in bipolar disorder; however, the mechanism of this is unclear. The present study investigated whether, in a sample of young adults (aged 18-40 years) with bipolar disorder, parental criticism was associated with Behavioral Approach System (BAS) dysregulation, including emotional reactivity to negative feedback and cognitive schemas of self-criticism/perfectionism. METHOD: Twenty-two young adults with bipolar I disorder and 22 matched control participants completed an interview, questionnaires, and a computer-based task with false negative feedback; emotional reactivity to this feedback was assessed. RESULTS: Compared to control participants, clinical participants exhibited higher levels (p = 0.001) of self-criticism, and a trend towards a greater decrease in positive affect after negative feedback (p = 0.053), even when controlling for mood symptoms. Among clinical participants, perceived criticism from paternal caregivers was associated with self-criticism and perfectionism, and low perceived paternal care was associated with decrease in positive affect. CONCLUSION: Strain in parental relationships may be associated with BAS dysregulation for individuals with bipolar disorder.

Key features of a unique community psychiatry fellowship: the emory university fellowship in community psychiatry/public health.

The Emory University Fellowship in Community Psychiatry/Public Health is a unique training opportunity whose mission is to train future leaders in the arena of community psychiatry. To complement the recent description of the Public Psychiatry Fellowship of New York State Psychiatric Institute at Columbia University Medical Center, this report describes the key features of Emory's fellowship-its academic curriculum, practicum experiences, site visits and other opportunities for collaboration, and ongoing mentoring and career development. Congruencies between these four key features and the seven core elements of Columbia's fellowship are highlighted, as are several important differences. Such descriptions of innovative training programs in community and public psychiatry are essential in promoting excellence in education, which will translate into vital enhancements in programs, policy, and community-based approaches to mental health services.

Training engagement, baseline cognitive functioning, and cognitive gains with computerized cognitive training: A cross-diagnostic study.

Computerized cognitive training (CCT) interventions are increasing in their use in outpatient mental health settings. These interventions have demonstrated efficacy for improving functional outcomes when combined with rehabilitation interventions. It has recently been suggested that patients with more cognitive impairment have a greater therapeutic response and that reduced engagement in training can identify cases who manifest low levels of benefit from treatment. Participants were psychiatric rehabilitation clients, with diagnoses of major depression, bipolar disorder and schizophrenia. Newly admitted cases received CCT, delivered via Brain HQ, with cognitive functioning divided into groups on the basis of a BACS t-score of 40 or less vs. more. Training engagement was indexed by the number of training levels achieved per day trained. Forty-nine cases trained on average for 17 days and completed a mean of 150 levels. Overall, patients improved by an average of 4.4 points (0.44 SD) in BACS t-scores (p < .001). Improvements were positively correlated with training engagement (r = 0.30, p < .05), but not with days trained (r = 0.09) or levels earned (r = 0.03) alone. Patients with higher levels of baseline cognitive performance had reduced cognitive gains (p < .003), but did not have less training engagement (p = .97). Diagnoses did not predict cognitive gains (p = .93) or target engagement (p = .74). Poorer performance at baseline and higher levels of training engagement accounted for >10% in independent variance in cognitive gains. The mean level of cognitive improvement far exceeded practice effects. The index of engagement, levels achieved per training day, is easily extracted from the training records of patients, which would allow for early and continuous monitoring of treatment engagement in CCT activities and therapist intervention as needed to improve engagement.

Developing a modern standard to define and assess professionalism in trainees.

OBJECTIVE: Assessing professionalism in medical education poses many challenges. The authors discuss common themes and principles in managing professionalism in medical education. METHODS: The authors review the development of standards of professionalism in medical education. They define educational goals for professionalism and also discuss the practical problems with assessing professionalism and addressing it with the trainees. Strategies for remediation of unprofessional conduct are outlined. RESULTS: Given the importance of role models in the development of professional behavior, maintaining an environment that fosters professionalism is an implicit feature of teaching professionalism. Professionalism should be a part of the objectives for each course and clinical rotation, using clearly defined goals and objectives. Assessment of professionalism should begin early and be conducted frequently, giving trainees the opportunity to change. A formal mentoring system can be an effective mechanism to develop role models and teach professionalism. CONCLUSION: Teaching professionalism through formal curricula is paramount in helping develop new generations of compassionate and responsible physicians. Additional strategies such as consistent role modeling of professional behaviors are also needed to encourage the development of professional physicians.

Brief reports: crisis intervention team training: changes in knowledge, attitudes, and stigma related to schizophrenia.

OBJECTIVE: Crisis intervention team (CIT) training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses. This study determined changes in knowledge, attitudes, and social distance related to schizophrenia among police officers after CIT training. METHODS: A survey was administered to 159 officers immediately before and after a 40-hour CIT training program in Georgia. Pre- and posttest data were gathered from surveys taken between December 2004 and July 2005. RESULTS: After the training, officers reported improved attitudes regarding aggressiveness among individuals with schizophrenia, became more supportive of treatment programs for schizophrenia, evidenced greater knowledge about schizophrenia, and reported less social distance toward individuals with schizophrenia. CONCLUSIONS: This study supports the hypothesis that an educational program for law enforcement officers may reduce stigmatizing attitudes toward persons with schizophrenia.

Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health.

Following a brief introduction to response planning for terrorism and other disasters, the authors present their experiences in developing a grassroots, interdisciplinary group charged with incorporating a mental health response component into the bioterrorism response plan for the metropolitan Atlanta area. This group was organized and supported by the Center for Public Health Preparedness at the DeKalb County Board of Health. Various viewpoints of key participating agencies are presented. Recommendations are provided for other localities and stakeholders who plan to incorporate a community mental health component into local disaster response plans.