A longitudinal follow-up study of Oklahoma City bombing survivors in the first quarter century after the disaster.

BACKGROUND: This study is one of the longest postdisaster prospective longitudinal studies of disaster-related psychopathology, completed nearly a quarter century after a terrorist bombing, and the longest follow-up study ever conducted using full diagnostic assessment in highly exposed disaster survivors. METHODS: Oklahoma City bombing survivors (87% injured) were randomly selected from a state survivor registry and interviewed approximately 6 months postdisaster (N = 182; 71% participation) and again nearly 25 years later (N = 103; 72% participation). Interviews were conducted using the Diagnostic Interview Schedule (a structured interview assessing full diagnostic criteria) for panic disorder, generalized anxiety disorder, and substance use disorder at baseline and also for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) at follow-up. The Disaster Supplement assessed disaster trauma exposure and subjective experience. RESULTS: At follow-up, 37% of participants exhibited bombing-related PTSD (34% at baseline) and 36% had MDD (23% at baseline). More new cases of PTSD than MDD developed over time. Nonremission rates were 51% for bombing-related PTSD and 33% for MDD. One-third of participants reported long-term nonemployability. CONCLUSIONS: The presence of long-term medical problems among survivors parallels the persistence of psychopathology. Ongoing medical problems might have contributed to psychiatric morbidity. Because no major variables predicted remission from bombing-related PTSD and MDD, all survivors with postdisaster psychopathology likely need access to long-term evaluation and care.

Characteristics and experiences of professionals providing 9/11 mental health services.

BACKGROUND: After disasters, mental health professionals might be called upon to help address the emotional consequences of the disaster among survivors and other affected groups, but the clinicians themselves could be affected. This exploratory study examined the experiences of 60 mental health professionals, most of whom provided mental health care to individuals affected by the September 11, 2001 terrorist attacks (9/11), and/or experienced 9/11 sequelae themselves. METHODS: Participants completed structured interviews 3 and/or 6 years after the disaster, with full diagnostic assessment of psychiatric disorders and questions specific to their personal and professional post-9/11 experience. RESULTS: Providing postdisaster care was somewhat stressful initially, but long-term effects were more positive than negative, with overall benefit to many personal lives. Most found their clients' 9/11 stories emotionally upsetting, yet characterized their 9/11 mental health work as positive. Work satisfaction increased by 3-fold, but this effect was transitory. One-third had postdisaster psychopathology, but most was pre-existing and therefore not a product of disaster-related stressors. CONCLUSIONS: Although most mental health professionals initially found the emotional difficulty of their work increased after 9/11, this negative effect had largely dissipated over the years. Opportunities for disaster mental health training and initial logistical support could benefit these professionals.

Learning and achievement characteristics of sheltered homeless population subgroups.

BACKGROUND: There is little systematic information about intelligence and academic achievement among sheltered homeless adults. This study adds descriptive data on intelligence and academic achievement, examines discrepancies across these concepts, and explores the associations among demographic and psychosocial characteristics in the context of intelligence categories and discrepancies. METHODS: We studied intelligence, academic achievement, and discrepancies between IQ and academic achievement among 188 individuals experiencing homelessness who were systematically recruited from a large, urban, 24-hour homeless recovery center. Participants completed structured interviews, urine drug testing, the Wechsler Abbreviated Scale of Intelligence, and the Wide Range Achievement Test, 4th edition. RESULTS: Average full-scale intelligence was low average (90) but higher than scores obtained in other studies of homeless populations. Academic achievement was lower than average (82 to 88). Performance/math deficits in the higher intelligence group indicate functional difficulties that could have contributed to homeless risk. CONCLUSIONS: The low-normal intelligence and below-average achievement scores are not extreme enough to warrant immediate attention and intervention for most individuals. Systematic screening during entry into homeless services might identify learning strengths and weaknesses, presenting modifiable factors that could be addressed in focused educational/vocational interventions.

Groundhog Day: research without old data and old references.

BACKGROUND: The use of older data and references is becoming increasingly disfavored for publication. A myopic focus on newer research risks losing sight of important research questions already addressed by now-invisible older studies. This creates a 'Groundhog Day' effect as illustrated by the 1993 movie of this name in which the protagonist has to relive the same day (Groundhog Day) over and over and over within a world with no memory of it. This article examines the consequences of the recent preference for newer data and references in current publication practices and is intended to stimulate new consideration of the utility of selected older data and references for the advancement of scientific knowledge. METHODS: Examples from the literature are used to exemplify the value of older data and older references. To illustrate the recency of references published in original medical research articles in a selected sample of recent academic medical journals, original research articles were examined in recent issues in selected psychiatry, medicine, and surgery journals. RESULTS: The literature examined reflected this article's initial assertion that journals are emphasizing the publication of research with newer data and more recent references. CONCLUSIONS: The current valuation of newer data above older data fails to appreciate the fact that new data eventually become old, and that old data were once new. The bias demonstrated in arbitrary policies pertaining to older data and older references can be addressed by instituting comparable treatment of older and newer data and references.

Deconstructing childhood conduct and adult antisocial criteria for the diagnosis of antisocial personality disorder.

BACKGROUND: Antisocial personality disorder (ASPD) is a serious psychiatric disorder that can be incapacitating and costly to individuals and society. The ASPD diagnosis has 2 main components, childhood conduct problems and adult antisocial behaviors, with specific age requirements. The nosological effects of these criteria on population subgroups defined by these aspects of the criteria have not been fully explored. METHODS: Data for ASPD were analyzed for 3,498 individuals in the St Louis, Missouri, site of the Epidemiologic Catchment Area study of general population psychiatric disorders collected in the early 1980s using structured diagnostic interviews for DSM-III criteria. Effects of the criteria on population subgroups defined by various combinations of the criteria were examined. RESULTS: Earlier-onset conduct disorder was more severe than later-onset childhood conduct disorder, with more total childhood and adult symptoms and negative psychosocial adult outcomes (substance use disorders, criminality, and homelessness). Three subgroups with adult antisocial behaviors (differentiated by no conduct disorder, later-onset conduct disorder, and earlier-onset conduct disorder meeting ASPD criteria) were similar in numbers of adult antisocial symptoms, but the ASPD subgroup had more negative psychosocial adult outcomes. CONCLUSIONS: These findings provide evidence for and against reconsideration of the 15-year age-of-onset requirement for conduct symptoms in ASPD criteria.

A prospective longitudinal study of tobacco use and tobacco use disorder in a homeless population.

BACKGROUND: Little is known about smoking habits and disorders among homeless populations. Previous research has not generally differentiated tobacco use from tobacco use disorders in this population. Known associations of tobacco use and morbidity and mortality in general populations may also apply to homeless populations. METHODS: A 2-year longitudinal prospective study of 255 homeless individuals examined tobacco use and tobacco use disorders in association with other psychiatric disorders and service use and homeless outcomes. RESULTS: The majority of the sample used tobacco daily and had a tobacco use disorder, characteristics that changed little over the 2-year follow-up period. Tobacco use disorder was associated with greater substance, medical, and psychiatric service use during the 2 follow-up years. However, tobacco use was not associated with change in housing status over the 2-year follow-up period. Cessation of tobacco use was associated with cessation of alcohol use. CONCLUSIONS: Smoking is a major health issue for homeless populations. This study found that smoking status was unassociated with the achievement of stable housing. In addition, homeless people who smoke were found to be more likely to use health care services, indicating a potential source of intervention for smoking cessation.

A systematic mental health assessment of first-year students at a historically Black college.

BACKGROUND: A systematic diagnostic mental health assessment was conducted with first-year students at Paul Quinn College, a small historically Black college/university (HBCU) in Dallas, Texas. METHODS: A sample of 128 students was assessed with the Mini-International Neuropsychiatric Interview for DSM-5 and the Childhood Trauma Questionnaire. RESULTS: Nearly one-third of students were diagnosed with a current psychiatric disorder, most commonly substance use disorders (17%) and major depressive disorder (9%). Despite these findings, few students had ever received psychiatric treatment, and considering their substantial trauma histories, few developed posttraumatic stress disorder, reflecting protective factors in the HBCU. CONCLUSIONS: The prevalence of psychiatric disorders in this HBCU study is consistent with findings of studies conducted at predominately White institutions. However, the relatively low access to treatment of these HBCU students suggests relevant mental health care disparities in this population. Further research is needed to develop interventions designed to help connect HBCU students to mental health care.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Personality in Combination with Alcohol and Drug Use and Psychiatric Disorders to Predict Psychosocial Characteristics and Behaviors of Hepatitis C Patients.

The objectives of this study were to assess the prevalence of personality disorders and to examine personality as a predictor of psychosocial characteristics and behaviors of HCV patients. HCV patients (n = 259) from three infectious disease and liver clinics who completed Cloninger's Temperament and Character Inventory (TCI), an inventory for personality traits, were included in the study. Patients with low scale scores in the character dimension of both cooperativeness and self-directedness (low CO/SD) were defined as having a personality disorder. Using low CO/SD in combination with demographic, psychiatric/substance use, and HCV-related variables, linear regression was used to construct separate models of risky behaviors, quality of life, functioning, burden of illness, and social support. The prevalence of low CO/SD was high in this sample of HCV patients. Low CO/SD was an independent predictor of risky behaviors, quality of life, functioning, and social support.

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use.

Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.

Quality of Life, Functioning, and Coping in HCV Patients Continuing Versus Ceasing Alcohol Use.

The purpose of this study was to compare quality of life, functioning, and coping among hepatitis C virus (HCV) patients who continued versus ceased alcohol use in the past year. HCV patients (n = 291) were recruited from three liver and infectious disease clinics. Student's t test was used to compare HCV patients who were former and active users of alcohol. The majority of HCV patients were male, African American, and without a high school degree. Compared to former users of alcohol, active users of alcohol self-reported lower ratings on home life, personal leisure, and overall quality of life. In the area of functioning, active users of alcohol self-reported lower ratings on home life, close relationships, sex life, and overall functioning. The two groups did not differ on coping. Most HCV clinicians advise HCV patients to avoid alcohol completely because of its adverse biological effects on the liver. Despite this important advice by their HCV clinicians, most HCV patients continue to use alcohol. HCV clinicians can additionally consider advising these patients that continued alcohol use is associated with lower quality of life and functioning as further evidence to convince these patients to avoid alcohol or to participate in alcohol cessation treatment.

Religious and Spiritual Aspects of Disaster Experience Among Survivors of the 9/11 Attacks on New York City's World Trade Center.

This study examined religious and spiritual aspects of disaster experience among 379 survivors of the 9/11 attacks on New York City's World Trade Center. Interviews conducted 35 months after the disaster provided structured diagnostic assessments of psychiatric disorders and specific detail of demographic characteristics, experience of the disaster, and variables related to religion and spirituality. The study participants overwhelmingly identified with a specific religion. The disaster appeared to have only modest effects on strength and importance of religion/spirituality, and changes were predominantly positive. Specific religions and faith groups differed in their disaster experience in important ways.

Transitions between Housing States among Urban Homeless Adults: a Bayesian Markov Model.

The purpose of this study is to explore how marginalization, substance abuse, and service utilization influence the transitions between streets, shelters, and housed states over the course of 2 years in a population of urban homeless adults. Survey responses from three yearly interviews of 400 homeless adults were matched with administrative services data collected from regional health, mental health, and housing service providers. To estimate the rates of transition between housed, street, and shelter status, a multi-state Markov model was developed within a Bayesian framework. These transition rates were then regressed on a set of independent variables measuring demographics, marginalization, substance abuse, and service utilization. Transitions from housing to shelters or streets were associated with not being from the local area, not having friends or family to count on, and unemployment. Pending charges and a recent history of being robbed were associated with the shelters-to-streets transition. Remaining on the streets was uniquely associated with engagement in "shadow work" and, surprisingly, a high use of routine services. These findings paint a picture of unique and separate processes for different types of housing transitions. These results reinforce the importance of focusing interventions on the needs of these unique housing transitions, paying particular attention to prior housing patterns, substance abuse, and the different ways that homeless adults are marginalized in our society.

A longitudinal study of housing status and crime in a homeless population.

BACKGROUND: It is well established that homelessness is associated with crime. Previous research suggests that this association is at least partially secondary to homeless status offenses (eg, vagrancy and trespassing resulting from behaviors intrinsic to homelessness). To investigate this relationship, this study compared criminal behavior in a homeless population under housed and unhoused conditions. METHODS: Reported criminal and housing histories of 255 homeless individuals were examined at 3 annual interviews. Lifetime criminal charges incurred while homeless vs housed were compared for types of offenses. Prospective longitudinal data from these interviews were used to examine housing status and recent crime. RESULTS: At baseline, homeless status offenses were the most frequently reported charges and were the only type of crime for which charges were incurred more frequently in the homeless condition. Over the 2-year followup period, recent crime was consistently higher in groups who had been homeless relative to groups who had been housed, and crime rates fell after obtaining housing. CONCLUSIONS: These findings suggest that homelessness itself is linked to criminal behavior through homeless status offenses. Negative effects of arrest and incarceration on housing acquisition warrant consideration of alternative legal system interventions to break the cycle of homelessness.

Associations of alcohol use disorder, alcohol use, housing, and service use in a homeless sample of 255 individuals followed over 2 years.

BACKGROUND: Homeless individuals with alcohol use disorders have multiple comorbidities and therefore various service needs. Despite need for services, homeless individuals face numerous barriers to treatment. Little is known about the associations of specific services in relation to homelessness in the context of alcohol problems. The current study analyzed 2-year prospective longitudinal data on a homeless sample, examining relationships between alcohol use disorder, alcohol use, housing status, and service use over time. METHODS: Two hundred fifty-five of 400 individuals recruited systematically from shelters and street locations completed 3 annual assessments (69% completion). Data on lifetime and current psychiatric disorders, housing status, and past-year service use were obtained and merged with service use data gathered from local agencies. Generalized estimating equation (GEE) models were created to predict dependent outcome variables of stable housing, alcohol use, and service use in both follow-up years. RESULTS: Lifetime alcohol use disorder was positively associated with substance and medical service use. Alcohol problems did not hinder attainment of stable housing, and placement in housing did not necessarily increase risk for alcohol use. Stable housing was negatively associated with psychiatric and substance service use. In the second year, when alcohol use was finally associated with receiving substance services, it appears that these services provided a gateway to psychiatric services. The psychiatric services in turn appeared to provide a gateway to medical services. CONCLUSIONS: Alcohol use behaved differently compared with lifetime alcohol use disorder in relation to service use. Lack of association between alcohol use and housing supports Housing First policy. Obtaining housing may have ameliorative effects on mental health, diminishing perceived need for psychiatric services. Services may also be more accessible during homelessness. Obtaining substance treatment may provide a gateway for those who use alcohol after becoming homeless to connect with psychiatric and medical services, informing policy and practice.

Prospective Longitudinal Substance Use Patterns in Patients Preparing for Hepatitis C Treatment.

OBJECTIVES: This study prospectively examined the independent courses of alcohol, drugs, and smoking over 18 months in 154 patients preparing for hepatitis C virus (HCV) treatment in relation to functioning, negative coping, and satisfaction with quality of life in data collected from a randomized controlled trial of multiple-family group psychoeducation for patients preparing for HCV treatment. Patients with HCV who had consistent abstinence, consistent use, or achievement of abstinence after study entry were examined for outcomes pertaining to functioning in the context of HCV, negative coping, and satisfaction with quality of life. METHODS: Of 309 patients considering treatment for HCV recruited from outpatient clinics at two major university medical centers and a Veterans Affairs medical center for a randomized controlled trial of a psychoeducation intervention, 154 completed baseline, 6-month, and 18-month assessments. The assessments included structured diagnostic interviews; questionnaires examining functioning, coping, and satisfaction with quality of life; medical record review; and urine testing for substances of abuse. For these analyses, substance use patterns were determined as consistent abstinence, consistent use, and achieving abstinence after study entry for alcohol and drug use and smoking. RESULTS: The entire sample generally improved in all of these three outcomes over the course of the study. The course of alcohol, drugs, and smoking predicted HCV-related functioning, negative coping, and satisfaction with quality-of-life outcomes over 18 months. Three specific patterns of use (consistent abstinence, consistent use, and achievement of abstinence after study entry) of these substances diverged in association with outcomes related to functioning, negative coping, and satisfaction with quality of life, not only across trajectories over time within substance types but also among types of substances. CONCLUSIONS: This study's finding that different substances were associated with distinct clinical outcomes suggests the need to conceptually unbundle different types of substances in managing HCV. Future research is needed to examine the clinical utility of further unbundling these substances and also to further investigate effects of various amounts of use of these substances.

Pilot Design and Implementation of an Innovative Mental Health and Wellness Clinic at a Historically Black College/University.

A pilot mental health and wellness clinic was developed and implemented on the campus of Paul Quinn College, a small Historically Black College and University (HBCU) in Dallas, TX, to address mental health disparities in an African-American student population. Additionally, a series of student engagement activities was developed and implemented to address stigma and enhance linkage to the clinic. The student engagement activities were well attended. In all, 14 students requested a total of 97 appointments during the spring 2016 semester, but attended only 41 appointments. Students sought treatment of a variety of psychiatric disorders, most commonly major depressive disorder and adjustment disorder. A model based on this program could conceivably be extended to serve students more broadly in other HBCUs as well as in community colleges.

A Systematic Comparison of African American and Non-African American Patients on Psychosocial Aspects of Hepatitis C Infection.

The purpose of this study was to compare African American and non-African American hepatitis C virus (HCV) patients on self-reported symptoms of HCV liver disease and psychosocial characteristics commonly affected by it in a sample of 309 patients enrolled in a randomized controlled trial. African Americans (n = 196) rated a higher reliance on religion/spirituality for coping with HCV compared to non-African Americans. This study's findings are a basis for encouragement of public health efforts and programs to seek partnerships with African American faith and religious communities to identify and treat undiagnosed cases of HCV and promote HCV awareness.

Memories of intimate partner violence and the process of change.

BACKGROUND: One in 4 U.S. women experience intimate partner violence (IPV) during their lives. Despite the magnitude of this problem, little is known about the natural history of relationships involving IPV and how women exit them. METHODS: Narrative interviews were conducted using open-ended qualitative narrative techniques with a convenience sample of 7 women who had ended a relationship of ≥6 months' duration involving IPV at least 6 months ago. The interviews were audio recorded and transcribed. Qualitative narrative analysis was conducted to identify IPV relationship phases and themes. RESULTS: From the analysis, 5 narrative phases and 2 topics emerged. The chronological presentation order of the phases was The Good Guy, Red Flags, Domestic Violence/Abuse, Mobilizing Resources, and Action. Material from the Moving On topic culminated these phases, and material from the Transition Points topic punctuated them. CONCLUSIONS: The phases that emerged were reminiscent of stages of change suggested by Prochaska and DiClemente's Transtheoretical Model of Change, but these women's narratives were overall less linear, with substantial between-phase overlap. The Red Flags phase emerged as particularly significant to the women in hindsight and may represent a potential opportunity for therapeutic intervention.