Barriers and Facilitators to Deaf Trauma Survivors' Help-Seeking Behavior: Lessons for Behavioral Clinical Trials Research.

Deaf individuals experience significant obstacles to participating in behavioral health research when careful consideration is not given to accessibility during the design of study methodology. To inform such considerations, we conducted an exploratory secondary analysis of a mixed-methods study that originally explored 16 Deaf trauma survivors' help-seeking experiences. Our objective was to identify key findings and qualitative themes from consumers' own words that could be applied to the design of behavioral clinical trials methodology. In many ways, the themes that emerged were not wholly dissimilar from the general preferences of members of other sociolinguistic minority groups-a need for communication access, empathy, respect, strict confidentiality procedures, trust, and transparency of the research process. Yet, how these themes are applied to the inclusion of Deaf research participants is distinct from any other sociolinguistic minority population, given Deaf people's unique sensory and linguistic characteristics. We summarize our findings in a preliminary "Checklist for Designing Deaf Behavioral Clinical Trials" to operationalize the steps researchers can take to apply Deaf-friendly approaches in their empirical work.

Acceptance and commitment therapy smoking cessation treatment for veterans with posttraumatic stress disorder: a pilot study.

OBJECTIVE: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking. METHODS: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms. RESULTS: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at three-month follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up. CONCLUSIONS: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial.

Posttraumatic stress disorder and substance use disorder comorbidity among individuals with physical disabilities: findings from the National Comorbidity Survey Replication.

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) affects multiple domains of functioning and presents complex challenges to recovery. Using data from the National Comorbidity Study Replication, a national epidemiological study of mental disorders (weighted N = 4,883), the current study sought to determine the prevalence of PTSD and SUD, the symptom presentation of these disorders, and help-seeking behaviors in relation to PTSD and SUD among individuals with physical disabilities (weighted n = 491; nondisabled weighted n = 4,392). Results indicated that individuals with physical disabilities exhibited higher rates of PTSD, SUD, and comorbid PTSD/SUD than nondisabled individuals. For example, they were 2.6 times more likely to meet criteria for lifetime PTSD, 1.5 times more likely for lifetime SUD, and 3.6 times more likely for lifetime PTSD/SUD compared to their nondisabled peers. Additionally, individuals with physical disabilities endorsed more recent/severe PTSD symptoms and more lifetime trauma events than nondisabled individuals with an average of 5 different trauma events compared to 3 in the nondisabled group. No significant pattern of differences was noted for SUD symptom presentation, or for receipt of lifetime or past-year PTSD or SUD treatment. Implications of these findings and recommendations for future research are discussed.

Smoking among individuals with schizophrenia in Korea: gender differences.

OBJECTIVE: This study examined gender differences in smoking and quitting among individuals diagnosed with schizophrenia in Korea. In addition, the study investigated differences in caffeine use by gender and smoking status. METHOD: An anonymous self-report survey was conducted with psychiatric inpatients. RESULTS: Compared to males, females were less likely to be current smokers (P<.001) and more likely to be former smokers (P<.01). Females were also less likely to be daily caffeine users (P<.001). Having more years of education (P<.05) and higher nicotine dependence scores (P<.05) were associated with decreased odds of intending to quit smoking, whereas having more previous quit attempts (P<.01) was associated with increased odds. These findings were significant even after adjusting for gender. Smokers were more likely to be daily caffeine users (P<.001) than their non-smoking counterparts. CONCLUSION: Nurses in Korea should play an active role in tobacco control for patients with schizophrenia by providing cessation counseling and educating the effect of caffeine use on cigarette consumption, while tailoring the service to gender differences found in this study.

Association of physician burnout with perceived EHR work stress and potentially actionable factors.

OBJECTIVE: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout. MATERIALS AND METHODS: Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors. RESULTS: Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04-1.47), not feeling valued (OR, 3.38; 95% CI, 1.69-7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87-4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63-4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12-2.67). DISCUSSION: Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. CONCLUSION: A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being.

Intentions to quit smoking: causal attribution, perceived illness severity, and event-related fear during an acute health event.

BACKGROUND: Experiencing a serious consequence related to one's health behavior may motivate behavior change. PURPOSE: This study sought to examine how causal attribution, perceived illness severity, and fear secondary to an acute health event relate to intentions to quit smoking. METHODS: Using a cross-sectional survey design, adult emergency department patients who smoked provided demographic data and ratings of nicotine dependence, causal attribution, perceived illness severity, event-related fear, and intentions to quit smoking. RESULTS: A linear regression analysis was used to examine the relations between the independent variables and quit intentions. We enrolled 186 participants. After adjusting for nicotine dependence, smoking-related causal attribution and event-related fear were associated with intentions to quit (ß = 0.26, p < 0.01 and ß = 0.21, p < 0.01, respectively). Perceived illness severity was correlated with event-related fear (r = 0.46, p < 0.001) but was not associated with intentions to quit (ß = -0.08, p = 0.32). CONCLUSION: While causal attribution and event-related fear were modestly associated with quit intentions, perceived illness severity was not. Longitudinal studies are needed to better explicate the relation between these variables and behavior change milestones.

Formative, multimethod case studies of learn to quit, an acceptance and commitment therapy smoking cessation app designed for people with serious mental illness.

Despite public health efforts, individuals with serious mental illness (SMI) still have very high rates of tobacco smoking. Innovative approaches to reach this population are needed. These series of case studies aimed to descriptively evaluate the usability, user experience (UX), and user engagement (UE) of Learn to Quit (LTQ), an acceptance and commitment therapy smoking cessation app designed for people with SMI, and to compare it with an app designed for the general population, NCI (National Cancer Institute) QuitGuide (QG). Both apps were combined with nicotine replacement therapy and technical coaching. Inspired by the ORBIT model, we implemented two case studies with crossover AB interventions, two B-phase training designs, and three bi-phasic AB single-case designs with Start-Point and Order randomization (A = QG, B = LTQ). Study outcomes were measured using the System Usability Scale, UX interviews, and background analytics. LTQ's usability levels were above the standard cutoff and on average higher than QG. UX outcomes suggested the relative benefits of LTQ's visual design, gamification and simple design structure. LTQ's overall UE was high; the app was opened for an average of 14 min per day (vs. QG: 7 min). However, users showed low levels of UE with each of the app's tracking feature. Measures of psychiatric functioning suggested the safety of LTQ in people with SMI. LTQ appears to be a usable and engaging smoking cessation app in people with SMI. An optimized version of LTQ should be tested in a Phase II study.

Using information technology to evaluate the detection of co-occurring substance use disorders amongst patients in a state mental health system: implications for co-occurring disorder state initiatives.

The current study describes a system-wide method of evaluating detection strategies for co-occurring disorders within a state mental health system. Information technology was used to merge administrative datasets from the New Jersey mental health and substance abuse systems and identify individuals treated in both systems. We measured a 53% detection rate of substance use disorders amongst adult patients in the mental health system with particularly low detection rates in acute settings (49.0%) and among female (43.7%), older (36.2%), and psychotic patients (43.6%). The methodology described here could help evaluate critical aspects of ongoing state co-occurring disorder quality improvement initiatives.

Changes in smoking associated with an acute health event: theoretical and practical implications.

BACKGROUND: Experiencing a serious adverse behavior-related consequence may motivate behavior change. PURPOSE: To examine how a sentinel health event is associated with changes in smoking. METHODS: We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed 1 month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence. RESULTS: Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached 1 month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes. CONCLUSION: Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings.

Attitudes toward the integration of smoking cessation treatment into drug abuse clinics.

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care.

Relationship between self-reported task persistence and history of quitting smoking, plans for quitting smoking, and current smoking status in adolescents.

The task persistence construct has previously been measured primarily behaviorally (e.g., with a mirror-tracing task, or breath holding), and only in adults. It has been shown to differentiate between adult smokers and non-smokers and to predict smoking cessation in adult smokers trying to quit. This theory-based analysis is the first to examine task persistence in adolescent smokers and to examine a two-item, internally consistent, self-report measure of task persistence. Results indicate that task persistence is greater among adolescent non-smokers as compared to adolescent current smokers, and those planning to quit smoking as compared to those with no plans to quit. Contrary to hypotheses, task persistence was not found to be related to prior successful attempts to quit smoking. Our results suggest that a brief, self-report measure of task persistence may be a methodologically sound, practical clinical tool for this population.

Addressing tobacco use through organizational change: a case study of an addiction treatment organization.

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.

Deaf people's help-seeking following trauma: Experiences with and recommendations for the Massachusetts behavioral health care system.

OBJECTIVE: Deaf trauma survivors are one of the more underserved populations in behavioral health care and experience significant obstacles to seeking help. Repeated encounters with these barriers fuel negative perceptions and avoidance of behavioral health treatment. The current study sought to explore Deaf trauma survivors' help-seeking experiences and elicit their recommendations for improving Deaf behavioral health services in Massachusetts. METHOD: We conducted semistructured American Sign Language interviews with 16 trauma-exposed Deaf individuals that included questions from the Life Events Checklist and the PTSD Symptom Scale Interview and questions about Deaf individuals' help-seeking behaviors. Qualitative responses regarding help-seeking experiences were analyzed using a grounded theory approach. RESULTS: In the aftermath of trauma, our participants emphasized a desire to work with a signing provider who is highly knowledgeable about Deaf culture, history, and experience and to interact with clinic staff who possess basic sign language skills and training in Deaf awareness. Most stressed the need for providers to better outreach into the Deaf community-to provide education about trauma, to describe available treatment resources, and to prove one's qualifications. Participants also provided suggestions for how behavioral health clinics can better protect Deaf survivors' confidentiality in a small-community context. CONCLUSIONS: Deaf-friendly trauma treatment should incorporate the components of trauma-informed care but also carefully consider key criteria expressed by our participants: direct signed communication, understanding of Deaf history and experience, stringent practices to protect confidentiality, provider visibility in the community, and reliance on peer support and Deaf role models in treatment interventions. (PsycINFO Database Record

Detection of co-occurring mental illness among adult patients in the New Jersey substance abuse treatment system.

OBJECTIVES: We assessed the detection of mental illness in an adult population of substance abuse patients and the rate of referral for mental health treatment. METHODS: We obtained combined administrative records from 1994 to 1997 provided by the New Jersey substance abuse and mental health systems and estimated detection and referral rates of patients with co-occurring disorders (n = 47,379). Mental illness was considered detected if a diagnosis was in the record and considered undetected if a diagnosis was not in the record but the patient was seen in both treatment systems within the same 12-month period. Predictors of detection and referral were identified. RESULTS: The detection rate of co-occurring mental illness was 21.9% (n=10364); 57.9% (n=6001) of these individuals were referred for mental health treatment. Methadone maintenance clinics had the lowest detection rate but the highest referral rate. Male, Hispanic, and African American patients, as well as those who used heroin or were in the criminal justice system, had a higher risk of mental illness not being detected. Once detected, African American patients, heroin users, and patients in the criminal justice system were less likely to be referred for treatment. CONCLUSIONS: There is a need to improve the detection of mental illness among substance abuse patients and to provide integrated treatment.

The patient-oriented clinician-researcher: advantages and challenges of being a double agent.

The number of clinically trained individuals who perform research is declining. Although it is often observed that the clinician-researcher is necessary, the reasons are rarely discussed. In this article, the authors critically consider the complexities of the role of the patient-oriented clinician-researcher at the interface of behavioral health treatment and research. The authors note that patient-oriented clinician-researchers can serve as effective "bridgers" between the research and practice communities and can facilitate both the development of clinically relevant research and the dissemination of evidence-based treatments into routine clinical services. However, care needs to be taken to address the potential for ethical and role conflicts. Programs can encourage trainees to become clinician-researchers by providing opportunities for them to meet with patient-oriented clinician-researchers and by including coursework that raises their awareness of ethical and role conflicts and provides them with the skills needed to be effective "bridgers."

Developments in pharmacotherapy for tobacco dependence: past, present and future.

In the mid-1970s there were no effective pharmacological treatments for tobacco dependence. The invention of nicotine gum was a major treatment advance and also greatly helped our understanding of the nature of tobacco dependence. There are now eight effective pharmacotherapies (nicotine gum, patch, nasal spray, inhaler, lozenge/tablet, bupropion, nortriptyline and clonidine) available to aid smoking cessation. Other non-nicotine agents that show promise are under investigation, including glucose, rimonabant, selegiline and varenicline. Greater knowledge of the mechanisms of action of the effective non-nicotine agents should lead to better understanding of the nature of tobacco dependence. Future research into optimal treatments should examine long-term combination pharmacotherapy combined with improved psychosocial support that is partly designed to enhance medication compliance. In addition, there is a need for studies designed to evaluate the efficacy of pharmacotherapies in populations such as youth, pregnant smokers and smokers with co-occurring mental health problems.

A Pilot Study of Deaf Trauma Survivors' Experiences: Early Traumas Unique to Being Deaf in a Hearing World.

Conducting semi-structured American Sign Language interviews with 17 Deaf trauma survivors, this pilot study explored Deaf individuals' trauma experiences and whether these experiences generally align with trauma in the hearing population. Most commonly reported traumas were physical assault, sudden unexpected deaths, and "other" very stressful events. Although some "other" events overlap with traumas in the general population, many are unique to Deaf people (e.g., corporal punishment at oral/aural school if caught using sign language, utter lack of communication with hearing parents). These findings suggest that Deaf individuals may experience developmental traumas distinct to being raised in a hearing world. Such traumas are not captured by available trauma assessments, nor are they considered in evidence-based trauma treatments.

Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect.

It has been hypothesized that smokers with schizophrenia take in more nicotine per cigarette than smokers without this disorder. This study examines this phenomenon by comparing the serum nicotine and cotinine levels in smokers with either schizophrenia or schizoaffective disorder compared to control smokers without mental illness. Serum cotinine and nicotine levels of smokers with schizophrenia or schizoaffective disorder were 1.3 times higher than control smokers (cotinine 291 versus 227 ng/mL; p = 0.0115; nicotine 28 versus 21 ng/mL; p < 0.001) despite smoking a similar number of cigarettes per day. Similar serum 3'-hydroxycotinine (3HC) to cotinine ratios in both groups indicate that this difference was not due to differences in the rate of metabolism of nicotine or cotinine. By examining serum nicotine and 3HC/cotinine ratios in addition to cotinine, this study expands upon previous research that relied on cotinine as an indirect indicator for nicotine intake. Our data support the hypothesis that the increased serum nicotine and cotinine levels observed are attributable to an increased nicotine intake per cigarette in smokers with schizophrenia as compared to those without mental illness.

Effectiveness of workshop training for psychosocial addiction treatments: a systematic review.

Workshop training for psychosocial substance abuse treatment has been an important part of the transfer of evidence-based approaches into larger practice. Although they are widely used, training methods such as self-study reading, internet-based courses, and educational workshops have not traditionally been the focus of empirical investigations. Based on electronic and manual searches of the literature, we summarize 17 evaluations of workshop training that describe the training program and the educational outcomes. In general, training tends to improve attendees' knowledge, attitudes, and confidence in working with clients who have substance abuse problems. Some skill improvements, when measured, are usually seen immediately after training but are less often maintained over a longer time. Extended contact, through follow-up consultation, supervision, or feedback, appears to be necessary for the long-term adoption of skills. There are also a number of institutional factors that may influence the extent to which providers adopt new practices. Given the popularity of this training format, the role of workshop training needs to be a focus of future evaluative research.

The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey.

New Jersey was the first state to implement a licensure standard for all residential addiction treatment programs to assess and treat tobacco dependence in the context of entirely tobacco-free facilities (including grounds). A program evaluation of the first year of the policy (2001-2002) assessed the impact on programs, clients, and staff. At 1-year follow-up, all 30 residential programs surveyed provided some tobacco dependence treatment and 50% had tobacco-free grounds. Eighty-five percent of the programs accepted the state's offer to provide free NRT, reaching more than 2,326 clients. Seventy-seven percent of all clients were smokers, and 65% of the smokers reported they wanted to stop or cut down tobacco use. Forty-one percent of the smokers reported that they did not use any tobacco during their entire residential stay. There was no increase in irregular discharges, or reduction in proportion of smokers among those entering residential treatment, compared with prior years. Licensure standards regulation can be an effective mechanism for increasing the quantity and quality of tobacco dependence treatment in residential addictions programs.