Alberto B. Santos

Comprehensive community-based interventions for youth with severe emotional disorders: Multisystemic therapy and the wraparound process

Two comprehensive community-based interventions for youth with severe emotional disorders are contrasted and compared. The interventions are multisystemic therapy (MST)—a brief but intensive, clinician-provided, and home-based treatment; and wraparound—a long-term approach to planning and coordinating the provision of both formal and informal services in the community. Both approaches are spreading rapidly across the country. As this occurs, it is important for families, clinicians, and policymakers to have sufficient information to understand the requirements and the research base for each. This paper provides a description of both MST and wraparound across multiple dimensions (i.e., origin, theory, target population, principles, role of family, cultural competence, staffing, training, quality monitoring, costs, and the evidence base). The respective similarities and differences are discussed and options for utilizing both for selected youth and families who require intensive and long-term care are explored briefly.

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

This study evaluated the impact of an integrated (mental health/substance abuse) assertive community treatment program on homeless persons with serious mental and substance use disorders. High rates of retention in treatment, housing stability, and community tenure were attained, and all but the most severe substance users appeared to gain these benefits. While the intervention appears to be an effective means of retaining in services and monitoring such difficult-to-treat and costly populations, it did not yield high rates of abstinence and social benefits in severe users.

Assertive community treatment

Assertive community treatment (ACT) started when a group of mental health professionals at the Mendota Mental Health Institute in Wisconsin—Arnold Marx, M.D., Leonard Stein, M.D., and Mary Ann Test, Ph.D.—recognized that many people with severe mental illnesses were being discharged from inpatient care in stable condition only to be readmitted relatively soon thereafter. This group looked at how the mental health system worked and tried to figure out what could be done so that individuals with severe mental illness could remain in the community and have a life that was not driven by their illness.

Project Among African-Americans to Explore Risks for Schizophrenia (PAARTNERS): Evidence for Impairment and Heritability of Neurocognitive Functioning in Families of Schizophrenia Patients

OBJECTIVE Neurocognitive impairments in schizophrenia are well replicated and widely regarded as candidate endophenotypes that may facilitate understanding of schizophrenia genetics and pathophysiology. The Project Among African-Americans to Explore Risks for Schizophrenia (PAARTNERS) aims to identify genes underlying liability to schizophrenia. The unprecedented size of its study group (N=1,872), made possible through use of a computerized neurocognitive battery, can help further investigation of the genetics of neurocognition. The current analysis evaluated two characteristics not fully addressed in prior research: 1) heritability of neurocognition in African American families and 2) relationship between neurocognition and psychopathology in families of African American probands with schizophrenia or schizoaffective disorder. METHOD Across eight data collection sites, patients with schizophrenia or schizoaffective disorder (N=610), their biological relatives (N=928), and community comparison subjects (N=334) completed a standardized diagnostic evaluation and the computerized neurocognitive battery. Performance accuracy and response time (speed) were measured separately for 10 neurocognitive domains. RESULTS The patients with schizophrenia or schizoaffective disorder exhibited less accuracy and speed in most neurocognitive domains than their relatives both with and without other psychiatric disorders, who in turn were more impaired than comparison subjects in most domains. Estimated trait heritability after inclusion of the mean effect of diagnostic status, age, and sex revealed significant heritabilities for most neurocognitive domains, with the highest for accuracy of abstraction/flexibility, verbal memory, face memory, spatial processing, and emotion processing and for speed of attention. CONCLUSION Neurocognitive functions in African American families are heritable and associated with schizophrenia. They show potential for gene-mapping studies.

Alcohol dependence and hospitalization in schizophrenia

Treatment of schizophrenia is often complicated by substance abuse. We report here findings of a retrospective study evaluating readmission rates of patients meeting DSM IV criteria comorbid for schizophrenia and alcohol or drug dependence treated with depot haloperidol or fluphenazine over a 2-year period. During the study period, 14 of the 26 (54%) male veteran patients were admitted to the VAMC, Charleston; 46% of patients met criteria for alcohol, marijuana or cocaine dependence. Patients with alcohol dependence appeared to be at highest risk for hospital admission (p < 0.05). Moreover, patients with alcohol dependence had longer hospital stays (p < 0.05) than patients without alcohol dependence. Marijuana or cocaine dependence was slightly, but not statistically more common among admitted patients. Marijuana or cocaine dependence did not predict length of stay or number of admissions. Alcohol dependence may be an important factor in schizophrenic exacerbation, and may be an important target for treatment.

The need for trauma assessment and related clinical services in a state-funded mental health system.

Previous data show that trauma is highly prevalent in public sector consumers and is associated with severe mental illness and high service use costs. Despite this, evidence suggests that trauma victims tend to go unrecognized and to receive inadequate mental health services. We surveyed all facilities (6 inpatient, 17 outpatient) within the South Carolina Department of Mental Health about their current services for trauma victims. Results indicate that most public mental health facilities do not routinely evaluate trauma history in an adequate manner or provide specialized trauma-related services. Implications and future directions are addressed, including the current trauma initiatives of many state-funded systems.

Training physician-scientists: a model for integrating research into psychiatric residency.

ObjectiveThe number of physicians engaged in research careers has declined significantly over the past two decades. Physicians with in-depth experience and formal training in research design, development, implementation, statistical analysis, and interpretation of scientific information are rare.MethodsIn response to this shortage, the Medical University of South Carolina (MUSC) launched an NIH-funded research track in 2006 to address the institutional, financial, and regulatory barriers to research training during residency. The primary aim was to incorporate a research track within a 4-year psychiatric residency program for physicians. A secondary goal was to extend recruitment into earlier phases of medical training by offering summer research fellowships to medical and undergraduate students.ResultsThis article describes the program including core mechanisms of training, recruitment, and outcomes to date.ConclusionsThe program provides a model to effectively integrate research training during residency without increasing the number of years of residency training. The training components described herein should be exportable to other psychiatric residency training programs and potentially other specialties of medicine.

Trauma Within the Psychiatric Setting: Conceptual Framework, Research Directions, and Policy Implications

People who have experienced traumatic tional functioning (Jordan et al., 1992). Epidemiological estimates put the current events (e.g., sexual/physical assault) frequently develop posttraumatic stress disorprevalence at 14% in the general population (Kaplan, Sadock, & Grebb, 1994), der (PTSD), a set of acute anxiety symptoms that are typically complicated by with even higher rates among certain disadvantaged groups. Recent studies show high rates of co-occurring Axis I and II mental health disorders (Keane & Wolfe, that trauma victimization is highly prevalent (51–98%) among people with severe 1990). PTSD is considered to be chronic and debilitating, with serious adverse efmental illness (schizophrenia, bipolar disorder), including individuals seen in the fects upon social, familial, and occupapublic sector (Mueser et al., 1998; Switzer et al., 1999). Further, evidence indicates that PTSD is associated with nearly the B. Christopher Frueh, Ph.D., Michael Johnson, highest rate of medical and mental health M.D., Paul Gold, Ph.D., Kathryn Magruder, service use, and is therefore one of the Ph.D., and Alberto Santos, M.D., are all with the Department of Psychiatry and Behavioral Scicostliest mental disorders (Greenberg et ences, Medical University of South Carolina, al., 1999; Solomon & Davidson, 1997). and the Charleston/Dorchester Community Given the above, it is clear that trauma Mental Health Center, South Carolina Departhas a prominent impact on the public ment of Mental Health. Marc Dalton, M.D., M.P.H., is with the Department of Psychiatry health and should be of great interest to and Behavioral Sciences, Medical University of those concerned with public mental health South Carolina. Thomas Hiers, Ph.D., is with administration and policy. Despite this, the Charleston/Dorchester Community Mental trauma survivors tend to receive inadeHealth Center. quate mental health services (Amaya-JackThis work was partially supported by NIMH grants K08MH0166001 to Dr. Frueh and son et al., 1999; Goodman et al., 1999) K08MH0154601 to Dr. Johnson. and may, in fact, be especially vulnerable Address for correspondence: B. Christopher to additional traumatic and/or iatrogenic Frueh, Ph.D., Mental Health Service (116), experiences that may routinely occur VAMC, 109 Bee St., Charleston, SC 29401. E-mail: fruehbc@musc.edu. within the psychiatric setting (Cohen,

Project among African-Americans to explore risks for schizophrenia (PAARTNERS): Recruitment and assessment methods

The Project among African-Americans to Explore Risks for Schizophrenia (PAARTNERS) is a multi-site, NIMH-funded study that seeks to identify genetic polymorphisms that confer susceptibility to schizophrenia among African-Americans by linkage mapping and targeted association analyses. Because deficits in certain dimensions of cognitive ability are thought to underlie liability to schizophrenia, the project also examines cognitive abilities in individuals affected by schizophrenia and their extended family members. This article describes PAARTNERS study design, ascertainment methods and preliminary sample characteristics. We aim to recruit a sample of 1260 African-American families, all of whom have at least one proband with schizophrenia or schizoaffective disorder. The data collection protocol includes a structured Diagnostic Interview for Genetic Studies, Family Interview for Genetic Studies, focused neurocognitive assessment, medical records review, and the collection of blood or buccal cells for genetic analyses. We have currently completed study procedures for 106 affected sib-pair, 457 case-parent trio and 23 multiplex families. A total of 289 probands have completed the best estimate final diagnosis process and 1153 probands and family members have been administered the computerized neuropsychological battery. This project lays the foundation for future analysis of cognitive and behavioral endophenotypes. This novel integration of diagnostic, neurocognitive and genetic data will also generate valuable information for future phenotypic and genetic studies of schizophrenia.

The contribution of treatment outcome research to the reform of children’s mental health services: Multisystemic therapy as an example

Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation.