Alejandro Interian

Effectiveness of a Time-Limited Cognitive Behavior Therapy–Type Intervention Among Primary Care Patients With Medically Unexplained Symptoms

PURPOSE Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients. METHODS We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care. RESULTS A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as “very much improved” or “much improved” compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9–8.8; P<.001). The intervention’s effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up. CONCLUSIONS This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Stigma and Depression Treatment Utilization Among Latinos: Utility of Four Stigma Measures

OBJECTIVES Stigma associated with mental illness is an important yet understudied issue among Latinos. This study examined the psychometric properties of four stigma measures with a sample of Spanish-speaking Latino primary care patients. The study evaluated the scale for Perceived Discrimination Devaluation (PDD), the Stigma Concerns About Mental Health Care (SCMHC) scale, the Latino Scale for Antidepressant Stigma (LSAS), and the Social Distance (SD) scale. METHODS Participants (N=200) were low-income Latinos who were screened for depression with the Patient Health Questionnaire (PHQ-2) and asked about their depression treatment history, and they completed the four stigma measures at two time points (25 and 30 months from baseline). The four stigma measures were examined for internal consistency, convergent validity, construct validity, and criterion-related validity. RESULTS The factor-analytic results generally provided support for the construct validity of the measures. The four stigma measures also demonstrated internal consistency between two time points. Patients who reported greater social distance from individuals with depression were more likely to have been receiving treatment for emotional care in the past three months (odds ratio [OR]=.70, p<.05). Also, Latinos who scored high on the SCMHC (OR=.64, p<.05) and LSAS (OR=.77, p<.05) were less likely to have been taking antidepressant medications. CONCLUSIONS The SCMHC, LSAS, and SD scales received support for their reliability and construct validity. Results also showed some support for their criterion-related validity. A more mixed picture emerged for the PDD. Stigma ratings were associated with depression treatment utilization. Stigma ratings changed over time and were associated with treatment experiences.

Lessons Learned from the Clinical Reappraisal Study of the Composite International Diagnostic Interview with Latinos

Given recent adaptations of the World Health Organizations World Mental Health Composite International Diagnostic Interview (WMH‐CIDI), new methodological studies are needed to evaluate the concordance of CIDI diagnoses with clinical diagnostic interviews. This paper summarizes lessons learned from a clinical reappraisal study done with US Latinos. We compare CIDI diagnoses with independent clinical diagnosis using the World Mental Health Structured Clinical Interview for DSM‐IV (WMH‐SCID 2000). Three sub‐samples stratified by diagnostic status (CIDI positive, CIDI negative, or CIDI sub‐threshold for a disorder) based on nine disorders were randomly selected for a telephone re‐interview using the SCID. We calculated sensitivity, specificity, and weight‐adjusted Cohens kappa. Weighted 12 month prevalence estimates of the SCID are slightly higher than those of the CIDI for generalized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence. For Latinos, CIDI‐SCID concordance at the aggregate disorder level is comparable, albeit lower, to other published reports. The CIDI does very well identifying negative cases and classifying disorders at the aggregate level. Good concordance was also found for major depressive episode and panic disorder. Yet, our data suggests that the CIDI presents problems for assessing post‐traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). Recommendations on how to improve future versions of the CIDI for Latinos are offered. Copyright

Improving Treatment Engagement of Underserved U.S. Racial-Ethnic Groups: A Review of Recent Interventions

OBJECTIVE Unequal mental health among U.S. underserved racial-ethnic populations has become a prominent national concern. Contributing to this inequity is our limited ability to engage individuals from underserved populations into treatment. To help address this, a systematic literature review was conducted to examine the evidence base for interventions that can improve mental health treatment engagement among underserved racial-ethnic minority populations. METHODS A MEDLINE search and bibliographic review yielded 1,611 studies that were reviewed according to several inclusion criteria: publication during or after 2001, U.S. adult sample, a randomized design, sufficient (≥50%) representation of underserved racial-ethnic groups, adequate sample size (≥27 participants per condition), explicit focus on mental health treatment engagement, and evaluation of an engagement outcome (for example, adherence or retention). RESULTS Ten studies met inclusion criteria. Evidence supported the efficacy of collaborative care for depression as an engagement enhancement intervention among underserved racial-ethnic populations. Several other interventions demonstrated possible efficacy. The effect of the interventions on clinical outcomes, such as symptom improvement and rehospitalization, was mixed. CONCLUSIONS Collaborative care for depression can be recommended for improving engagement in depression care in primary care among underserved racial-ethnic populations. Future research should continue to examine approaches with initial evidence of efficacy in order to expand the number of engagement enhancement interventions for underserved racial-ethnic adult populations. Additional issues for future engagement research include relative intervention efficacy across racial-ethnic groups, inclusion of other understudied groups (for example, Asian Americans and Native Americans), and greater clarification of the impact of improved engagement on clinical outcomes.

Gender Differences in the Risk and Protective Factors Associated With PTSD: A Prospective Study of National Guard Troops Deployed to Iraq

This study examines gender differences in post-traumatic stress symptoms (PTSS) and PTSS risk/protective factors among soldiers deployed to Iraq. We pay special attention to two potentially modifiable military factors, military preparedness and unit cohesion, which may buffer the deleterious psychological effects of combat. Longitudinal data were collected on 922 New Jersey National Guard soldiers (91 women) deployed to Iraq in 2008. Anonymous surveys administered at pre- and post-deployment included the PTSD Checklist (PCL), the Unit Support Scale, and a preparedness scale adapted from the Iowa Gulf War Study. Bivariate analyses and hierarchical multiple regression were used to identify predictors of PTSS and their explanatory effects on the relationship between gender and PTSS. Women had a higher prevalence of probable post-deployment PTSD than men (18.7% vs. 8.7%; OR = 2.45; CI [1.37, 4.37]) and significantly higher post-deployment PTSS (33.73 vs. 27.37; p = .001). While there were no gender differences in combat exposure, women scored higher on pre-deployment PTSS (26.9 vs. 23.1; p ≤ .001) and lower on military preparedness (1.65 vs. 2.41; p ≤ .001) and unit cohesion (32.5 vs. 38.1; p ≤ .001). In a multivariate model, controlling for all PTSS risk/resilience factors reduced the gender difference as measured by the unstandardized Beta (B) by 45%, with 18% uniquely attributable to low cohesion and low preparedness. In the fully controlled model, gender remained a significant predictor of PTSS but the effect size was small (d = .26). Modifiable military institutional factors may account for much of the increased vulnerability of women soldiers to PTSD.

Readjustment Stressors and Early Mental Health Treatment Seeking by Returning National Guard Soldiers With PTSD

OBJECTIVES Readjustment stressors are commonly encountered by veterans returning from combat operations and may help motivate treatment seeking for posttraumatic stress disorder (PTSD). The study examined rates of readjustment stressors (marital, family, and employment) and their relationship to early mental health treatment seeking among returning National Guard soldiers with PTSD. METHODS Participants were 157 soldiers who were surveyed approximately three months after returning from combat operations in Iraq and scored positive on the PTSD Checklist (PCL). The survey asked soldiers about their experience with nine readjustment stressors as well as their use of mental health care in the three months after returning. RESULTS Many readjustment stressors were common in this cohort, and most soldiers experienced at least one stressor (72%). Univariate analyses showed that readjustment stressors were related to higher rates of treatment seeking. These findings remained significant after multivariate analyses adjusted for depression and PTSD severity but were no longer significant after adjustment for age and marital status. CONCLUSIONS Readjustment stressors are common among soldiers returning from duty with PTSD and may be more predictive than PTSD symptom levels in treatment seeking. These effects appeared to be at least partially accounted for by demographic variables and the role of greater familial and occupational responsibilities among older veterans. Treatment seeking may be motivated by social encouragement or social interference and less by symptom severity.

The relationship between ataque de nervios and unexplained neurological symptoms: A preliminary analysis

Within somatization, unexplained neurological symptoms (UNSs) have been shown to mark a distinct subgroup with greater clinical severity. However, some UNSs resemble ataque de nervios somatic symptoms. This raises questions about cultural factors related to Hispanics with somatization characterized by UNSs. To examine cultural factors, preliminary analyses examined the relationship between Hispanic ethnicity, UNSs, and ataque de nervios. Data were obtained from 127 primary care patients (95 Hispanic, 32 European American) with somatization. The Composite International Diagnostic Interview provided somatization data, whereas the Primary Care Evaluation of Mental Disorders was used for data on Axis I disorders. Ataque de nervios was assessed via a proxy measure. Within each ethnic group, cross-tabs examined the relationship between ataque de nervios and multiple UNSs, and ataque de nervios and selected Axis I disorders. Only among Hispanics, a significant overlap was found between ataque de nervios and having four or more UNSs (p < .001), and ataque de nervios and a diagnosis of panic disorder (p = .05). Although equal percentages of European Americans and Hispanics experience multiple UNSs, these results show that the presentation of UNSs among some Hispanics may be qualitatively different, because it may involve features related to ataque de nervios. A diagnosis of panic disorder also appears to interact with cultural factors.

A RANDOMIZED-CONTROLLED TRIAL OF AN INTERVENTION TO IMPROVE ANTIDEPRESSANT ADHERENCE AMONG LATINOS WITH DEPRESSION

Studies have consistently shown that Latinos with depression have lower adherence to antidepressant medication. Given that low adherence is associated with poorer response to treatment, this is a likely source of unequal care. The current study examined the efficacy of a motivational interviewing intervention for improving antidepressant adherence among Latinos with a depressive disorder.

Adherence disparities in mental health: opportunities and challenges.

Research has consistently demonstrated the limited adherence to psychiatric treatment in general and particularly to psychotropic medications that characterizes community care. Although strategies used to define adherence vary and rates of adherence differ across mental disorders, research frequently reveals that adherence among US racial and ethnic minorities is lower than among non-Latino white populations. Remedies for the challenges imposed by the differential adherence rates across ethnic and racial groups require the coordinated expertise of both healthcare researchers and policymakers in addition to consumers, family members, frontline clinicians, and others who influence the lives of those with mental illness. We thus convened a multidisciplinary meeting of national leaders in the areas of treatment adherence and racial/ethnic disparities in mental health care to develop research and policy agenda to address problems with treatment adherence with a particular focus on health disparities. The meeting attendees (see Acknowledgments) were nominated by a core advisory group and represented a range of constituencies, including researchers on adherence to mental health treatments, public mental health system leaders, NIMH and professional association leaders, consumers and advocates, and academic leaders in public health and disparities across medicine (we did note the limitations of the schedules of several invitees and limited funds, which also prevented us from having the full range of participants that we would have preferred, and we note that our group did not include consumers from racial/ethnic minorities). An environmental scan summarizing current research findings was prepared and distributed for review before the meeting. This report describes the meeting and synthesizes its main findings.

Multiple deployments and combat trauma: do homefront stressors increase the risk for posttraumatic stress symptoms?

Multiple deployments are common among military personnel who served in Operation Enduring Freedom and Operation Iraqi Freedom and are associated with greater posttraumatic stress symptoms (PTSS). Homefront stressors (i.e., family, occupational problems) resulting from deployments may increase the risk of PTSS. Moreover, with multiple deployments, a new deployment may occur while still experiencing homefront stressors from previous tours. This prospective study assessed whether homefront stressors from a previous tour increased the risk of PTSS after a new deployment. It also examined the effects of homefront stressors at postdeployment. Survey data were obtained from U.S. National Guard soldiers with previous deployments prior to (Wave 1) and after (Wave 2) a new deployment to Iraq (N = 196). Homefront stressors reported at Wave 1 (β = .154, p = .015) and Wave 2 (β = .214, p = .002) were both significantly predictive of PTSS at postdeployment, even after adjusting for warzone stressors, predeployment PTSS, and other variables. A pattern of chronic homefront stressors (i.e., homefront stressors at pre- and postdeployment) was associated with higher levels of PTSS at postdeployment (β = .220, p = .002). Service members with multiple deployments are at greater risk for PTSS if deployed with homefront stressors from previous tours and/or face these stressors at postdeployment.