Amy W. Wagner

Suicide Attempt Self-Injury Interview (SASII): Development, Reliability, and Validity of a Scale to Assess Suicide Attempts and Intentional Self-Injury.

The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.

Assessment of depression in patients with Alzheimer's disease: concordance among informants.

This study is an investigation of the concordance among different sources of information on ratings of depression in patients with Alzheimers disease (AD). Informants were 75 outpatients with diagnosed AD (22 with major depressive disorder), their caregivers, and geriatric clinicians. Clinicians rated each patient on the Hamilton Rating Scale for Depression on the basis of (a) the patients report, (b) the caregivers report, and (c) the clinicians evaluation. Overall, patients perceived themselves as less depressed than did caregivers or clinicians; for nondepressed patients, caregivers reported patients less depressed than clinicians reported; for depressed patients, no significant differences were obtained between caregiver or clinician. Certain items were more discrepant among informants and significantly differentiated depressed from nondepressed AD patients. Level of patient dementia did not affect ratings. These findings support the need for comprehensive, accurate assessment of depression in AD patients.

Alzheimer's Disease and Depression.

This article reviews the empirical literature available on the phenomenon of depression in Alzheimers disease (AD). Although not extensively studied, there is accumulating evidence to suggest that depression affects a large number of patients with AD and can have profound effects on both the long-term functioning of these patients and the well-being of their caregivers. Thus far, the field is dominated by studies of prevalence. Considerably rarer are studies investigating etiology, association with other aspects of disease, impact on patients and caregivers, assessment, and treatment. The conceptual issues, methodological differences, and implications of the studies that exist thus far are discussed.

A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

Objective: To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. Background: Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. Methods: The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. Results: Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. Conclusions: Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. (Trial Registration: clinicaltrials.gov identifier: NCT00270959)

Posttraumatic Distress, Alcohol Disorders, and Recurrent Trauma Across Level 1 Trauma Centers

BACKGROUND Injured survivors of individual and mass trauma receive their initial evaluation in acute care. Few investigations have comprehensively screened for posttraumatic stress disorder (PTSD) symptoms and related comorbidities across sites. METHODS This investigation included 269 randomly selected injury survivors hospitalized at two level 1 trauma centers. All patients were screened for PTSD, depressive, and peritraumatic dissociative symptoms during their surgical inpatient admission. Prior traumatic life events and alcohol abuse/dependence also were assessed. RESULTS In this study, 58% of the patients demonstrated high levels of immediate posttraumatic distress or alcohol abuse/dependence. Regression analyses identified greater prior trauma, female gender, nonwhite ethnicity, and site as significant independent predictors for high levels of posttraumatic distress. CONCLUSIONS High levels of posttraumatic distress, recurrent trauma, and alcohol abuse/dependence were present in more than half of acute care inpatients. Early mental health screening and intervention procedures that target both PTSD and alcohol use should be developed for acute care settings.

Imagery rehearsal therapy for posttraumatic nightmares in U.S. veterans

Imagery rehearsal therapy (IRT) may help reduce residual nightmares and posttraumatic stress disorder (PTSD) symptoms in veterans after trauma-focused PTSD treatment. Fifteen male U.S. veterans with PTSD and trauma-related nightmares, who had not previously completed trauma-focused PTSD treatment, attended 6 IRT group sessions. No benefits were observed immediately posttreatment. At 3- and 6-month follow-up, however, trauma-related nightmare frequency (nights/week) decreased (p < .01). The number of trauma-related nightmares/week (p < .01), number of total nightmares/week (p < .05), and PTSD symptoms (p < .05) also decreased at 3 months. The overall F test for time was significant (p < .05) for nightmare severity and fear of sleep. No effects were found on measures of the impact of nightmares, sleep quality, or depression. Clinical and research implications are discussed.

Caregiver expressed emotion and depression in Alzheimer's disease

Expressed Emotion (EE) has been a useful construct for understanding the relationship between family interactions and depression in patients with psychiatric disorders. It has not, however, been well studied in patients with Alzheimers disease (AD) and their caregivers despite its potential utility in clarifying patient-caregiver interactions and how such interactions may affect patient function, and caregiver burden, mood and quality of care. This study investigated the rate of EE in caregivers of patients with AD and depression. It also investigated the relationship of caregiver EE to patient status and caregiver burden and depression. Fifty-seven AD patient-caregiver dyads were studied in a cross-sectional design. Caregiver measures included the EE Speech Sample, Burden Inventory, and Center for Epidemiological Studies-Depression Scale. Patient measures included the Hamilton Depression Rating Scale, Record of Independent Living, and Revised Memory and Behavior Problem Checklist. Twenty-three (40%) car...

Behavior problems among dementia residents in special care units: changes over time.

pecial Care Units (SCUs) have recently been developed to S care for the increasing number of dementia residents in nursing homes. Because behavior problems are prevalent among individuals with dementia,’-4 a major focus of care in SCUs is on the management of problematic behaviors’ Unfortunately, little information is available on the prevalence and course of behavior problems over time among SCU patients specifically information critical to effective longterm care. SCUs are, in part, designed to improve the functioning and subjective experience of dementia patients (OTA). As such, the existing longitudinal studies on SCUs have investigated primarily the effectiveness of these units on overall patient functioning. The findings of these studies are mixed, with some reporting no changes in behavior problems over time6-8 and others finding decreases in behavior probl e m ~ . ~ ’ ~ However, because of the lack of data on the natural course of behavior problems, it is difficult to determine whether the observed changes represent more or less improvement than might be expected in a different environment. Further, sample sizes are generally small, measures of behavior problems varied between studies, and, in some cases, significance levels were not reported.” The current study sought to investigate the nature and change over time of behavior problems among residents in SCUs, using a large, multi-site sample and a comprehensive measure of behavior problems. Given the exploratory nature of this study, few predictions were made. However, previous studies that have focused on the general course of dementia (Alzheimer’s disease (AD) in particular), suggest possibilities for this longitudinal investigation. Teri, Larson, and Reifler (1988) found an overall increase in behavior problems with increased levels of cognitive impairment in their sample of AD outpatient^.^ In contrast, emotional behaviors (depression in particular) have been found to be more prevalent among patients with milder levels of cognitive impairment.’3*’4 Therefore, because the majority of SCU residents suffer from progressive dementia such as AD, we hypothesized (1) an overall increase in behavior problems over time, especially in behaviors related to

Assessing Barriers to Care and Readiness for Cognitive Behavioral Therapy in Early Acute Care PTSD Interventions

Cognitive Behavioral Therapy (CBT) interventions are efficacious in reducing posttraumatic stress disorder (PTSD) but are challenging to implement in acute care and other non-specialty mental health settings. This investigation identified barriers impacting CBT delivery through a content analysis of interventionist chart notes from an acute care PTSD prevention trial. Only 8.5% of all intervention patients were able to complete CBT. Lack of engagement, clinical and logistical barriers had the greatest impact on CBT entry. Treatment preferences and stigma only prevented entry when more primary barriers resolved. Patients with prior diagnosis of alcohol abuse or dependence were able to enter CBT after six months of sobriety. Based on the first trial, we developed a CBT readiness assessment tool. We implemented and evaluated the tool in a second early intervention trial. Lack of engagement emerged again as the primary impediment to CBT entry. Patients who were willing to enter CBT treatment but demonstrated high rates of past trauma or diagnosis of PTSD were also the least likely to engage in any PTSD treatment one month post-discharge. Findings support the need for additional investigations into engagement and alternative delivery strategies, including those which dismantle traditional office-based, multi-session CBT into stepped, deliverable components.

Subtype differentiation of patients with borderline personality disorder using a circumplex model of interpersonal behavior.

The considerable heterogeneity of symptomatology in persons with borderline personality disorder (BPD) has led some to suggest the existence of subtypes within this diagnosis. However, no study to date has examined subtypes according to differences in interpersonal functioning, despite the central role of interpersonal problems in the BPD diagnosis. The interpersonal problems of 95 patients with BPD were investigated using the German version of the Inventory of Interpersonal Problems, a self-report measure based on a circumplex model of interpersonal functioning. Data were analyzed by means of cluster analysis. The results supported the existence of two distinct subtypes of persons with BPD, labeled “autonomous” and “dependent.” Four-month longitudinal assessment indicated that these types were stable over time, suggesting the categorization reflected trait, as opposed to state, patterns of interpersonal behavior. Implications of these findings for future research and management of BPD are discussed.