Bradley D. Stein

A National Survey of Stress Reactions after the September 11, 2001, Terrorist Attacks

BACKGROUND People who are not present at a traumatic event may also experience stress reactions. We assessed the immediate mental health effects of the terrorist attacks on September 11, 2001. METHODS Using random-digit dialing three to five days after September 11, we interviewed a nationally representative sample of 569 U.S. adults about their reactions to the terrorist attacks and their perceptions of their childrens reactions. RESULTS Forty-four percent of the adults reported one or more substantial stress symptoms; 91 percent had one or more symptoms to at least some degree. Respondents throughout the country reported stress syndromes. They coped by talking with others (98 percent), turning to religion (90 percent), participating in group activities (60 percent), and making donations (36 percent). Eighty-five percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 34 percent restricted their childrens television viewing. Thirty-five percent of children had one or more stress symptoms, and 47 percent were worried about their own safety or the safety of loved ones. CONCLUSIONS After the September 11 terrorist attacks, Americans across the country, including children, had substantial symptoms of stress. Even clinicians who practice in regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.

Violence Exposure, Posttraumatic Stress Disorder, and Depressive Symptoms Among Recent Immigrant Schoolchildren

OBJECTIVE Many recent immigrant children are at risk for violence exposure and related psychological distress resulting from experiences before, during, and after immigration. This study examines the rates of violence exposure and associated symptoms among recent immigrant children in Los Angeles. METHOD 1,004 recent immigrant schoolchildren (aged 8-15 years) were surveyed about their prior exposure to violence and symptoms of posttraumatic stress disorder (PTSD) and depression. Participants included children whose native language was Spanish, Korean, Russian, or Western Armenian. RESULTS Participants reported high levels of violence exposure, both personal victimization and witnessing violence, in the previous year and in their lifetimes. Thirty-two percent of children reported PTSD symptoms in the clinical range, and 16% reported depressive symptoms in the clinical range. Although boys and older children were more likely to have experienced violence, girls reported more PTSD and depressive symptoms. Linear multiple regressions revealed that PTSD symptoms were predicted by both recent and lifetime violence exposure (p values < .001 and p < .05, respectively), when depressive symptoms and gender were controlled. On the other hand, depressive symptoms were predicted by recent victimization only (p < .001) when PTSD and gender were controlled. CONCLUSION These findings document the need for interventions addressing the psychological sequelae of violence exposure in immigrant children.

Impact of Teen Depression on Academic, Social, and Physical Functioning

OBJECTIVE: This study aimed to determine the impact of teen depression on peer, family, school, and physical functioning and the burden on parents. METHODS: Patients participated in a longitudinal study of teens with and without probable depression, drawn from 11 primary care offices in Los Angeles, California, and Washington, DC. A total of 4856 teens completed full screening assessments; 4713 were eligible for the study, and 187 (4.0%) met the criteria for probable depression and were invited to participate, as were teens who were not depressed. A total of 184 baseline assessments for teens with probable depression and 184 for nondepressed teens were completed, as were 339 (90%) parent interviews. Follow-up interviews were conducted with 328 teens (89%) and 302 parents (82%). Measures included teen reports of peer and parent support, 2 measures of school functioning, grades, physical health, and days of impairment. Parent reports included peer, school, and family functioning and subjective and objective burdens on parents. RESULTS: Teens with depression and their parents reported more impairment in all areas, compared with teens without depression at baseline, and reported more coexisting emotional and behavioral problems. Both depression and coexisting problems were related to impairment. There was a lasting impact of depressive symptoms on most measures of peer, family, and school functioning 6 months later, but controlling for coexisting baseline emotional and behavioral problems attenuated this relationship for some measures. CONCLUSION: Improvements in teen depression might have benefits that extend beyond clinical symptoms, improving peer, family, and school functioning over time.

Perceived Barriers to Treatment for Adolescent Depression

Background and Objective:Adolescent depression is common, disabling, and is associated with academic, social, behavioral, and health consequences. Despite the availability of evidence-based depression care, few teens receive it, even when recognized by primary care clinicians. Perceived barriers such as teen worry about what others think or parent concerns about cost and access to care may contribute to low rates of care. We sought to better understand perceived barriers and their impact on service use. Design:After completing an eligibility and diagnostic telephone interview, all depressed teens and a matched sample of nondepressed teens recruited from 7 primary care practices were enrolled and completed telephone interviews at baseline and 6 months (August 2005–September 2006). Participants:Three hundred sixty-eight adolescent patients aged 13 to 17 (184 depressed and 184 nondepressed) and 338 of their parents. Measures:Perceived barriers to depression care and use of services for depression (psychotherapy and antidepressant medication). Results:Teens with depression were significantly more likely to perceive barriers to care compared with nondepressed teens. Parents were less likely to report barriers than their teens; perceived stigma and concern about family member response were among the significant teen barriers. Teen perceived barriers scores were negatively associated with any use of antidepressants (P < 0.01), use of antidepressants for at least 1 month (P < 0.001), and any psychotherapy or antidepressant use (P < 0.05) at 6 months. Conclusions:To improve treatment for adolescent depression, interventions should address both teen and parent perceived barriers and primary care clinicians should elicit information from both adolescents and their parents.

Providing Evidence-Based Practice to Ethnically Diverse Youths: Examples from the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Program.

At first glance, implementing evidence-based treatments for ethnically diverse youth may appear to raise some concerns. Do manualized treatments work for the diverse youth we see in our communities? Should clinicians only use culturally-specific treatments? Unfortunately, the literature is not definitive. Several studies have found that tailoring interventions for specific populations can increase their effectiveness1–5 while others have found that cultural adaptations of an intervention may actually dilute the effectiveness of the original treatment even though retention is improved.6 What appears to be important is to strike a balance between fidelity to evidence-based treatment and culturally-informed care. This paper provides illustrations from a school-community-academic partnership’s dissemination of the Cognitive-Behavioral Intervention for Trauma in Schools7 program to ethnically diverse communities nationwide. CBITS is an evidence-based intervention program initially developed for ethnic minority and immigrant youth exposed to trauma. CBITS was created to decrease the negative effects of trauma exposure in an ethnically and linguistically diverse group of primarily low-income children while being delivered in the real-world setting of schools. 8, 9 In a randomized controlled study, Mexican and Central American youth showed significant reduction in post-traumatic stress and depressive symptoms.10, 11 Similar positive effects have been found in dissemination evaluations of CBITS in other communities12, including urban African American13, Native American14, and rural communities.15 Although our CBITS partnership recommends program evaluations, we recognize that it is not always feasible for each community to do systematic evaluation for each adaptation or modification of CBITS. In delivering CBITS, we have confronted common issues that arise when trying to deliver an evidence-based intervention to youth from a broad range of ethnic and socioeconomic backgrounds. We present several examples of how we use community partnerships throughout all phases of dissemination, from program development, pre-implementation planning, to delivery of CBITS groups (see Figure 1). Community partnerships refer to collaboration between key stakeholders from the local school and its surrounding community including school personnel, parents, community organizations, faith-based groups, clinicians and researchers. This approach addresses contextual and cultural issues at every stage so that CBITS is tailored for each unique community. We have found this to be a promising model for reaching diverse and underserved populations and increasing community engagement.8, 16 Figure 1 Model for Using Community Partnerships to Provide Culturally-Sensitive Evidence-Based Treatment

Supply of buprenorphine waivered physicians: The influence of state policies

Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine.

School-based disaster mental health services: Clinical, policy, and community challenges.

The consequences of Hurricane Katrina have far-reaching implications for the mental health system in the Gulf Coast region, with some of the most vulnerable survivors being children and adolescents.

Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002–11

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver programs impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.

Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices, Opioid Treatment Programs, and Substance Abuse Treatment Facilities in Urban and Rural Counties

POLICY POINTS Buprenorphine is an effective opioid dependence treatment that has expanded access to care since its 2002 approval, but it can only be prescribed by physicians waivered to treat a limited number of individuals. We examined the impact of 2006 legislation that increased waivered physician patient limits from 30 to 100 on buprenorphine use, and found that 100-patient-waivered physicians were significantly associated with growth in buprenorphine use, with no such relationship for 30-patient-waivered physicians. Policies relaxing patient limits may be more effective in increasing buprenorphine use than alternatives such as opening new substance abuse treatment facilities or increasing the overall number of waivered physicians. CONTEXT Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation-as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities-on buprenorphine distributed per capita over the past decade. METHODS Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a states annual total buprenorphine dispensed per capita as a function of the states number of buprenorphine providers. FINDINGS The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers. CONCLUSIONS The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.

Adapting and Testing Telephone Based Depression Care Management Intervention for Adolescent Mothers

This phase 1 clinical trial combined qualitative and quantitative methods to modify a collaborative care, telephone-based, depression care management intervention for adolescent mothers and to determine the acceptability, feasibility, and initial efficacy of the intervention in a sample of adolescent mothers (n = 97) who were recruited from a Teen Parent Program. Outcomes included measures of depressive symptoms, functioning, and use of mental health services. Acceptability of the intervention was demonstrated, but feasibility issues related to the complex life challenges confronting the adolescent mother. Although only four adolescent mothers received mental health treatment, there was a trend for improved depressive symptoms over time. Results of the study provide data for the need of further refinement of the intervention before a large clinical trial is conducted for adolescent mothers with symptoms of depression.