Brian E. Perron

Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis

OBJECTIVE Collaborative chronic care models (CCMs) improve outcome in chronic medical illnesses and depression treated in primary care settings. The effect of such models across other treatment settings and mental health conditions has not been comprehensively assessed. The authors performed a systematic review and meta-analysis to assess the comparative effectiveness of CCMs for mental health conditions across disorders and treatment settings. METHOD Randomized controlled trials comparing CCMs with other care conditions, published or in press by August 15, 2011, were identified in a literature search and through contact with investigators. CCMs were defined a priori as interventions with at least three of the six components of the Improving Chronic Illness Care initiative (patient self-management support, clinical information systems, delivery system redesign, decision support, organizational support, and community resource linkages). Articles were included if the CCM effect on mental health symptoms or mental quality of life was reported. Data extraction included analyses of these outcomes plus social role function, physical and overall quality of life, and costs. Meta-analyses included comparisons using unadjusted continuous measures. RESULTS Seventy-eight articles yielded 161 analyses from 57 trials (depression, N=40; bipolar disorder, N=4; anxiety disorders, N=3; multiple/other disorders, N=10). The meta-analysis indicated significant effects across disorders and care settings for depression as well as for mental and physical quality of life and social role function (Cohens d values, 0.20-0.33). Total health care costs did not differ between CCMs and comparison models. A systematic review largely confirmed and extended these findings across conditions and outcome domains. CONCLUSIONS CCMs can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration.

Implementation of Evidence-Based Practice in Community Behavioral Health: Agency Director Perspectives

Despite a growing supply of evidence-based mental health treatments, we have little evidence about how to implement them in real-world care. This qualitative pilot study captured the perspectives of agency directors on the challenge of implementing evidence-based practices in community mental health agencies. Directors identified challenges as limited access to research, provider resistance, and training costs. Director leadership, support to providers, and partnerships with universities were leverage points to implement evidenced-based treatments. Directors’ mental models of EBP invoked such concepts as agency reputation, financial solvency, and market niche. Findings have potential to shape implementation interventions.

Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive substances.

Relapse to uncontrolled use of a psychoactive substance is arguably the single most defining characteristic of an addiction. Relapse following addiction treatment is very common with serious consequences to individuals, families, and the public system of care, making predictors of relapse a highly significant area of study. Before the turn of the century, most of the addiction treatment outcome literature focused on psychosocial predictors of relapse. More recently, investigating biological predictors of relapse specifically and treatment outcome broadly has gained momentum. This line of research has linked sleep disturbances to the risk of relapse among persons who are recovering from an alcohol addiction. Given common neurobiological and psychosocial processes in sleep and addictive behaviors, we hypothesize that the link between sleep disturbance and relapse risk observed among alcohol addiction generalizes to all other types of psychoactive substances. This hypothesis has the potential for helping develop more effective and targeted treatment approaches for persons with addiction. As initial support for the hypothesis, this paper reviews evidence on common neurobiological processes among various types of psychoactive substances that suggests sleep is a universal risk factor for relapse. A conceptual framework is also presented to articulate causal mechanisms. The paper concludes with implications for research and practice.

Differences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use disorders

BackgroundTreatment for drug use disorders (DUD) can be effective, but only a small proportion of people with DUD seek or receive treatment. Research on racial and ethnic treatment differences and disparities remains unclear. Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatment. The purpose of the current study was to explore the role of race and ethnicity in service utilization.MethodsUsing data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), this study examined racial and ethnic differences in use of 14 types of treatment services for DUD and 27 different treatment barriers among persons who met lifetime criteria for a DUD. Multivariate logistic regression analyses were used to examine service utilization and barriers among the racial and ethnic groups, while adjusting for other sociodemographic and clinical variables.Results and discussionAmong Blacks, Hispanics and Whites in the overall NESARC sample, approximately 10.5% met criteria for at least one lifetime drug use disorder. Approximately 16.2% of persons with a lifetime DUD received at least one type of service. Overall, this study indicated that Whites were less likely to report receiving help for drug-related problems than Blacks, Blacks used a greater number of different types of services, and no racial and ethnic differences were observed with respect to perceived barriers to drug treatment. However, by examining types of services separately, a complex picture of racial and ethnic differences emerges. Most notably, Whites were most likely to use professional services, whereas Blacks were most likely to use 12-step and clergy. The service use pattern of Hispanics most resembled that of Whites.ConclusionWhile structural barriers to accessing treatment were observed, broad-based educational programs and interventions that are appropriately targeted to racial and ethnic groups remains an important area for prevention and treatment.

Prevalence and correlates of traumatic brain injury among delinquent youths

BACKGROUND Delinquent youth frequently exhibit high-risk behaviours that can result in serious injury. However, little is known about traumatic brain injuries (TBIs) and their correlates in this population. AIMS To examine the period prevalence and correlates of TBIs in delinquent youths. METHOD Interviews were conducted with 720 (97.3%) residents of 27 Missouri Division of Youth Services rehabilitation facilities between March 1 and May 31, 2003. Participants [mean age (M age) = 15.5, standard deviation (SD) = 1.2, 87% male] completed measures assessing TBI, substance use, psychiatric symptoms, and antisocial traits/behaviours. TBI was defined as ever having sustained a head injury causing unconsciousness for more than 20 minutes. RESULTS Nearly one-in-five youths (18.3%) reported a lifetime TBI. Youths with TBIs were significantly more likely than youths without to be male, have received a psychiatric diagnosis, report an earlier onset of criminal behaviour/substance use and more lifetime substance use problems and past-year criminal acts, evidence psychiatric symptoms, report lifetime suicidality, be impulsive, fearless, and external in locus of control and criminally victimized in the year preceding incarceration. Male gender and frequency of own criminal victimization were important predictors of TBI in multivariate analyses. Regression analyses adjusted for demographic factors, indicated that youths with TBIs were at significantly elevated risk for current depressive/anxious symptoms, antisocial behaviour, and substance abuse problems. CONCLUSIONS TBI is common among delinquent youth and associated with wide ranging psychiatric dysfunction; however, the causal role of TBIs in the pathogenesis of co-morbid conditions remains unclear.

Violence among men and women in substance use disorder treatment: A multi-level event-based analysis

BACKGROUND This study examined associations between acute alcohol and drug use and violence towards others in conflict incidents (overall, partner, and non-partner conflict incidents) by men and women recruited from substance use disorder (SUD) treatment. METHODS Semi-structured interviews were used to obtain details about interpersonal conflict incidents (substance use, whether specific conflicts were with intimate partners or non-partners) in the 180 days pre-treatment. Participants for this study were selected for screening positive for past-year violence (N=160; 77% men, 23% women). RESULTS Multi-level multinomial regression models showed that after adjusting for clustering within individual participants, the most consistent predictors of violence across models were acute cocaine use (significant for overall, intimate partner and non-partner models), acute heavy alcohol use (significant for overall and non-partner models), and male gender (significant in all models). CONCLUSIONS This study was the first to explicitly examine the role of acute alcohol and drug use across overall, partner and non-partner conflict incidents. Consistent with prior studies using a variety of methodologies, alcohol, cocaine use and male gender was most consistently and positively related to violence severity (e.g., resulting in injury). The results provide important and novel event-level information regarding the relationship between acute alcohol and specific drug use and the severity of violence in interpersonal conflict incidents.

Criminal victimization and comorbid substance use and psychiatric disorders in the United States: results from the NESARC.

PURPOSE Criminal victimization produces enormous personal and societal costs, yet few investigations have systematically examined substance use and psychiatric disorders of crime victims. Our objectives were to (i) examine the prevalence and patterns of criminal victimization in the United States and (ii) their associations with specific substance use disorders, prevalent psychiatric conditions, and violent and nonviolent antisocial behaviors in controlled multivariate analyses. METHODS Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US residents 18 years of age and older (N=43,093). Interviews conducted between 2001 and 2002 included measures of past-year criminal victimization and Diagnostic and Statistical Manual of Mental Disorders, IV mood, anxiety, substance use, and personality disorders. RESULTS More than 1-in-25 adults in the United States (4.1%) reported past-year criminal victimization. Respondents who reported lower levels of income, lived in urban areas, and were separated or divorced were at significantly heightened risk for criminal victimization. Persons reporting various forms of violent and nonviolent antisocial behavior also were more likely to be victims of crime. In controlled multivariate analyses, crime victims evidenced significantly increased rates of alcohol, cocaine, and opioid use disorders. Paranoid personality disorder, major depressive disorder, and a family history of antisocial behavior were also significantly associated with past-year criminal victimization. CONCLUSIONS Criminal victimization is prevalent in the United States and associated with significant psychiatric comorbidities and behavioral dysfunction. Poor, unmarried persons living in urban areas who have family histories of antisocial conduct and personal histories of specific substance use and psychiatric disorders are at substantially elevated risk for criminal victimization.

Correlates of cruelty to animals in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE To examine the sociodemographic, behavioral, and psychiatric correlates of cruelty to animals in the US. MATERIALS AND METHODS Data were derived from a nationally representative sample of adults residing in the US Structured psychiatric interviews (N=43,093) were completed by trained lay interviewers between 2001 and 2002. Personality, substance use, mood, and anxiety disorders and cruelty to animals were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule (DSM-IV) version. RESULTS The lifetime prevalence of animal cruelty in US adults was 1.8%. Men, African-Americans, Native-Americans/Asians, native-born Americans, persons with lower levels of income and education and adults living the western region of the US reported comparatively high levels of cruelty to animals, whereas Hispanics reported comparatively low levels of such behavior. Cruelty to animals was significantly associated with all assessed antisocial behaviors. Adjusted analyses revealed strong associations between lifetime alcohol use disorders, conduct disorder, antisocial, obsessive-compulsive, and histrionic personality disorders, pathological gambling, family history of antisocial behavior, and cruelty to animals. CONCLUSIONS Cruelty to animals is associated with elevated rates observed in young, poor, men with family histories of antisocial behavior and personal histories of conduct disorder in childhood, and antisocial, obsessive-compulsive and histrionic personality disorders, and pathological gambling in adulthood. Given these associations, and the widespread ownership of pets and animals, effective screening of children, adolescents and adults for animal cruelty and appropriate mental health interventions should be deployed.

Specialty substance use disorder services following brief alcohol intervention: A meta-analysis of randomized controlled trials

BACKGROUND AND AIMS Brief alcohol interventions in medical settings are efficacious in improving self-reported alcohol consumption among those with low-severity alcohol problems. Screening, Brief Intervention and Referral to Treatment initiatives presume that brief interventions are efficacious in linking patients to higher levels of care, but pertinent evidence has not been evaluated. We estimated main and subgroup effects of brief alcohol interventions, regardless of their inclusion of a referral-specific component, in increasing the utilization of alcohol-related care. METHODS A systematic review of English language papers published in electronic databases to 2013. We included randomized controlled trials (RCTs) of brief alcohol interventions in general health-care settings with adult and adolescent samples. We excluded studies that lacked alcohol services utilization data. Extractions of study characteristics and outcomes were standardized and conducted independently. The primary outcome was post-treatment alcohol services utilization assessed by self-report or administrative data, which we compared across intervention and control groups. RESULTS Thirteen RCTs met inclusion criteria and nine were meta-analyzed (n = 993 and n = 937 intervention and control group participants, respectively). In our main analyses the pooled risk ratio (RR) was = 1.08, 95% confidence interval (CI) = 0.92-1.28. Five studies compared referral-specific interventions with a control condition without such interventions (pooled RR = 1.08, 95% CI = 0.81-1.43). Other subgroup analyses of studies with common characteristics (e.g. age, setting, severity, risk of bias) yielded non-statistically significant results. CONCLUSIONS There is a lack of evidence that brief alcohol interventions have any efficacy for increasing the receipt of alcohol-related services.

Paternal Psychosocial Characteristics and Corporal Punishment of Their 3-Year-Old Children

This study uses data from 2,309 biological fathers who participated in the Fragile Families and Child Well-Being Study (FFCWS) to examine associations between psychosocial characteristics and levels of corporal punishment (CP) toward their 3-year-old children over the past month. Results indicate that 61% of the fathers reported no CP over the past month, 23% reported using CP once or twice, and 16% reported using CP a few times in the past month or more. In multivariate models controlling for important sociodemographic factors as well as characteristics of the child, fathers’ parenting stress, major depression, heavy alcohol use, and drug use were significantly associated with greater use of CP, whereas involvement with the child and generalized anxiety disorder were not. Girls were less likely to be the recipient of CP than were boys, and child externalizing behavior problems but not internalizing behavior problems were associated with more CP.