Bruce Bongar

Guidelines for the systematic treatment of the depressed patient

PART I: INTRODUCTION TO TREATMENT GUIDELINES 1. The Context of Contemporary Practice 2. The Nature of Current Guidelines PART II: GUIDELINES FOR TREATMENT RELEVANT ASSESSMENT 3. Treatment Relevant Assessment 4. Issues in Treatment Relevant Assessment 5. Integrating and Economizing Treatment Relevant Assessment PART III: GUIDELINES MANAGEMENT AND TREATMENT 6. Reasonable and Basic Treatment Guidelines 7. Guidelines for Optimal and Enhanced Treatment PART IV: THE NATURE OF DEPRESSION 8. The Significance of the Problem of Depression 9. Concepts from Basic Research on Depression PART V: CONTEMPORARY TREATMENT MODELS 10. Treatment Benefit Research Issues 11. Benefits of Treatment: What Works 12. Structuring Treatment: From Managed Care to Therapy Manuals 13. Models of Treatment in Clinical Practice

Psychosocial Consequences of Bone Marrow Transplantation in Donor and Nondonor Siblings

We investigated the psychosocial effects of bone marrow transplantation (BMT) on siblings of transplant recipients. We asked how donor siblings compared with nondonor siblings on quantitative measures of behavior, psychological distress, and sense of self. Participants included 44 siblings (21 donors and 23 nondonors, ages 6–18 yr) of surviving pediatric BMT patients. On self-report measures, donors reported significantly more anxiety and lower self-esteem than nondonors. On teacher-rated scales, donors showed significantly more adaptive skills in school. On these same scales, nondonors showed significantly more school problems than donors. One-third of the siblings in each group reported a moderate level of post-traumatic stress reaction. Exploratory multiple regression analyses point to factors that might influence sibling adjustment and suggest counseling strategies and avenues for future research.

Suicidality in Borderline Personality Disorder

Recent research on the relationship between borderline personality disorder (BPD) and suicidal behavior is reviewed. Risk factors for attempted and completed suicide as well as the effect of the comorbidity of BPD with other Axis I and II disorders are considered. Explanations for suicidality in BPD are discussed. General assessment strategies are offered, along with treatment recommendations. Specifically, research has shown that borderline patients improve in the long-term, decreasing in suicidality, self-destructiveness, and interpersonal maladjustment, if survival is effectively managed during the turbulent years of youth. Clinical lore at times can lead clinicians to disregard the danger of suicide completion among chronically parasuicidal patients, which can prevent effective intervention during suicidal crises and result in unfortunate outcomes.

A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) Measure.

Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

MMPI-2 assessment of malingered emotional distress related to a workplace injury : A mixed group validation

In this study, we examined the capacity of MMPI–2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 2001) validity indexes to identify malingered depression associated with a workplace injury. We compared 27 graduate students simulating depression with archival records of 33 inpatients diagnosed with major depressive disorder. We employed a mixed-group validation design to generate true positive rates (TPR) and false positive rates (FPR) for the various MMPI–2 validity scales [F, FB, F(p), FBS, F – K, Ds2] while we accounted for base rates of malingering in each sample. The Fake Bad scale (FBS) was the only validity measure that produced acceptable TPR and FPR or a significant correlation with malingering status.

The Utility of MMPI-2 Suicide Items for Assessing Suicidal Potential: Development of a Suicidal Potential Scale:

The assessment of suicidal potential is one of the most challenging and stress-inducing tasks facing clinicians. Studies that have attempted to identify specific MMPI codetypes, scales, or individual items predictive of completed suicide have produced inconsistent findings. This study focused on the relationship between the six most direct MMPI-2 suicide items (Items 150, 303, 506, 520, 524, and 530) and verbally reported history of suicidal ideation and behavior among a sample of psychotherapy outpatients (n = 116). These six MMPI-2 suicide items provided valuable information regarding suicidal ideation and behavior above and beyond that of verbal self-report. These items were grouped together to create a single scale, the Suicidal Potential Scale (SPS) that manifested strong internal consistency. The SPS provides the clinician with a reliable method of assessing for selfreported suicidal ideation and behavior.

Assessing risk for completed suicide in patients with alcohol dependence: Clinicians' views of critical factors.

The assessment of potential for suicide among patients with a diagnosis of alcohol dependence has consistently been a dilemma for clinicians. Specifically, a problem for both clinicians and researchers has been determining what risk factors distinguish patients with suicidal ideation from those that are in danger of completed suicide. Identifying what clinicians who specialize in substance abuse view as critical in the assessment and treatment of suicidal patients is a first step in gaining a greater understanding of suicide risk within an alcoholic population. The views of these clinicians are presented and compared with empirical findings on the subject.

Essential clinical and legal issues when working with the suicidal patient.

The legal and clinical literatures on the standards of care for adult suicidal patients are reviewed. We discuss the components of an effective risk management approach that balances the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of legal theories and an overview of the clinical literature, we detail the essential guidelines for sound assessment, intervention, and postvention procedures.

Cultural versus classic risk and protective factors for suicide

ABSTRACT The current study examined the predictive value of cultural versus classic risk and protective factors for suicide in a community sample of 322 ethnic, sexual, and gender minority adults. Cultural factors played a significant and substantial role in predicting suicide attempts (explained 8% of variance in attempts and correctly classified 8.5% of attempters) over and above the classic factors of hopelessness, depression, and reason for living (which explained 17% of variance in attempts and correctly classified 14.1% of attempters). Findings suggest that cultural factors are important to include in standard suicide practice.

Innovations in the practice of culturally competent suicide risk management.

Although guidelines for culturally competent suicide risk management are sparse, recent advances in theory and assessment provide direction for culturally competent practice. The Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010) was one of the first comprehensive efforts to provide a framework that guides an understanding of how culture influences suicide risk across multiple cultural identities. The Cultural Assessment of Risk for Suicide (CARS), a 39-item self-report measure assessing culturally specific suicide risk factors, was developed based on the Cultural Theory and Model of Suicide. These theoretical and measurement works, although foundational in their importance for synthesizing a broad literature, have not been tested and translated into applied clinical practice. The current case study is a translational effort that applies these approaches to culturally competent suicide practice with “Zoe,” an Asian American veteran trans woman in her early thirties with moderate-high suicide risk. Application of the Cultural Theory and Model of Suicide and the CARS illuminated cultural risk factors that were not considered in Zoe’s original safety plan (e.g., family conflict, minority stress; hidden suicidal ideation and behaviors; and cultural expressions of suicidal distress as anger, fatigue, and shame). These results yielded differences in Zoe’s risk management plan and created a culturally informed approach that corresponded with a concomitant decrease in suicidal symptoms. This study demonstrated that the CARS may detect alternative cultural expressions of suicidal distress and behaviors and yield important implications for suicide risk assessment and management planning for culturally diverse clients.