Jennifer F. Havens

Longitudinal study of mental health and psychosocial predictors of medical treatment adherence in mothers living with HIV disease.

Cross-sectional studies to date that examine psychosocial correlates of antiretroviral adherence have insufficiently addressed the challenges of long-term adherence. This longitudinal study examined mental health, substance abuse, and psychosocial predictors of long-term adherence to antiretroviral medications and medical appointments among HIV-seropositive mothers recruited from an infectious disease clinic of a large urban medical center. Individual interviews were conducted at baseline and two follow-up points, 8 to 18 months after enrollment. Based on a model of health behavior, we examined psychiatric and psychosocial predictors of adherence to antiretroviral medications and medical appointments over time. Presence of a psychiatric disorder, negative stressful life events, more household members, and parenting stress were significantly associated with both missed pills and missed medical appointments at follow-up. Baseline substance abuse was associated with missed pills at follow-up and lack of disclosure to family members at baseline was associated with missed medical appointments at follow-up. These findings suggest that interventions that integrate mental health, substance abuse and medical care may be important to improving the medical adherence and health of HIV-seropositive women, particularly in multistressed populations with substantial caregiving and other life demands.

Adherence to antiretroviral medications and medical care in HIV-infected adults diagnosed with mental and substance abuse disorders

Abstract This paper examines factors associated with adherence to antiretroviral medications (ARVs) in an HIV-infected population at high risk for non-adherence: individuals living with psychiatric and substance abuse disorders. Data were examined from baseline interviews of a multisite cohort intervention study of 1138 HIV-infected adults with both a psychiatric and substance abuse disorder (based on a structured psychiatric research interview using DSM-IV criteria). The baseline interview documented mental illness and substance use in the past year, mental illness and substance abuse severity, demographics, service utilization in the past three months, general health and HIV-related conditions, self-reported spirituality and self-reported ARV medication use. Among the participants, 62% were prescribed ARVs at baseline (n = 542) and 45% of those on ARVs reported skipping medications in the past three days. Reports of non-adherence were significantly associated with having a detectable viral load (p<.01). The factors associated with non-adherence were current drug and alcohol abuse, increased psychological distress, less attendance at medical appointments, non-adherence to psychiatric medications and lower self-reported spirituality. Increased psychological distress was significantly associated with non-adherence, independent of substance abuse (p<.05). The data suggest that both mental illness and substance use must be addressed in HIV-infected adults living with these co-morbid illnesses to improve adherence to ARVs.

Making Psychiatric Emergency Services Work Better for Children and Families

p r o n h b l v i f o i P sychiatric emergencies in children and adolescents present an important opportunity to meaningfully engage children and families with mental health services. Many young people presenting in psychiatric crisis have serious and untreated mental illness; another subset of children and families have encountered insurmountable difficulties with accessing mental health services and use emergency departments as their last resort. After the series of school shooting events begun by the Columbine shootings, many school systems have implemented protocols requiring emergency psychiatric evaluation of children and adolescents displaying suicidal or homicidal ideation/behavior or severe aggression in the school setting. Emergency departments ideally would provide high-quality evaluation and treatment planning for the range of young patients accessing mental health services in psychiatric crisis. Instead, children and families often encounter a system poorly equipped to safely and effectively evaluate and manage their child’s or teenager’s mental health problem. Across the country, young patients are often managed in medical or adult psychiatry settings, which commonly lack roundthe-clock access to child and adolescent psychiatric clinicians and, in the case of medical emergency departments, the facility capacity to safely manage psychiatric patients. Many of these young people require immediate clinical intervention. There is generally little capacity to provide care to acutely ill children and adolescents in the outpatient clinic system; often the only option for these patients is admission to inpatient units. The article by Case et al. in this issue of the Journal clearly documents the significant burden that pediatric mental health visits place on emergency departments across the United States. The clear increase in these types of visits seen in the 1990s has persisted. Previous smaller studies of a

Utilization Patterns at a Specialized Children's Comprehensive Psychiatric Emergency Program

OBJECTIVE Most youths experiencing a psychiatric crisis present to emergency departments (EDs) that lack the specialized staff to evaluate them, so youths are often discharged without appropriate mental health assessment or treatment. To better understand the needs of this population, this study described clinical details and disposition associated with visits for psychiatric emergencies to a specialized ED staffed 24/7 by child psychiatrists. METHODS Through retrospective chart review, 1,180 visits to the ED during its first year of operation were reviewed for clinical characteristics, prior service utilization, and demographic characteristics. Bivariate analyses (chi-square test and Wilcoxon rank sum test) compared differences in disposition (evaluate and release, brief stabilization, and inpatient psychiatric admission) associated with characteristics of the childrens first visit (N=885). Measures with bivariate association of p<.10 were further assessed by using multinomial logistic regression analyses. RESULTS For most visits (59%), children were evaluated and released, 13% were briefly stabilized, and 28% were admitted for psychiatric treatment. Youths with mood or psychotic disorders were more likely to be admitted, as were those with current suicidality or aggression. Many youths who presented with aggression were also identified as having suicidality or self-harm. CONCLUSIONS Clinical factors, especially suicidality, predicted psychiatric admission. Admission rates for youths with suicidality were significantly higher in this study than previously reported, suggesting the availability of child psychiatrists in this ED allowed greater ascertainment of suicide risk (and thus hospitalization to mitigate that risk) than occurs in EDs without such staffing.

Teen Suicide: Fanning the Flames of a Public Health Crisis

ntil a few weeks ago (for nearly 2 months), the most popular television show in the United States, acU cording to the Internet Movie Database, was about a teenager killing herself. A wildly engaging show bingewatched by children and teens on Netflix and advertised on posters pasted on subways and billboards across the nation, 13 Reasons Why is about an attractive, intelligent, and funny high school student who commits suicide, leaving behind 13 tapes about how people contributed to her death. Combining suicide, symbolic immortality, and revenge fantasy with teen drama, attractive actors, popular music, and cliffhanger endings, 13 Reasons Why covers the bases on how not to represent suicide in the popular media. The Centers for Disease Control and Prevention (CDC), the Canadian Psychiatric Association, and the World Health Organization have clear, if unenforceable, guidelines for how suicide should be reported. They all agree that how suicide is reported can make the difference between eliciting the Werther effect (a term coined by David Phillips to describe the phenomenon of copycat suicides following media reports) or the so-called Papagano effect, in which careful reporting may lead to a decrease in suicide attempts. The guidelines consistently recommend against providing detailed descriptions of methods used; portraying suicide in a simplistic way; sensationalizing suicide; or focusing on the positive qualities of the suicide completer. They recommend that information about how or where to seek help be included and the multifactorial nature of suicide, including a history of mental health issues and complex psychosocial circumstances, be portrayed. 13 Reasons Why flies in the face of these recommendations. Furthermore, they all emphasize that suicide should never be depicted as a means to an end or a potential solution. Again, this is antithetical to what happens in 13 Reasons Why. In the recommendations by the CDC, the authors warn that “if suicide is presented as an effective means for accomplishing specific ends, it may be perceived by a potentially suicidal person as an attractive solution.” So are kids watching 13 Reasons Why and deciding that suicide is an attractive solution? The American Academy of Child and Adolescent Psychiatry’s Emergency Child Psychiatry and the Physically Ill Child Committees operate listservs linking child psychiatry emergency department providers across the United States and Canada. Over the past 6 weeks, these listservs have lit up with clinicians reporting cases (completed copycat suicides, attempts, gestures, and ideation) in which the children are reporting being triggered by the series. In a survey sent to pediatric emergency services across the country, preliminary data received from 14 sites show that 95% of sites

STAIR Narrative Therapy for Adolescents

Skills Training in Affective and Interpersonal Regulation (STAIR) plus Narrative Therapy – Adolescent Version (SNT-A; Cloitre et al. Skills training in affective and interpersonal regulation for adolescents – revised version (Unpublished manual). National Center for PTSD, Palo Alto) is an evidence-based psychosocial intervention for adolescents with trauma-related difficulties. As its name suggests, STAIR emphasizes the development of emotional and interpersonal skills that can support present functioning and enhance future resilience. In some settings, due to limited amounts of time available (e.g., inpatient stays), only the skills training component of the treatment (STAIR-A) is implemented. However, in other settings, such as in outpatient services or school-based programs, the treatment is extended to include review of traumatic events and the creation of a narrative about the trauma in the context of a developing life story (SNT-A). This chapter provides an overview of the rationale for SNT-A as well as a session-by-session overview accompanied by an illustrative case example to highlight how this approach is applied in real-world practice. We subsequently review typical challenges that can arise when implementing the treatment and discuss how to address them. Finally, we provide a brief summary of the evidence base supporting the use of SNT-A.

Trauma-Informed Care in Inpatient and Residential Settings

A history of exposure to traumatic events is the norm in youth utilizing residential care, whether it be acute or subacute inpatient care or longer-term residential placement. Studies of youth in inpatient psychiatric settings reveal traumatic exposures in over 90 % of admitted youth and rates of post-traumatic stress disorder (PTSD) from 25 to 33 % (Adam et al. 1992; Craine et al. 1988; Gold 2008; Havens et al. 2012a, b; Allwood et al. 2008; Lipschitz et al. 1999). By definition, youth placed within the child welfare system have been exposed to abuse and/or neglect. Studies in this population reveal rates of PTSD from 19 to 40 % (Kolko et al. 2010; Famularo et al. 1996). Despite these realitites, inpatient psychiatricand residential treatment settings often struggle to adeqautely identify and address trauma exposure and its mental health consequences in youth, leading to inadeqaute treatmetn planning and milieu management problems. This chapter describes the features of trauma-informed milieu settings and outlines the steps in implementing four essential component: 1) youth trauma screening processes; 2) multi-disciplinarystaff trauma training; 3) trauma skills groups for youth, and; 4) strategies for sustainability of trauma practices. Examples are provided from the authors’ experiences in implementing trauma-informed care in inpatient child and adolescent psychiatry and juvenile detneion settings