Jennifer I. Manuel

The influence of stress and social support on depressive symptoms in mothers with young children

Limited research has examined the associations of stress, social support, and depression among mothers with young children over time. Longitudinal studies are needed to identify risk and protective factors for maternal depression given that depression can be cyclical and may affect women through the early years of their childrens development. This study examined the relationships among stress, social support, and depressive symptoms in a national sample of low-income urban American women with young children. A secondary data analysis of the Fragile Families and Child Wellbeing Study, a national longitudinal panel study of nearly 5000 births across 20 cities with populations of 200,000 or more in the United States, was conducted. The analytic sample included all mothers (N = 3675) who completed assessments at baseline through year 5 of the study between 1998 and 2005. Multivariate models using generalized estimating equations were used to estimate the probability of being depressed as a function of stress-related risk factors, social support factors, and sociodemographic variables. The rate of depression each year ranged from 15% to 21%. The results suggest that stress related to economic hardship, parenting, and poor physical health increases the risk of depression among low-income urban mothers with young children. Instrumental and partner support were found to be potential protective factors in reducing the negative effects of stress, but only to a certain degree. Future efforts are needed to strengthen social support and mitigate chronic stressors that contribute to mental health problems in low-income communities.

Preparing Social Work Practitioners to Use Evidence-Based Practice: A Comparison of Experiences From an Implementation Project

The implementation of evidence-based practice (EBP) as a professional model of practice for social work has been suggested as one approach to support informed clinical decision making. However, different barriers and processes have been identified that impact the use of EBP at individual, organizational, and systemic levels. This article describes results from a project that sought to enhance practitioner use of EBP by using a supportive strategy including training and technical assistance through a partnership between university-based researchers and three social work agencies. Results compare similarities and differences across each of the three agencies in terms of barriers and promoters at the team, organizational, and system levels. Results suggest that comprehensive multilevel interventions are needed to support the use of EBP in social work organizations and that further research is needed to test explicit partnership components. Findings suggest that a multilevel approach has the greatest potential to support implementation of EBP in social agencies.

AGENCY–UNIVERSITY PARTNERSHIP FOR EVIDENCE-BASED PRACTICE IN SOCIAL WORK

Little is known about evidence-based practice (EBP) in social service agencies beyond studies of researcher, practitioner, and educator opinions. The Bringing Evidence for Social Work Training (BEST) Project involved 16 participants from 3 social service agencies. The experiential training, delivered by 2 doctoral students, focused on a team-identified practice issue and followed the EBP process of motivation, question formulation, search, evaluation, and application planning. Posttraining focus group data were analyzed. Results suggest that university researchers who based in schools of social work can successfully collaborate with agencies to support the process of identifying, evaluating, and discussing the application of research evidence in practice. University–agency training partnerships should be considered as 1 of many potential strategies for advancing EBP in social work.

An integrated relapse prevention and relationship safety intervention for women on methadone: testing short-term effects on intimate partner violence and substance use.

This study tests the feasibility, safety, and short-term preliminary effects of a relapse prevention and relationship safety (RPRS) intervention in reducing drug use and the experience of intimate partner violence (IPV) among women on methadone. For this randomized controlled trial, 34 women who met IPV and drug use criteria were randomly assigned to either the RPRS condition (n = 16) or a one-session informational control (IC) condition (n = 18). RPRS participants were more likely than IC participants to report a decrease in minor physical or sexual IPV (OR = 7.1, p = .05), minor psychological IPV (OR = 5.3, p = .03) and severe psychological IPV (OR = 6.07, p = .03) at the 3month follow-up. Data suggest that RPRS participants were also more likely than IC participants to report a decrease in any drug use at 3 months (OR = 3.3, p = .08). This study provides preliminary evidence that the RPRS intervention is effective in reducing IPV and drug use among women on methadone.

Implementing Evidence-Based Practice: Practitioner Assessment of an Agency-Based Training Program

Responding to the call for evidence-based practice (EBP) in social work, the authors conducted a multiphase exploratory study to test the acceptability of a training-based collaborative agency–university partnership strategy supporting EBP. The Bringing Evidence for Social Work Training (BEST) study includes an agency training component consisting of 10 modules designed to support the implementation of EBP in social agencies. Qualitative data from post-training participant focus groups were analyzed in order to describe practitioner perceptions of the 10 training modules and trainer experiences of implementation. Based on the findings from this study the authors suggest that the BEST training was generally acceptable to agency team members, but not sufficient to sustain the use of EBP in practice.

Does Assertive Community Treatment Increase Medication Adherence for People With Co-occurring Psychotic and Substance Use Disorders?

OBJECTIVE: This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM). METHOD: Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days (“poor adherence”) versus less than 20% missed medication days (“adequate adherence”). RESULTS: Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM. CONCLUSIONS: Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

Factors Associated With Initiation on Clozapine and on Other Antipsychotics Among Medicaid Enrollees

OBJECTIVE Demographic and clinical factors associated with starting clozapine and other antipsychotics were examined. METHODS New York State Medicaid claims from 2008 to 2009 identified individuals with a schizophrenia spectrum disorder, continuous Medicaid eligibility during the study, and at least one clinic service and antipsychotic fill. The sample included individuals who initiated an antipsychotic without any fills for the same medication in the prior 90 days (N=7,035). RESULTS Only 144 patients (2%) started on clozapine. They were more likely to be younger, white males who had received services in a state-operated facility, with more hospital admissions and higher total psychiatric costs. African Americans and Hispanics were less likely than whites to start on clozapine. Individuals with substance use disorders were less likely than those without them to start on clozapine. CONCLUSIONS Clozapine was rarely prescribed, and problematic disparities were found. Quality improvement efforts are needed to ensure that patients are offered this effective treatment when appropriate.

“I Hope I Can Make it Out There”: Perceptions of Women with Severe Mental Illness on the Transition from Hospital to Community

This study explores the experience of women with severe mental illness in transition from psychiatric hospital care to the community. Three focus groups were conducted among women with severe mental illness from transitional residences at two state psychiatric hospitals. Focus group transcripts and notes were coded according to women’s perceived challenges and facilitators of transition. Participants described several challenges including fear of insufficient treatment support, safety concerns, social isolation, stigma, and lack of resources to meet daily needs. The supports that women described as important were an orientation to the neighborhood and residence, access to treatment support with flexibility, and connection to social supports.

Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study

OBJECTIVE This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors. METHODS Data were extracted from the New York State Office of Mental Healths Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time. RESULTS Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up. CONCLUSIONS Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.

Development and Use of a Transition Readiness Scale to Help Manage ACT Team Capacity

OBJECTIVE This article describes the creation, validation, and use of an assertive community treatment (ACT) Transition Readiness Scale (TRS) to identify clients who may be ready to transition from ACT services. Scale development was prompted by concerns over long stays on ACT teams and the resulting impact on access. METHODS Data were extracted from a centralized clinical reporting system for all 1,365 persons enrolled for at least 12 months as of August 2008 in the 42 ACT teams in New York City, including 382 clients of eight of those ACT teams. Data in seven domains deemed relevant to transition readiness were used to calculate readiness scores for each client. An algorithm assigned clients to one of three categories: consider for transition, readiness unclear, and not ready. RESULTS Via the TRS algorithm, of the 1,365 clients, 192 (14%) were assigned to the consider-for-transition group, 382 (28%) to the unclear group, and 791 (58%) to the not ready group. Clinicians on the eight ACT teams categorized 15% of their current clients in the consider-for-transition group, whereas the TRS algorithm classified 18% in this category. Overall, the TRS agreed with the category assigned by ACT team clinicians in 69% of cases. CONCLUSIONS The TRS may provide ACT teams and program administrators with a tool to identify clients who may be ready to transition to less intensive services, thereby opening scarce slots. Because ACT cases are complex, data summaries can offer useful syntheses of information, particularly when data from several assessments are used to summarize a clients trajectory.