Jessica L. Hamblen

A Randomized Controlled Trial of Cognitive-Behavioral Treatment for Posttraumatic Stress Disorder in Severe Mental Illness

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations.

Trauma in the Lives of Older Men: Findings from the Normative Aging Study

Research on the prevalence of traumatic exposure has tended to focus on younger populations, limiting our knowledge about trauma and its effects in older adults. In this study, lifetime trauma exposure was assessed in a sample of 436 male military veterans of World War II and the Korean Conflict (age 59–92). A clinician-administered screening measure, the Brief Trauma Interview, was developed to assess lifetime exposure to 10 categories of trauma using DSM-IV criteria. PTSD was assessed in interview and questionnaires. Despite a high prevalence of trauma exposure, symptom levels were relatively low. Few men met criteria for current or lifetime PTSD. Secondary analyses found that lifetime symptom severity was higher in men who met the DSM-IV A.2 criterion, in contrast with men who did not meet A.2. Findings indicate that trauma is highly prevalent among older men, although many may be asymptomatic.

Resilience in the face of disaster: prevalence and longitudinal course of mental disorders following hurricane Ike.

Objectives Natural disasters may increase risk for a broad range of psychiatric disorders, both in the short- and in the medium-term. We sought to determine the prevalence and longitudinal course of posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder (PD), depression, and suicidality in the first 18 months after Hurricane Ike. Methods Six hundred fifty-eight adults representative of Galveston and Chambers Counties, Texas participated in a random, population-based survey. The initial assessment was conducted 2 to 5 months after Hurricane Ike struck Galveston Bay on September 13, 2008. Follow-up assessments were conducted at 5 to 9 and 14 to 18 months after Hurricane Ike. Results Past-month prevalence of any mental disorder (20.6% to 10.9%) and hurricane-related PTSD (6.9% to 2.5%) decreased over time. Past-month prevalence of PTSD related to a non-disaster traumatic event (5.8% to 7.1%), GAD (3.1% to 1.8%), PD (0.8% to 0.7%), depression (5.0% to 5.6%), and suicidality (2.6% to 4.2%) remained relatively stable over time. Conclusions PTSD, both due to the hurricane and due to other traumatic events, was the most prevalent psychiatric disorder 2 to 5 months after Hurricane Ike. Prevalence of psychiatric disorders declined rapidly over time, suggesting that the vast majority of individuals exposed to this natural disaster ‘bounced back’ and were resilient to long-term mental health consequences of this large-scale traumatic event.

A Cognitive-Behavioral Treatment Program for Posttraumatic Stress Disorder in Persons with Severe Mental Illness

Clients with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have high rates of exposure to trauma over their lives, and are at sharply increased risk for the development of posttraumatic stress disorder (PTSD). However, at present there are no validated treatments of PTSD in the SMI population. In this article we describe a new cognitive-behavioral treatment program for PTSD in clients with SMI. We begin with a brief review of the research on trauma and PTSD in clients with SMI. Next, we summarize findings on the treatment of PTSD in the general population, followed by considerations in the development of a treatment program for clients with SMI. We then describe our program, which is based primarily on the principles of cognitive restructuring and involves treatment closely integrated with the ongoing provision of comprehensive services for the SMI. We conclude with a description of how common challenges of working with clients with SMI are handled in the treatment program, including substance abuse, cognitive impairment, and psychosis. Two companion articles to this one provide clinical examples of clients treated in this program (Hamblen, et al., in press) and summarize the results of a pilot study of the program that establish its feasibility and clinical promise (Rosenberg, Mueser, Jankowski, Salyers, & Acker, 2004).

A Guide to the Literature on Psychotherapy for PTSD

FULL DISCLOSURE POLICY In accordance with the Accreditation Council for Continuing Medical Educations Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears at the beginning of each CME-accredited article in this issue.

A Psychometric Analysis of Project Liberty's Adult Enhanced Services Referral Tool

OBJECTIVES Project Liberty was the first federally funded crisis counseling program to offer evidence-informed treatments to crisis counseling recipients in need of more intensive clinical intervention. The Adult Enhanced Services Referral Tool was developed as a screening instrument for making and monitoring referrals to enhanced services. This study aimed to examine how well the tool functioned for identifying persons who would perceive a need for professional treatment. METHODS A one-page tool was created that assessed demographic characteristics, risk categories, and psychological reactions to the focal event, September 11, 2001. Psychosocial reactions were assessed by the 12-item SPRINT-E, which is an expanded version of the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). The SPRINT-E was embedded in the Adult Enhanced Services Referral Tool. Data were collected from 788 clients who received crisis counseling between June and October 2003. RESULTS The SPRINT-E is a unidimensional measure of distress and dysfunction. Internal consistency was excellent for the total sample (alpha=.93) and subsamples. Among the 543 clients offered referral, 71 percent accepted. Among those offered referral, the number of intense reactions (score of 4, quite a bit, or 5, very much) was by far the strongest predictor of referral acceptance. CONCLUSIONS The SPRINT-E was successfully integrated into the crisis counseling program and provided an apparently successful, empirical basis for referral from counseling to professional treatment. Results of the brief psychological assessment provided a stronger basis for referral to treatment than membership in a risk category (for example, family member of deceased) alone.

Challenges in Implementing Disaster Mental Health Programs: State Program Directors’ Perspectives

The Crisis Counseling Assistance and Training Program grants supplemental federal funding to states and territories for individual and community crisis intervention services in the aftermath of presidentially declared disasters. Little research has been conducted to evaluate the effectiveness of these services, and few data exist to guide policies and programs. A qualitative study of thirty-eight state program directors (representing 95 percent of all such programs over a five-year period) identified the numerous challenges that states experience when planning, applying for, implementing, maintaining, phasing out, and evaluating these federally funded programs. The results highlighted the importance of including mental health in state-level disaster plans, fostering collaborative relationships across institutions, clarifying program guidelines, sharing innovations across programs, and building state capacity for needs assessment and program evaluation.

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4–23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322–1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Cognitive-Behavioral Treatment for PTSD in People with Severe Mental Illness: Three Case Studies

In this article, we present three case studies of clients with severe mental illness (SMI) and posttraumatic stress disorder (PTSD) who participated in a recently developed cognitive-behavioral treatment program (Mueser, Rosenberg, Jankowski, Hamblen, & Descamps, 2004). Each client had PTSD, and a DSM-IV Axis I diagnosis (1 bipolar disorder, 2 schizoaffective disorder), as well as multiple other problems that would ordinarily have resulted in exclusion from established cognitive-behavioral programs for PTSD (e.g., substance dependence, suicidal ideation, cognitive impairment, psychotic symptoms, acute psychosocial stressors). All clients were able to complete the program, and all demonstrated significant improvements in PTSD, with two out of three no longer meeting criteria for PTSD at the three-month follow-up. Clients also showed modest improvements in other psychiatric symptoms. These case studies, combined with the results of a larger pilot study of the treatment program (Rosenberg, Mueser, Jankowski, Salyers, & Ackers, 2004), demonstrate the feasibility of the program, and suggest that PTSD can be effectively treated in persons with SMI.

Interventions for Individuals After Mass Violence and Disaster: Recommendations from the Roundtable on Screening and Assessment, Outreach, and Intervention for Mental Health and Substance Abuse Needs Following Disasters and Mass Violence

Abstract In August 2003, an international expert panel was convened by the U.S. Department of Health and Human Services and the U.S. Department of Veterans Affairs in Bethesda, Maryland, to discuss outreach and intervention for behavioral health needs following disasters and mass violence. This document is the outgrowth of a paper prepared by the working group on individual interventions that was formed at the roundtable. In this document, we discuss basic considerations regarding individual post-disaster interventions and outreach strategies. We then provide brief overviews of the research base and recommendations concerning interventions for different time periods in the aftermath of mass violence or disaster.