Mark S. Salzer

Use of Vocational Rehabilitative Services Among Adults with Autism

This study examined the experiences of individuals with autism spectrum disorders (ASD) in the US Vocational Rehabilitation System (VRS). Subjects included all 382,221 adults ages 18–65 served by this system whose cases were closed in 2005; 1,707 were diagnosed with ASD. Adults with ASD were more likely than adults with other impairments to be denied services because they were considered too severely disabled. Among those served, adults with ASD received the most expensive set of services. They and adults with MR were most likely to be competitively employed at case closure. Post hoc analyses suggest that their employment was highly associated with on-the-job supports. The results suggest the importance of the VRS in serving adults with ASD.

Who joins support groups among parents of children with autism

This study identified factors associated with support group participation among families of children with autism. A survey was administered to 1005 caregivers of children with autism in Pennsylvania. Two-thirds of respondents (66.4%) had ever participated in an autism-specific support group. In adjusted analyses, demographic characteristics, including age and sex of the child, ethnicity and parental education and income, were associated with support group participation. Parents of children with self-injurious behavior, sleep problems or severe language deficits were more likely to belong, as were parents whose diagnosing clinician referred them to a support group. The results of this study suggest the importance of clinician referrals to groups, and the need to make groups available to under-served populations.

Research to improve the quality of care for depression: alternatives to the simple randomized clinical trial

Recognition of gaps between evidence gained from mental health research and clinical practice in the community together with changes in treatment patterns and patient/provider preferences for care have led to interest in enhancements in the designs and analyses of clinical and community trials of mental health interventions. Gaps between clinical trials and community care include differences in populations and treatment strategies. To bridge these gaps, we propose enhancing the simple randomized trial with several different designs with the immediate aims of improving patient recruitment and adherence in psychiatric intervention studies thus bringing study designs more in line with clinical practice. The goals are to estimate treatment efficacy and effectiveness so that both internal and external validity are optimized. In this discussion, we address design and analytic issues with respect to a number of enhancements of the randomized trial design, including partial patient-provider preference designs, randomized encouragement and consent designs, fixed adaptive design, and random between- and within-patient adaptive designs. Each has advantages and disadvantages depending on the effect under investigation. Some of these enhancements, such as the fixed adaptive design, have begun to be implemented in effectiveness trials in mental health services research, but all are worthy of more attention.

A randomized, controlled study of Internet peer-to-peer interactions among women newly diagnosed with breast cancer

Objective: Peer‐to‐peer interactions are associated with enhanced psychosocial adjustment among women with breast cancer. Millions of women with cancer and others with various health conditions use the Internet to establish peer relationships, usually without professional moderation. This paper reports findings from the first randomized, controlled study of the benefits of these types of Internet‐based peer interactions.

Validating the Empowerment Scale With a Multisite Sample of Consumers of Mental Health Services

OBJECTIVE Empowerment is a key aspect of recovery and a common term in the mental health field, but there are few consistent definitions or validated measures of the construct. This study conducted psychometric testing on the Empowerment Scale, a widely used measure in the field. METHODS As part of the Consumer-Operated Multi-Site study funded by the Substance Abuse and Mental Health Services Administration, consumers with a psychiatric disability were administered the Empowerment Scale along with several other scales to measure clinical status and psychosocial factors. RESULTS Analyses produced five factors with acceptable fit statistics. The total scale demonstrated excellent reliability and validity. CONCLUSIONS Analyses provide additional evidence that the total Empowerment Scale score is a reliable, valid measure; subscales of the scale appear less robust. Empowerment is considered an essential factor in recovery-oriented programs and systems, and the use of psychometrically sound measures such as the Empowerment Scale therefore may be useful to evaluators.

Certified Peer Specialist Roles and Activities: Results From a National Survey

OBJECTIVE In 2001 Georgia became the first state to allow services provided by certified peer specialists (CPSs) to be reimbursed by Medicaid. Six other states have since followed Georgias lead, with many others in the process of doing so. This study examined where CPSs work and what they do. METHODS CPSs (N=291) from 28 states completed an online survey. RESULTS CPSs primarily did their work within the agency rather than in the community and worked most often with individuals rather than groups. CPSs frequently provided peer support and focus on self-determination, health and wellness, hope, communication with providers, illness management, and stigma. They spent the least amount of time supporting peoples family, parenting, dating, or spiritual relationships. CONCLUSIONS CPS work settings and modalities varied greatly, although a core set of activities was identified. Implications for developing and refining CPS roles in the system are discussed, along with suggestions for additional training and supervision.

Peer support for persons with co-occurring disorders and community tenure: a survival analysis.

Individuals with co-occurring mental health and substance abuse diagnoses experience high rehospitalization rates. Consumer-delivered services are recognized as an important intervention for this population, but no studies have examined the extent to which such services are associated with enhanced community tenure and prevention of rehospitalizations. This longitudinal, comparison group study examines the effect of participation in The Friends Connection, a peer support program for individuals with co-occurring disorders, on 3-year rehospitalization patterns. Results from a survival analysis suggest that program participants have longer community tenure (i.e., periods of living in the community without rehospitalization) than a comparison group. Chi-square tests also indicate that significantly more people in the comparison group (73%) are rehospitalized in a 3-year period versus those in the Friends Connection group (62%). These results suggest that Friends Connection may facilitate community tenure and prevent rehospitalizations for a group that is at high-risk for rehospitalizations. The findings lend additional support of the potential effectiveness of peer support programs as part of a service delivery system that facilitates recovery of individuals with co-occurring disorders.

From adherence to self-determination: evolution of a treatment paradigm for people with serious mental illnesses.

Treatment adherence and nonadherence is the current paradigm for understanding why people with serious mental illnesses have low rates of participation in many evidence-based practices. The authors propose the concept of self-determination as an evolution in this explanatory paradigm. A review of the research literature led them to the conclusion that notions of adherence are significantly limited, promoting a value-based perspective suggesting people who do not opt for prescribed treatments are somehow flawed or otherwise symptomatic. Consistent with a trend in public health and health psychology, ideas of decisions and behavior related to health and wellness are promoted. Self-determination frames these decisions as choices and is described herein via the evolution of ideas from resistance and compliance to collaboration and engagement. Developments in recovery and hope-based mental health systems have shepherded interest in self-determination. Two ways to promote self-determination are proffered: aiding the rational actor through approaches such as shared decision making and addressing environmental forces that are barriers to choice. Although significant progress has been made toward self-determination, important hurdles remain.

A Comparative Study of Campus Experiences of College Students With Mental Illnesses Versus a General College Sample

Abstract Objective: Examine campus experiences and relationships of college students with mental illnesses compared to general student norms using the College Student Experiences Questionnaire to understand potential sources of distress and retention issues. Participants: Responses were obtained from 449 former and current students with mental illnesses from more than 300 colleges and universities around the country. Methods: Participants completed an online survey available from July 2005 to July 2006. Results: Multivariate analysis of variance and t test results indicate that college students with mental illnesses report less engagement on campus and poorer relationships, and that these factors were associated with lower graduation rates. Students reporting they were treated differently “most of the time” because of a mental illness had the lowest levels of engagement and poorest relationships. Conclusions: More attention is needed to developing interventions that enhance social functioning and engagement and address stigma on campus in order to reduce distress and enhance retention.

The conflict between random assignment and treatment preference: implications for internal validity

The gold standard for most clinical and services outcome studies is random assignment to treatment condition because this kind of design diminishes many threats to internal validity. Although we agree with the power of randomized clinical trials, we argue in this paper that random assignment raises other, unanticipated threats to internal validity as a result of failing to consider treatment preference in research participant behavior. Treatment preference arises from an individuals knowledge and appraisal of treatment options. Treatment preferences impact: (1) the recruitment phase because people consider whether they want to participate in a study that involves the possibility of receiving an undesirable treatment or waiting for treatment, (2) degree of engagement in the intervention condition, and (3) attrition from the study. The benefits and limitations of research strategies that augment randomization while respecting treatment preference are reviewed including: approaches that enhance enrollment and engagement; pilot testing assumptions about randomization; and partially randomized clinical trials.