Shula Minsky

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness

BACKGROUND A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Solutions for Wellness: Results of a Manualized Psychoeducational Program for Adults with Psychiatric Disorders

Objective: The growing problem of premature death in people with serious mental illness is a critical call to action. Few resources exist that can help integrate physical health into behavioral health treatment. This study examined the effectiveness of a manualized, psychoeducational wellness toolkit called the Solutions for Wellness (SFW). The study aimed to examine whether mental health consumers who volunteered to participate in an intensive group intervention with the SFW program increased knowledge about wellness and changes in attitudes/intentions to pursue healthier lifestyle choices. Methods: Thirty-four participants with mental illness participated in an intensive 10-week manualized group wellness program. The primary outcome measures were change in knowledge and attitudes/intentions. Secondary outcomes were change in body mass index (BMI), weight, systolic and diastolic blood pressure, pulse, waist circumference, hope, and clinician rating of clinical status. Pre-post changes in several of these variables were compared with a group of 31 participants who did not receive the intervention. Blood pressure, pulse, and waist circumference were collected only in the intervention group. Results: 26 participants (76%) completed the program and attended 47% of sessions. Using an intent-to-treat analysis, statistically significant pre–post improvements in knowledge (p = .001), attitudes (p = .007), BMI (p = .0066), weight (p = .0079), systolic blood pressure (p = .006), diastolic blood pressure (p = .024), and waist circumference (p = .0007) were observed. Conclusions: Compared with a group of participants who did not receive the intervention, the intervention group evidenced statistically significant improvement in knowledge about and attitudes/intentions toward making healthier lifestyle choices, weight, and BMI. In contrast, the group of participants who did not receive the intervention did not show any improvement in knowledge or attitudes, and they gained weight. In addition, the intervention group also evidenced statistically significant improvement in waist circumference and systolic and diastolic blood pressure. Randomized, controlled clinical trials of this intervention are needed.

Ethnicity and Clinical Psychiatric Diagnosis in Childhood

This paper focuses on whether a consistent difference by ethnicity existed in the clinical diagnosis of children and adolescents in two behavioral health service environments and reviews plausible explanations for such a difference. Key measures were clinical diagnosis and ethnicity, abstracted from the administrative dataset of a New Jersey behavioral health care organization during 2000–2002, and a data collection conducted for the State of Indiana during 1991–1992. Sample sizes were 5,394 and 10,437, respectively. Only primary diagnoses were used in this study, classified into externalizing versus internalizing disorders. Logistic regression was performed for the dependent variable of presence/absence of an externalizing disorder or internalizing disorder. A main effect for ethnicity was found; African American youth received more externalizing diagnoses than did European American youth (odds ratio 2.01 (CI: 1.73–2.33) in one sample and 1.67 (CI: 1.44–1.94) in the other); African American youth also received fewer internalizing diagnoses than European American youth (odds ratio 0.55 (CI: .48–.63) in one sample and 0.75 (CI:.64–.88) in the other. Potential explanations for these findings include: 1. Biopsychosocial origin; 2. Clinician bias; 3. Discordant normative behavioral expectations between parents and service providers; and 4. Interaction between differential expression of underlying pathology and tolerance for such expressions.

Partial hospitalization: compatible with evidence-based and recovery-oriented treatment?

Partial hospitalization is a service modality that some have suggested is incompatible with both evidence-based and recovery-oriented treatment. The purpose of this study was to examine the accuracy of this assumption. Toward this end, a specific partial hospitalization program was examined using administrative data, self-reports regarding recovery orientation, and fidelity ratings from independent assessors. Findings support that the partial hospitalization program studied has reasonable lengths of stay, provides recovery-oriented services, and has implemented evidence-based practices. We conclude that partial hospitalization programs have the potential to become part of an evidence-based and recovery-oriented system.

Service Use and Self-Reported Symptoms Among Persons With Positive PTSD Screens and Serious Mental Illness.

OBJECTIVE Although many studies have reported higher rates of trauma exposure and posttraumatic stress disorder (PTSD) among persons with severe mental illness, the screening, diagnosis, and treatment of PTSD in public mental health centers remain at a suboptimal level and PTSD is often overlooked and untreated. This study used routine PTSD screening and service use data in electronic medical records to determine the association of PTSD, psychiatric symptoms, and service use in a sample of individuals with serious mental illness in a community-based treatment setting. METHODS The sample included 1,834 active clients between January 2007 and November 2010 who were screened for PTSD and who completed the 24-item Behavior and Symptom Identification Scale (BASIS-24). Service data included services provided a year before and a year after the screening date. RESULTS PTSD was associated with more severe psychiatric symptoms and increased no-show rates but not with increased service use or use of high-intensity services. PTSD likelihood interacted with race in accounting for elevated scores among African Americans on the psychosis domain of the BASIS-24. CONCLUSIONS PTSD screening is feasible and recommended in service environments and may contribute significantly to better understanding of racial-ethnic and other differences in service use and diagnostic practices.

Concordance Between Measured and Self-Perceived Weight Status of Persons With Serious Mental Illness

OBJECTIVE This study investigated concordance between self-perceived and measured weight status for persons with serious mental illness. METHODS A total of 586 mental health clients assessed their weight as underweight, normal, overweight, or obese. The agreement between these self-assessments and the same categories based on measured body mass index was related to gender, ethnicity, education, age, and psychiatric diagnosis. RESULTS Three hundred consumers (51%) underestimated their weight (they thought they weighed less than they did); only 35 (6%) overestimated it. In logistic regression analyses, gender, education, and psychiatric diagnosis showed significant effects on accuracy of self-perception, but ethnicity and age did not. CONCLUSIONS People with serious mental illness are more likely than others to have weight problems, which contribute to higher rates of morbidity and mortality. However, they also tend to underestimate their weight. This gap between reality and self-perception must be addressed.

Cost-Effectiveness of a PTSD Intervention Tailored for Individuals With Severe Mental Illness

OBJECTIVE This study examined the cost-effectiveness of a cognitive-behavioral therapy (CBT) intervention for posttraumatic stress disorder (PTSD) that is tailored for adults with a co-occurring severe mental illness. METHODS Data were from a randomized trial involving 183 adult clients of two outpatient clinics and three partial hospitalization programs. All had a severe mental illness diagnosis (major mood disorder, schizophrenia, or schizoaffective disorder) and severe PTSD. Participants were randomly assigned to the tailored 12- to 16-session CBT intervention for PTSD (CBT-P) or a three-session breathing retraining and psychoeducation intervention (BRF). Cost estimates included intervention costs for training, supervision, fidelity assessment, personnel, and overhead and related mental health care costs for outpatient, inpatient, and emergency department services and for medications. The incremental cost-effectiveness ratio comparing CBT-P with BRF measured the added cost or savings per remission from PTSD at 12 months postintervention. Generalized linear models were used to estimate intervention effects on annual mental health care costs and the likelihood of a remission from PTSD. Ten thousand bootstrap replications were used to assess uncertainty. RESULTS Annual mean mental health care costs were

Managing atypical antipsychotic-associated weight gain: 12-month data on a multimodal weight control program.

25,539 per client (in 2010 dollars) for BRF participants and

Diagnostic Patterns in Latino, African American, and European American Psychiatric Patients

29,530 per client for CBT-P participants, a nonsignificant difference. The mean incremental cost-effectiveness ratio was

A Program for Managing Weight Gain Associated With Atypical Antipsychotics

36,893 per additional PTSD remission yielded by CBT-P compared with BRF (95% confidence interval=-