Teresa L. Kramer

Parental Incarceration Among Adolescents Receiving Mental Health Services

The Bureau of Justice Statistics estimates that approximately 1 in every 50 youth in the U.S. had a parent in State or Federal prison in 1999. Studies of children of incarcerated parents suggest that these youth are at risk for experiencing emotional and behavioral problems. Using a sample of 258 adolescents receiving routine mental health services, this study explored: (1) differences in demographic characteristics, lifetime exposure to risk factors, recent stressful life experiences, and clinical profiles of adolescents with and without a history of parental incarceration; and (2) the effect of parental incarceration relative to other risk factors on levels of emotional and behavioral problems and treatment outcomes. Nearly half (43%) of the youth studied had experienced the incarceration of one or both parents. Youth who experienced parental incarceration had been exposed to significantly more risk factors during their lifetimes including parental substance abuse, extreme poverty, and abuse or neglect. They were more likely than other treated youth to present with attention-deficit/hyperactivity and conduct disorders and less likely to have major depression. Findings provide preliminary evidence that parental incarceration may have a discrete negative effect on certain outcomes of treatment.

Ministers’ Perceptions of Depression: A Model to Understand and Improve Care

While depression is a significant worldwide health problem, fewer than half of individuals seek care. Faith-based communities may play an important role in improving the knowledge of and linkage to depression care. Focus groups of Caucasian and African-American clergy were conducted to explore these issues. Using a grounded theory approach five themes emerged, including explanatory models of depression, barriers and facilitators to care, and recommendations for involving religious communities. A model of depression care pathways was constructed that integrates secular and spiritual approaches. The findings highlight the need for targeted interventions to build trust between clergy and mental health professionals.

Service Utilization and Outcomes in Medically Ill Veterans with Posttraumatic Stress and Depressive Disorders

This study examined behavioral health service utilization, health-related quality of life, and psychological distress in medically hospitalized male veterans (N = 743) with and without current or lifetime comorbid posttraumatic stress disorder (PTSD) and depressive disorder. Participants completed psychiatric and psychosocial self-report measures at baseline and follow-up. Clinical/functional status and service utilization rates were compared for patients with PTSD only, depressive disorder only, comorbid PTSD/depressive disorder, and neither disorder. Patients with PTSD/depressive disorder were more likely to use mental health/substance abuse services, have longer lengths of stay, and report more psychological distress than others. Results indicate that screening, early detection, and referral are critical in treating these comorbid patients because of increased psychological distress and high service-use rates.

How Well Do Automated Performance Measures Assess Guideline Implementation for New-Onset Depression in the Veterans Health Administration?

BACKGROUND Because most guidelines focus on patients with new episodes of depression, algorithms to identify such samples must be accurate. This study examined whether the Veterans Health Administrations (VHAs) electronic medical record database could identify valid cases of new-onset depression. RESULTS Of 109 individuals receiving outpatient care at one of three VHA medical centers who were identified with newly diagnosed depressive disorder, 39 (35.8%) actually had documentation of depression diagnosis and antidepressant prescription or other treatment within the previous six months. Good to excellent agreement was found between indicators of guideline-concordant care using automated and manual chart review methods. DISCUSSION Electronic medical records can validly identify many cases of new-onset depression, although with a higher-than-anticipated rate of false-positives. Half of depressed veterans received care consistent with clinical guidelines for psychopharmacological intervention, regardless of data source. SUMMARY Clinical managers, administrators, and policy advocates must weigh the cost-benefit of administrative versus medical record reviews to assess quality.

Implementing Cognitive Behavioral Therapy in the real world: A case study of two mental health centers

BackgroundBehavioral health services for children and adolescents in the U.S. are lacking in accessibility, availability and quality. Evidence-based interventions for emotional and behavioral disorders can improve quality, yet few studies have systematically examined their implementation in routine care settings.MethodsUsing quantitative and qualitative data, we evaluated a multi-faceted implementation strategy to implement cognitive-behavioral therapy (CBT) for depressed adolescents into two publicly-funded mental healthcare centers. Extent of implementation during the studys duration and variables influencing implementation were explored.ResultsOf the 35 clinicians eligible to participate, 25 (71%) were randomized into intervention (n = 11) or usual care (n = 14). Nine intervention clinicians completed the CBT training. Sixteen adolescents were enrolled in CBT with six of the intervention clinicians; half of these received at least six CBT manually-based sessions. Multiple barriers to CBT adoption and sustained use were identified by clinicians in qualitative interviews.ConclusionStrategies to implement evidence-based interventions into routine clinical settings should include multi-method, pre-implementation assessments of the clinical environment and address multiple barriers to initial uptake as well as long-term sustainability.

Heart rate variability: Pre-deployment predictor of post-deployment PTSD symptoms.

Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores.

Comparing outcomes of routine care for depression: The dilemma of case-mix adjustment

The purpose of this study was to formulate and test two case-mix models for depression treatment that permit comparisons of patient outcomes across diverse clinical settings. It assessed demographics; eight, diagnostic-specific, case-mix variables; and clinical status at baseline and follow-up for 187 patients. Regressions were performed to test two models for four dependent variables including depression severity and diagnosis. Individual treatment settings were then ranked based on a comparison of actual versus predicted outcomes using regression coefficients and predictor variables. A model inclusive of baseline physical health status and depression severity predicted depression severity, mental health, and physical health functioning at follow-up. A simpler model performed well in predicting depression remission. This study identifies variables to be included in case-mix adjustment models and demonstrates statistical methods to control for differences across settings when comparing depression outcomes.

Modes of Large-Scale Brain Network Organization during Threat Processing and Posttraumatic Stress Disorder Symptom Reduction during TF-CBT among Adolescent Girls.

Posttraumatic stress disorder (PTSD) is often chronic and disabling across the lifespan. The gold standard treatment for adolescent PTSD is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), though treatment response is variable and mediating neural mechanisms are not well understood. Here, we test whether PTSD symptom reduction during TF-CBT is associated with individual differences in large-scale brain network organization during emotion processing. Twenty adolescent girls, aged 11–16, with PTSD related to assaultive violence completed a 12-session protocol of TF-CBT. Participants completed an emotion processing task, in which neutral and fearful facial expressions were presented either overtly or covertly during 3T fMRI, before and after treatment. Analyses focused on characterizing network properties of modularity, assortativity, and global efficiency within an 824 region-of-interest brain parcellation separately during each of the task blocks using weighted functional connectivity matrices. We similarly analyzed an existing dataset of healthy adolescent girls undergoing an identical emotion processing task to characterize normative network organization. Pre-treatment individual differences in modularity, assortativity, and global efficiency during covert fear vs neutral blocks predicted PTSD symptom reduction. Patients who responded better to treatment had greater network modularity and assortativity but lesser efficiency, a pattern that closely resembled the control participants. At a group level, greater symptom reduction was associated with greater pre-to-post-treatment increases in network assortativity and modularity, but this was more pronounced among participants with less symptom improvement. The results support the hypothesis that modularized and resilient brain organization during emotion processing operate as mechanisms enabling symptom reduction during TF-CBT.

Physical victimization of rural methamphetamine and cocaine users.

Substance use and physical violence often coincide, but little has been published on the correlates associated with receipt of partner versus nonpartner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants’ substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine, and methamphetamine abuse/dependence; and number of drugs used in the past 6 months. In males, received nonpartner violence was associated with age, cocaine abuse/dependence, and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.

Childhood conduct problems and other early risk factors in rural adult stimulant users.

CONTEXT Understanding childhood risk factors associated with adult substance use and legal problems is important for treatment and prevention. PURPOSE To examine the relationship of early substance use, conduct problems before age 15, and family history of substance abuse on adult outcomes in rural, stimulant users. METHODS Adult cocaine and methamphetamine users (N = 544) in rural Arkansas and Kentucky were interviewed. Data were analyzed using both bivariate analyses and multiple logistic and log-linear regression models, with dependent variables being any substance abuse/dependence, stimulant abuse/dependence, total number of arrests since age 18 and days incarcerated since age 18. FINDINGS One third reported 3 or more conduct disorder problems prior to age 15; half reported initiation of substances (excluding alcohol) before age 15; and 60% reported family history of substance problems. All 3 variables were associated with adult substance abuse/dependence but only the latter two were associated with stimulant abuse/dependence. CONCLUSIONS This study highlights early risk factors for adult substance abuse/dependence among rural stimulant users.