Integrated Behavioral Treatment for Veterans With Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial.

Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems.

PTSD as a mediator between lifetime sexual abuse and substance use among jail diversion participants.

Objective: Many of the individuals with serious mental illness involved in the criminal justice system have experienced interpersonal victimization, such as sexual abuse, and have high rates of alcohol and drug use disorders. Little attention has been paid to the prevalence of posttraumatic stress disorder (PTSD) and its potential role in the substance misuse of offenders with mental illness.

Methods: The study used a path analytic framework to test the hypothesis that PTSD mediates the relationship between sexual abuse and level of alcohol and drug use among individuals (N=386) with mental illness enrolled in a multisite (N=7) jail diversion project.

Perceived coercion among jail diversion participants in a multisite study.

Objective: Although jail diversion is considered an appropriate and humane response to the disproportionately high volume of people with mental illness who are incarcerated, little is known regarding the perceptions of jail diversion participants, the extent to which they feel coerced into participating, and whether perceived coercion reduces involvement in mental health services. This study addressed perceived coercion among participants in postbooking jail diversion programs in a multisite study and examined characteristics associated with the perception of coercion.

Methods: Data collected in interviews with 905 jail diversion participants from 2003 to 2005 were analyzed with random-effects proportional odds models.

Criminal justice involvement, behavioral health service use, and costs of forensic assertive community treatment: a randomized trial.

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs.

Therapist fidelity with an exposure-based treatment of PTSD in adults with schizophrenia or schizoaffective disorder.

This study examined therapists' fidelity to a manualized, multicomponent cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Independent raters assessed therapists' competence and adherence, rating 20% of randomly selected audio taped sessions (n=57 sessions, coded by two raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged "very good" or higher (6 on 7-point Likert scale).

Diagnostic practices for traumatized youths: do clinicians incorporate symptom scale results?

Clinician generated diagnoses are subject to heuristic biases, and structured diagnostic interviews are useful but costly diagnostic aids. Because dimensional rating scales may hold potential to improve diagnostic practices in community mental health settings, we examined how community clinicians incorporate the results of the Trauma Symptom Checklist for Children (TSCC; Briere 1996) into their diagnostic practices. Results suggest clinicians may attend to the TSCC anxiety and depression scores, but most scales agreed poorly with diagnoses assigned.

Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study.

In an open trial design, adults (n=20) with posttraumatic stress disorder (PTSD) and either schizophrenia or schizoaffective disorder were treated via an 11-week cognitive-behavioral intervention for PTSD that consisted of education, anxiety management therapy, social skills training, and exposure therapy, provided at community mental health centers. Results offer preliminary hope for effective treatment of PTSD among adults with schizophrenia or schizoaffective disorder, especially among treatment completers (n=13). Data showed significant PTSD symptom improvement, maintained at 3-month follow-up.

Disseminating evidence-based practices for adults with PTSD and severe mental illness in public-sector mental health agencies.

Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care.

How many forensic assertive community treatment teams do we need?

Despite the growing interest in forensic assertive community treatment (FACT), there is no standardized definition of FACT eligibility and no guidelines for how many FACT teams communities may need. In this brief report a definition for FACT eligibility is proposed-severe and persistent mental illness and three jail detentions in a one-year period-and modeled by using 5.5 years of administrative data (July 1, 1993, through December 31, 1998) from a large, urban county in the western United States.

Workshop-based training in trauma-focused CBT: an in-depth analysis of impact on provider practices.

Despite evidence that more intensive methods are more effective, many clinical settings continue to train practitioners using workshops. To more fully understand the strengths and limitations of workshops, the present investigation studied changes in practitioner behavior following a workshop in trauma-focused cognitive-behavioral therapy (TF-CBT). A chart review indicated no changes in TF-CBT use following the training, although therapists indicated that CBT was the most effective treatment for traumatized youths and was their primary approach to treating trauma.

Targeting trauma-related interventions and improving outcomes for women with co-occurring disorders.

National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero.

An update on the South Carolina trauma initiative.

Seven years ago the South Carolina Department of Mental Health developed a statewide effort to improve its response to consumers who are trauma survivors. The initiative's goals included sensitizing stakeholders to the impact of trauma, influencing policies, educating and training clinicians, addressing concerns about the safety and dignity of psychiatric settings (for example, sanctuary trauma), and increasing knowledge by supporting a strong empirical research platform. In the brief report presented here, the authors describe the past seven years in terms of obstacles encountered, progress, and future directions of this initiative in the hope of providing information and guidance to other state systems.

Are there racial differences in the experience of harmful or traumatic events within psychiatric settings?

The current study examined racial differences in the reported frequency and distress associated with potentially harmful or traumatic experiences occurring within psychiatric settings. One hundred and forty-two (109 African-American; 32 Caucasian) randomly selected adult consumers recruited from a community psychosocial day program completed a battery of self-report measures to assess experiences in the psychiatric setting, lifetime trauma exposure, PTSD severity, and were the subject of a chart review. A subset of participants (20%) also completed a qualitative interview exploring their perceptions of events occurring in psychiatric settings.

Screening for PTSD in public-sector mental health settings: the diagnostic utility of the PTSD checklist.

There are few available data on how to accurately screen for and assess posttraumatic stress disorder (PTSD) among severely mentally ill adults, a group with high rates of unrecognized trauma and PTSD symptoms. We examined the diagnostic utility of a widely used screening instrument, the PTSD Checklist (PCL), for diagnosing PTSD among 44 traumatized, adult, public-sector mental health patients recruited through a community mental health program. Participants completed the PCL and the Clinician-Administered PTSD Scale (CAPS), which is considered the "gold standard" for determining PTSD diagnoses.

Unrecognized trauma and PTSD among public mental health consumers with chronic and severe mental illness.

Lifetime prevalence of traumatic events and current PTSD was assessed among 142 mental health consumers with serious mental illness served by a psychosocial rehabilitation day program. Lifetime exposure to trauma was high (87%). The rate of PTSD based on the PTSD Checklist (PCL) was also high (19-30% depending on different scoring criteria).

Clinicians' perspectives on cognitive-behavioral treatment for PTSD among persons with severe mental illness.

Objective: As an intermediate step in the development of a cognitive-behavioral posttraumatic stress disorder (PTSD) treatment program for persons with severe mental illness, a focus group gathered feedback from clinicians and clinical supervisors within a public-sector mental health system.

Methods: Five qualitative focus group discussions were held with 33 clinicians and clinical supervisors within a state-funded community mental health center system.

Results: Clinicians perceived trauma to be a significant adverse factor in the lives of their mental health services consumers, were reluctant to address trauma with them, and yet believed that cognitive-behavioral treatments for PTSD may be effective and appropriate for them.

Consumers' perceptions of negative experiences and "sanctuary harm" in psychiatric settings.

Objective: Recent studies show a high prevalence of trauma symptoms among people with serious mental illness who are treated in public-sector mental health systems. Unfortunately, growing evidence suggests that many consumers have had traumatic or harmful experiences while being treated in various psychiatric settings. This study explores consumers' perceptions of such harmful inpatient experiences, events that the authors place under the rubric of "sanctuary harm.

Patients' reports of traumatic or harmful experiences within the psychiatric setting.

Objective: This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector mental health system.

Methods: Participants were 142 randomly selected adult psychiatric patients who were recruited through a day hospital program. Participants completed a battery of self-report measures to assess traumatic and harmful events that occurred during the course of their mental health care, lifetime trauma exposure, and symptoms of posttraumatic stress disorder.

Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model.

The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians.

Trauma history screening in a community mental health center.

Objective: This study assessed the lifetime prevalence of traumatic events among consumers of a community mental health center by using a brief trauma screening instrument. This study also examined the relationship between trauma exposure and physical and mental health sequelae and determined whether the routine administration of a trauma screening measure at intake would result in increased diagnoses of posttraumatic stress disorder (PTSD) and in changes in treatment planning in a practice setting.

Methods: A 13-item self-report trauma screening instrument, a shortened version of the Trauma Assessment of Adults instrument, was incorporated into the intake assessment process at a community mental health center (CMHC).

The need for trauma assessment and related clinical services in a state-funded mental health system.

Previous data show that trauma is highly prevalent in public sector consumers and is associated with severe mental illness and high service use costs. Despite this, evidence suggests that trauma victims tend to go unrecognized and to receive inadequate mental health services. We surveyed all facilities (6 inpatient, 17 outpatient) within the South Carolina Department of Mental Health about their current services for trauma victims.