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Gaither ML, Bassett ED, Wilson AL, Marder SR, Bradford DW, Bernard JD, Glynn SM. Implementation of Cognitive Behavioral Therapy for psychosis via telehealth: An expert consultation and clinical service model. Psychol Serv 2024:2024-75937-001. [PMID: 38635219 DOI: 10.1037/ser0000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Individuals living with psychosis are often underserved in the United States, partly due to the dearth of providers trained in evidence-based practices for this population. One such practice is Cognitive Behavioral Therapy for psychosis, which the Substance Abuse and Mental Health Services Administration has identified as a standard of care for this population. The explosion of telehealth, in large part due to the COVID-19 pandemic, has led to increased opportunities for virtual psychotherapy. Telehealth offers a number of benefits, such as the ability to address service inequities, including lack of access to a local provider well-trained in the modality of therapy needed. The current article describes the National Psychosis Telehealth Program within the National Expert Consultation and Specialized Services (formerly VA National Telemental Health Center) program, U.S. Department of Veterans Affairs. The goal of this telehealth program is to utilize an expert consultation model and offer a remote individual, time-limited Cognitive Behavioral Therapy for psychosis protocol to Veterans across the nation in order to decrease access disparities to this relatively scarce service. We share our initiation activities and lessons learned as we developed this program in hopes of encouraging others to consider similar efforts at their sites. We also include a typical, complex case that serves to illustrate the challenges and benefits of this approach. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | | | - Amy L Wilson
- National Expert Consultation and Specialized Services
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2
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Bowersox NW, Smith CM, Austin K, Bradford DW, Browne J, Nelson SM, Szymanski BR, Glynn SM. Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis. Schizophr Res 2024; 264:362-369. [PMID: 38219412 DOI: 10.1016/j.schres.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/15/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Abstract
Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Colin M Smith
- Duke Hubert-Yeargan Center for Global Health, Durham, NC, USA
| | - Karen Austin
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Daniel W Bradford
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA; Duke University Medical Center, Durham, NC, USA
| | - Julia Browne
- Center of Innovation in Long Term Services and Supports, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sharon M Nelson
- Center for Evaluation and Implementation Resources, VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; Psychology Department, Pennsylvania State University, University Park, PA, USA
| | - Benjamin R Szymanski
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Shirley M Glynn
- VA Greater Los Angeles Healthcare System at West Los Angeles, Los Angeles, CA, USA; Semel Institute of Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
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Fortuna KL, Lebby S, Geiger P, Johnson D, MacDonald S, Chefetz I, Ferron JC, St George L, Rossom R, Kalisa J, Mestrovic T, Nicholson J, Pringle W, Rotondi AJ, Sippel LM, Sica A, Solesio ME, Wright M, Zisman-Ilani Y, Gambee D, Hill J, Brundrett A, Cather C, Rhee TG, Daumit GL, Angel J, Manion I, Deegan PE, Butler JA, Pitts N, Brodey DE, Williams AM, Parks J, Reimann B, Wahrenberger JT, Morgan O, Bradford DW, Bright N, Stafford E, Bohm AR, Carney T, Haragirimana C, Gold A, Storm M, Walker R. Lived Experience-Led Research Agenda to Address Early Death in People With a Diagnosis of a Serious Mental Illness: A Consensus Statement. JAMA Netw Open 2023; 6:e2315479. [PMID: 37234010 DOI: 10.1001/jamanetworkopen.2023.15479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Importance People with serious mental illness (SMI), defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorder, or disabling major depressive disorder) die approximately 10 to 25 years earlier than the general population. Objective To develop the first-ever lived experience-led research agenda to address early mortality in people with SMI. Evidence Review A virtual 2-day roundtable comprising 40 individuals convened on May 24 and May 26, 2022, and used a virtual Delphi method to arrive at expert group consensus. Participants responded to 6 rounds of virtual Delphi discussion via email that prioritized research topics and agreement on recommendations. The roundtable was composed of individuals with lived experience of mental health and/or substance misuse, peer support specialists, recovery coaches, parents and caregivers of people with SMI, researchers and clinician-scientists with and without lived experience, policy makers, and patient-led organizations. Twenty-two of 28 (78.6%) of the authors who provided data represented people with lived experiences. Roundtable members were selected by reviewing the peer-reviewed and gray literature on early mortality and SMI, direct email, and snowball sampling. Findings The following recommendations are presented in order of priority as identified by the roundtable participants: (1) improve the empirical understanding of the direct and indirect social and biological contributions of trauma on morbidity and early mortality; (2) advance the role of family, extended families, and informal supporters; (3) recognize the importance of co-occurring disorders and early mortality; (4) redefine clinical education to reduce stigma and support clinicians through technological advancements to improve diagnostic accuracy; (5) examine outcomes meaningful to people with an SMI diagnosis, such as loneliness and sense of belonging, and stigma and their complex relationship with early mortality; (6) advance the science of pharmaceuticals, drug discovery, and choice in medication use; (7) use precision medicine to inform treatment; and (8) redefine the terms system literacy and health literacy. Conclusions and Relevance The recommendations of this roundtable are a starting point for changing practice and highlighting lived experience-led research priorities as an option to move the field forward.
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Affiliation(s)
- Karen L Fortuna
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
| | - Stephanie Lebby
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- College of Nursing and Health Sciences, The University of Vermont, Burlington, Vermont
| | - Pamela Geiger
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
| | | | - Sandi MacDonald
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- International Association of Pre-Menstrual Disorders, Boston, Massachusetts
| | - Ilana Chefetz
- The Hormel Institute, University of Minnesota, Austin, Minnesota
| | - Joelle C Ferron
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
| | | | | | - Joseph Kalisa
- OPROMAMER, Rwanda, Africa
- University of Rwanda, Rwanda, Africa
| | - Tomislav Mestrovic
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
- Department of Health Metrics Sciences, University of Washington School of Medicine, Seattle, Washington
- University North, University Centre Varazdin, Varazdin, Croatia
| | - Joanne Nicholson
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | | | - Armando J Rotondi
- Center for Behavioral Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Pennsylvania Healthcare System, Pittsburgh
| | - Lauren M Sippel
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- Northeast Program Evaluation Center, Department of Veterans Affairs, West Haven, Connecticut
- National Center for PTSD Evaluation Division, Department of Veterans Affairs, West Haven, Connecticut
| | - Amie Sica
- Riverside Community Mental Health, Dedham, Massachusetts
| | - Maria E Solesio
- Rutgers University, Department of Biology, Camden, New Jersey
| | - Maggie Wright
- Families in Trauma and Recovery, PeerLed, Lived Experience Social Enterprise, Fife Renewables Innovation Centre, Ajax Way, LEVEN, Fife, Scotland
| | - Yaara Zisman-Ilani
- Temple University, Department of Social and Behavioral Sciences, College of Public Health, Philadelphia, Pennsylvania
| | - David Gambee
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
| | - Julia Hill
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
| | | | - Corinne Cather
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Taeho Greg Rhee
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, Connecticut
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut
| | - Gail L Daumit
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Angel
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Pennsylvania Healthcare System, Pittsburgh
| | - Ian Manion
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
| | | | - Jason A Butler
- Uncompagre Band of the Ute Indian Tribe from the Uintah and Ouray Agency in Fort Duchesne, Utah
| | | | | | | | - Joseph Parks
- The National Council for Mental Wellbeing, Washington, DC
| | - Brie Reimann
- The National Council for Mental Wellbeing, Washington, DC
| | - J Todd Wahrenberger
- Pittsburgh Mercy, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Daniel W Bradford
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Washington, DC
- Duke University School of Medicine, Durham, North Carolina
| | - Nicole Bright
- L.E.A.R.N. (Lived Experience Academic and Research Network) Queensland, Australia
| | | | - Andrew R Bohm
- Geisel School of Medicine, Department of Psychiatry, Dartmouth College; Concord, New Hampshire
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Tracy Carney
- Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, Pennsylvania
| | | | - Alisa Gold
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- Massachusetts Department of Mental Health, Boston, Massachusetts
| | - Marianne Storm
- Health Science, University of Stavanger, Stavanger, Norway
| | - Robert Walker
- Collaborative Design for Recovery and Health, Nashua, New Hampshire
- Massachusetts Department of Mental Health, Boston, Massachusetts
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Bradford DW, Austin K, Nelson SM, Merrill S, Bowersox NW. Predictors of High-Intensity Psychiatric Service Utilization by Veterans Health Administration Patients With Early Psychosis. Psychiatr Serv 2022; 73:287-292. [PMID: 34346728 DOI: 10.1176/appi.ps.202000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE People with early episode psychosis (EEP) have more negative care outcomes than do people with later episode psychosis (LEP), including higher levels of high-intensity psychiatric service use. It is unclear whether these differences are best explained by clinical differences between these two groups or whether people with EEP have specific treatment needs. An assessment of the treatment needs of patients with EEP can help inform the implementation of national treatment programming designed to provide better care to this group. METHODS Administrative data were used to compare characteristics of Veterans Health Administration patients who had EEP (i.e., a psychotic diagnosis, diagnosis history of ≤4 years, and age ≤30 years; N=4,595) with those with LEP (i.e., a psychotic diagnosis, longer diagnosis history, and older age; N=108,713) who received care during a 1-year evaluation period. The authors generated logistic regressions to assess the potential impact of EEP status on the likelihood of receipt of emergency department (ED) and inpatient psychiatric admissions while controlling for other patient characteristics. RESULTS Patients with EEP had elevated psychiatric comorbidity and mental health severity yet received equivalent outpatient mental health services. Patients with EEP were more likely to have had an ED visit for the treatment of a mental health condition and inpatient psychiatric admissions; this pattern persisted in analyses that controlled for group differences. CONCLUSIONS Patients with EEP have unique mental health treatment needs. The development and implementation of EEP-specific treatments could help address these needs and reduce the number of patients using higher levels of psychiatric services within large health care systems.
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Affiliation(s)
- Daniel W Bradford
- Psychosocial Rehabilitation and Recovery Services (Bradford) and Serious Mental Illness Treatment Resource and Evaluation Center (Austin, Nelson, Merrill, Bowersox), Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs Central Office, Washington, D.C.; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Bradford); Department of Psychiatry, University of Michigan, Ann Arbor (Nelson, Bowersox)
| | - Karen Austin
- Psychosocial Rehabilitation and Recovery Services (Bradford) and Serious Mental Illness Treatment Resource and Evaluation Center (Austin, Nelson, Merrill, Bowersox), Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs Central Office, Washington, D.C.; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Bradford); Department of Psychiatry, University of Michigan, Ann Arbor (Nelson, Bowersox)
| | - Sharon M Nelson
- Psychosocial Rehabilitation and Recovery Services (Bradford) and Serious Mental Illness Treatment Resource and Evaluation Center (Austin, Nelson, Merrill, Bowersox), Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs Central Office, Washington, D.C.; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Bradford); Department of Psychiatry, University of Michigan, Ann Arbor (Nelson, Bowersox)
| | - Stephanie Merrill
- Psychosocial Rehabilitation and Recovery Services (Bradford) and Serious Mental Illness Treatment Resource and Evaluation Center (Austin, Nelson, Merrill, Bowersox), Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs Central Office, Washington, D.C.; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Bradford); Department of Psychiatry, University of Michigan, Ann Arbor (Nelson, Bowersox)
| | - Nicholas W Bowersox
- Psychosocial Rehabilitation and Recovery Services (Bradford) and Serious Mental Illness Treatment Resource and Evaluation Center (Austin, Nelson, Merrill, Bowersox), Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs Central Office, Washington, D.C.; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Bradford); Department of Psychiatry, University of Michigan, Ann Arbor (Nelson, Bowersox)
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5
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Elbogen EB, Molloy K, Wagner HR, Kimbrel N, Beckham JC, Van Male L, Leinbach J, Bradford DW. Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans. J Affect Disord 2020; 260:703-709. [PMID: 31561113 PMCID: PMC6878990 DOI: 10.1016/j.jad.2019.09.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/02/2019] [Accepted: 09/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study investigates the empirical association between psychosocial protective factors and subsequent suicidal ideation in veterans. METHODS We conducted a national longitudinal survey in which participants were randomly drawn from over one million U.S. military service members who served after September 11, 2001. Data were provided by a total of 1090 veterans representative of all 50 states and all military branches in two waves of data collection one year apart (79% retention rate). RESULTS In chi-square analyses, psychosocial protective factors at wave 1 (employment, meeting basic needs, self-care, living stability, social support, spirituality, resilience, and self-determination) were significantly related to lower suicidal ideation at wave 2. In multivariable analyses controlling for covariates at wave 1 including suicidal ideation, the total number of protective factors endorsed at wave 1 significantly predicted reduced odds of suicidal ideation at wave 2. In multivariable analysis examining individual risk and protective factors, again controlling for covariates, results showed that money to cover basic needs and higher psychological resilience at wave 1 were associated with significantly lower odds of suicidal ideation at wave 2. LIMITATIONS The study measured the link between psychosocial protective factors and suicidal ideation but not suicide attempts, which would be an important next step for this research. CONCLUSIONS The results indicate that psychosocial rehabilitation and holistic approaches targeting financial well-being, homelessness, resilience, self-care, social support, spirituality, and work may offer a promising avenue in both veteran and non-veteran populations for treatment safety planning as well as suicide risk management and prevention.
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Affiliation(s)
- Eric B. Elbogen
- Durham VA Health Care System, Durham, NC,VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - Kiera Molloy
- Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - H. Ryan Wagner
- Durham VA Health Care System, Durham, NC,VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - Nathan Kimbrel
- Durham VA Health Care System, Durham, NC,VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - Jean C. Beckham
- Durham VA Health Care System, Durham, NC,VISN 6 Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - Lynn Van Male
- Veterans Health Administration, Office of Mental Health and Suicide Prevention, Washington, DC,Oregon Health & Sciences University, Department of Psychiatry, Portland, OR
| | - Jonathan Leinbach
- Durham VA Health Care System, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
| | - Daniel W. Bradford
- Durham VA Health Care System, Durham, NC,Department of Psychiatry, Duke University Medical Center, Durham, NC
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6
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Hunt MG, Cuddeback GS, Bromley E, Bradford DW, Hoff RA. Changing Rates of Mental Health Disorders Among Veterans Treated in the VHA During Troop Drawdown, 2007-2013. Community Ment Health J 2019; 55:1120-1124. [PMID: 31292835 DOI: 10.1007/s10597-019-00437-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/25/2019] [Indexed: 11/25/2022]
Abstract
Nationally representative data on mental health disorder prevalence are critical to set informed mental health priorities and policies. Data indicating mental health diagnoses within our nation's veteran population treated at the Veterans Health Administration (VHA) are available, but have yet to be examined for changing trends to inform both VHA and community care. We use VHA national program evaluation data from a time of increasing military enrollment (2007) to troop draw down (2013) to examine changes over time in the number of diagnoses in veterans receiving VHA services. The number of veterans in all diagnostic categories increased during our study period with the smallest increase in psychotic disorders (8%) and the largest in posttraumatic stress disorder (71%). Trends in behavioral health diagnoses among veterans have important implications for policy and clinician competencies within VHA and community providers as veteran mental health care needs change.
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Affiliation(s)
- Marcia G Hunt
- VISN1 Mental Illness Research Education and Clinical Center (MIRECC), New England Healthcare System, 950 Campbell Avenue, West Haven, CT, 06511, USA. .,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Gary S Cuddeback
- School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro Street, CB#3550, Chapel Hill, NC, 27590, USA
| | - Elizabeth Bromley
- Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC), West Los Angeles VA Healthcare Center, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, Center for Health Services and Society, University of California, Los Angeles, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA, 90024, USA
| | - Daniel W Bradford
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA
| | - Rani A Hoff
- VISN1 Mental Illness Research Education and Clinical Center (MIRECC), New England Healthcare System, 950 Campbell Avenue, West Haven, CT, 06511, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
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7
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Van Voorhees EE, Wagner HR, Beckham JC, Bradford DW, Neal LC, Penk WE, Elbogen EB. Effects of social support and resilient coping on violent behavior in military veterans. Psychol Serv 2018; 15:181-190. [PMID: 29723020 DOI: 10.1037/ser0000187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Violence toward others has been identified as a serious postdeployment adjustment problem in a subset of Iraq- and Afghanistan-era veterans. In the current study, we examined the intricate links between posttraumatic stress disorder (PTSD), commonly cited psychosocial risk and protective factors, and violent behavior using a national randomly selected longitudinal sample of Iraq- and Afghanistan-era United States veterans. A total of 1,090 veterans from the 50 United States and all United States military branches completed 2 waves of self-report survey-data collection 1 year apart (retention rate = 79%). History of severe violent behavior at Wave 1 was the most substantial predictor of subsequent violence. In bivariate analyses, high correlations were observed among risk and protective factors, and between risk and protective factors and severe violence at both time points. In multivariate analyses, baseline violence (OR = 12.43, p < .001), baseline alcohol misuse (OR = 1.06, p < .05), increases in PTSD symptoms between Waves 1 and 2 (OR = 1.01, p < .05), and decreases in social support between Waves 1 and 2 (OR = .83, p < .05) were associated with increased risk for violence at Wave 2. Our findings suggest that rather than focusing specifically on PTSD symptoms, alcohol use, resilience, or social support in isolation, it may be more useful to consider how these risk and protective factors work in combination to convey how military personnel and veterans are managing the transition from wartime military service to civilian life, and at what point it might be most effective to intervene. (PsycINFO Database Record
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Affiliation(s)
- Elizabeth E Van Voorhees
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center
| | - H Ryan Wagner
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center
| | - Jean C Beckham
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center
| | - Daniel W Bradford
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine
| | - Lydia C Neal
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center
| | - Walter E Penk
- Psychiatry and Behavioral Sciences, Texas A&M College of Medicine
| | - Eric B Elbogen
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center
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8
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Bradford DW, Cuddeback G, Elbogen EB. Promoting mental health recovery and improving clinical assessment using video technology. Psychiatr Rehabil J 2017; 40:412-414. [PMID: 28493736 DOI: 10.1037/prj0000267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
TOPIC Although individuals with medical problems (e.g., diabetes, hypertension) can monitor their symptoms using objective measures (e.g., blood glucose, blood pressure), objective measures are not typically used by individuals with psychotic disorders to monitor symptoms of mental illness. PURPOSE To examine the benefits and limitations of the use of video self-observation for treatment of individuals with psychotic disorders. SOURCES USED The authors reviewed studies examining video self-observation among individuals with severe mental illnesses. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Individuals with psychotic disorders who viewed videos of themselves while symptomatic reported some benefit to this approach, with 1 study showing sustained improvement in understanding of mental illness. Still, some individuals reported negative feelings about the process, and also attributed symptoms to stress or drug abuse rather than their psychotic disorder. The authors found no studies examining the potential for video self-observation as a strategy to improve clinical decision-making in the context of mental health care. Implications of this approach for mental health recovery and clinical practice are discussed. (PsycINFO Database Record
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9
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Bromley E, Mikesell L, Whelan F, Hellemann G, Hunt M, Cuddeback G, Bradford DW, Young AS. Clinical Factors Associated with Successful Discharge from Assertive Community Treatment. Community Ment Health J 2017; 53:916-921. [PMID: 28116636 DOI: 10.1007/s10597-017-0083-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/09/2017] [Indexed: 11/30/2022]
Abstract
We sought to explore clinical factors associated with successful transition from Assertive Community Treatment to less intensive clinical services. Mixed-method observational follow up study of veterans discharged from three VA-affiliated ACT teams to less intensive clinical services. Of the 240 veterans in ACT, 9% (n = 21) were discharged during the study period. Among the 11 of 21 discharged veterans who enrolled in the follow up study, reason for discharge, designated by the veteran's primary clinician at the time of discharge, predicted outcomes (p = 0.02) at 9 months, with "disengagement" as a reason for discharge predicting poorer outcomes. Six of 11 veterans experienced poor outcomes at 9 months, including incarceration and substance use relapse. ACT clinicians rarely discharge clients. Many clients may experience negative clinical events following ACT discharge, and clients may be difficult to follow post-discharge. Client disengagement from ACT may indicate higher likelihood of poor outcomes following discharge to less intensive clinical services.
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Affiliation(s)
- Elizabeth Bromley
- Desert Pacific VA Mental Illness Research, Education and Clinical Center (MIRECC), West Los Angeles VA Healthcare Center, Los Angeles, USA. .,Semel Institute for Neuroscience and Human Behavior, UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, USA. .,Center for Health Services and Society, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA, 90024, USA.
| | - Lisa Mikesell
- School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - Fiona Whelan
- Semel Institute for Neuroscience and Human Behavior, UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, USA
| | - Gerhard Hellemann
- Semel Institute for Neuroscience and Human Behavior, UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, USA
| | - Marcia Hunt
- VA Connecticut Healthcare System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, USA
| | - Gary Cuddeback
- Cecil G. Sheps Center for Health Services Research, School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Alexander S Young
- Desert Pacific VA Mental Illness Research, Education and Clinical Center (MIRECC), West Los Angeles VA Healthcare Center, Los Angeles, USA.,Semel Institute for Neuroscience and Human Behavior, UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, USA
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10
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Bradford DW, Goulet J, Hunt M, Cunningham NC, Hoff R. A Cohort Study of Mortality in Individuals With and Without Schizophrenia After Diagnosis of Lung Cancer. J Clin Psychiatry 2016; 77:e1626-e1630. [PMID: 27780332 DOI: 10.4088/jcp.15m10281] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/25/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Individuals with serious mental illness have increased mortality relative to those without these illnesses. Although cancer is a leading cause of death, few studies have evaluated potential disparities relative to mortality for individuals with serious mental illness who are diagnosed with cancer. In this study, we evaluated mortality after diagnosis of a common malignancy (lung cancer) in a prototypical serious mental illness (schizophrenia). METHODS Using administrative data in the Veterans Affairs system, we identified 34,664 individuals who were diagnosed with lung cancer between October 1, 2001, and September 30, 2005. We conducted a survival analysis comparing individuals with and without ICD-9-CM schizophrenia using data through September 30, 2010. Controlling variables were age, gender, smoking status, marital status, service connection, homelessness status, and presence of a substance use disorder. RESULTS Our results demonstrated significantly poorer survival after lung cancer diagnosis for individuals with schizophrenia compared to those without schizophrenia. The hazard ratio for all-cause mortality associated with schizophrenia was 1.33 (95% CI, 1.22-1.44). CONCLUSIONS Individuals with schizophrenia are at higher risk of death after diagnosis of lung cancer than those without schizophrenia. Future studies should further characterize cause of death, quality of cancer care received, and barriers to care.
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Affiliation(s)
- Daniel W Bradford
- Durham VA Medical Center, 1830 Hillandale Rd, Durham, NC 27705. .,Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph Goulet
- Pain, Research, Informatics, Multi-morbidities, and Education Center (PRIME), VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marcia Hunt
- Mental Illness Research, Education, and Clinical Center, Veterans Health Administration, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Natasha C Cunningham
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Rani Hoff
- Mental Illness Research, Education, and Clinical Center, Veterans Health Administration, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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11
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Bradford DW, Cunningham N. Psychotic disorders cause the greatest mortality disparity among mental disorders, though more deaths are attributable overall to mood and anxiety disorders. Evid Based Ment Health 2016; 19:58. [PMID: 26811387 PMCID: PMC10699416 DOI: 10.1136/eb-2015-102100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel W Bradford
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Natasha Cunningham
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
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12
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Szabo ST, Kilts JD, Naylor JC, Youssef NA, Strauss JL, Morey RA, Brancu M, Hamer RM, Bradford DW, Marx CE. Amino acids as biomarker candidates for suicidality in male OEF/OIF Veterans: relevance to NMDA receptor modulation and nitric oxide signaling. Mil Med 2015; 179:486-91. [PMID: 24806493 DOI: 10.7205/milmed-d-13-00337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Veteran populations are exposed to multiple stressful events, and suicidality among veterans is a serious problem. Identifying biomarkers of suicidality may enhance detection, prevention, and treatment. Multiple neurotransmitter systems are implicated in the neurobiology of suicidality, including amino acid neurotransmitter systems. Amino acids as biomarker candidates for suicidality were quantified using mass spectrometry in serum samples from 90 male U.S. Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Amino acid levels in veterans reporting suicidal ideation (SI) on the Beck Scale for Suicidal Ideation (BSS) (BSS score > 0, n = 19) were compared with those reporting no SI (BSS score = 0, n = 71). Glycine, an excitatory amino acid and N-methyl-d-aspartate receptor modulator, was significantly elevated in serum samples from veterans reporting SI (p = 0.043). Serine and aspartate/asparagine, also excitatory neurotransmitters, were nonsignificantly increased in veterans reporting SI (p = 0.082 and p = 0.097, respectively). In contrast, arginine (nitric oxide [NO] precursor) and citrulline (by-product of NO formation) were nonsignificantly decreased in veterans reporting SI (p = 0.097 and p = 0.093, respectively). Profiling amino acids as possible biomarker candidates for suicidality in OEF/OIF veterans may have clinical utility for identifying suicidal risk. Glutamatergic neurotransmission and NO signaling may be relevant to the neurobiology of suicidality in OEF/OIF veterans.
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Affiliation(s)
- Steven T Szabo
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Jason D Kilts
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Jennifer C Naylor
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Nagy A Youssef
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Jennifer L Strauss
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Rajendra A Morey
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Mira Brancu
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Robert M Hamer
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | - Daniel W Bradford
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
| | | | - Christine E Marx
- Durham Veterans Affairs Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Mental Health Service Line (116A), Durham, NC 27705
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13
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Youssef NA, Bradford DW, Kilts JD, Szabo ST, Naylor JC, Allen TB, Strauss JL, Hamer RM, Brunca M, Shampine LJ, Marx CE. Exploratory Investigation of Biomarker Candidates for Suicide in Schizophrenia and Bipolar Disorder. Crisis 2015; 36:46-54. [DOI: 10.1027/0227-5910/a000280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Clozapine and lithium increase neurosteroids in rodents, and both drugs demonstrate antisuicidal actions. We therefore hypothesized that neurosteroid levels may be reduced in patients with schizophrenia or bipolar disorder who completed suicide. Aims: To investigate neurosteroid levels in the parietal cortex and posterior cingulate in schizophrenia and bipolar patients who died by suicide, and compare them with patients with these disorders who died of other causes. Method: Neurosteroid levels were quantified by gas chromatography/mass spectrometry in the parietal cortex and posterior cingulate. Mann–Whitney analyses were conducted in exploratory post hoc analyses to investigate neurosteroids as possible biomarker candidates for suicide. Results: The study showed that pregnenolone was significantly decreased in the parietal cortex in the combined group of patients with schizophrenia or bipolar disorder who died by suicide (n = 13) compared with patients with these disorders who died of other causes (n = 17, p = .02). Pregnenolone levels were also lower in the parietal cortex in the individual group of schizophrenia patients who died by suicide (n = 4) compared with schizophrenia patients who died of other causes (n = 11) p = .04). Conclusion: Pregnenolone alterations may be relevant to the neurobiology of suicide in schizophrenia and bipolar disorder.
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Affiliation(s)
- Nagy A. Youssef
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Daniel W. Bradford
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Jason D. Kilts
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Steven T. Szabo
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Jennifer C. Naylor
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Trina B. Allen
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Jennifer L. Strauss
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Durham, NC, USA
| | - Robert M. Hamer
- Department of Psychiatry, University of North Carolina at Chapel Hill, NC, USA
| | - Mira Brunca
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Lawrence J. Shampine
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
| | - Christine E. Marx
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) and Durham VA Medical Center, Durham, NC, USA
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14
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Cunningham NT, Dennis N, Dattilo W, Hunt M, Bradford DW. Continuation of clozapine during chemotherapy: a case report and review of literature. Psychosomatics 2014; 55:673-9. [PMID: 25497505 DOI: 10.1016/j.psym.2014.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Natasha T Cunningham
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
| | - Nora Dennis
- Mental Illness, Research, Education and Clinical Center, Veterans Affairs New England, Hyannis, MA
| | - Wilbur Dattilo
- Mental Illness, Research, Education and Clinical Center, Veterans Affairs New England, Hyannis, MA
| | - Marcia Hunt
- Department of Psychiatry, Yale Medical School, New Haven, CT; Department of Psychiatry and Behavioral Sciences
| | - Daniel W Bradford
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC; Mental Health Service Line, Durham Veterans Affairs Medical Center, Durham, NC
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15
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Gierisch JM, Nieuwsma JA, Bradford DW, Wilder CM, Mann-Wrobel MC, McBroom AJ, Hasselblad V, Williams JW. Pharmacologic and behavioral interventions to improve cardiovascular risk factors in adults with serious mental illness: a systematic review and meta-analysis. J Clin Psychiatry 2014; 75:e424-40. [PMID: 24922495 DOI: 10.4088/jcp.13r08558] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 10/07/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Individuals with serious mental illness have high rates of cardiovascular disease (CVD) risk factors and mortality. This systematic review was conducted to evaluate pharmacologic and behavioral interventions to reduce CVD risk in adults with serious mental illness. DATA SOURCES MEDLINE, EMBASE, PsycINFO, ClinicalTrials.gov, and Cochrane Database of Systematic Reviews were searched from January 1980 to July 2012 for English language studies. Examples of search terms used include schizophrenia, bipolar disorder, antipsychotics, weight, glucose, lipid, and cardiovascular disease. STUDY SELECTION Two reviewers independently screened citations and identified 33 randomized controlled trials of at least 2 months' duration that enrolled adults with serious mental illness and evaluated pharmacologic or behavioral interventions targeting weight, glucose, or lipid control. DATA EXTRACTION Reviewers extracted data, assessed applicability, and evaluated study quality; the team jointly graded overall strength of evidence. RESULTS We included 33 studies. Most studies targeted weight control (28 studies). Compared with control groups, weight control was improved with behavioral interventions (mean difference = -3.13 kg; 95% CI, -4.21 to -2.05), metformin (mean difference = -4.13 kg; 95% CI, -6.58 to -1.68), anticonvulsive medications topiramate and zonisamide (mean difference = -5.11 kg; 95% CI, -9.48 to -0.74), and adjunctive or antipsychotic switching to aripiprazole (meta-analysis not possible). Evidence was insufficient for all other interventions and for effects on glucose and lipid control. The small number of studies precluded analyses of variability in treatment effects by patient characteristics. CONCLUSIONS Few studies have evaluated interventions addressing 1 or more CVD risk factors in people with serious mental illness. Glucose- and lipid-related results were mainly reported as secondary outcome assessments in studies of weight-management interventions. Comparative effectiveness studies are needed to test multimodal strategies, agents known to be effective in nonserious mental illness populations, and antipsychotic-management strategies.
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Affiliation(s)
- Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham Veteran Affairs Medical Center (152), 508 Fulton St, Durham, NC 27705
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16
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Bradford DW, Cunningham NT, Slubicki MN, McDuffie JR, Kilbourne AM, Nagi A, Williams JW. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: a systematic review. J Clin Psychiatry 2013; 74:e754-64. [PMID: 24021516 DOI: 10.4088/jcp.12r07666] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To conduct a systematic review of studies of interventions that integrated medical and mental health care to improve general medical outcomes in individuals with serious mental illness. DATA SOURCES English-language publications in MEDLINE (via PubMed), EMBASE, PsycINFO, and the Cochrane Library, from database inception through January 18, 2013, were searched using terms for our diagnoses of interest, a broad set of terms for care models, and a set of terms for randomized controlled trials (RCTs) or quasi-experimental design. Bibliographies of included articles were examined for additional sources. ClinicalTrials.gov was searched using the terms for our diagnoses of interest (serious mental illness,SMI,bipolar disorder,schizophrenia,orschizoaffective disorder) to assess for evidence of publication bias and ongoing studies. STUDY SELECTION 4 RCTs were included from 1,729 articles reviewed. Inclusion criteria were RCT or quasi-experimental design; adult outpatient population with 25% or greater carrying a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder; intervention with a stated goal to improve medical outcomes through integration of care, using a comparator of usual care or other quality improvement strategy; and outcomes assessing process of care, clinical outcomes, or physical functioning. DATA EXTRACTION A trained researcher abstracted the following data from the included articles: study design, funding source, setting, population characteristics, eligibility and exclusion criteria, number of subjects and providers, intervention(s), comparison(s), length of follow-up, and outcome(s). These abstracted data were then overread by a second reviewer. RESULTS Of the 4 studies reviewed, 2 good-quality studies (according to the guidelines of the Agency for Healthcare Research and Quality) that evaluated processes of preventive and chronic disease care demonstrated positive effects of integrated care. Specifically, integrated care interventions were associated with increased rates of immunization and screening. All 4 RCTs evaluated changes in physical functioning, with mixed results: 2 studies demonstrated small improvements in the physical health component of the 36-Item Short-Form Health Survey (SF-36) and the 12-Item Short-Form Health Survey, and 2 studies demonstrated no significant difference in SF-36 scores. No studies reported on clinical outcomes related to preventive care or chronic medical care. CONCLUSIONS Integrated care models have positive effects on processes of preventive and chronic disease care but have inconsistent effects on physical functioning for individuals with serious mental illness. The relatively small number of trials and limited range of treatment models tested and outcomes reported point to the need for additional study in this important area.
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Affiliation(s)
- Daniel W Bradford
- Psychosocial Rehabilitation and Recovery Center, Durham VA Medical Center, 1830 Hillandale Rd, Durham, NC 27705
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17
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Strauss JL, Zervakis JB, Stechuchak KM, Olsen MK, Swanson J, Swartz MS, Weinberger M, Marx CE, Calhoun PS, Bradford DW, Butterfield MI, Oddone EZ. Adverse impact of coercive treatments on psychiatric inpatients' satisfaction with care. Community Ment Health J 2013; 49:457-65. [PMID: 23054144 DOI: 10.1007/s10597-012-9539-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
Consumers' satisfaction with inpatient mental health care is recognized as a key quality indicator that prospectively predicts functional and clinical outcomes. Coercive treatment experience is a frequently cited source of dissatisfaction with inpatient care, yet more research is needed to understand the factors that influence consumers' perceptions of coercion and its effects on satisfaction, including potential "downstream" effects of past coercive events on current treatment satisfaction. The current study examined associations between objective and subjective indices of coercive treatments and patients' satisfaction with care in a psychiatric inpatient sample (N = 240). Lower satisfaction ratings were independently associated with three coercive treatment variables: current involuntary admission, perceived coercion during current admission, and self-reported history of being refused a requested medication. Albeit preliminary, these results document associations between patients' satisfaction ratings and their subjective experiences of coercion during both current and prior hospitalizations.
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Affiliation(s)
- Jennifer L Strauss
- Center for Health Services Research in Primary Care, VISN 6 MIRECC, Bldg 6, 508 Fulton Street, Durham, NC 27705, USA.
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18
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Naylor JC, Dolber TR, Strauss JL, Kilts JD, Strauman TJ, Bradford DW, Szabo ST, Youssef NA, Connor KM, Davidson JR, Marx CE. A pilot randomized controlled trial with paroxetine for subthreshold PTSD in Operation Enduring Freedom/Operation Iraqi Freedom era veterans. Psychiatry Res 2013; 206:318-20. [PMID: 23276723 PMCID: PMC3788578 DOI: 10.1016/j.psychres.2012.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 09/18/2012] [Accepted: 11/09/2012] [Indexed: 11/26/2022]
Abstract
Subthreshold posttraumatic stress disorder (PTSD) is associated with increased risk for suicidality, depression, and functional impairment. We thus conducted a small (N=12) pilot randomized controlled trial (RCT) with paroxetine for subthreshold PTSD in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) era veterans. Hospital Anxiety and Depression Scale (HADS) scores improved by 30.4% in the paroxetine group. Paroxetine may have promise for subthreshold PTSD.
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Affiliation(s)
- Jennifer C. Naylor
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Trygve R. Dolber
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Jennifer L. Strauss
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jason D. Kilts
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | | | - Daniel W. Bradford
- Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Steven T. Szabo
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Nagy A. Youssef
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kathryn M. Connor
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jonathan R.T. Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Christine E. Marx
- VA Mid-Atlantic Mental Illness, Research and Clinical Center (MIRECC), Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA,Corresponding author at: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham VA Medical Center, 508 Fulton Street, MHSL 116A, Durham, North Carolina 27705, USA. Tel.: +1 919 286 0411x7426; fax: +1 919 286 6811
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19
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Affiliation(s)
- Eric B Elbogen
- Department of Psychiatry, University of North Carolina-Chapel Hill School of Medicine, CB 7167, Chapel Hill, NC 27599, USA.
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20
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Resnik L, Bradford DW, Glynn SM, Jette AM, Hernandez CJ, Wills S. Issues in defining and measuring veteran community reintegration: Proceedings of the Working Group on Community Reintegration,VA Rehabilitation Outcomes Conference, Miami, Florida. ACTA ACUST UNITED AC 2012; 49:87-100. [DOI: 10.1682/jrrd.2010.06.0107] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
This study examined the impact of physical and sexual trauma on a sample of 239 homeless men. Study participants completed a self-administered survey that collected data on demographics, exposure to psychological trauma, physical health and mental health problems, and substance use or misuse. Binomial logistic regression analyses were used to examine the relative significance of demographic factors and the four types of trauma exposure associated with three outcomes: mental health, substance abuse, and physical health problems. The authors found that trauma history was significantly associated with more mental health problems but was not associated with substance abuse problems for homeless men. This study reinforces service providers' perceptions that because many homeless men experience the long-term, deleterious effects of not only current stressors, but also abuse and victimization that often begin in childhood, homeless men are a subpopulation in need of proactive prevention services that emphasize long-term continuity of care rather than sporadic crisis-based services. Study findings suggest that mentally ill, homeless men need proactive services that address the sequelae of abuse with care that is specialized and distinctly different from care for homeless adults with substance abuse or physical health care issues.
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Affiliation(s)
- Mimi M Kim
- Institute for Health, Social, and Community Research, Shaw University, Raleigh, NC 27601, USA.
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22
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Abstract
PURPOSE To make decisions about implementing systematic depression screening, primary care physicians who serve Spanish-speaking populations need to know whether Spanish language depression-screening instruments are accurate. We aimed to review systematically the evidence regarding diagnostic accuracy of depression-screening instruments in Spanish-speaking primary care populations. METHODS We searched PubMed, PsycINFO, CINAHL, EMBASE, and Cochrane Libraries from inception to May 28, 2008, for studies examining the diagnostic accuracy of Spanish language depression case-finding instrument(s) administered to primary-care outpatients. Two authors independently assessed studies for inclusion and quality. RESULTS Twelve studies met inclusion criteria. In general primary care screening, the Spanish language version of the Center for Epidemiologic Studies-Depression scale (CES-D) had sensitivities ranging from 76% to 92% and specificities ranging from 70% to 74%. We found no US study reporting the accuracy of the Primary Care Evaluation of Mental Disorders (PRIME-MD-9) or the Patient Health Questionnaire (PHQ-9) depression module in Spanish-speakers. One fair-quality European study and 1 poor-quality study conducted in Honduras found the 9-item PRIME-MD had sensitivities ranging from 72% to 77% and specificities ranging from 86% to 100%. The 2-item PRIME-MD was 92% sensitive, but only 44% specific for depression in 1 US study. In geriatric outpatients, the 15-item Spanish language version of the Geriatric Depression Scale (GDS) had sensitivities ranging from 76% to 82%, and specificities ranging from 64% to 98%. In postpartum women, the Spanish language version of the Edinburgh Postnatal Depression Scale (EPDS) was 72% to 89% sensitive and 86% to 95% specific for major depression (2 non-US studies). The Spanish language version of the Postpartum Depression Screening Scale (PDSS) was 78% sensitive and 85% specific for combined major/minor depression (1 US study). CONCLUSIONS For depression screening in Spanish-speaking outpatients, fair evidence supports the diagnostic accuracy of the CES-D and PRIME-MD-9 in general primary care, the GDS-15-Spanish for geriatric patients, and the Spanish language versions of the EPDS or PDSS for postpartum patients. The ultrashort 2-item version of PRIME-MD may lack specificity in US Spanish-speakers.
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Affiliation(s)
- Daniel S Reuland
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, and the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina 27599 - 7110, USA.
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Abstract
OBJECTIVE People with serious mental illness have higher mortality rates than the general population, and this difference is not explained by such causes as suicide or accidents. This study therefore examined access and barriers to medical care among persons with serious mental illness. METHODS Using a nationally representative sample, the authors examined access and barriers to medical care among individuals reporting psychotic and mood disorders. The National Health Interview Survey (NHIS) and NHIS-Disability Component for 1994 and 1995 were merged to provide a sample of 156,475 people over age 18. Individuals with psychotic disorders, bipolar disorder, or major depression were compared with persons without mental disorders on the following outcomes: having a primary care physician, being unable to get needed medical care, being unable to get a needed prescription medication, and delaying medical care because of cost. RESULTS Persons with psychotic disorders (odds ratio [OR]=.55, 95% confidence interval [CI]=.44-.69) and bipolar disorder (OR=.74, CI=.56-.98) had significantly reduced odds of having a primary care physician compared with people without mental disorders. For any barriers to care, persons with psychotic disorders, bipolar disorder, or major depressive disorder had greatly increased odds (ORs=2.5-7.0) of reporting difficulties in accessing care. CONCLUSIONS Persons with psychotic disorders and bipolar disorder reported markedly more difficulty in obtaining a primary care physician and greater barriers to care than the general population. Interventions are needed to improve provision of primary medical care to this population.
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Affiliation(s)
- Daniel W Bradford
- Psychosocial Rehabilitation and Recovery Center, Durham VA Medical Center, MHSL (116D)/Hillandale 2, 508 Fulton St., Durham, NC 27705, USA.
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Kim MM, Swanson JW, Swartz MS, Bradford DW, Mustillo SA, Elbogen EB. Healthcare barriers among severely mentally ill homeless adults: evidence from the five-site health and risk study. Adm Policy Ment Health 2007; 34:363-75. [PMID: 17294124 DOI: 10.1007/s10488-007-0115-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 01/11/2007] [Indexed: 11/29/2022]
Abstract
UNLABELLED Few studies have examined barriers to physical and mental healthcare among homeless mentally adults. METHODS This study examined physical and mental healthcare barriers reported by 154 recently homeless mentally ill persons. RESULTS Practical concerns (e.g. transportation and cost) were key components of barriers to accessing general medical care among uninsured men with poorer overall mental health, PTSD, and STD infections. Perceived stigma was an important component of mental healthcare barriers reported most frequently by those with greater psychiatric symptoms. CONCLUSION Focusing on individual characteristics underlying barriers to healthcare may lead to better interventions for improving access to needed care.
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Affiliation(s)
- Mimi M Kim
- Services Effectiveness Research Program in the Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Brightleaf Square Suite 23-A, 905 West Main Street, Durham, NC 27710, USA.
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Marx CE, Shampine LJ, Khisti RT, Trost WT, Bradford DW, Grobin AC, Massing MW, Madison RD, Butterfield MI, Lieberman JA, Morrow AL. Olanzapine and fluoxetine administration and coadministration increase rat hippocampal pregnenolone, allopregnanolone and peripheral deoxycorticosterone: implications for therapeutic actions. Pharmacol Biochem Behav 2006; 84:609-17. [PMID: 16996120 DOI: 10.1016/j.pbb.2006.07.032] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 07/19/2006] [Accepted: 07/25/2006] [Indexed: 12/17/2022]
Abstract
Olanzapine and fluoxetine elevate the GABAergic neuroactive steroid allopregnanolone to physiologically relevant concentrations in rodent cerebral cortex. It is unknown if these agents also alter pregnenolone or deoxycorticosterone. Since olanzapine and fluoxetine in combination have clinical utility and may demonstrate synergistic effects, we investigated neuroactive steroid alterations following olanzapine, fluoxetine or coadministration. Male rats received IP vehicle, olanzapine, fluoxetine or the combination of both agents in higher-dose (0, 10, 20 or 10/20 mg/kg, respectively) and lower-dose (0, 5, 10 or 5/10 mg/kg, respectively) experiments. Pregnenolone and allopregnanolone levels in hippocampus were determined by gas chromatography/mass spectrometry. Peripheral deoxycorticosterone and other steroid levels were determined by radioimmunoassay. Olanzapine, fluoxetine or the combination increased hippocampal pregnenolone and serum deoxycorticosterone in both higher- and lower-dose experiments, and elevated hippocampal allopregnanolone in higher-dose conditions. No synergistic effects on pregnenolone or allopregnanolone were observed following olanzapine and fluoxetine coadministration compared to either compound alone. Pregnenolone and its sulfate enhance learning and memory in rodent models, and therefore pregnenolone elevations may be relevant to cognitive changes in psychotic and affective disorders. Since pregnenolone decreases have been linked to depression, it is possible that olanzapine- and fluoxetine-induced pregnenolone elevations may contribute to the antidepressant actions of these agents.
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Marx CE, Shampine LJ, Duncan GE, VanDoren MJ, Grobin AC, Massing MW, Madison RD, Bradford DW, Butterfield MI, Lieberman JA, Morrow AL. Clozapine markedly elevates pregnenolone in rat hippocampus, cerebral cortex, and serum: candidate mechanism for superior efficacy? Pharmacol Biochem Behav 2006; 84:598-608. [PMID: 16962649 DOI: 10.1016/j.pbb.2006.07.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 07/19/2006] [Accepted: 08/17/2006] [Indexed: 12/26/2022]
Abstract
Clozapine demonstrates superior efficacy in patients with schizophrenia, but the precise mechanisms contributing to this clinical advantage are not clear. Clozapine and olanzapine increase the GABAergic neuroactive steroid (NS) allopregnanolone, and it has been hypothesized that NS induction may contribute to the therapeutic actions of these agents. Pregnenolone administration improves learning and memory in rodent models, and decreases in this NS have been associated with depressive symptoms in humans. These pregnenolone characteristics may be relevant to the actions of antipsychotics. We therefore investigated potential pregnenolone alterations in rat hippocampus and cerebral cortex following clozapine, olanzapine, and other second generation agents as a candidate NS mechanism contributing to antipsychotic efficacy. In the first set of experiments, intact, adrenalectomized, and sham-operated male rats received vehicle or clozapine (20 mg/kg) IP. In the second set, male rats received vehicle, olanzapine (5 mg/kg), quetiapine (20 mg/kg), ziprasidone (10 mg/kg) or aripiprazole (5 mg/kg) IP. Pregnenolone levels were determined by gas chromatography/mass spectrometry. Clozapine markedly elevates pregnenolone in rat hippocampus, cerebral cortex, and serum; hippocampal levels were strongly correlated with serum levels (r=0.987). Olanzapine also elevates pregnenolone levels, but to a lesser degree than clozapine. Pregnenolone induction may contribute to the clinical actions of clozapine and olanzapine.
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Bradford DW, Gaynes BN, Kim MM, Kaufman JS, Weinberger M. Can Shelter-Based Interventions Improve Treatment Engagement in Homeless Individuals With Psychiatric and/or Substance Misuse Disorders? Med Care 2005; 43:763-8. [PMID: 16034289 DOI: 10.1097/01.mlr.0000170402.35730.ea] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND High proportions of homeless individuals have mental illness and substance use disorders. Few of these individuals engage in consistent treatment, although they are likely to benefit from it. Shelter-based interventions to help this population engage in treatment have not been studied in a rigorous manner. OBJECTIVES We sought to evaluate the effectiveness of a shelter-based intervention, including intensive outreach by a psychiatric social worker and availability of weekly psychiatrist visits with continuity of care to engage homeless individuals with psychiatric and substance use problems. RESEARCH DESIGN This was a randomized controlled trial. SUBJECTS A total of 102 individuals were referred to a shelter-based psychiatric clinic. MEASURES The primary outcome measure was first appointment attendance at a community mental health center (CMHC). Secondary outcome measures were attendance at second and third CMHC appointments, participation in a substance abuse program, and employment and housing status at shelter exit. RESULTS Individuals receiving the intervention were more likely to attend > or =1 CMHC appointment (64.7% versus 37.3%, P = 0.006) and to participate in a substance abuse program (51.4% versus 12.5%, P = 0.0006) than those in the control group. There was a trend towards being more likely to attend 2 CMHC visits (33.3% versus 17.7%, P = 0.083), but no significant differences in attending 3 visits, being employed, or having housing. CONCLUSIONS Shelter-based interventions hold promise for improving treatment engagement in homeless populations with psychiatric and substance use problems. Further study should address how to foster care beyond an initial CMHC appointment and clarify key program components using a wider range of outcome measures.
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Affiliation(s)
- Daniel W Bradford
- Robert Wood Johnson Clinical Scholars Program, Chapel Hill, North Carolina, USA.
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Abstract
Schizophrenia is a severe mental illness characterised by abnormalities of thought and perception that affects 1-2% of the population. Patients who experience a first episode of schizophrenia should be treated early and optimally with antipsychotic agents to lessen the morbidity of the initial episode and possibly improve the course of the illness. Positive psychotic symptoms remit in the majority of patients who are treated with adequate trials of antipsychotic medications, but most relapse within 1 year. Non-adherence is strongly related to the likelihood of recurrence of symptoms. Innovative programmes that integrate early intervention, psychosocial treatments and atypical antipsychotic pharmacotherapy show promise in improving outcomes. The available research supports the use of antipsychotic medications early in the first-episode of schizophrenia and for at least 1 year after remission of positive symptoms. Antidepressants, benzodiazepines and mood stabilisers have roles in the acute and maintenance phases of treatment for some patients. Atypical antipsychotics represent a great advance in the treatment of first-episode schizophrenia with strong evidence for greater tolerability with equal or better therapeutic efficacy. Future research will further define their roles in treatment and hopefully identify targets for prevention of first-episode schizophrenia.
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Affiliation(s)
- Daniel W Bradford
- University of North Carolina School of Medicine, Neurosciences Hospital, Chapel Hill, North Carolina 27599-7160, USA
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Abstract
CONTEXT A number of studies have found race- and sex-based differences in rates of cardiovascular procedures in the United States. Similarly, mental disorders might be expected to be associated with lower rates of such procedures on the basis of clinical, socioeconomic, patient, and provider factors. OBJECTIVE To assess whether having a comorbid mental disorder is associated with a lower likelihood of cardiac catheterization and/or revascularization after acute myocardial infarction. DESIGN Retrospective cohort study using data from medical charts and administrative files as part of the Cooperative Cardiovascular Project. SETTING Acute care nongovernmental hospitals in the United States. PATIENTS National cohort of 113653 eligible patients 65 years or older who were hospitalized for confirmed acute myocardial infarction between February 1994 and July 1995. MAIN OUTCOME MEASURES Likelihood of cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass graft (CABG) surgery during the index hospitalization, comparing patients with and without mental disorders (classified as schizophrenia, major affective disorder, substance abuse/dependence disorder, or other mental disorder). RESULTS Compared with the remainder of the sample, patients with any comorbid mental disorder (n = 5365; 4.7%) were significantly less likely to undergo PTCA (11.8% vs 16.8%; P<.001) or CABG (8.2% vs 12.6%; P<.001). After adjusting for demographic, clinical, hospital, and regional factors, individuals with mental disorders were 41% (for schizophrenia) to 78% (for substance use) as likely to undergo cardiac catheterization as those without mental disorders (P<.001 for all). Among those undergoing catheterization, rates of PTCA or CABG for patients with mental disorders were not significantly different from rates for patients without mental disorders (for those with any mental disorder, P = .12 for PTCA and P = .06 for CABG). In multivariate models, the 30-day mortality did not differ between patients with and without mental disorders. CONCLUSIONS In this study, individuals with comorbid mental disorders were substantially less likely to undergo coronary revascularization procedures than those without mental disorders. Further research is needed to understand the degree to which patient and provider factors contribute to this difference and its implications for quality and long-term outcomes of care.
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Affiliation(s)
- B G Druss
- Department of Psychiatry, Yale University School of Medicine, VA Northeast Program Evaluation Center, New Haven, Conn, USA.
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Hinder F, Matsumoto N, Booke M, Bradford DW, Traber LD, Herndon DN, Traber DL. Inhalation injury increases the anastomotic bronchial blood flow in the pouch model of the left ovine lung. Shock 1997; 8:131-5. [PMID: 9261904 DOI: 10.1097/00024382-199708000-00012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pulmonary parenchymal damage often occurs after airway injury. Bronchial venous drainage empties into the pulmonary microvasculature. We developed an in vivo model to study the bronchopulmonary portal system after smoke inhalation injury. Eight ewes were instrumented with hydraulic occluders on the left pulmonary artery (LPA), the left pulmonary vein, and the bronchoesophageal artery (BEA); a catheter in the LPA; and Swan-Ganz and femoral artery catheters. The vasculature between the occluders was defined as pouch. At stable mean arterial and right pulmonary arterial pressures, LPA occlusion reduced the left pulmonary artery pressure (LPAP) from 17 +/- 1 mmHg to 8 +/- 1 mmHg (p < .05). After left pulmonary vein occlusion, LPAP rose to 28 +/- 4 mmHg (p < .05 vs. baseline), indicating that systemic blood had entered the pouch. Opening the pouch to atmospheric pressure revealed an anastomotic bronchial blood flow (anastomotic Qbr) of .76 +/- .11% of cardiac output (CO). BEA occlusion reduced the anastomotic Qbr to .32 +/- .06% of CO (p < .05). Smoke inhalation injury resulted in a further increase in the maximal LPAP to 38 +/- 5 mmHg (p < .05 vs. right pulmonary artery pressure). The anastomotic Qbr rose to 1.29 +/- .13% of CO (p < .05) and was reduced to .40 +/- .09% of CO (p < .05) by BEA occlusion. Inhalation injury increased the anastomotic Qbr mainly due to BEA vasodilatation. Because the BEA supplies the injured airway, it may deliver deleterious material to the lung parenchyma.
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Affiliation(s)
- F Hinder
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0866
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Booke M, Bradford DW, Hinder F, Nishida K, Biondo NA, Traber LD, Traber DL. Inhaled nitric oxide selectively reduces pulmonary hypertension after ovine smoke inhalation but does not improve oxygenation. J Burn Care Rehabil 1997; 18:27-33. [PMID: 9063784 DOI: 10.1097/00004630-199701000-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Inhaled nitric oxide (NO) is known to selectively reduce pulmonary hypertension and improve the ventilation-perfusion relationship in subjects with lung injury of various origin. However, some forms of lung injury do not react to inhaled NO at all, or show only a reduction in pulmonary arterial pressure. Very little is known about the effects of inhaled NO after smoke inhalation injury. We investigated the effects of inhaled NO in an established model of ovine smoke inhalation injury. Chronically instrumented sheep (n = 8) had tracheostomies and were insufflated with smoke generated from burning cotton cloth (4 times at 12 breaths each). They were then connected to a ventilator with oxygen-enriched air to achieve arterial oxygen tensions within the normal range. After 48 hours, NO was added to the inspired gas in ascending concentrations of up to 100 ppm. Systemic and pulmonary hemodynamics as well as oxygen transport were analyzed. Inhaled NO dose dependently lowered the pulmonary hypertension. Concentrations higher than 20 ppm did not further reduce the pulmonary artery pressure. Right ventricular stroke work index was significantly improved owing to the reduction in pulmonary vascular resistance. Arterial oxygenation, however, was not optimized by inhaled NO, probably because of interstitial edema formation.
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Affiliation(s)
- M Booke
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0833, USA
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Booke M, Bradford DW, Hinder F, Harper D, Brauchle RW, Traber LD, Traber DL. Effects of inhaled nitric oxide and nebulized prostacyclin on hypoxic pulmonary vasoconstriction in anesthetized sheep. Crit Care Med 1996; 24:1841-8. [PMID: 8917035 DOI: 10.1097/00003246-199611000-00014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Inhaled nitric oxide has been shown to be a selective pulmonary vasodilator, leading to reduced pulmonary arterial pressure and improved ventilation/perfusion ratio in the acute respiratory distress syndrome. This local pulmonary vasodilation theoretically can be achieved by the airway application of a short-acting vasodilator, such as prostacyclin. We hypothesized that nebulized prostacyclin has the same properties for selective pulmonary vasodilation as inhaled nitric oxide. DESIGN Prospective, experimental study in sheep. SETTING Investigational intensive care unit in a university hospital. SUBJECTS Six adult ewes of the Merino breed. INTERVENTIONS Sheep (n = 6) were surgically prepared for chronic study. After 5 days of recovery, the sheep had tracheostomies performed under anesthesia. Intubation with a modified Robert-Shaw tube allowed side-separated ventilation. The entire left lung was ventilated with pure nitrogen, whereas the right lung was ventilated with pure oxygen. Nitric oxide and prostacyclin were added in different concentrations to the nitrogen, with which the left lung was ventilated. MEASUREMENTS AND MAIN RESULTS The blood flows to the left and right lungs were measured with ultrasonic flow probes on the common and left pulmonary artery. Measurements were taken after each compound had been administered for 10 mins at a predefined dose. Both inhaled nitric oxide and nebulized prostacyclin caused effective, selective, dose-dependent pulmonary vasodilation. Inhaled nitric oxide was able to abolish hypoxic pulmonary vasoconstriction when insufflated into the animals at a concentration of 50 ppm of nitrogen, but 100 ppm of nitric oxide had no further effect. Prostacyclin, at a dosage of 10 micrograms/min, showed maximum pulmonary vasodilation, which could not be further increased by doubling the dosage. However, prostacyclin produced less dilation than high doses of nitric oxide, and its maximum pulmonary vasodilation was comparable with that effect obtained under ventilation with 20 ppm of nitric oxide. CONCLUSIONS Both drugs selectively dilated the pulmonary vasculature in ventilated alveoli. Prostacyclin nebulization is an excellent tool to reduce pulmonary hypertension and to improve the ventilation/perfusion ratio. Prostacyclin nebulization can be used without the highly sophisticated technical equipment that is needed for controlled nitric oxide inhalation, and may therefore become a new, noninvasive therapeutic approach for treatment of adult respiratory distress syndrome in hospitals that cannot provide nitric oxide inhalation.
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Affiliation(s)
- M Booke
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0833, USA
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Tao W, Schroeder T, Bidani A, Cardenas VJ, Nguyen PD, Bradford DW, Traber DL, Zwischenberger JB. Improved gas exchange performance of the intravascular oxygenator by active blood mixing. ASAIO J 1994; 40:M527-32. [PMID: 8555572 DOI: 10.1097/00002480-199407000-00056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The intravascular oxygenator and carbon dioxide removal device (IVOX; CardioPulmonics, Salt Lake City, UT) has been shown to perform 30% of the gas exchange in animals and patients with acute respiratory failure. Among the factors that limit gas exchange is the mass transfer resistance in the blood phase. To determine if a reduction in mass transfer resistance by mixing venous blood can enhance the O2 transfer and CO2 removal by IVOX, a right atrium-pulmonary artery venovenous bypass circuit was used in sheep to model the adult vena cava. A size 9 IVOX (894 fibers with 0.41 m2 surface area, n = 5) was incorporated in the bypass circuit and the blood flow controlled by a roller pump ranging from 1 to 4 l/min. An intra-aortic balloon was placed near the shaft of the IVOX and pulsated at the rate adjusted to best improve CO2 removal (100-120 bpm). O2 transfer and CO2 removal were measured with balloon pulsation on and off at different flow rates. Results showed that blood mixing by pulsation of the balloon caused a 25-49% increase in O2 transfer by IVOX, and this increase remained relatively constant throughout the full flow range. CO2 removal was also increased by up to 35%, but at flows between 3.5 and 4 l/min, the effect of mixing was diminished. It is concluded that reduction in the mass transfer resistance by blood mixing improves gas exchange. Because O2 is more diffusion limited, it is more dependent upon mixing of blood for gas exchange than CO2. More design improvements to incorporate active mixing may further enhance the gas exchange performance of IVOX.
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Affiliation(s)
- W Tao
- Department of Surgery, University of Texas Medical Branch 77555-0528, USA
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