RESUMEN
OBJECTIVE: Many therapists are reluctant to conduct exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). Negative beliefs about the safety and tolerability of ERP are common, especially for harm-related OCD symptoms. The study examined the nature and frequency of ERP-related serious negative consequences (SNC) and therapist attitudes and experiences providing ERP for harm-related OCD. METHODS: An anonymous survey was completed by 277 therapists with experience treating OCD using ERP. Questions assessed clinical experiences of harm-related exposures, the nature of SNC, and concerns and clinical considerations regarding ERP. RESULTS: Therapist's willingness to treat harm-related OCD was high. SNCs were reported for 6 clients (per-client risk: adults 0.05%, youth 0.01%) and 13 therapists (per therapist risk 4.73%, therapist per-year risk 0.004%). Qualitative analysis identified themes relating to the conduct of treatment, specific exposure types, professional issues, and negative perceptions of ERP. CONCLUSION: SNC associated with ERP for OCD are rare and primarily represent unintended secondary consequences of OCD or misunderstandings regarding the process and rationale behind ERP. Improving access to ERP will require good communication with clients, families, and other professionals regarding the rationale and safety of ERP.
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Competencia Clínica , Terapia Cognitivo-Conductual/métodos , Conocimientos, Actitudes y Práctica en Salud , Terapia Implosiva/métodos , Trastorno Obsesivo Compulsivo/terapia , Adolescente , Adulto , Actitud , Emociones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastorno Obsesivo Compulsivo/psicología , Relaciones Médico-Paciente , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Trauma-informed care (TIC) initiatives in state child welfare agencies are receiving more attention, but little empirical evidence exists as to their efficacy. The purpose of this study was to assess changes in self-reported practices and perceptions of child welfare staff involved in a multifaceted, statewide TIC intervention. Ten child welfare offices were matched and randomized to an early or delayed cohort. Staff were surveyed at Time 1 prior to any intervention, Time 2 postintervention for Cohort 1, and Time 3 postintervention for Cohort 2. The survey covered six domains: trauma screening, case planning, mental health and family involvement, progress monitoring, collaboration, and perceptions of the state's overall system performance. Linear mixed modeling assessed the effect of the intervention. Cohort by time interaction was significant for three intervention targets. We demonstrate, using a rigorous study design, the mixed results of a multimodal intervention to improve trauma-informed attitudes, practices, and system performance. TIC initiatives must account for complex, dynamic contextual factors.
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Maltrato a los Niños/diagnóstico , Servicios de Protección Infantil/educación , Protección a la Infancia , Conocimientos, Actitudes y Práctica en Salud , Adulto , Niño , Maltrato a los Niños/psicología , Estudios de Cohortes , Estudios Cruzados , HumanosRESUMEN
In 2015, the Lancet Commission on Global Surgery (LCoGS) working groups developed a National Surgical, Obstetric, and Anesthesia Plan (NSOAP) framework to guide national surgical system development globally predicated on six data points (indicators) which can assess surgical systems. Zambia as well as other subSaharan Africa (SSA) countries have forged ahead in designing and implementing interventions based on LCoGS indicators collected to inform NSOAP. Concurrently, the Zambian team and others have recognized the need for rigorous scientific inquiry to assess and iteratively improve upon the NSOAP process and outputs. Based on the Zambian experience, as well as that of ours in Colombia, we have identified "core principles" through convergent works which inform a scientific framework through which NSOAP can be evaluated. We propose that when contextualized, participatory action research (PAR) and dissemination and implementation science are methodologies upon which a robust framework can be developed to achieving objective and iterative NSOAP evaluation, and ultimately universal health coverage as envisioned by the World Health Organization (WHO).
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Anestesia , África del Sur del Sahara , Atención a la Salud , Femenino , Humanos , Embarazo , ZambiaRESUMEN
The objective of this study was to compare structured case management (CM) to usual care (UC) for helping victims of child abuse and neglect (CAN) with mental disorders access evidence-based treatment (EBT). N=121 children and adolescents aged 4-17 with a history of CAN and a current mental disorder were recruited in three German states in a multi-center parallel group trial. They were randomly assigned, stratified by study site and level of psychosocial functioning, to receive CM additionally to UC or only UC. CM was delivered by trained professionals and volunteers, most of them affiliated to local child welfare agencies or NGOs. UC comprised child welfare services typically delivered in Germany. The primary outcome was EBT utilization after 6 months. Secondary outcome was the time until commencement of EBT. Outcomes were determined by semi-structured clinical interviews with assessors blinded to group allocation. Predictors of access to EBT and barriers to utilization of treatment were analyzed. The intent to treat analysis showed that after 6 months 23 of 60 participants recruited to CM (38%) and 19 of 61 participants recruited to UC (31%) were using EBT, χ2 (1, N=121)=0.689, p=.261. Female gender, out-of-home placement, and home state were significant predictors of access to EBT. Less than 40% of participants across both groups were successfully referred to EBT. Access to EBT seems to be in part due to system-level barriers, namely lack of implementation of EBT in community settings. TRIAL REGISTRATION: DRKS00003979 German Clinical Trials Register.
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Manejo de Caso , Maltrato a los Niños/psicología , Servicios de Salud del Niño/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Trastornos Mentales/terapia , Servicios de Salud Mental/estadística & datos numéricos , Adolescente , Niño , Maltrato a los Niños/terapia , Protección a la Infancia , Práctica Clínica Basada en la Evidencia , Femenino , Alemania , Humanos , Análisis de Intención de Tratar , Estimación de Kaplan-Meier , Masculino , Trastornos Mentales/etiología , Factores SexualesRESUMEN
Despite decades of research, visions of transforming neuropsychiatry through the development of brain imaging-based "growth charts" or "lab tests" have remained out of reach. In recent years, there is renewed enthusiasm about the prospect of achieving clinically useful tools capable of aiding the diagnosis and management of neuropsychiatric disorders. The present work explores the basis for this enthusiasm. We assert that there is no single advance that currently has the potential to drive the field of clinical brain imaging forward. Instead, there has been a constellation of advances that, if combined, could lead to the identification of objective brain imaging-based markers of illness. In particular, we focus on advances that are helping to (1) elucidate the research agenda for biological psychiatry (e.g., neuroscience focus, precision medicine), (2) shift research models for clinical brain imaging (e.g., big data exploration, standardization), (3) break down research silos (e.g., open science, calls for reproducibility and transparency), and (4) improve imaging technologies and methods. Although an arduous road remains ahead, these advances are repositioning the brain imaging community for long-term success.
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Encéfalo/diagnóstico por imagen , Neuroimagen/métodos , Neuropsiquiatría/métodos , Humanos , Neuroimagen/normas , Neuropsiquiatría/normasRESUMEN
BACKGROUND: Increased psychophysiological reactivity is a hallmark intermediate phenotype of posttraumatic stress disorder (PTSD). Individuals with PTSD exhibit greater skin conductance (SC) responses to trauma scripts than trauma survivors without PTSD. However, trauma scripts require time for development and cannot be easily used in a single visit. Thus, there is a need for a low-cost, easy-to-use, SC recording protocol for PTSD assessment. METHODS: Using a mobile device (eSense) connected to a portable tablet computer, we assessed SC reactivity to a standard trauma interview (STI) in 63 participants recruited from Grady Memorial Hospital in Atlanta, GA, approximately 1 year after trauma exposure. SC response (SCR) was calculated by subtracting the SC level (SCL) at the end of the baseline recording from the maximum SCL during the STI. RESULTS: SCL was significantly higher during the STI compared to baseline (P < .001), and individuals with PTSD showed significantly greater SCR than individuals without PTSD (P = .006). Logistic regression using SCR with PTSD diagnosis as the outcome showed an odds ratio of 1.76 (95% CI: 1.11-2.78). Lastly, higher SCR during the STI was also significantly associated with PTSD symptom total score controlling for demographics and trauma severity (b = 0.42, P = .001). CONCLUSIONS: The current study demonstrated feasibility of the use of a mobile device for assessing psychophysiological reactivity in those with PTSD. The use of this low-cost, easy-to-use mobile device to collect objective physiological data in concert with a STI can be easily disseminated in clinical and research settings.
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Respuesta Galvánica de la Piel/fisiología , Entrevista Psicológica/métodos , Aplicaciones Móviles , Monitoreo Ambulatorio/métodos , Trastornos por Estrés Postraumático/diagnóstico , Adulto , Estudios de Factibilidad , Femenino , Humanos , Masculino , Monitoreo Ambulatorio/instrumentaciónRESUMEN
Policymakers shape implementation and sustainment of evidence-based practices (EBPs), whether they are developing or responding to legislation and policies or negotiating public sector resource constraints. As part of a large mixed-method study, we conducted qualitative interviews with 24 policymakers involved in delivery of the same EBP in two U.S. states. We analyzed transcripts via open and focused coding techniques to identify the commonality, diversity, and complexity of implementation challenges; approaches to overcoming those challenges; and the importance of system-level contextual factors in ensuring successful implementation. Key findings centered on building support and leadership for EBPs; funding and contractual strategies; partnering with stakeholders; tackling challenges via proactive planning and problem solving; and the political, legal, and systemic pressures affecting EBP longevity. The policymaker perspectives offer guidance on nurturing system and organizational practice environments to achieve positive outcomes and for optimally addressing macro-level influences that bear upon the instantiation of EBPs in public sector child welfare systems.
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Maltrato a los Niños/prevención & control , Protección a la Infancia/estadística & datos numéricos , Práctica Clínica Basada en la Evidencia/organización & administración , Implementación de Plan de Salud , Planificación en Salud/organización & administración , Formulación de Políticas , Comités Consultivos , Niño , Conducta Cooperativa , Humanos , Relaciones Interinstitucionales , Estados UnidosRESUMEN
BACKGROUND: We examined the adequacy of pharmacotherapy and psychotherapy received by primary care patients with anxiety disorders over up to 5 years of follow-up. METHOD: Five hundred thirty-four primary care patients at 15 US sites, who screened positive for anxiety symptoms, were assessed for anxiety disorders. Those meeting anxiety disorder criteria were offered participation and interviewed again at six and 12 months postintake, and yearly thereafter for up to 5 years. We utilized existing definitions of appropriate pharmacotherapy and created definitions of potentially adequate psychotherapy/cognitive-behavioral therapy (CBT). RESULTS: At intake, of 534 primary care participants with anxiety disorders, 19% reported receiving appropriate pharmacotherapy and 14% potentially adequate CBT. Overall, 28% of participants reported receiving potentially adequate anxiety treatment, whether pharmacotherapy, psychotherapy, or both. Over up to five years of follow-up, appropriate pharmacotherapy was received by 60% and potentially adequate CBT by 36% of the sample. Examined together, 69% of participants received any potentially adequate treatment during the follow-up period. Over the course of follow-up, primary care patients with MDD, panic disorder with agoraphobia, and with medicaid/medicare were more likely to receive appropriate anxiety treatment. Ethnic minority members were less likely to receive potentially adequate care. CONCLUSIONS: Potentially adequate anxiety treatment was rarely received by primary care patients with anxiety disorders at intake. Encouragingly, rates improved over the course of the study. However, potentially adequate CBT remained much less utilized than pharmacotherapy and racial-ethnic minority members were less likely to received care, suggesting much room for improved dissemination of quality treatment.
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Ansiolíticos/uso terapéutico , Trastornos de Ansiedad/terapia , Actitud del Personal de Salud , Terapia Cognitivo-Conductual , Atención Primaria de Salud , Psicoterapia , Adulto , Agorafobia/diagnóstico , Agorafobia/psicología , Agorafobia/terapia , Ansiolíticos/efectos adversos , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/psicología , Comorbilidad , Trastorno Depresivo Mayor/diagnóstico , Trastorno Depresivo Mayor/psicología , Trastorno Depresivo Mayor/terapia , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , New England , Satisfacción del Paciente , Encuestas y CuestionariosRESUMEN
BACKGROUND: Obsessive compulsive disorder (OCD) is a disabling condition associated with significant personal and societal burdens. Despite the availability of efficacious treatments, in most cases, the disorder remains unrecognized and untreated. Lack of knowledge (i.e. poor mental health literacy, MHL) regarding OCD may be an impediment to seeking treatment. Therefore, the current study assessed public knowledge and beliefs about OCD and examined factors influencing MHL. METHODS: Five hundred seventy-seven US adults participated in a telephone survey. After hearing a vignette describing someone with OCD, participants' MHL for OCD was assessed across three domains as follows: recognition of OCD, knowledge and beliefs about available help, and concerns about being negatively evaluated for reporting symptoms. RESULTS: The majority of participants (90.9%) reported that the symptoms were a cause for concern and that the person in the vignette should seek professional help (89.5%). However, only one-third of respondents correctly labeled the disorder as OCD. More respondents were optimistic about the likely success of psychotherapy than medication, but primary care physicians were the most frequently reported source of professional help. Finally, less education, lower income, and being in an older cohort were associated with poorer recognition of OCD. CONCLUSIONS: When presented with brief vignettes describing a person with OCD, most community members can recognize the benefits of seeking professional help. However, recognition of the disorder and knowledge of treatment options can be improved.
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Conocimientos, Actitudes y Práctica en Salud , Alfabetización en Salud/estadística & datos numéricos , Trastorno Obsesivo Compulsivo , Adulto , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Terapia Cognitivo-Conductual , Escolaridad , Femenino , Conocimientos, Actitudes y Práctica en Salud/etnología , Humanos , Renta/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Trastorno Obsesivo Compulsivo/tratamiento farmacológico , Trastorno Obsesivo Compulsivo/terapia , Aceptación de la Atención de Salud , Estigma Social , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
OBJECTIVE: Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs. METHOD: Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion. RESULTS: Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors. CONCLUSIONS: There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.