Training Interprofessional Staff in Whole Health Clinical Care at the Veterans Health Administration.

Introduction: The Veterans Health Administration (VHA) initiated a system-wide redesign in 2011 toward a patient-centered approach called the Whole Health System (WHS) of care. Education of VHA clinical staff in WHS-informed care, Whole Health Clinical Care (WHCC), is one critical element of this redesign effort. At a minimum, WHCC education should address core competencies for clinicians and be considered satisfactory for learners. This is the first study to evaluate learner satisfaction and perceived achievement of course objectives in WHCC that incorporated active learning strategies. Method: A large VA Healthcare System developed an in-person workshop focused on WHCC that used multiple active learning activities. These activities included case presentations, role playing, experiential learning, and group discussion. Results: Sixty-two interprofessional staff attended the workshop in November 2019. Forty (64.50%) participants completed post-workshop surveys within 30 days. Data suggest participants were highly satisfied with the workshop and that they successfully met stated learning objectives. Conclusions: We call on VHA and private-sector hospitals to train clinical staff in WHCC that incorporates use of active learning strategies.

The relative association between individual difference variables and general psychotherapy outcome expectation in socially anxious individuals.

OBJECTIVE: Although patients' psychotherapy outcome expectation relates to their treatment outcome, little is known about correlates of this expectation. Moreover, the limited research has largely assessed convenience variables as correlates, with little replication and few examinations of the relative strength of associations between the correlates and outcome expectation. This clinical analogue study examined the relation between socially anxious undergraduates' (N = 178) characteristics and their general psychotherapy outcome expectation. We investigated characteristics supported as correlates in prior studies. METHODS: Data derived from a baseline assessment prior to a larger experiment. Participants' mean level of social anxiety was within 1 standard deviation of the mean of clinical, treatment-seeking samples, and 65.2% of the sample either had therapy experience or were actively considering it. RESULTS: Participants' general outcome expectation was significantly associated with positive beliefs about and intention to seek therapy. Multivariate regression models showed a positive association between psychological mindedness (B = .59, p < .001) and outcome expectation. Subgroup analyses indicated that for participants with prior therapy experience, greater satisfaction with that treatment (B = 5.26, p < .001) was associated with higher outcome expectation. CONCLUSION: Results are discussed with regard to their implications for treatment-seeking intentions and treatment planning.

Typologies of Violence Exposure and Cognitive Processing in Incarcerated Male Adolescents.

Incarcerated youth experience high rates of violence exposure (VE), cognitive processing (CP) deficits, and mental health (MH) problems. It is not clear whether VE combined with CP deficits are particularly salient risk factors for MH dysfunction. Male incarcerated youth offenders (n = 115) completed standardized self-reports of MH and VE. CP was measured with executive functioning tasks and academic assessments. Person-centered Ward's Squared Euclidian Distance cluster analysis was used to examine unique patterns of CP and VE. Cluster analysis defined five distinct profiles of MH functioning, CP, and VE rates within incarcerated adolescents. Two groups, with high rates of VE and CP deficits, showed high rates of MH problems. Linear techniques may obscure important differences within this population.

Clinician interventions and participant characteristics that foster adaptive patient expectations for psychotherapy and psychotherapeutic change.

Patients' expectations about the efficacy and nature of psychotherapy have long been considered important common treatment factors, and the empirical literature has largely supported this perspective. In this practice-oriented review, we examine the research on the association between patients' psychotherapy expectations and both adaptive treatment processes and outcomes. We also examine the research on specific psychotherapist interventions and patient and psychotherapist characteristics that influence the development of positive expectations for psychotherapy and psychotherapeutic change. The primary function of this review is to derive applied clinical strategies from the extant empirical literature in order to help clinicians in their attempts to address and influence their patients' psychotherapy-related expectations. Although the literature is not yet conclusive in supporting such strategies, we place the results in theoretical, clinical, and empirical contexts to suggest the most likely best practices at this time, and to stimulate further research on the expectation construct.

Expectations.

Patients' expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. In this article, we define outcome expectations and present assessment methods and clinical examples of outcome expectations. Our research review includes a comprehensive meta-analysis (N =8,016 patients across 46 independent samples) of the association between pretherapy or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d=.24, p<.001, indicating a small but significant positive effect of outcome expectations on adaptive treatment outcomes. We also provide a narrative review of mediators of the expectation-outcome link and patient factors that relate to their outcome expectations. Finally, we discuss limitations of the research base and offer therapeutic practices based on our findings.

Exercise treatment for bipolar disorder: potential mechanisms of action mediated through increased neurogenesis and decreased allostatic load.

Outcomes are frequently suboptimal for patients with bipolar disorder who are treated with pharmacotherapy alone. Adjunct exercise has the potential to substantially improve acute and long-term outcomes, although how exercise would improve the course of bipolar disorder needs to be elucidated. We propose that exercise may improve mood and functioning by increasing neurogenesis and reducing allostatic load. We review data suggesting that exercise increases levels of brain-derived neurotrophic factor, which in turn increases neurogenesis and decreases allostatic load. Exercise as a psychosocial adjunct for bipolar disorder should be assessed with rigorous randomized clinical trials.

RESEARCH: Cognitive rehabilitation for bipolar disorder: An open trial for employed patients with residual depressive symptoms.

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, individuals with bipolar disorder often continue to experience impairments in psychosocial functioning, particularly occupational functioning. Two determinants of psychosocial functioning of euthymic (neither fully depressed nor manic) individuals with bipolar disorder are residual depressive symptoms and cognitive impairment (i.e., difficulties with executive functioning, attention, and memory). The present study explored whether a new cognitive remediation (CR) treatment designed to treat residual depressive symptoms and, for the first time to the best of our knowledge, address cognitive impairment would be associated with improvement in psychosocial functioning in individuals with bipolar disorder. Following a neuropsychological and clinical assessment 18 individuals with DSM-IV bipolar disorder were treated with 14 individual sessions of CR. Results indicated that at the end of treatment, as well as at the 3-months follow-up, patients showed lower residual depressive symptoms, and increased occupational, as well as overall psychosocial functioning. Pretreatment neuropsychological impairment predicted treatment response. Improvements in executive functioning were associated with improvements in occupational functioning. These findings suggest that treating residual depressive symptoms and cognitive impairment may be an avenue to improving occupational and overall functioning in individuals with bipolar disorder.

Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: results from the STEP-BD study.

OBJECTIVE: Symptoms of bipolar disorder are increasingly recognized among children and adolescents, but little is known about the course of bipolar disorder among adults who experience childhood onset of symptoms. METHODS: We examined prospective outcomes during up to two years of naturalistic treatment among 3,658 adult bipolar I and II outpatients participating in a multicenter clinical effectiveness study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Age at illness onset was identified retrospectively by clinician assessment at study entry. RESULTS: Compared to patients with onset of mood symptoms after age 18 years (n = 1,187), those with onset before age 13 years (n = 1,068) experienced earlier recurrence of mood episodes after initial remission, fewer days of euthymia, and greater impairment in functioning and quality of life over the two-year follow-up. Outcomes for those with onset between age 13 and 18 years (n = 1,403) were generally intermediate between these two groups. CONCLUSION: Consistent with previous reports in smaller cohorts, adults with retrospectively obtained early-onset bipolar disorder appear to be at greater risk for recurrence, chronicity of mood symptoms, and functional impairment during prospective observation.

A brief review of antidepressant efficacy, effectiveness, indications, and usage for major depressive disorder.

OBJECTIVE: Antidepressants treat major depressive disorder (MDD) with the burden of associated side effects and difficulties with compliance. The purpose of this article is to review the efficacy and effectiveness of antidepressants for MDD. METHODS: The authors conducted a focused review of selected key issues and references relevant to the clinically relevant pharmacologic treatment of MDD. Principles of treatment are reviewed. Antidepressants reviewed include SSRIs, mixed norepinephrine or serotonin uptake inhibitors, dopamine or norepinephrine uptake inhibitors, norepinephrine uptake inhibitors, antidepressants with mixed properties, and monoamine oxidase inhibitors. Augmentation and psychotherapy strategies are reviewed. RESULTS: Antidepressant efficacy has been established in randomized clinical trials and effectiveness studies for acute and long-term treatment, but many patients do not achieve remission. Augmentation strategies and focused psychotherapy can be helpful. CONCLUSIONS: Antidepressants help most patients with MDD but some are resistant to treatment and have a difficult long-term course.