The Impact of Traumatic Stress, Social Support, and Substance Problems on Graduation Among Female Offenders in a Prescription Drug Court Program.

Trauma exposure and comorbid substance use are highly prevalent among female drug court participants. Despite the pervasiveness of the issue, few studies have investigated the impact of posttraumatic stress symptoms (PTSS) and nonmedical prescription drug use among this specific population. The present study examined the impact of posttraumatic stress, social support, and nonmedical prescription drug use on graduation outcomes among female participants in a specialized drug court program (N = 210). Participants either received motivational enhancement therapy/cognitive behavioral therapy (MET-CBT; N = 210) or both MET-CBT and Seeking Safety through intensive outpatient treatment (n = 109). The findings indicated that graduation was negatively correlated with posttraumatic stress, r = -.19, p = .007, d = 0.40; past 90-day nonmedical prescription painkiller, opiate, and analgesic use, r = -.19, p = .001, d = 0.44; tangible social support, r = -.24, p = < .001, d = 0.51; and past-month substance use problems, r = -.25, p < .001, d = .50. In addition, past-month substance use problems, OR = 0.84, 95% CI [0.72, 0.97]; PTSS, OR = 0.90, 95 % CI [0.82, 0.99]; and tangible social support, OR = 0.94, 95% CI [0.89, 0.98], were significant negative predictors of graduation. These results speak to the importance of facilitating the development of specialized evidence-based drug court interventions that target and improve comorbid substance use and trauma outcomes among female drug court participants to reduce recidivism and set a precedent for future research to replicate and expand upon these findings.

Predictors of Continuing Bonds Among Bereaved Adolescents.

This study examined the relationship between continuing bonds (CBs) among 50 bereaved youth (ages 11-17) and their bereaved adult caregivers, and predictors of CBs among youth. Results indicated there was not a significant relationship between caregiver CB and youth CB. However, significant relationships were found between youth bereavement symptomatology, their relationship to the deceased, and youth CB. Specifically, youth with higher levels of symptomatology and those who lost an immediate family member were more likely to maintain CBs. Results suggest the need for practitioners to incorporate grief symptomatology and CBs in assessment and intervention with bereaved youth.

Assessing Longitudinal Invariance of the Center for Epidemiologic Studies-Depression Scale Among Middle-Aged and Older Adults.

BACKGROUND AND PURPOSE: The longitudinal invariance of the Center for Epidemiologic Studies-Depression (CES-D) scale among middle-aged and older adults is unknown. This study examined the factorial invariance of the CES-D scale in a large cohort of community-based adults longitudinally. METHODS: 1,204 participants completed the 20-item CES-D scale at 4 time points 1 year apart. Structural equation modeling was used to identify best fitting model using longitudinal data at baseline and at 1-, 2-, and 3-year follow-up. RESULTS: The 4-factor model showed partial invariance over 3 years. Two of the 6 noninvariant items were consistently noninvariant at the 3 follow-up points. CONCLUSION: Special consideration should be given to these 2 items when using the CES-D scale in healthy adults (45-75 years old).

The Role of Conflict Identification and Management in Sustaining Community Collaboration: Report on a Four-Year Exploratory Study.

Community collaboration has become increasingly common in behavioral health services. Conflict is likely to occur in any community coalition bringing together organizations with differing mandates, missions, and histories. However, research on how coalitions identify and handle conflict, and on the impact of conflict on sustainability is scarce. An exploratory study examined conflict in two federally funded children's "systems of care" using site visits and concept mapping to describe differences in how sites conceptualize and respond to conflict. Results suggest that unacknowledged and unaddressed conflict can negatively affect the development and sustainability of sites, and that focusing on cooperation may, paradoxically, make it more difficult to acknowledge conflict and to implement conflict transformation processes. Implications for behavioral health administrators are discussed, including potential interventions that could address these issues.

Symptom severity, social supports, coping styles, and quality of life among individuals' diagnosed with Ménierè's disease.

OBJECTIVES: To (1) examine the quality of life of individuals with Ménierè's disease in relation to symptom severity, social supports, and coping styles and (2) develop a prediction model to identify factors most strongly associated with quality of life. METHODS: Data were collected using a web-based survey that included previously developed and validated measures (i.e. SF-12, Dizziness Handicap Inventory, Hearing Handicap Inventory for Elderly Screening Version, Iowa Tinnitus Handicap Questionnaire, Interpersonal Support Evaluation List, Brief COPES, Lehman's Quality of Life). Ninety-five individuals with Ménierè's disease who were members of one of five online Ménierè's disease support groups responded to the survey. RESULTS: The findings indicated that symptom severity was negatively associated with patients' quality of life, social supports were positively associated with quality of life, and the use of negative coping styles (e.g. substance use, blaming) was negatively associated with quality of life. Four predictors (i.e. SF-12 mental health, dizziness severity, self-esteem support, and negative coping styles) accounted for 62% of the variance in quality of life. DISCUSSION: The findings suggest that the factors associated with the quality of life of patients with Ménierè's disease are similar to those reported in the literature among patients with other chronic illnesses. The results also suggested that emphasis on psychosocial factors may be an important aspect of a comprehensive treatment intervention for individuals with Ménierè's disease.

An Exploratory Study of Conflict and Its Management in Systems of Care for Children with Mental, Emotional, or Behavioral Problems and Their Families.

Since 1993, the Substance Abuse and Mental Health Services Administration has invested more than $1 billion establishing systems of care (SOC) in over 173 local communities to provide services to children with mental, emotional, and behavioral problems and their families. The SOC model requires that effective partnerships be developed between parents and professionals and also among different service sectors and agencies. To date, there has been no systematic examination of these interagency partnerships associated with the presence of conflict and its management. This paper reports the findings from a survey of the members of the governing boards of currently funded and graduated SOC sites related to interorganizational conflict. The results indicated that conflict was common in SOC regardless of the stage of the system's development. The most common types of conflict included incompatible goals, interpersonal relationships, and overlapping authority. When conflict occurred, a number of management efforts were used including analyzing the conflict and developing a strategy to deal with it and dealing with the conflict behind the scenes. Suggestions are provided for identifying and managing conflict.

The Psychometric Properties of the Simple Screening Instrument for Substance Abuse.

The Simple Screening Instrument for Substance Abuse (SSI-SA) is gaining widespread use as a self-report measure of substance abuse; yet, little information exists regarding the instrument's psychometric properties. This study examined the SSI's psychometric properties within a population of 6,664 adult Medicaid enrollees in Florida, who responded to a survey conducted as part of a statewide evaluation of Medicaid services. The SSI-SA had excellent internal consistency (.85). Evidence of the SSI's validity was strong; SSI-SA scores distinguished among individuals with and without substance abuse needs and were significantly correlated with a measure of functioning in daily living. Using the recommended SSI-SA cutoff score of 4 or higher to indicate the presence of a substance abuse problem, the SSI-SA had respectable sensitivity (.82) and specificity (.90).

Impact of mental health problems on self-perceived oral health needs in a Medicaid population.

The purpose of this study was to examine the prevalence of self-perceived oral health needs among Medicaid-enrolled adults with and without mental health problems and to identify factors predictive of enrollees' perceived oral health needs. The study involved a secondary analysis of 1,721 respondents to the Florida Health Services Survey. Contrary to the previous research, the findings from this study indicated that respondents with mental health problems (52.9%) did not differ significantly in their dental needs compared to those who did not have mental health problems (49.3%). The results from a logistic regression suggested that after controlling for demographic characteristics, substance abuse problems and functional needs increased the likelihood of self-reported oral health needs, whereas the receipt of Supplemental Security Income (SSI) was associated with decreased dental needs. The prevalence of unmet dental needs among these respondents (i.e., 23%) supported the conclusion that a significant gap exists in the accessibility of oral health services among this population.

A clustering method to identify who benefits most from the treatment group in clinical trials.

In randomized controlled trials (RCTs), the most compelling need is to determine whether the treatment condition was more effective than control. However, it is generally recognized that not all participants in the treatment group of most clinical trials benefit equally. While subgroup analyses are often used to compare treatment effectiveness across pre-determined subgroups categorized by patient characteristics, methods to empirically identify naturally occurring clusters of persons who benefit most from the treatment group have rarely been implemented. This article provides a modeling framework to accomplish this important task. Utilizing information about individuals from the treatment group who had poor outcomes, the present study proposes an a priori clustering strategy that classifies the individuals with initially good outcomes in the treatment group into: (a) group GE (good outcome, effective), the latent subgroup of individuals for whom the treatment is likely to be effective and (b) group GI (good outcome, ineffective), the latent subgroup of individuals for whom the treatment is not likely to be effective. The method is illustrated through a re-analysis of a publically available data set from the National Institute on Drug Abuse. The RCT examines the effectiveness of motivational enhancement therapy from 461 outpatients with substance abuse problems. The proposed method identified latent subgroups GE and GI, and the comparison between the two groups revealed several significantly different and informative characteristics even though both subgroups had good outcomes during the immediate post-therapy period. As a diagnostic means utilizing out-of-sample forecasting performance, the present study compared the relapse rates during the long-term follow-up period for the two subgroups. As expected, group GI, composed of individuals for whom the treatment was hypothesized to be ineffective, had a significantly higher relapse rate than group GE (63% vs. 27%; χ2 = 9.99, p-value = .002).

Community characteristics and implementation factors associated with effective systems of care.

How are characteristics of communities associated with the implementation of the principles of systems of care (SOC)? This study uses multilevel modeling with a stratified random sample (N = 225) of US counties to explore community-level predictors of the implementation factors of the System of Care Implementation Survey. A model composed of community-level social indicators fits well with 5 of 14 factors identified as relevant for effective SOCs. As hypothesized, community disadvantage was negatively and residential stability positively associated with the implementation of SOC principles. Designation as a mental health professional shortage area was positively related to some implementation scores, as was the percentage of minority residents, while rurality was not significantly associated with any of the factors. Given the limitations of the study, the results should be interpreted with caution, but suggest that further research is merited to clarify these relationships that could inform efforts directed at promoting SOCs.

Multilevel confirmatory factor analysis of the Systems of Care Implementation Survey (SOCIS).

A major impediment to obtaining national information on systems of care implementation has been the lack of a psychometrically sound large-scale survey instrument. The present study provided information on the factorial and concurrent validity of the Systems of Care Implementation Survey scales. Multilevel confirmatory factor analysis and multilevel regression analysis were used to test these indicators of internal and external validity. Two hundred twenty-five counties were randomly selected and stratified by population size and poverty level. Nine hundred ten informants responded to the survey questionnaire, M = 4.04 informants per county (SD = 3.17). Results indicated that all models had at least adequate fit to the data, with nine of the 14 factor models having excellent fit. Overall, 11 of the 14 factors had some indication that receiving federal funding to create systems of care was associated with higher scores on the factors. Implications for future research were discussed.

Development of a measure to assess the implementation of children's systems of care: the Systems of Care Implementation Survey (SOCIS).

The children's system of care framework has been extensively implemented in the U.S. Since its inception in 1993, the Comprehensive Community Mental Health Services for Children and Their Families Program has invested in excess of $1 billion supporting the development of systems of care in 164 grantee sites across the country. Despite these efforts to implement children's systems of care nationally, little is known about the extent to which the principles and values actually have been put into practice outside of the funded grantee sites. This paper describes the development of the Systems of Care Implementation Survey, a measure designed specifically for the first ever study assessing the level of implementation of factors contributing to effective children's systems of care in a nationally representative sample of counties throughout the U.S.

Levels of system of care implementation: a national study.

The results of a survey to measure the implementation of the systems of care (SOC) approach in a nationally representative sample of counties are presented. The results from 910 informants within 225 counties reveal a moderate level of implementation of SOC factors, with the level of poverty and population size influencing implementation. Furthermore, mental health informants generally tended to rate the implementation of systems of care greater than administrators associated with the school system, other family serving agency personnel or family members. Family members and school personnel tended to rate the implementation lowest, while staff from the other child serving agencies tended to rate the implementation closer to mental health administrators. A quarter of the counties (26%) surveyed rated themselves as having adequate levels of implementation on 11 or more of the 14 factors, while 75% rated themselves as having adequate levels of implementation on six or more of the 14 factors measured. Implications for federal policies regarding systems of care implementation are discussed.

Adherence to practice guidelines, clinical outcomes, and costs among Medicaid enrollees with severe mental illnesses.

The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.

The psychometric properties of the Colorado Symptom Index.

The Colorado Symptom Index (CSI: Shern et al. 1994, Milbank Quart 72:123-148) is widely used in research as a self-report measure of psychiatric symptomatology, yet little information exists regarding the scale's psychometric properties. Additionally, the CSI has no cut-off score denoting the need for further psychiatric assessment. This study examined the CSI's psychometric properties and established a cut-off score. Analyses were based on 3,874 adult Florida Medicaid respondents. The CSI had excellent internal consistency (.92) and test-retest reliability (.71). Evidence of the CSI's validity was strong; CSI scores distinguished among individuals with and without mental health services needs and were significantly correlated with functioning. Results using a contrasting groups approach indicate that 30 is a reasonable "clinical" cut-off score. At this score, the CSI had respectable sensitivity (.76) and specificity (.68) and a ROC curve analysis suggests that the CSI is "fair to good" discriminator of individuals with psychiatric disabilities.

Medicaid managed care and the distribution of societal costs for persons with severe mental illness.

OBJECTIVE: Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers. METHOD: Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences. RESULTS: Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care. CONCLUSIONS: Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.

Predictors of enrollees' satisfaction with a county-sponsored indigent health care plan.

This article summarizes the findings from a study examining the predictors of satisfaction among individuals enrolled in a county-sponsored indigent health care plan. Mail survey procedures were used to obtain information from enrollees regarding their satisfaction with the health care plan, as well as enrollees' demographics, health care status, and trust in their providers. Results of a stepwise regression model developed using a random half of the respondents revealed enrollees' trust in health care providers was the strongest predictor of general satisfaction, followed by perception of change in health status, and age. The model explained 49% of the variance and demonstrated little shrinkage when cross-validated on the remaining half of the respondents. Trust in health care providers, followed by perception of change in health status also emerged as the strongest predictors of enrollees' satisfaction with freedom of choice.

Predictors of emotional well-being in at-risk adolescent girls: developing preventive intervention strategies.

This article examines the degree to which various demographic characteristics, personality traits, and environmental factors are associated with overall emotional well-being of 125 adolescent girls whose mothers were involved in welfare reform. Daughters participated in a 4-year, mixed method study and annually completed a structured interview protocol and a sub-group also completed a qualitative interview. The quantitative findings from the study suggest that daughters having an internal locus of control, experiencing fewer negative life events, and reporting stronger parental and teacher social support had enhanced emotional well-being over the 4-year study compared to daughters without these factors. The findings were further elaborated with examples from qualitative interviews conducted with the daughters. The findings were used to propose prevention activities using a tertiary mental health preventive intervention framework.

Understanding the findings of resilience-related research for fostering the development of African American adolescents.

African American youth face a number of challenges to prosocial development that the majority of American youth never encounter. Despite this, the research clearly documents that African American youth often are resilient in the face of these challenges. This article explores various factors associated with resilience in African American children and their implications for practitioners. An ecologic framework described by Bronfenbrenner is used as an organizing framework for understanding interventions at the micro-, mezzo-, and exo-system levels. In this article, the importance of identity formation, maintenance of social networks, and exposure to safe and supportive environments is expressed in conjunction with recommendations for practitioners. Practitioners are encouraged to stress the promotion of ethnic and racial identity and self-efficacy with the youth and their family and the involvement of the youth and family in meaningful activities through local community centers, schools, churches, and other organizations serving youth. A case study of an African American girl, from age 16 into adulthood and motherhood, is presented to illustrate the interplay between protective and risk factors.

Evaluation of a summer research institute in behavioral health for undergraduate students.

Because of the need for additional researchers in the interdisciplinary field of behavioral health services research, the Florida Mental Health Institute at the University of South Florida developed and pilot tested a summer research institute for undergraduate students. Participants completed a 6-week program in which they developed a research project with a mentor and participated in a research seminar. The long-term objectives of the program were to attract promising students to the field and encourage them to pursue careers in behavioral health services research; short-term goals of the program were to strengthen participants' research skills and knowledge, provide an intensive and enjoyable learning experience, and positively impact participants' intentions to pursue graduate education in behavioral health. These goals were evaluated using a pre-post design with 6-month follow-up. Findings suggested that short-term goals were met. Suggestions for future improvements and implementation at other research settings are discussed.