The relationship between uncertainty in illness and psychological adjustment to chronic illness.

Using Mishel's Uncertainty in illness theory, this integrative review sought to identify how uncertainty in illness and psychological adjustment to illness are associated with chronic illness to guide development of interventions to support psychological adjustment. A search was conducted via EBSCOHost to answer the question "What is the relationship between uncertainty in illness and psychological adjustment to chronic illness?" Two key factors were identified as having an impact on psychological adjustment to chronic illness in the presence of uncertainty in illness including uncertainty appraisal and the type of coping strategies used in response to the appraisal. Individuals with a chronic illness diagnosis are more likely to experience increased levels of uncertainty in illness and decreased psychological adjustment to illness. A better understanding of these two concepts is important to augment and or guide the development of interventions to support psychological adjustment.

Sex Differences, Age, and Burn Size Contribute to Risk of PTSD and Depression After Burn Injury.

The prevalence of psychological symptoms in burn survivors has been well documented; however, the role of biological sex requires further investigation. This study explored sex differences among burn survivors and examined the impact of sex, age, and total body surface area (TBSA) of the burn injury on (1) the risk of developing PTSD and depression and, subsequently, (2) the influence of initial risk on symptom outcomes 30 days post-injury. Participants included 374 adult patients enrolled in the Burn Behavioral Health program at a regional Burn Center. T-tests and chi-square tests were conducted to determine differences between sexes on outcome measures. A path analysis was conducted to evaluate relationships between variables of interest. Findings revealed significant sex discrepancies in risk and symptom outcomes. Compared to men, women reported greater total risk scores of developing PTSD and depression (p = .005) early after their burn injury. A subscale analysis showed that women reported greater risk scores on depression (p < .001), but not on PTSD. Women did not report higher depression scores 30 days post-injury compared to men but did report higher PTSD scores than men (p = .020). When sex, age, and TBSA were included in a path analysis, female sex (p=.001), younger age (p<.001), and larger TBSA of the burn injury (p=.024) were associated with greater risk. Additionally, risk scores significantly predicted PTSD (p<.001) and depression (p<.001) symptoms 30 days post-injury. Our research shows how sex, age, and TBSA affect the risk of PTSD and depression among burn survivors. It underscores the importance of accounting for sex and age differences in mental health risk, especially in women and younger patients. This emphasizes the urgency of early screening and intervention.

Mental health symptoms and engagement in a stepped-care mental health service among patients with a violent versus nonviolent injury.

BACKGROUND: Few studies have examined mental health symptom trajectories and engagement in mental health follow-up in relation to mechanism of injury. This study examined differences in engagement between survivors of nonviolent and violent injury in the Trauma Resilience and Recovery Program (TRRP), a stepped-care, technology-enhanced model that provides evidence-based mental health screening and treatment to patients admitted to our Level I trauma service. METHODS: This study analyzed data from 2,527 adults enrolled in TRRP at hospital bedside between 2018 and 2022, including 398 patients (16%) with a violent injury and 2,129 patients (84%) with a nonviolent injury. Bivariate and hierarchical logistic regression analyses examined relations between injury type (violent vs. nonviolent) engagement in TRRP and mental health symptoms at 30 day follow-up. RESULTS: Engagement in services at bedside was similar across survivors of violent and nonviolent traumatic injury. Patients with violent injury had higher levels of posttraumatic stress disorder and depressive symptoms 30 days postinjury but were less likely to engage in mental health screening. Among patients who screened positive for posttraumatic stress disorder and depression, patients with violent injury were more likely to accept treatment referrals. CONCLUSION: Patients with a violent traumatic injury have higher levels of mental health needs yet face greater barriers to accessing mental health services following their injury relative to those with a nonviolent injury. Effective strategies are needed to ensure continuity of care and access to mental health care to promote resilience and emotional and functional recovery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Social support in relation to posttraumatic stress disorder symptoms among patients with violent versus nonviolent injury.

OBJECTIVE: Violent injuries have become increasingly more common in the United States. Individuals experiencing violent injury are at increased risk for the development of posttraumatic stress disorder (PTSD) as compared to those experiencing nonviolent injury. Social support is touted as a protective factor against various psychiatric symptoms (i.e., PTSD), though little is known about the relation between PTSD symptoms and social support in traumatic injury populations. The aims of the present paper were twofold: (1) examine the prevalence of PTSD as a function of injury type (2) explore differences in levels of social support as a function of injury type and (3) explore the association between injury type and later PTSD symptoms as moderated by baseline social support. METHOD: Participants were 553 adults from a level-one trauma center in the Southeast United States who experienced a violent injury or nonviolent injury and completed measures of social support at baseline as well as PTSD symptoms at the 30-day follow-up timepoint. The study utilized data from both the baseline timepoint (i.e., upon admission to the trauma surgery unit), as well as a 30-day follow-up timepoint. RESULTS: Results demonstrated that those endorsing nonviolent injury reported lower levels of social support and PTSD symptoms. Social support predicted later PTSD symptoms until injury type was included as a covariate in the model. Social support did not moderate the relationship between injury type and later PTSD symptoms. CONCLUSIONS: Findings highlight the interrelatedness of key risk variables (i.e., injury type) with protective factors in influencing the trajectory of psychopathology postinjury. Violence intervention and interruption programs may have the capacity to fill patient needs when social support networks are insufficient. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Behavioral Health Screening and Follow-Up Services in Pediatric Trauma Centers Across the United States.

OBJECTIVE: Over 120,000 U.S. children are hospitalized for traumatic injury annually, a major risk factor for behavioral health problems such as acute/posttraumatic stress disorder (PTSD) and depression. Pediatric trauma centers (PTCs) are well positioned to address the recent mandate by the American College of Surgeons Committee on Trauma to screen and refer for behavioral health symptoms. However, most PTCs do not provide screening or intervention, or use varying approaches. The objective of this mixed-methods study was to assess PTCs' availability of behavioral health resources and identify barriers and facilitators to service implementation following pediatric traumatic injury (PTI). METHODS: Survey data were collected from 83 Level I (75%) and Level II (25%) PTC program managers and coordinators across 36 states. Semistructured, qualitative interviews with participants (N = 24) assessed the feasibility of implementing behavioral health education, screening, and treatment for PTI patients and caregivers. RESULTS: Roughly half of centers provide behavioral health screening, predominantly administered by nurses for acute stress/PTSD. Themes from qualitative interviews suggest that (1) service provision varies by behavioral health condition, resource, delivery method, and provider; (2) centers are enthusiastic about service implementation including screening, inpatient brief interventions, and follow-up assessment; but (3) require training and lack staff, time, and funding to implement services. CONCLUSIONS: Sustainable, scalable, evidence-based service models are needed to assess behavioral health symptoms after PTI. Leadership investment is needed for successful implementation. Technology-enhanced, stepped-care approaches seem feasible and acceptable to PTCs to ensure the availability of personalized care while addressing barriers to sustainability.

Implementation of a Stepped Care Program to Address Emotional Recovery among Traumatic Injury Patients.

BACKGROUND: Annually, over 600,000 adults served in US trauma centers (≥20%) develop posttraumatic stress disorder (PTSD) and/or depression in the first year after injury. American College of Surgeons guidelines include screening and addressing mental health recovery in trauma centers. Yet, many trauma centers do not monitor and address mental health recovery, and it is a priority to learn how to implement evidence-informed mental health programs in trauma centers. STUDY DESIGN: This report describes our application of the Exploration, Preparation, Implementation, Sustainment model to implement the Trauma Resilience and Recovery Program (TRRP) in 3 Level I and II trauma centers to address patients' mental health needs. TRRP is a scalable and sustainable stepped model of care-one of the few in the US-that provides early intervention and direct services after traumatic injury. RESULTS: Trauma centers are well positioned to accelerate patients' mental health recovery via early identification, education, screening, and referrals to mental health agencies that provide best-practice care. We found that TRRP was acceptable to the 3 partnering trauma centers we studied. Early engagement of patient, provider, and hospital administration stakeholders enhanced buy-in during the early stages of the implementation process and promoted sustainability. Active processes to support monitoring, evaluation, and adaptation were critical. CONCLUSIONS: Our work demonstrates the feasibility of implementing and adapting TRRP, a cost-efficient and sustainable stepped care intervention, in Level I and II trauma centers. Several factors should be carefully considered by trauma centers seeking to integrate behavioral health interventions into their trauma program.

Implementation of a stepped care program to address posttraumatic stress disorder and depression in a Level II trauma center.

BACKGROUND: The Trauma Resilience and Recovery Program (TRRP) is a technology enhanced model of care that includes education, screening, and service referrals to address posttraumatic stress disorder and depression following traumatic injury. TRRP has shown high rates of engagement at a Level I trauma center, but Level II centers have fewer resources and face more challenges to addressing patients' mental health needs. METHODS: We utilized clinical administrative data to examine engagement in TRRP in a Level II trauma center with 816 adult trauma activation patients. RESULTS: Most patients (86%) enrolled in TRRP, but only 30% completed screens during a 30-day follow-up call. Three-quarters of patients who endorsed clinically significant symptoms accepted treatment recommendations/referrals. CONCLUSIONS: Engagement at each step of the model was lower than previously reported in a Level I center. Differences likely correspond to lower rates of mental health symptoms in the trauma patients at this setting. We discuss program adaptations that may be needed to improve patient engagement.

Assessment of Traumatic Stress Symptoms During the Acute Posttrauma Period.

A substantial majority of adults in the United States will experience a potentially traumatic event (PTE) in their lifetime. A considerable proportion of those individuals will go on to develop posttraumatic stress disorder (PTSD). Distinguishing between those who will develop PTSD and those who will recover, however, remains as a challenge to the field. Recent work has pointed to the increased potential of identifying individuals at greatest risk for PTSD through repeated assessment during the acute posttrauma period, the 30-day period after the PTE. Obtaining the necessary data during this period, however, has proven to be a challenge. Technological innovations such as personal mobile devices and wearable passive sensors have given the field new tools to capture nuanced in vivo changes indicative of recovery or nonrecovery. Despite their potential, there are numerous points for clinicians and research teams to consider when implementing these technologies into acute posttrauma care. The limitations of this work and considerations for future research in the use of technology during the acute posttrauma period are discussed.

Longitudinal and bidirectional associations between posttraumatic stress disorder and emotional support among disaster-affected men and women.

Research has demonstrated a negative association between social support and symptoms of posttraumatic stress disorder (PTSD). This has been interpreted as a protective influence of social support against the development of posttraumatic stress symptoms (PTSS). Research on the opposite association is more limited, but findings suggest that PTSS have a negative impact on social support. There is conflicting evidence that these effects are moderated by gender. Few studies have assessed both associations and gender moderation in a postdisaster context. We examined the longitudinal and bidirectional effects of emotional support and PTSS and whether gender moderates these effects among U.S. survivors of the 2017-2018 season. Participants (N = 1,347) were assessed at four time points over 1 year. Bidirectional effects were assessed using cross-lagged, autoregressive analyses with the combined sample (Model 1) and grouped by gender (Model 2) to assess gender moderation. The results supported small bidirectional negative effects of social support and PTSS on one another from one assessment point (e.g. Wave 1) to the subsequent point (e.g., Wave 2) for all waves, ßs = -.07-.15, p < .001-p = .040. Multigroup analyses suggested the effects were not significantly different by gender. Overall, the results suggest that social support and PTSS may mutually diminish one another. Such effects may result in a positive or negative cascade wherein high PTSS may lead to lower social support and, therefore, even higher PTSS and vice versa. These findings support the importance of including social support in interventions to promote PTSS prevention and recovery.

A Distinction Without a Difference? A Multi-Method Approach to Understanding PTSD and Depression Symptom Overlap Among Disaster-Exposed Adolescents.

Among adolescents exposed to trauma, posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur. Despite the prevalence of comorbidity, the question of how PTSD and MDD are related and appropriate conceptual models for understanding their linkage in adolescence remains unclear. This study applies a multi-methodological approach to advance conceptual and theoretical understanding of the overlap between PTSD and MDD diagnoses/symptoms. We tested three methodological approaches with three distinct theoretical underpinnings on the structure of each disorder proposed in the literature: confirmatory factor analysis (CFA) with dimensional constructs, latent class analysis (LCA) with person-based categorical constructs, and network analysis with symptom-to-symptom associations. Across the three different analytical approaches, there was a significant overlap between PTSD and MDD. Overall, there was no compelling evidence for distinct boundaries between disorders among trauma-exposed adolescents. Instead, we found considerable evidence that the typical latent-construct-based conceptualizations, whether categorical or dimensional, may need revision.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery.

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Differences in mental health engagement and follow-up among Black and White patients after traumatic injury.

BACKGROUND: Severe injury necessitating hospitalization is experienced by nearly three million US adults annually. Posttraumatic stress disorder and depression are prevalent clinical outcomes. The mechanisms by which programs equitably promote mental health recovery among trauma-exposed patients are understudied. We evaluated clinical outcomes and engagement among a cohort of Black and White patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate mental health recovery after traumatic injury. METHODS: Trauma Resilience and Recovery Program is a four-step model that includes (1) bedside psychoeducation about mental health recovery following traumatic injury, (2) a text-messaging symptom tracking system, (3) a 30-day postinjury mental health screen, and (4) referrals to mental health services. Data describe 1,550 patients enrolled in TRRP within a Level I trauma center ( Mage = 40.86; SD, 17.32), 611 of whom identified as Black (74.5% male) and 939 of whom identified as White (67.7% male). RESULTS: Enrollment in TRRP was nearly universal (97.9%) regardless of race or injury mechanism. Enrollment and usage of the text-message system were statistically similar between Black (35.7%) and White patients (39.5%). Trauma Resilience and Recovery Program reengaged Black and White patients at a similar rate at the 30-day postinjury follow-up. However, Black patients were more likely to report peritraumatic distress at the bedside and clinical elevations in posttraumatic stress disorder and depression on the 30-day screen. Referrals were more likely to be accepted by Black patients relative to White patients with clinically elevated symptoms. CONCLUSION: Enrollment and engagement were comparable among Black and White patients served by TRRP. Data provide preliminary evidence to suggest that TRRP is feasible and acceptable and engages patients in mental health follow-up equitably. However, research that includes careful measurement of social determinants of health and long-term follow-up examining initiation, completion, and benefit from treatment is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury.

Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.

Assessing service quality and access in trauma centers through behavioral health screening, education, and treatment after pediatric injury.

BACKGROUND: Over 120,000 U.S. children are hospitalized annually for traumatic injury, with approximately 20% developing acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or depression. The ACS COT recommends that trauma centers address emotional recovery after injury; however, few pediatric trauma centers (PTCs) assess behavioral health symptoms. This study describes results from a survey with PTC providers assessing the landscape of behavioral health screening, education, and treatment. METHODS: Trauma program leaders from 83 US Level I and II trauma centers across 36 states completed a survey assessing center characteristics and decision-making, availability, and perceptions of behavioral health resources. RESULTS: Nearly half (46%) of centers provide behavioral health screens for pediatric patients, and 18% screen family members, with screens mostly conducted by nurses or social workers for ASD or PTSD. Two-thirds provide child behavioral health education and 47% provide education to caregivers/family. Two-thirds provide treatment connections, typically via referrals or outpatient clinics. Behavioral health screening, education, and treatment connections were rated as very important (M > 8.5/10), with higher ratings for the importance of screening children versus caregivers. Child maltreatment (59%), observed patient distress (53%), child substance use (52%), injury mechanism (42%) and severity (42%) were prioritized in screening decision-making. CONCLUSION: Service provision varies by method, resource, and provider, highlighting the lack of a roadmap for centers to provide behavioral health services. Adoption of universal education and screening procedures in PTCs is crucial to increase access to services for injured children and caregivers. PTCs are well-positioned to offer these services. LEVEL OF EVIDENCE: Level II.

Prediction of posttraumatic stress and depression one-month post-injury: A comparison of two screening instruments.

OBJECTIVE: To examine the combined and individual utility of 2 screening tools in prediction of depression and PTSD one-month post traumatic injury. METHOD: 484 Level I Trauma Center patients were administered the Peritraumatic Distress Inventory (PDI) and Injured Trauma Survivor Screen (ITSS). Approximately 30 days post-injury, patients completed the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) and Patient Health Questionnaire (PHQ-8). RESULTS: Receiver operating characteristic curve (ROC) curves for the PDI suggested a cutoff score of 17.5 predicting PTSD (Sensitivity = 70%; Specificity = 62%) and depression (Sensitivity = 74%; Specificity = 64%). For the ITSS, ROC curves suggested a cutoff score of 1.5 to predict PTSD (Sensitivity = 72%; Specificity = 60%) and depression (Sensitivity = 67%; Specificity = 62%). Inclusion of both instruments in regression analyses accounted for 2.4%-6.8% greater variance than 1 measure alone in predicting PCL-5 and PHQ-8 scores. CONCLUSIONS: The ITSS and PDI each demonstrated significant clinical utility in practice. Use of both measures, versus either alone, likely does not produce sufficient added clinical benefit. Follow-up screening and/or ongoing symptom monitoring is recommended as an adjunct to brief bedside screening. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

HOME DM-BAT: home-based diabetes-modified behavioral activation treatment for low-income seniors with type 2 diabetes-study protocol for a randomized controlled trial.

BACKGROUND: About 13% of African Americans and 13% of Hispanics have diabetes, compared to 8% of non-Hispanic Whites (NHWs). This is more pronounced in the elderly where about 25-30% of those aged 65 and older have diabetes. Studies have found associations between social determinants of health (SDoH) and increased incidence, prevalence, and burden of diabetes; however, few interventions have accounted for the context in which the elderly live by addressing SDoH. Specifically, psychosocial factors (such as cognitive dysfunction, functional impairment, and social isolation) impacting this population may be under-addressed due to numerous medical concerns addressed during the clinical visit. The long-term goal of the project is to identify strategies to improve glycemic control and reduce diabetes complications and mortality in African Americans and Hispanics/Latinos with type 2 diabetes. METHODS: This is a 5-year prospective, randomized clinical trial, which will test the effectiveness of a home-based diabetes-modified behavioral activation treatment for low-income, minority seniors with type 2 diabetes mellitus (T2DM) (HOME DM-BAT). Two hundred, aged 65 and older and with an HbA1c ≥8%, will be randomized into one of two groups: (1) an intervention using in-home, nurse telephone-delivered diabetes education, and behavioral activation or (2) a usual care group using in-home, nurse telephone-delivered, health education/supportive therapy. Participants will be followed for 12 months to ascertain the effect of the intervention on glycemic control, blood pressure, and low-density lipoprotein (LDL) cholesterol. The primary hypothesis is low-income, minority seniors with poorly controlled type 2 diabetes randomized to HOME DM-BAT will have significantly greater improvements in clinical outcomes at 12 months of follow-up compared to usual care. DISCUSSION: Results from this study will provide important insight into the effectiveness of a home-based diabetes-modified behavioral activation treatment for low-income, minority seniors with uncontrolled type 2 diabetes mellitus and inform strategies to improve glycemic control and reduce diabetes complications in minority elderly with T2DM. TRIAL REGISTRATION: ClinicalTrials.gov NCT04203147 ). Registered on December 18, 2019, with the National Institutes of Health Clinical Trials Registry.

Barriers to Accessing Mental Health Care After a Sexual Assault Medical Forensic Examination.

BACKGROUND: Research indicates low rates of accessing mental health care following sexual assault; however, barriers associated with accessing care are not well understood. DESIGN: Participants (N = 37) were recruited from a local hospital following a sexual assault medical forensic examination (SAMFE). Hierarchical linear regressions models examined the effects of age, racial identity, student status, insurance status, relationship to perpetrator, time since assault, problematic drinking, and posttraumatic stress symptoms on (a) barriers to accessing care and (b) the likelihood of seeking mental health treatment at no charge. RESULTS: Lack of insurance was associated with more barriers to accessing mental health care and a higher likelihood of seeking post-SAMFE care at no charge. Posttraumatic stress symptoms were associated with more barriers to accessing care (p = 0.038). Identifying as a student (p = 0.026) and engaging in problematic drinking (p = 0.047) were associated with a lower likelihood of seeking post-SAMFE care, whereas increased symptoms of posttraumatic stress were associated with a greater likelihood of seeking post-SAMFE care (p = 0.007). CONCLUSIONS: Providing post-SAMFE care, irrespective of insurance, may be a needed first step in addressing the mental health needs of individuals with recent sexual assault. Secondary prevention programs targeted toward alcohol misuse may also be warranted.

Addressing the psychological impact of elder mistreatment: Community-based training partnerships and telehealth-delivered interventions.

This manuscript describes a two-pronged approach to addressing elder abuse in community-residing older adults. Part 1 of the program involves briefly training community healthcare providers to screen for elder abuse and refer for services; Part 2 is an intervention program that addresses mental health impacts of elder abuse in a non-stigmatizing, non-threatening manner, and leverages telehealth for greater reach.

A New Paradigm for Addressing Health Disparities in Inner-City Environments: Adopting a Disaster Zone Approach.

Inner cities are characterized by intergenerational poverty, limited educational opportunities, poor health, and high levels of segregation. Human capital, defined as the intangible, yet integral economically productive aspects of individuals, is limited by factors influencing inner-city populations. Inner-city environments are consistent with definitions of disasters causing a level of suffering that exceeds the capacity of the affected community. This article presents a framework for improving health among inner-city populations using a multidisciplinary approach drawn from medicine, economics, and disaster response. Results from focus groups and photovoice conducted in Milwaukee, WI are used as a case study for a perspective on using this approach to address health disparities. A disaster approach provides a long-term focus on improving overall health and decreasing health disparities in the inner city, instead of a short-term focus on immediate relief of a single symptom. Adopting a disaster approach to inner-city environments is an innovative way to address the needs of those living in some of the most marginalized communities in the country.