Changes in functional connectivity of the amygdala during cognitive reappraisal predict symptom reduction during trauma-focused cognitive-behavioral therapy among adolescent girls with post-traumatic stress disorder.

BACKGROUND: While trauma-focused cognitive-behavioral therapy (TF-CBT) is the 'gold standard' treatment for pediatric post-traumatic stress disorder (PTSD), little is known about the neural mechanisms by which TF-CBT produces clinical benefit. Here, we test the hypothesis that PTSD symptom reduction during TF-CBT among adolescent girls with PTSD is associated with changes in patterns of brain functional connectivity (FC) with the amygdala during cognitive reappraisal. METHOD: Adolescent girls with PTSD related to physical or sexual assault (n = 34) were enrolled in TF-CBT, delivered in an approximately 12-session format, in an open trial. Before and after treatment, they were engaged in a cognitive reappraisal task, probing neural mechanisms of explicit emotion regulation, during 3 T functional magnetic resonance imaging. RESULTS: Among adolescent girls completing TF-CBT with usable pre- and post-treatment scans (n = 20), improvements in self-reported emotion from pre- to post-treatment were positively related to improvements in PTSD symptoms. Adolescent girls with greater post-treatment symptom reduction were also able to suppress amygdala-insula FC while re-appraising, which was not evident in girls with less symptom reduction. Pre- to post-treatment changes in right amygdala to left insula FC that scaled with PTSD symptom reduction also scaled with improvements in emotion regulation. CONCLUSIONS: These preliminary results suggest the neurocircuitry mechanisms through which TF-CBT produces clinical outcomes, providing putative brain targets for augmenting TF-CBT response.

Comparing outcomes of routine care for depression: the dilemma of case-mix adjustment.

The purpose of this study was to formulate and test two case-mix models for depression treatment that permit comparisons of patient outcomes across diverse clinical settings. It assessed demographics; eight, diagnostic-specific, case-mix variables; and clinical status at baseline and follow-up for 187 patients. Regressions were performed to test two models for four dependent variables including depression severity and diagnosis. Individual treatment settings were then ranked based on a comparison of actual versus predicted outcomes using regression coefficients and predictor variables. A model inclusive of baseline physical health status and depression severity predicted depression severity, mental health, and physical health functioning at follow-up. A simpler model performed well in predicting depression remission. This study identifies variables to be included in case-mix adjustment models and demonstrates statistical methods to control for differences across settings when comparing depression outcomes.

Toward a level playing field: predictive factors for the outcomes of mental health treatment for adolescents.

OBJECTIVE: To understand better the effectiveness of routine treatment for emotional and behavioral problems experienced by adolescents, methods are needed to control for between-provider differences in the distribution of factors that adversely affect treatment success. Such methods are necessary to fairly compare providers' outcomes and to aid clinicians in identifying adolescents for whom routine care may need to be altered. As a preliminary step toward developing a model to adjust treatment outcomes to account for predictive factors, findings from studies of treated samples of adolescents were reviewed to identify the factors that influence the likelihood of treatment success for this population. METHOD: Medline and PSYCInfo databases were searched for studies of treated adolescents that reported the association between expert-nominated predictive factors and outcomes. Thirty-four studies met inclusion criteria. RESULTS: Significant predictors identified in these studies include diagnosis, baseline severity of symptoms and functional impairment, family dysfunction, and previous treatment. Several expert-nominated factors have not been adequately studied in treated samples. CONCLUSIONS: Much basic work is needed before a convincing body of empirical evidence can explain predictive factors for adolescent mental health treatment outcomes. Future efforts should determine a reduced set of predictive factors that can be measured with minimal burden to providers.

Psychiatric practice variations in the diagnosis and treatment of major depression.

OBJECTIVE: Practice variations in the diagnosis, treatment, and outcomes of patients with major depression were examined within six psychiatric practices participating in a national outcomes-management project. METHODS: Six of 20 psychiatric clinics met selection criteria for this study and provided a database of 5, 106 patients. Patients completed the BASIS-32, the Short-Form-36 Health Survey, and a Beginning Services Survey. Treatment information was also obtained directly from the clinician or through a medical record review. RESULTS: Although 73.1 to 77 percent of patients screened positive for a depressive disorder, only 18.5 to 36.8 percent were diagnosed with major depression (p<.001). Between 39 and 72 percent of patients received psychotropic medications, a significant difference across sites (p<.001). In addition, the number of psychotherapy sessions was significantly different across sites (p<.001). CONCLUSIONS: Patient care varies considerably across psychiatric practices, a finding that is particularly relevant for developers of performance indicators and risk-adjustment strategies for mental health.

Measuring treatment effectiveness. Part one: Newly emerging outcomes databases for organizations.

Provider organizations are under increased pressure from payors to produce outcomes data that demonstrate the effectiveness of their treatment services. More and more, providers are collaborating on joint outcomes projects that allow them to benchmark their results with similar organizations. Here are five brief descriptions of such projects. They span a wide spectrum of organizations and include hospitals and comprehensive healthcare systems, behavioral group practices, child welfare agencies, and psychosocial rehabilitation programs. Part one begins below, part two, on page 45.

Making the grade: update on report card initiatives for 1997.

Report cards for healthcare services are increasingly in the news, offering the hope that objective information on the quality of health plan and providers services will eventually enable purchasers and consumers to make selections based on true value. Following is a series of five brief articles that review ongoing report card initiatives in private and public sectors of the behavioral healthcare system. The first four articles review actual report cards designed to hold organizations--particularly managed care--accountable for the quality of their services. The last article reviews research on performance measurement across all segments of the behavioral healthcare industry.

The comorbidity of post-traumatic stress disorder and suicidality in Vietnam veterans.

Vietnam veterans (N = 232) recruited from three sources were assessed for suicidal thinking and behaviors, and symptoms of posttraumatic stress disorder (PTSD) and depression. Findings support the notion that suicidal thoughts are prevalent in this group, with veterans in psychotherapy reporting a greater likelihood of such symptoms (82.6%) than veterans in the community (35.7%) or those seeking assistance through a veteran's outreach center (66.7%). Thoughts of ending one's life and a previous suicide attempt were significantly correlated with a diagnosis of PTSD (r = .53, p < .001; and r = .33, p < .001, respectively). Veterans with a diagnosis of PTSD and depression or dysthymia were also more likely to report suicidal thinking and behaviors than veterans with only one of the diagnoses.

Children of disaster in the second decade: a 17-year follow-up of Buffalo Creek survivors.

OBJECTIVE: To conduct a long-term follow-up of child survivors of a devastating human-caused disaster. METHOD: Child survivors (2-15) of the Buffalo Creek dam collapse, first evaluated in 1974, 2 years postdisaster, were reevaluated 17 years postdisaster when they were adults. Of the original 207 children, 99 were located and reevaluated using ratings on the Psychiatric Evaluation Form, the Impact of Event Scale, and the SCL-90 and lifetime and current diagnoses from the Structured Clinical Interview for DSM-III-R. RESULTS: Ratings of psychiatric symptoms at the two points in time showed significant decreases in overall severity ratings and in anxiety, belligerence, somatic concerns, and agitation. A few symptoms, not present in the child sample, increased over time (substance abuse, suicidal ideation). The current rate of disaster-related post-traumatic stress disorder (PTSD) was 7%, down from a postflood rate of 32%. There were no differences by age group in current psychological status; however, women evidenced more PTSD-related symptoms than did men. All current PTSD cases were women. Comparisons with similar subjects from a nonexposed community showed no differences. CONCLUSIONS: The findings indicated that the children studied, although having shown earlier effects, had "recovered" from the event by the time of long-term follow-up.

Vulnerability-stress factors in development of posttraumatic stress disorder.

Log-linear chi 2 analyses were conducted to examine potential interactions between the presence of precrime axis I psychiatric diagnoses and differential levels of crime stress in association with posttraumatic stress disorder (PTSD) in a community sample of 295 female crime victims. High crime stress was defined as crime that included either perceived life threat, actual injury, or completed rape. Crime stress level was significantly associated with PTSD after the crime. Thirty-five percent of subjects with high crime stress exposure met criteria for PTSD, as opposed to 13% of those with low crime stress exposure. Precrime diagnosis was not associated with high crime stress exposure, indicating that this is not a vulnerability factor for exposure to crime characteristics associated with increased rates of PTSD. There were no significant independent associations between precrime axis I diagnoses and PTSD after the crime. However, a significant interaction was observed among crime stress level, precrime depression, and PTSD such that the rate of PTSD was substantially higher in association with precrime depression only in the high crime stress exposure group. Major findings are consistent with previous results implicating trauma exposure as the primary factor in development of PTSD. However, the results indicate that precrime depression may constitute a vulnerability factor for development of PTSD under conditions of high crime stress exposure.