Foster care, externalizing disorders, and antipsychotic use among Medicaid-enrolled youths.

OBJECTIVES: The authors investigated the extent to which clinical diagnoses of externalizing disorders explain higher rates of antipsychotic use by foster care youths. METHODS: Medicaid claims data from 44 states for 2009 for youths in foster care (N=301,894) and those not in foster care (N=5,092,574) were analyzed, excluding those with schizophrenia, bipolar disorder, autism, and major depressive disorder. Logistic regressions assessed the relationship between foster care, externalizing disorders, and antipsychotic use. RESULTS: Foster care youths had higher rates of externalizing disorders than the comparison group (attention-deficit hyperactivity disorder, 17.3% versus 6.5%; disruptive behavior disorder, 7.2% versus 2.5%; conduct disorder, 2.3% versus .5%) and greater antipsychotic use (7.4% versus 1.4%). Foster care remained a significant predictor of antipsychotic use after control for demographic and diagnostic covariates, including externalizing disorders (adjusted odds ratio=2.59, 95% confidence interval=2.54-2.63). CONCLUSIONS: High rates of externalizing disorder diagnoses only partially explained elevated levels of antipsychotic use in this vulnerable population.

Stigmatization and receptivity to mental health services among recently bereaved adults.

Severe grief symptoms, treatment receptivity, attitudes about grief, and stigmatization concerns were assessed in a community-based sample of 135 widowed participants in the Yale Bereavement Study. There was a statistically significant association between the severity of grief symptoms and reported negative reactions from friends and family members. However, more than 90% of the respondents with complicated grief, a severe grief disorder, reported that they would be relieved to know that having such a diagnosis was indicative of a recognizable psychiatric condition, and 100% reported that they would be interested in receiving treatment for their severe grief symptoms.

To pray or not to pray: considering gender and religious concordance in praying with the ill.

Analysis of Covariance was conducted on quantitative data collected by chaplains from January 2005 to December 2008. Data from 82 Catholic, Jewish, and Protestant chaplains, consisting of 53 CPE students and 29 professional chaplains were used in this study. Overall, chaplains exhibited a statistically significant higher rate of prayer with patients from their own religion (religious concordance) than they did with patients of different religions (religious discordance). There was also an interaction of chaplain religion and religious concordance wherein Protestant chaplains were 50% more likely to pray with Protestant patients than with patients of other religions, and Catholic chaplains were 20% more likely to pray with Catholic patients than with other patients. Chaplains were also significantly more likely to pray with patients of their own gender (gender concordance) than with patients of the other gender (gender discordance).

Topography of referrals to chaplains in the Metropolitan Chaplaincy Study.

Understanding referral patterns to chaplains is essential not only to ensure proper patient treatment, but also to assist chaplains seeking to expand the range of patient situations in which they are called to intervene. Information about more than 58,000 chaplain visits was documented during the first two years (2005-2006) of the Metropolitan Chaplaincy Study. Data from 15,655 of these visits, which were made in response to referrals (26.9% of all visits), were analyzed in the present study. Seventy-eight percent of referral requests were met within the same day, and 94.9% of requests and were met within 2 days. Nurses were the most frequent source of referrals to chaplains (45.0%), followed by self-referrals from patients or requests from their family members (30.3%), with the remainder coming from a variety of hospital disciplines. The most common reason for referrals was that patients requested to see a chaplain. Other relatively common reasons for referrals were problems or issues related to illness or treatment, and end-of-life issues, concerns about death and the death of patients, with reasons for referrals differing by referral source. The most common reason for referrals among professional staff was that patients were feeling bad or in pain, followed by medical issues, and end-of-life issues. Patient and family referrals usually involved positive patient affect, whereas staff referrals usually involved negative patient affect.

What do chaplains really do? III. Referrals in the New York Chaplaincy Study.

The current study examines patterns of referrals to chaplains documented in the 1994-1996 New York Chaplaincy Study. The data were collected at thirteen healthcare institutions in the Greater New York City area. Of the 38,600 usable records in the sample, 18.4% were referrals, which form the sample for the current study (N = 7,094). The most common sources of referrals were nurses (27.8%) and patients themselves (22.3%), with relatively few referrals coming from physicians and social workers. The study shows the range of patient issues that are referred to chaplains, including emotional, spiritual, medical, relationship/support, and a change in diagnosis or prognosis. Although the reasons for referral varied by hospital setting and referral source, overall, patients were referred more frequently for emotional (30.0%) than for spiritual issues (19.9%). Results are discussed in relation to the need to clarify the role of the chaplain to the rest of the healthcare team, to recognize when there is a spiritual cause of emotional distress, and to establish effective referral protocols.

Psychiatric illness in the next of kin of patients who die in the intensive care unit.

OBJECTIVES: To determine the rates of psychiatric illness in next of kin following the death of a relative in a medical intensive care unit. DESIGN: Cross-sectional survey. SETTING: A university teaching hospital, New Haven, CT. PATIENTS: Forty-one next of kin who had served as primary surrogate decision makers before the death of their loved one in the intensive care unit 3-12 months previously. INTERVENTIONS: Structured Clinical Interviews for DSM-IV and the Inventory of Complicated Grief-Revised were used to determine prevalence of psychiatric illness. Formal questionnaires were used to evaluate key features of the intensive care unit experience. Bivariate statistics were used to identify factors associated with the presence of psychiatric illness. MEASUREMENTS AND MAIN RESULTS: Following 107 patient deaths, 51 next of kin were successfully contacted and 41 (80%) agreed to study participation. Thirty-four percent (95% confidence interval, 20% to 51%) met criteria for at least one psychiatric illness: major depressive disorder (27%), generalized anxiety disorder (10%), panic disorder (10%), or complicated grief disorder (5%). Disorders were more common in spouses than other kinship relations (63% vs. 16%, p = .002), those experiencing additional stressors after the loss (53% vs. 21%, p = .03), those who said the patient was ill <5 yrs (45% vs. 8%, p = .03), and those who said the patient's physician was not comforting (71% vs. 23%, p = .02). CONCLUSIONS: In a cohort of bereaved next of kin of patients who died in the intensive care unit, we identified a high prevalence of psychiatric illness, particularly major depressive disorder. More work is needed to identify those at risk for psychiatric illness so that appropriate interventions may be targeted.

Selected findings from the "New York" and the "metropolitan" chaplaincy studies: a 10-year comparison of chaplaincy in the New York City area.

In recent years, the chaplain-to-patient ratio in U.S. hospitals has remained roughly the same while the role of the hospital chaplain has expanded. We compared data on 33,000 chaplain visits from the New York Chaplaincy Study (1994-1996) with 58,000 chaplain visits from the Metropolitan Chaplaincy Study (2005-2006), in order to explore whether changes in both the role of the healthcare chaplain and changes in the healthcare system itself have affected the amount of time that chaplains are able to spend with patients. The overall pattern of lengths of visits was stable over time, but chaplains in the Metropolitan Chaplaincy Study had proportionally fewer visits with family members and more visits with patients, more visits based on referrals, and spent more time dealing with end-of-life issues than chaplains in the earlier New York Chaplaincy Study. We discuss ways that chaplains seem to be adjusting successfully to increasing demands on their time.

Change in pastoral skills, emotional intelligence, self-reflection, and social desirability across a unit of CPE.

Clinical Pastoral Education (CPE) is experiential learning of the art and science of pastoral care. CPE students increase capacities in psychological strengths such as self-awareness and empathy, and improve skills in interpersonal and inter-professional relationships. Previous research has documented different kinds of change and experiences for students depending on the length of the CPE unit (short/intensive vs. long/extended). The current study involves CPE students who have taken either an intensive unit or an extended unit and compares the average amount of change in pastoral skills, emotional intelligence, self-reflection, and insight while controlling for the influence of social desirability. Intensive and extended unit students were different from each other in terms of age and experience, beginning level of pastoral skill, and amount of change in the measured abilities. Limitations and strengths of this study and the need for future research are discussed.

Factors of complicated grief pre-death in caregivers of cancer patients.

PURPOSE: Over the past decade, Prigerson and her colleagues have shown that symptoms of 'complicated grief'-intense yearning, difficulty accepting the death, excessive bitterness, numbness, emptiness, and feeling uneasy moving on and that the future is bleak-are distinct from depression and anxiety and are independently associated with substantial morbidity. Little is known about complicated grief experienced by family caregivers prior to the death. This study sought to examine differences in caregiver age groups and potential risk factors for complicated grief pre-death. METHOD: Two hundred and forty eight caregivers from multiple sites nationwide (20-86 years of age) identified themselves as primary caregivers to a terminally ill cancer patient. Each caregiver was interviewed using the following measures: the Pre-Death Inventory of Complicated Grief-Caregiver Version; the Brief Interpersonal Support Evaluation List; the Structured Clinical Interview for the DSM-IV Axis I; the Life Orientation Test-Revised; the SEPRATE Measure of Stressful Life Events; the Covinsky Family Impact Survey; and mental health access questions. RESULTS: The study found that those under 60 years old had higher levels of complicated grief pre-death than caregivers 60 and older (t(246) = 2.30, p < 0.05). Significant correlations were also found between levels of complicated grief pre-loss and the following psychosocial factors: perceived social support (r = -0.415, p < 0.001); history of depression (r = -0.169, p < 0.05); current depression (r = -0.158, p < 0.05); current annual income (Spearman rho = -0.210, p < 0.01); annual income at time of patient's diagnosis (Spearman rho = -0.155, p = 0.05); pessimistic thinking (r = 0.320, p < 0.001); and number of moderate to severe stressful life events (Spearman rho = 0.218, p = 0.001). In a multi-variate analysis (R(2) = 0.368), pessimistic thinking (Beta = 0.208, p < 0.05) and severity of stressful life events (Beta = 0.222, p < 0.05) remained as important factors to developing complicated grief pre-death. CONCLUSIONS: These results suggest that mental health professionals who work with caregivers should pay particular attention to pessimistic thinking and stressful life events, beyond the stress of the loved one's illness, that caretakers experience. Additionally, although not reaching significance, mental health professionals should also consider younger caregivers at greater risk for complicated grief pre-loss.

Associations between caregiver-perceived delirium in patients with cancer and generalized anxiety in their caregivers.

BACKGROUND: Delirium, a common complication of advanced cancer, may put caregivers at risk for poor mental health outcomes. We looked for a relationship between caregiver-perceived delirium in a patient with advanced cancer and rates of caregiver psychiatric disorders. METHODS: Using cross-sectional data from 200 caregivers of patients with cancer with a life expectancy of less than 6 months, we determined the frequency of caregiver-perceived delirium, which was defined as caregivers who reported witnessing the patient "confused, delirious" on the Stressful Caregiving Response to Experiences of Dying (SCARED) weekly or more often. We tested for associations between caregiver-reported delirium and presence of caregiver mental disorders, using the Structured Clinical Interview for the DSM-IV to diagnose mental disorders and caregiver burden, as measured by the caregiver burden scale (CBS). RESULTS: Of the 200 caregivers who completed the SCARED, 38 (19.0%) reported seeing the patient "confused, delirious" at least once per week in the month prior to study enrollment and 7 (3.5%) met criteria for generalized anxiety (GA). Caregivers of patients with caregiver-perceived delirium were 12 times more likely to have GA (odds ratio [OR] 12.12; p < 0.01). The relationship between caregiver-perceived delirium and caregiver GA persisted after adjusting for caregiver burden and exposure to other stressful patient experiences (OR = 9.99; p = 0.04). CONCLUSIONS: This is the first report of an association between caregiver-perceived delirium and a caregiver mental health outcome. Further studies, using improved measures of delirium, are needed.

Differences in risk factors for suicidality between African American and White patients vulnerable to suicide.

Risk factors for suicidal ideation and attempts have been shown to differ between African Americans and Whites across the lifespan. In the present study, risk factors for suicidality were examined separately by race/ethnicity in a population of 131 older adult patients considered vulnerable to suicide due to substance abuse and/or medical frailty. In adjusted analyses, social support was significantly associated with suicidality in African American patients, while younger age and the presence of an anxiety disorder were significantly associated with suicidality in White patients. The results suggest that race/ethnicity-specific risk profiles may improve the detection of suicidality in vulnerable populations.

Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life.

PURPOSE: Religion and spirituality play a role in coping with illness for many cancer patients. This study examined religiousness and spiritual support in advanced cancer patients of diverse racial/ethnic backgrounds and associations with quality of life (QOL), treatment preferences, and advance care planning. METHODS: The Coping With Cancer study is a federally funded, multi-institutional investigation examining factors associated with advanced cancer patient and caregiver well-being. Patients with an advanced cancer diagnosis and failure of first-line chemotherapy were interviewed at baseline regarding religiousness, spiritual support, QOL, treatment preferences, and advance care planning. RESULTS: Most (88%) of the study population (N = 230) considered religion to be at least somewhat important. Nearly half (47%) reported that their spiritual needs were minimally or not at all supported by a religious community, and 72% reported that their spiritual needs were supported minimally or not at all by the medical system. Spiritual support by religious communities or the medical system was significantly associated with patient QOL (P = .0003). Religiousness was significantly associated with wanting all measures to extend life (odds ratio, 1.96; 95% CI, 1.08 to 3.57). CONCLUSION: Many advanced cancer patients' spiritual needs are not supported by religious communities or the medical system, and spiritual support is associated with better QOL. Religious individuals more frequently want aggressive measures to extend life.

Religious coping is associated with the quality of life of patients with advanced cancer.

BACKGROUND: For patients confronting a life-threatening illness such as advanced cancer, religious coping can be an important factor influencing their quality of life (QOL). OBJECTIVE: The study's main purpose was to examine the association between religious coping and QOL among 170 patients with advanced cancer. Both positive religious coping (e.g., benevolent religious appraisals) and negative religious coping (e.g., anger at God) and multiple dimensions of QOL (physical, physical symptom, psychological, existential, and support) were studied. DESIGN: Structured interviews were conducted with 170 patients recruited as part of an ongoing multi-institutional longitudinal evaluation of the prevalence of mental illness and patterns of mental health service utilization in advanced cancer patients and their primary informal caregivers. MEASUREMENTS: Patients completed measures of QOL (McGill QOL questionnaire), religious coping (Brief Measure of Religious Coping [RCOPE] and Multidimensional Measure of Religion/ Spirituality), self-efficacy (General Self-Efficacy Scale), and sociodemographic variables. RESULTS: Linear regression analyses revealed that after controlling for sociodemographic variables, lifetime history of depression and self-efficacy, greater use of positive religious coping was associated with better overall QOL as well as higher scores on the existential and support QOL dimensions. Greater use of positive religious coping was also related to more physical symptoms. In contrast, greater use of negative religious coping was related to poorer overall QOL and lower scores on the existential and psychological QOL dimensions. CONCLUSIONS: Findings show that religious coping plays an important role for the QOL of patients and the types of religious coping strategies used are related to better or poorer QOL.

An exploration of associations between separation anxiety in childhood and complicated grief in later life.

Recent studies have suggested that the vulnerability to complicated grief (CG) may be rooted in insecure attachment styles developed in childhood. The aim of this study was to examine the etiologic relevance of childhood separation anxiety (CSA) to the onset of CG relative to major depressive disorder, posttraumatic stress disorder, and generalized anxiety disorder in bereaved individuals. The Structured Clinical Interview for the DSM-IV, Inventory of Complicated Grief-Revised, and CSA items from the Panic Agoraphobic Spectrum Questionnaire were administered to 283 recently bereaved community-dwelling residents at an average of 10.6 months postloss. CSA was significantly associated with CG (OR = 3.2; 95% CI, 1.2-8.9), adjusting for sex, level of education, kinship relationship to the deceased, prior history of psychiatric disorder, and history of childhood abuse. CSA was not significantly associated with major depressive disorder, posttraumatic stress disorder, or generalized anxiety disorder.

Assessing grief and bereavement: observations from the field.

The purpose of this article is to describe the evaluations involved in the Yale Bereavement Study (YBS), a three-year NIMH and NCI-funded longitudinal study conducted from January 2000 through May 2003. The quantitative and qualitative questions included in the YBS gave the respondents an opportunity to describe their most recent loss, rate and review their past losses, and assess all aspects of their current life situations. In this article, the first author describes, in a qualitative manner, the ways in which this assessment, per se, appeared helpful and not harmful to the respondents. Also, developed here is the implication for potential application of a modified version of the YBS which could be used in both research and clinical practice.

Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study.

BACKGROUND: Psychological morbidity has been proposed as a source of distress in cancer patients. This study aimed to: 1) determine the prevalence of diagnosable psychiatric illnesses, and 2) describe the mental health services received and predictors of service utilization in patients with advanced cancer. METHODS: This was a cross-sectional, multi-institutional study of 251 eligible patients with advanced cancer. Eligibility included: distant metastases, primary therapy failure, nonpaid caregiver, age > or =20 years, stamina for the interview, English or Spanish-speaking, and adequate cognitive ability. Trained interviewers administered the Structured Clinical Interview for the Diagnostic Statistical Manual IV (DSM-IV) modules for Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder, Post-Traumatic Stress Disorder, and a detailed questionnaire regarding mental health service utilization. RESULTS: Overall, 12% met criteria for a major psychiatric condition and 28% had accessed a mental health intervention for a psychiatric illness since the cancer diagnosis. Seventeen percent had discussions with a mental health professional; 90% were willing to receive treatment for emotional problems. Mental health services were not accessed by 55% of patients with major psychiatric disorders. Cancer patients who had discussed psychological concerns with mental health staff (odds ratio [OR] = 19.2; 95% confidence interval [95% CI], 8.90-41.50) and non-Hispanic white patients (OR = 2.7; 95% CI, 1.01-7.43) were more likely to receive mental health services in adjusted analysis. CONCLUSIONS: Advanced cancer patients experience major psychiatric disorders at a prevalence similar to the general population, but affected individuals have a low rate of utilizing mental health services. Oncology providers can enhance utilization of mental health services, and potentially improve clinical outcomes, by discussing mental health concerns with their patients.

Psychiatric disorders and mental health service use among caregivers of advanced cancer patients.

PURPOSE: Despite research demonstrating the psychological burden of caregiving for advanced cancer patients, limited information exists on the prevalence of psychiatric disorders and mental health service use among these informal caregivers. METHODS: Two hundred informal caregivers of advanced cancer patients were interviewed and administered the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and an assessment of mental health service use. RESULTS: Thirteen percent of caregivers met criteria for a psychiatric disorder; 25% accessed treatment for mental health concerns since the patient's cancer diagnosis. The frequencies of current psychiatric disorders were as follows: panic disorder, 8.0% (95% CI, 4.6% to 12.7%), major depressive disorder, 4.5% (95% CI, 2.1% to 8.4%), post-traumatic stress disorder, 4.0% (95% CI, 1.7% to 7.7%), and generalized anxiety disorder, 3.5% (95% CI, 1.4% to 7.1%). Among caregivers with a current psychiatric disorder, 81% discussed mental health concerns with a health professional before the patient's cancer diagnosis compared with 46% after the diagnosis (McNemar test = 5.40; P = .02). Only 46% of caregivers with a current psychiatric disorder accessed mental health services. Caregivers who discussed mental health concerns with a clinician before the patient's cancer diagnosis (odds ratio [OR] = 3.51; 95% CI, 1.42 to 8.71) and after the diagnosis (OR = 21.23; 95% CI, 9.02 to 49.94) were more likely than caregivers not having these discussions to receive mental health services. CONCLUSION: Many caregivers of advanced cancer patients either meet criteria or are being treated for psychiatric problems. Discussing mental health issues positively influences the receipt of mental health services and should be actively pursued in this vulnerable population.