Beyond screening for domestic violence: a systems model approach in a managed care setting.

BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted "systems model" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance; and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.

Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.

BACKGROUND: Primary care treatment of depression needs improvement. OBJECTIVE: To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN: Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING: Two managed care adult primary care clinics. PARTICIPANTS: A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS: For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES: For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS: Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION: Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

The contribution of attachment to burden in adult children of institutionalized parents with dementia.

The impact of adult attachment to parents, perceived disease severity, and caregiving behaviors, moderated by perceived caregiving adequacy, were investigated in 108 adult children of patients with dementia. Multiple regression analyses indicated that attachment style, the trait aspect of attachment, predicted both aspects of caregiver burden: caregiving difficulty and psychological symptomatology. Attachment preoccupation, the state aspect of attachment, predicted psychological symptomatology. No other variables, including demographics, were significant predictors. This suggests that a secure attachment style appears to protect caregivers from some of the strain of caregiving. Preoccupation with the attachment relationship contributed to burden in this population.

Five scales in search of a construct: exploring continued attachment to parents in college students.

The multitude of measures and differences across self-report indices of continued parental attachment raise questions regarding the validity and meaning of these scales. The purpose of this study was to examine the convergent and construct validity of 5 measures of continued parental attachment. Five attachment scales and 6 personality scales were administered to 216 undergraduate students. Factor analyses and correlational analyses indicate that the 5 attachment measures differentiate healthy from pathological bonding with parents, the construct being assessed has multiple dimensions, and scores on these attachment measures are correlated with personify variables as would be expected. These attachment scales appear to assess a construct that is related to attachment, although they may be more illustrative of the general affective quality of relationships. Subsequent assessment efforts should employ more specific ratings and measure concrete behavioral manifestations of attachment to most effectively examine the construct.

Culture shock and synergy. Academic/managed care/corporate alliances in outcomes management.

The Behavioral Health Outcomes Study is a partnership in conducting outcomes measurement involving a corporate healthcare purchaser, five managed behavioral healthcare organizations and academic researchers. The goals of this study are to: evaluate the feasibility of incorporating patient self-reported data in outcomes research; identify factors that may be predictors of outcome; and evaluate the effectiveness of an employee-sponsored aftercare program. The differing perspectives and needs of the three partners have created a number of challenges in the areas of goals, confidentiality, proprietary vs. open access issues and methodology. However, after the study's first year, it is clear not only that outcomes research can be conducted under such a partnership, but that the partnership generates a kind of synergy in problem-solving.

The effect of psychiatric disorders on weight loss in obesity clinic patients.

Research on psychiatric disorders in obesity has indicated that obese people are not psychiatrically different from nonobese people. Few studies, however, have addressed the potential impact of psychopathology on weight control. In the present study, a consecutive sample of 37 patients presenting to a major metropolitan weight control unit were given structured diagnostic interviews (Structured Clinical Interviews for Diagnosis I and II). These patients completed one of two 12-week diet programs involving either behavior modification or liquid protein diets. After 12 weeks of a liquid protein formula diet, patients with no personality disorder lost significantly more weight than personality disordered patients; personality disordered patients on a behavioral diet tended (p < .15) to lose more weight during a 12-week diet than the patients without personality disorders. These data suggest that there are differential responses to liquid protein and behavioral diets, depending on the presence or absence of a personality disorder.

Classification of adult attachment: an integrative taxonomy from attachment and psychoanalytic theories.

Developmental and psychoanalytic theorists have focused increasingly on empirically determined early childhood antecedents of adult attachments, with several resulting taxonomic models. This article suggests a theoretically based and clinically based model of attachment consistent with both psychoanalytic and attachment theories, resulting in an integrative taxonomy of four adult attachment styles: dependent, avoidant, hostile, and resistant-ambivalent. These styles reflect behavioral manifestations of dependence and anger, as derived from the interaction of primitive relational drives, defenses, and interpersonal experience. In addition to theoretical construction, brief clinical examples are presented to facilitate discussion of the model.

An attachment classification of desperate love.

The assessment utility of attachment theory constructs for research and diagnostic purposes is being increasingly explored and demonstrated. This study focuses on the association between desperate love and a modification of Ainsworth, Blehar, Waters, and Wall's (1978) taxonomy of attachment styles, hypothesizing that the experience of desperate love will be positively associated with the dependent and resistant/ambivalent attachment styles with no gender differences. The findings based on multivariate regression analyses generally corroborate the attachment style hypotheses, although with significant gender differences. Discussion focuses on the possible contrasts in the intrapsychic experience of desperate love for men and women as well as indications of causal trends for future research.

Parental attachment and emotional distress in the transition to college.

The continued attachment to parents and peers in adults has been examined in two ways: the individual difference approach, examining characteristic attachment styles across relationships, and the general intensity approach, examining the salience of emotional and behavioral reactions to a particular separation. The present study examines the intensity of attachment to parents at the transition to college. This voluntary separation from parents was expected to elicit heightened attachment for college students, especially residential students, which would decrease over time. In addition, it was expected that high levels of parental attachment at the beginning of college would predispose students to later depression. Results indicate that parental attachment decreases during the first semester of college only for residential students. In addition, maternal attachment is significantly higher for females than for males. Finally, high levels of parental attachment in males at the beginning of college were predictive of high levels of depressed mood at the end of the first semester, while no relationship was found for females.

Differentiation of personality types among opiate addicts.

A wide range of studies indicate that although sociopathic characteristics are predominant in opiate addiction, depressive and psychotic features are also frequently observed. To test the hypothesis that there are really three types of individuals who become addicted to opiates (rather than a single, predominant personality style), fifty-three opiate addicts were given the Loevinger Sentence Completion Test, the Bellak Ego Functions Interview, and the Rorschach. Variables derived from these three procedures were submitted to cluster and discriminant function analyses. Three groups of addicts were identified--those primarily with impaired interpersonal relationships and affective lability (42%), those primarily characterized by thought disorder and impaired ego functioning (30%), and a group with diminished ideational and verbal activity (28%). Comparison of the assessment of these three groups with independently defined normal, neurotic, and schizophrenic samples provided support for three opiate-addicted personality types, each respectively characterized as character disordered, borderline psychotic, and depressed. Although there seems to be a predominance of character-disordered individuals who become addicted to opiates, the data indicate several additional types of opiate addicts with different types of psychopathology who may require different approaches to management and treatment.

The role of attachment in the post-divorce experience.

The loss of the spouse resulting from marital breakdown appears to be a central component of post-divorce distress. However, comparatively little empirical research has examined the nature of this broken bond or its impact on the divorced adult. This study tests the hypothesis that the continuing positive feelings for the ex-spouse following divorce are very salient for the individual and are related to increased distress. Sixty recently divorced women selected from court records were randomly assigned to one of three conditions in which they recalled the ex-spouse in a positive, loving interaction (PS); the ex-spouse in a conflictual interaction (C); or a friend in a positive, loving interaction (PS). A post-recall thought sampling procedure was employed to measure the frequency of thoughts about the ex-spouse. The subjects in the PS condition had significantly more post-recall thoughts of the ex-spouse and significantly more thoughts about coping than those in either the C or the PF conditions. The implications of these data for theories of post-divorce adaptation and adult attachment are discussed.

Assessment of tardive dyskinesia using the Abnormal Involuntary Movement Scale.

Over a 10-month period, 33 patients with tardive dyskinesia (TD) were evaluated with the Abnormal Involuntary Movement Scale (AIMS) simultaneously and independently by two experienced and two inexperienced raters. The experienced raters generally had higher levels of agreement and their scores were more consistent over time. It is concluded that experience with TD influences AIMS inter-rater reliability and that it is useful to differentiate TD movements into the dimensions of quality, frequency, and amplitude, dimensions not currently used in the AIMS. The usefulness and difficulty of developing more specific guidelines for AIMS ratings are discussed.

A methodology for the use of the Rorschach in clinical research.

Traditional approaches to the Rorschach produce a myriad of isolated but overlapping variables and ratios which limit the utilization of the Rorschach in research. Several new conceptual approaches to the Rorschach provide the basis for integrating the multitude of Rorschach scores into more molar variables that can be scored reliably and that measure central dimensions of personality organization. These new approaches assess dimensions of explicit personality theories rather than being derived from the test alone. Factor analysis of variables derived from several of these new approaches along with several more traditional scores, indicate seven basic factors which assess important dimensions on the Rorschach: degree of reality testing, primary experiential mode (action or ideation), degree of access to primitive modes of thought and the extent to which these modes are integrated effectively, degree of the investment in appropriate and inappropriate interpersonal relationships, and severity of pathological thinking. These seven empirically independent, orthogonal factors can be assessed by single variables that significantly differentiate opiate addicts and psychiatric patients and significantly correlate with independent estimates of ego functioning and development as evaluated in the Bellak clinical interview and on the Loevinger Sentence Completion Test.