Organizational structure, climate, and collaboration between juvenile justice and community mental health centers: implications for evidence-based practice implementation for adolescent substance use disorder treatment.

BACKGROUND: Substance use disorders are prevalent among youth involved with the criminal justice system, however, evidence-based substance use disorder treatment is often unavailable to this population. The goal of this study was to identify barriers to effective implementation of evidence-based practices among juvenile justice and community mental health organizations through the lens of an adopter-based innovation model. METHODS: In this mixed-methods study, qualitative interviews were conducted with n = 15 juvenile justice staff and n = 14 community mental health staff from two counties implementing substance use services for justice involved youth. In addition, n = 28 juvenile justice staff and n = 85 community mental health center staff also completed quantitative measures of organizational effectiveness including the implementation leadership scale (ILS), organizational readiness for change (ORIC), and the implementation climate scale (ICS). RESULTS: Organizationally, staff from community mental health centers reported more "red tape" and formalized procedures around daily processes, while many juvenile justice staff reported a high degree of autonomy. Community mental health respondents also reported broad concern about their capacity for providing new interventions. Staff across the two different organizations expressed support for evidence-based practices, agreed with the importance of treating substance use disorders in this population, and were enthusiastic about implementing the interventions. CONCLUSIONS: While both community mental health and juvenile justice staff express commitment to implementing evidence-based practices, systems-level changes are needed to increase capacity for providing evidence-based services.

Anxiety symptoms in schizophrenia spectrum disorders: associations with social function, positive and negative symptoms, hope and trauma history.

OBJECTIVE: Anxiety is commonly observed in schizophrenia, but its relationship with other features of illness is unclear. METHOD: We examined correlations between measures of anxiety, positive and negative symptoms, hope, psychosocial function and trauma history among 128 participants with schizophrenia or schizoaffective disorder. Cluster analyses were conducted to determine whether we could detect a subgroup with severe anxiety. RESULTS: Higher levels of anxiety were associated with greater hallucinations, withdrawal, depression, hopelessness, better insight and poorer function. Cluster analyses produced three groups according to anxiety level: subclinical anxiety (n = 37), moderate anxiety (n = 55) and severe anxiety (n = 36). anova revealed that the severe anxiety group had more severe hallucinations, poorer psychosocial function and less hope than either of the other two groups. Self-report of sexual trauma predicted higher levels of anxiety overall. CONCLUSION: A subgroup of persons with severe anxiety may be identifiable in schizophrenia with a unique clinical profile.

Reliability of instruments in a cooperative, multisite study: employment intervention demonstration program.

Reliability of well-known instruments was examined in 202 people with severe mental illness participating in a multisite vocational study. We examined interrater reliability of the Positive and Negative Syndrome Scale (PANSS) and the internal consistency and test-retest reliability of the PANSS, the Rosenberg Self-Esteem Scale, the Medical Outcomes Study Short Form-36 (SF-36), and the Quality of Life Interview. Most scales had good levels of reliability, with intraclass correlation coefficients (ICCs) and coefficient alphas above .70. However, the SF-36 scales were generally less stable over time, particularly Social Functioning (ICC = .55). Test-retest reliability was lower among less educated respondents and among ethnic minorities. We recommend close monitoring of psychometric issues in future multisite studies.

An exploratory analysis of racial factors in staff burnout among assertive community treatment workers.

We examined racial differences in burnout among case managers working with people with severe mental illness, using the Maslach Burnout Inventory. Compared to Caucasians, African Americans reported significantly less Emotional Exhaustion and Depersonalization, but did not differ on levels of Personal Accomplishment. These differences could not be explained by geographic location or perceptions of the work environment; however, age accounted for group differences in Depersonalization. Racial incongruence with caseload appeared to be one factor in burnout, particularly for Emotional Exhaustion. Race of both staff and clients may be important to consider in understanding staff burnout.

A prospective analysis of work in schizophrenia.

This study examined the longitudinal course of competitive employment in patients with schizophrenia following treatment for an acute exacerbation, and prospectively predicts work approximately 2 years later from sociodemographic and clinical characteristics. A sample of 528 patients was assessed at baseline, and 313 were followed up 1 and 2 years later. Assessments included sociodemographic characteristics, premorbid functioning, work history, symptoms, social functioning, recent efforts to find work, and interest in work. Analyses examined changes in competitive work from baseline to the followups, the correlates of work history, the prospective prediction of work at the 1- and 2-year followup assessments, and correlates of competitive work. Competitive employment increased significantly from 10 percent at baseline to 23 percent and 21 percent at the 1- and 2-year followups, respectively. At baseline, among patients who were not competitively working, 61 percent reported interest in working. Patients who were not competitively employed at baseline but reported making recent efforts to find work were more likely to be working at the followups than other not employed patients. Work at the 1- and 2-year followups was predicted by prior work experience, patient and mother's educational level, cognitive impairment, and social functioning. Similar correlates of current work status were found. Interventions may need to target educational level, cognitive impairment, and social competence and functioning in order to improve the competitive employment outcomes of persons with schizophrenia.

Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness.

Interrater reliability, internal consistency, test-retest reliability, and convergent validity were examined for the Trauma History Questionnaire (THQ), the Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale (CAPS), and the PTSD Checklist (PCL) in 30 clients with severe mental illnesses. Interrater reliability for the THQ and CAPS was high, as was internal consistency of CAPS and PCL subscales. The test-retest reliability of the THQ was moderate to high for different traumas. PTSD diagnoses on the CAPS and PCL showed moderate test-retest reliability. Lower levels of test-retest reliability for PTSD diagnoses were related to psychosis diagnoses and symptoms. However, when more stringent criteria for PTSD were used on the CAPS, it had excellent test-retest reliability across all clients. CAPS and PCL diagnoses of PTSD showed moderate convergent validity. The results support the reliability of trauma and PTSD assessments in clients with severe mental illness.

Social functioning, psychopathology, and medication side effects in relation to substance use and abuse in schizophrenia.

OBJECTIVE: To identify correlates of self-reported substance use and problems associated with that use in people with schizophrenia. METHODS: A sample of 404 patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder and longitudinal assessments of substance use were examined. Three groups were formed according to consistency of substance use over time: No/Low Alcohol, Alcohol Only, and Drug Use (with or without alcohol use). Similar groups were formed regarding problems associated with alcohol use. Groups were compared on demographics, psychiatric history, psychopathology, medication side effects, and social functioning. RESULTS: Substance users were more likely to be young, male, and to have lower levels of education. Substance users generally had fewer negative symptoms, more social contacts, and better social-leisure functioning. However, substance users, especially drug users, also were rated as having more interpersonal and family problems, had an earlier age at first psychiatric hospitalization, and were more likely to have been recently hospitalized. Patients reporting problems with alcohol use reported more frequent alcohol and drug use, greater severity of akathisia, and problems in interpersonal, family, and self-efficacy domains. CONCLUSIONS: Many of the same variables that correlate with substance use disorder also correlated with moderate substance use in this sample of people with schizophrenia. Although moderate users of alcohol and drugs may have better social functioning in some areas, they also are likely to have substantial problems in interpersonal relationships, especially those involving family members.

Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.

OBJECTIVES: This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness. METHODS: Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina. RESULTS: The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively. CONCLUSIONS: Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.

Recent victimization in women and men with severe mental illness: prevalence and correlates.

The problem of violence against individuals with severe mental illness (SMI) has received relatively, little notice, despite several studies suggesting an exceptionally high prevalence of victimization in this population. This paper describes the results of an investigation of the prevalence and correlates of past year physical and sexual assault among a large sample of women and men with SMI drawn from inpatient and outpatient settings across 4 states. Results confirmed preliminary findings of a high prevalence of victimization in this population (with sexual abuse more prevalent for women and physical abuse more prevalent for men), and indicated the existence of a range of correlates of recent victimization, including demographic factors and living circumstances, history of childhood abuse, and psychiatric illness severity and substance abuse. The research and clinical implications of these findings are discussed.

Reliability and validity of the SF-12 health survey among people with severe mental illness.

OBJECTIVE: The objective of this work was to assess the reliability and validity of the Medical Outcomes Study Short-Form 12-Item Health Survey (SF-12) in a large sample of people with severe mental illness (SMI). METHODS: We examined the internal factor structure of the SF-12, compared component scores for this sample with normative levels, examined test-retest reliability, and examined convergent and divergent validity by comparing SF-12 scores to other indexes of physical and mental health. RESULTS: The SF-12 distinguished this sample of people with SMI from the general population, was stable over a 1-week interval, consisted of 2 fairly distinct factors, and was related to physical and mental health indexes in expected ways. CONCLUSIONS: The SF-12 appears to be a psychometrically sound instrument for measuring health-related quality of life for people with SMI.

Measurement of fidelity in psychiatric rehabilitation.

Until recently, most psychiatric rehabilitation models have been poorly defined and few have had systematic methods for measuring their implementation. We review the historical roots for the development of fidelity measures and describe recent applications in both research and practice.

Transferring clients from intensive case management: impact on client functioning.

The effects of transferring clients from assertive community treatment to a less intensive (step-down) case management program were examined. Service use decreased significantly after transfer to the step-down program, and no negative effects of transfer on hospital use or client functioning were evident. Critical elements for successful step-down are suggested and discussed.