Serious negative consequences associated with exposure and response prevention for obsessive-compulsive disorder: A survey of therapist attitudes and experiences

OBJECTIVE

Many therapists are reluctant to conduct exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). Negative beliefs about the safety and tolerability of ERP are common, especially for harm-related OCD symptoms. The study examined the nature and frequency of ERP-related serious negative consequences (SNC) and therapist attitudes and experiences providing ERP for harm-related OCD.

METHODS

An anonymous survey was completed by 277 therapists with experience treating OCD using ERP. Questions assessed clinical experiences of harm-related exposures, the nature of SNC, and concerns and clinical considerations regarding ERP.

RESULTS

Therapist's willingness to treat harm-related OCD was high. SNCs were reported for 6 clients (per-client risk: adults 0.05%, youth 0.01%) and 13 therapists (per therapist risk 4.73%, therapist per-year risk 0.004%). Qualitative analysis identified themes relating to the conduct of treatment, specific exposure types, professional issues, and negative perceptions of ERP.

CONCLUSION

SNC associated with ERP for OCD are rare and primarily represent unintended secondary consequences of OCD or misunderstandings regarding the process and rationale behind ERP. Improving access to ERP will require good communication with clients, families, and other professionals regarding the rationale and safety of ERP.

Benchmarking the "Question, Persuade, Refer" Program Against Evaluations of Established Suicide Prevention Gatekeeper Trainings

Gatekeeper training is a common approach for aiding suicidal youth. This study utilizes comparative effectiveness "benchmarks" from established programs to evaluate the Question, Persuade, Refer (QPR) program. The QPR program was implemented with adults (N = 2,389) working in youth-serving community agencies. Questionnaires assessed suicide prevention knowledge, attitudes, subjective norms, perceived behavioral control, and behaviors. Consistent with benchmarked studies, participants in QPR demonstrated knowledge and suicide prevention behavior gains compared with control groups. Future research should utilize benchmarking methods as a measure of effectiveness, and more thoroughly assess mechanisms that promote behavior change.

Effectiveness of a Trauma-Informed Care Initiative in a State Child Welfare System: A Randomized Study

Trauma-informed care (TIC) initiatives in state child welfare agencies are receiving more attention, but little empirical evidence exists as to their efficacy. The purpose of this study was to assess changes in self-reported practices and perceptions of child welfare staff involved in a multifaceted, statewide TIC intervention. Ten child welfare offices were matched and randomized to an early or delayed cohort. Staff were surveyed at Time 1 prior to any intervention, Time 2 postintervention for Cohort 1, and Time 3 postintervention for Cohort 2. The survey covered six domains: trauma screening, case planning, mental health and family involvement, progress monitoring, collaboration, and perceptions of the state's overall system performance. Linear mixed modeling assessed the effect of the intervention. Cohort by time interaction was significant for three intervention targets. We demonstrate, using a rigorous study design, the mixed results of a multimodal intervention to improve trauma-informed attitudes, practices, and system performance. TIC initiatives must account for complex, dynamic contextual factors.

Clinically useful brain imaging for neuropsychiatry: How can we get there?

Despite decades of research, visions of transforming neuropsychiatry through the development of brain imaging-based "growth charts" or "lab tests" have remained out of reach. In recent years, there is renewed enthusiasm about the prospect of achieving clinically useful tools capable of aiding the diagnosis and management of neuropsychiatric disorders. The present work explores the basis for this enthusiasm. We assert that there is no single advance that currently has the potential to drive the field of clinical brain imaging forward. Instead, there has been a constellation of advances that, if combined, could lead to the identification of objective brain imaging-based markers of illness. In particular, we focus on advances that are helping to (1) elucidate the research agenda for biological psychiatry (e.g., neuroscience focus, precision medicine), (2) shift research models for clinical brain imaging (e.g., big data exploration, standardization), (3) break down research silos (e.g., open science, calls for reproducibility and transparency), and (4) improve imaging technologies and methods. Although an arduous road remains ahead, these advances are repositioning the brain imaging community for long-term success.

Mobile assessment of heightened skin conductance in posttraumatic stress disorder

BACKGROUND

Increased psychophysiological reactivity is a hallmark intermediate phenotype of posttraumatic stress disorder (PTSD). Individuals with PTSD exhibit greater skin conductance (SC) responses to trauma scripts than trauma survivors without PTSD. However, trauma scripts require time for development and cannot be easily used in a single visit. Thus, there is a need for a low-cost, easy-to-use, SC recording protocol for PTSD assessment.

METHODS

Using a mobile device (eSense) connected to a portable tablet computer, we assessed SC reactivity to a standard trauma interview (STI) in 63 participants recruited from Grady Memorial Hospital in Atlanta, GA, approximately 1 year after trauma exposure. SC response (SCR) was calculated by subtracting the SC level (SCL) at the end of the baseline recording from the maximum SCL during the STI.

RESULTS

SCL was significantly higher during the STI compared to baseline (P < .001), and individuals with PTSD showed significantly greater SCR than individuals without PTSD (P = .006). Logistic regression using SCR with PTSD diagnosis as the outcome showed an odds ratio of 1.76 (95% CI: 1.11-2.78). Lastly, higher SCR during the STI was also significantly associated with PTSD symptom total score controlling for demographics and trauma severity (b = 0.42, P = .001).

CONCLUSIONS

The current study demonstrated feasibility of the use of a mobile device for assessing psychophysiological reactivity in those with PTSD. The use of this low-cost, easy-to-use mobile device to collect objective physiological data in concert with a STI can be easily disseminated in clinical and research settings.

From a "perfect storm" to "smooth sailing": policymaker perspectives on implementation and sustainment of an evidence-based practice in two states

Policymakers shape implementation and sustainment of evidence-based practices (EBPs), whether they are developing or responding to legislation and policies or negotiating public sector resource constraints. As part of a large mixed-method study, we conducted qualitative interviews with 24 policymakers involved in delivery of the same EBP in two U.S. states. We analyzed transcripts via open and focused coding techniques to identify the commonality, diversity, and complexity of implementation challenges; approaches to overcoming those challenges; and the importance of system-level contextual factors in ensuring successful implementation. Key findings centered on building support and leadership for EBPs; funding and contractual strategies; partnering with stakeholders; tackling challenges via proactive planning and problem solving; and the political, legal, and systemic pressures affecting EBP longevity. The policymaker perspectives offer guidance on nurturing system and organizational practice environments to achieve positive outcomes and for optimally addressing macro-level influences that bear upon the instantiation of EBPs in public sector child welfare systems.

Research for improved health: variability and impact of structural characteristics in federally funded community engaged research

BACKGROUND

Although there is strong scientific, policy, and community support for community-engaged research (CEnR)-including community-based participatory research (CBPR)-the science of CEnR is still developing.

OBJECTIVE

To describe structural differences in federally funded CEnR projects by type of research (i.e., descriptive, intervention, or dissemination/policy change) and race/ethnicity of the population served.

METHODS

We identified 333 federally funded projects in 2009 that potentially involved CEnR, 294 principal investigators/project directors (PI/PD) were eligible to participate in a key informant (KI) survey from late 2011 to early 2012 that asked about partnership structure (68% response rate).

RESULTS

The National Institute on Minority Health & Health Disparities (19.1%), National Cancer Institute (NCI; 13.3%), and the Centers for Disease Control and Prevention (CDC; 12.6%) funded the most CEnR projects. Most were intervention projects (66.0%). Projects serving American Indian or Alaskan Native (AIAN) populations (compared with other community of color or multiple-race/unspecified) were likely to be descriptive projects (p<.01), receive less funding (p<.05), and have higher rates of written partnership agreements (p<.05), research integrity training (p<.05), approval of publications (p<.01), and data ownership (p<.01). AIAN-serving projects also reported similar rates of research productivity and greater levels of resource sharing compared with those serving multiple-race/unspecified groups.

CONCLUSIONS

There is clear variability in the structure of CEnR projects with future research needed to determine the impact of this variability on partnering processes and outcomes. In addition, projects in AIAN communities receive lower levels of funding yet still have comparable research productivity to those projects in other racial/ethnic communities.

Adequacy of treatment received by primary care patients with anxiety disorders

BACKGROUND

We examined the adequacy of pharmacotherapy and psychotherapy received by primary care patients with anxiety disorders over up to 5 years of follow-up.

METHOD

Five hundred thirty-four primary care patients at 15 US sites, who screened positive for anxiety symptoms, were assessed for anxiety disorders. Those meeting anxiety disorder criteria were offered participation and interviewed again at six and 12 months postintake, and yearly thereafter for up to 5 years. We utilized existing definitions of appropriate pharmacotherapy and created definitions of potentially adequate psychotherapy/cognitive-behavioral therapy (CBT).

RESULTS

At intake, of 534 primary care participants with anxiety disorders, 19% reported receiving appropriate pharmacotherapy and 14% potentially adequate CBT. Overall, 28% of participants reported receiving potentially adequate anxiety treatment, whether pharmacotherapy, psychotherapy, or both. Over up to five years of follow-up, appropriate pharmacotherapy was received by 60% and potentially adequate CBT by 36% of the sample. Examined together, 69% of participants received any potentially adequate treatment during the follow-up period. Over the course of follow-up, primary care patients with MDD, panic disorder with agoraphobia, and with medicaid/medicare were more likely to receive appropriate anxiety treatment. Ethnic minority members were less likely to receive potentially adequate care.

CONCLUSIONS

Potentially adequate anxiety treatment was rarely received by primary care patients with anxiety disorders at intake. Encouragingly, rates improved over the course of the study. However, potentially adequate CBT remained much less utilized than pharmacotherapy and racial-ethnic minority members were less likely to received care, suggesting much room for improved dissemination of quality treatment.

A systematic review of school-based suicide prevention programs

OBJECTIVE

Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs.

METHOD

Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion.

RESULTS

Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors.

CONCLUSIONS

There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.

The public's knowledge and beliefs about obsessive compulsive disorder

BACKGROUND

Obsessive compulsive disorder (OCD) is a disabling condition associated with significant personal and societal burdens. Despite the availability of efficacious treatments, in most cases, the disorder remains unrecognized and untreated. Lack of knowledge (i.e. poor mental health literacy, MHL) regarding OCD may be an impediment to seeking treatment. Therefore, the current study assessed public knowledge and beliefs about OCD and examined factors influencing MHL.

METHODS

Five hundred seventy-seven US adults participated in a telephone survey. After hearing a vignette describing someone with OCD, participants' MHL for OCD was assessed across three domains as follows: recognition of OCD, knowledge and beliefs about available help, and concerns about being negatively evaluated for reporting symptoms.

RESULTS

The majority of participants (90.9%) reported that the symptoms were a cause for concern and that the person in the vignette should seek professional help (89.5%). However, only one-third of respondents correctly labeled the disorder as OCD. More respondents were optimistic about the likely success of psychotherapy than medication, but primary care physicians were the most frequently reported source of professional help. Finally, less education, lower income, and being in an older cohort were associated with poorer recognition of OCD.

CONCLUSIONS

When presented with brief vignettes describing a person with OCD, most community members can recognize the benefits of seeking professional help. However, recognition of the disorder and knowledge of treatment options can be improved.

CBT competence in novice therapists improves anxiety outcomes

OBJECTIVE

This study explores the relationships between therapist variables (cognitive behavioral therapy [CBT] competence, and CBT adherence) and clinical outcomes of computer-assisted CBT for anxiety disorders delivered by novice therapists in a primary care setting.

METHODS

Participants were recruited for a randomized controlled trial of evidence-based treatment, including computer-assisted CBT, versus treatment as usual. Therapists (anxiety clinical specialists; ACSs) were nonexpert clinicians, many of whom had no prior experience in delivering psychotherapy (and in particular, very little experience with CBT). Trained raters reviewed randomly selected treatment sessions from 176 participants and rated therapists on measures of CBT competence and CBT adherence. Patients were assessed at baseline and at 6-, 12-, and 18-month follow-ups on measures of anxiety, depression, and functioning, and an average Reliable Change Index was calculated as a composite measure of outcome. CBT competence and CBT adherence were entered as predictors of outcome, after controlling for baseline covariates.

RESULTS

Higher CBT competence was associated with better clinical outcomes whereas CBT adherence was not. Also, CBT competence was inversely correlated with years of clinical experience and trended (not significantly, though) down as the study progressed. CBT adherence was inversely correlated with therapist tenure in the study.

CONCLUSIONS

Therapist competence was related to improved clinical outcomes when CBT for anxiety disorders was delivered by novice clinicians with technology assistance. The results highlight the value of the initial training for novice therapists as well as booster training to limit declines in therapist adherence.