Faculty Bibliography

Despite high rates of trauma exposure (46%-96%) and significant posttraumatic stress disorder (PTSD; 21%-29%) symptoms in adolescent psychiatric inpatients, there is a dearth of research on effective interventions delivered in inpatient settings. The current report describes the development of Brief STAIR-A, a repeatable 3-module version of skills training in affective and interpersonal regulation (STAIR) developed for adolescents in inpatient care. An uncontrolled design was used to conduct a preliminary examination of the group intervention's effectiveness. Adolescent psychiatric inpatients (N = 38; ages 12 years-17 years) admitted to a public hospital participated in Brief STAIR-A and attended a median of 6 sessions (range 3-36). They completed measures of PTSD and depressive symptom severity, coping skill use, and coping efficacy upon admission and again prior to discharge. Participants reported significant reductions in symptom severity (d = 0.65-0.67), no change in the absolute level of coping skills used (d = 0.16), but greater coping efficacy when discharged from care (d = 0.75). Results from this pilot study suggest that this brief group treatment shows promise for treating adolescents' trauma-related difficulties in inpatient psychiatry settings, but additional research examining its effectiveness is essential.

Traumatic experience and posttraumatic stress disorder (PTSD) is highly prevalent among adolescents hospitalized in psychiatric facilities and also among those who are incarcerated. However, it is often not detected in the course of routine evaluations, even those done by mental health professionals. Lack of recognition of trauma exposure and PTSD in hospitalized or incarcerated adolescents has serious implications. The severe behavior problems that result in hospitalizations or incarceration may actually be the result of emotional dysregulation, which is one of the core PTSD problems. This article describes strategies for integrating and evaluating systematic screening, assessment and developmentally appropriate interventions in a public hospital and juvenile justice settings. While research on these interventions is ongoing, preliminary findings have been positive. It is essential that the important role that trauma plays in severe psychopathology be recognized and effectively addressed if we are to help these young people change their trajectory from one of continued victimization to one of effective self-regulation.

This presentation reviewed clinical issues related to the under-recognition of trauma exposure and PTSD in acute care settings serving children and adolescents and describes strategies for integrating and evaluating systematic screening and developmentally appropriate intervention in the inpatient milieu. In addition, it reviewed clinical characteristics of a sample of adolescent inpatients identified with probable PTSD. 2012 Bentham Science Publishers

Trauma exposure and posttraumatic stress disorder (PTSD), though prevalent among adolescent psychiatric inpatients, are underidentified in standard clinical practice. In a retrospective chart review of 140 adolescents admitted to a psychiatric inpatient unit, we examined associations between probable PTSD identified through the Child PTSD Symptom Scale and adolescents' service use and clinical characteristics. Results suggest a large discrepancy between rates of probable PTSD identified through standardized assessment and during the emergency room psychiatric evaluation (28.6% vs. 2.2%). Adolescents with probable PTSD had greater clinical severity and service utilization, an increased likelihood of being diagnosed with bipolar disorder (27.5% vs. 9.2%) and being prescribed antipsychotic medications (47.5% vs. 27.6%), and were prescribed more psychotropic medications. Upon discharge, those with probable PTSD were more than those without to be assigned a diagnosis of PTSD (45% vs. 7.1%), a comorbid diagnosis of major depressive disorder (30% vs. 14.3%), to be prescribed an antidepressant medication (52.5% vs. 33.7%), and to be prescribed more medications. The underidentification of trauma exposure and PTSD has important implications for the care of adolescents given that accurate diagnosis is a prerequisite for providing effective care. Improved methods for identifying trauma-related problems in standard clinical practice are needed.

The renin-angiotensin system (RAS) and its active peptide angiotensin II (AngII) have major involvements not only in hypertension but also in mood and anxiety disorders. Substantial evidence supports the notion that AngII acts as a neuromodulator in the brain. In this review, we provide an overview of the link between the RAS and anxiety or mood disorders, and focus on recent advances in the understanding of AngII-linked, NADPH oxidase-derived oxidative stress in the central nervous system, which may underlie pathogenesis of mood and anxiety disorders.

An implementation study of cognitive-behavioral therapies (CBT) was conducted for traumatized youth in a postdisaster context. Headed by the New York State Office of Mental Health, the study targeted youth (N = 306) ages 5-21 affected by the World Trade Center disaster. They received either trauma-specific CBT or brief CBT skills depending upon the severity of trauma symptoms. Clinicians were trained to deliver these interventions and received monthly consultation. A regression discontinuity design was used to assess optimal strategies for matching need to service intensity. At 6-months postbaseline, both groups had improved. Rate of change was similar despite differences in severity of need. The implications for the implementation of evidence-based treatments postdisaster are discussed

This paper examines factors associated with adherence to antiretroviral medications (ARVs) in an HIV-infected population at high risk for non-adherence: individuals living with psychiatric and substance abuse disorders. Data were examined from baseline interviews of a multisite cohort intervention study of 1138 HIV-infected adults with both a psychiatric and substance abuse disorder (based on a structured psychiatric research interview using DSM-IV criteria). The baseline interview documented mental illness and substance use in the past year, mental illness and substance abuse severity, demographics, service utilization in the past three months, general health and HIV-related conditions, self-reported spirituality and self-reported ARV medication use. Among the participants, 62% were prescribed ARVs at baseline (n = 542) and 45% of those on ARVs reported skipping medications in the past three days. Reports of non-adherence were significantly associated with having a detectable viral load (p<.01). The factors associated with non-adherence were current drug and alcohol abuse, increased psychological distress, less attendance at medical appointments, non-adherence to psychiatric medications and lower self-reported spirituality. Increased psychological distress was significantly associated with non-adherence, independent of substance abuse (p<.05). The data suggest that both mental illness and substance use must be addressed in HIV-infected adults living with these co-morbid illnesses to improve adherence to ARVs

The Child and Adolescent Trauma Treatments and Services Consortium (CATS) was the largest youth trauma project associated with the September 11 World Trade Center disaster. CATS was created as a collaborative project involving New York State policymakers; academic scientists; clinical treatment developers; and routine practicing clinicians, supervisors, and administrators. The CATS project was established to deliver evidence-based cognitive-behavioral trauma treatments for children and adolescents affected by the September 11 terrorist attack in New York City and to examine implementation processes and outcomes associated with delivery of these treatments. Referrals were obtained on 1,764 children and adolescents; of these, 1,387 were subsequently assessed with a standardized clinical battery and 704 found to be eligible for services. Ultimately 700 youth participated in the project. Treatments were delivered in either school or clinic settings by clinicians employed in 9 provider organizations in New York City. All participating clinicians were trained on the cognitive behavioral therapy models by the treatment developers and received case consultation for 18 months by expert clinician consultants and the treatment developers. The challenges of mounting a large trauma treatment project within routine clinical practices in the aftermath of a disaster and simultaneously evaluating the project have been significant. We outline the major challenges, describe strategies we employed to address them, and make recommendations based on critical lessons learned

Cross-sectional studies to date that examine psychosocial correlates of antiretroviral adherence have insufficiently addressed the challenges of long-term adherence. This longitudinal study examined mental health, substance abuse, and psychosocial predictors of long-term adherence to antiretroviral medications and medical appointments among HIV-seropositive mothers recruited from an infectious disease clinic of a large urban medical center. Individual interviews were conducted at baseline and two follow-up points, 8 to 18 months after enrollment. Based on a model of health behavior, we examined psychiatric and psychosocial predictors of adherence to antiretroviral medications and medical appointments over time. Presence of a psychiatric disorder, negative stressful life events, more household members, and parenting stress were significantly associated with both missed pills and missed medical appointments at follow-up. Baseline substance abuse was associated with missed pills at follow-up and lack of disclosure to family members at baseline was associated with missed medical appointments at follow-up. These findings suggest that interventions that integrate mental health, substance abuse and medical care may be important to improving the medical adherence and health of HIV-seropositive women, particularly in multistressed populations with substantial caregiving and other life demands.