Effective services are needed to assist young people with serious mental health conditions to successfully transition to employment or education, especially among those with intensive adolescent mental health service utilization. To meet these needs, the Individual Placement and Support (IPS) model of supported employment was adapted and its feasibility was tested in a psychiatric treatment program for early-emerging adults. Participants were 17-20 years old (mean age = 18.5 years). Most were African American, under the custody of the state, with a primary mood disorder diagnosis. Adaptations to IPS included adding the following: near age peer mentors, a supported education component, and a career development focus. This open trial feasibility study tracked the model's development, recruitment, and retention and tracked vocational and educational outcomes for 12 months. Model refinement resulted in the development of a separate educational specialist position, greater integration of the peer mentor with the vocational team, and further specification of the role of peer mentor. There was an 80% retention rate in the feasibility evaluation. Of the 35 participants, 49% started a job and/or enrolled in an education program over the 12-month period.
BACKGROUND: Research on the motivations of research participants has focused primarily on vulnerable populations at risk of exploitation, and there is little research on the motivations and reasons of general medical patients participating in research. Given a significant increase in research studies recruiting participants with diabetes, we sought to better understand the motivations of patients with diabetes considering a general medical research protocol.
METHODS: The analyses presented here compare the reasoning and willingness to participate in a hypothetical research study of medically ill subjects (patients with diabetes, n=51) with non-ill (n=57) subjects. Responses on the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) were correlated with demographic variables and scores on the Mini-Mental State Examination (MMSE) and Short-Form-36 (SF-36). RESULTS: Overall, 44% of the group with diabetes and 56% of the comparison group indicated a willingness to participate in the research study. The reasons diabetic and comparison groups offered for willingness or unwillingness to participate in research did not differ significantly. 75% mentioned reasons related to treatment, 63% altruism; none mentioned money. Of those patients with diabetes who would not participate in research, 94% cited risk, and 89% expressed an aversion to research.
CONCLUSIONS: The present study suggests that when research is not related to their diagnosis, persons with diabetes do not differ significantly from non-ill comparison subjects in their motivations to participate in research. Given the similarity of our subjects' motivations to those of other medically ill populations, it may be that investigators can now focus more closely on the decision-making characteristics of their patients involved in clinical research rather than their diagnoses.
Developing a community-based participatory research model to engage transition age youth using mental health service in research
We present a model for the development and conduct of a community-based participatory research project with transition age youth (TAY) mental health service users. Community-based participatory research frameworks can facilitate equitable partnerships and meaningful inclusion but have not been fully drawn upon in mental health research. The model included TAY as trained research associates involved in every aspect of the research process. We describe the development of the project, creation of the research team, training, the design and conduct of the study, and challenges faced. The methods developed successfully provided support for the meaningful participation of TAY in the project.
INTRODUCTION: Medication assisted treatment for opioid dependence alters the pain experience. This study will evaluate changes pain sensitivity and tolerance with opioid treatments; and duration of this effect after treatment cessation.
METHOD: 120 Individuals with chronic pain were recruited in 4 groups (N = 30): 1-methadone for opioid addiction; 2-buprenorphine for opioid addiction; 3-history of opioid maintenance treatment for opioid addiction but with prolonged abstinence (M = 121 weeks; SD = 23.3); and 4-opioid naive controls. Participants completed a psychological assessment and a cold water task including, time to first pain (sensitivity) and time to stopping the pain task (tolerance). Data analysis used survival analyses.
RESULTS: A Kaplan-Meier-Cox survival analysis showed group differences for both pain sensitivity (log rank = 15.50; p < .001) and tolerance (log rank = 20.11; p < .001). Current or historical use of opioid maintenance resulted in differing pain sensitivity compared to opioid naive (p's < .01). However, tolerance to pain was better among those with a history of opioid maintenance compared to active methadone patients (p < .05), with the highest tolerance found among opioid naive control group participants (p's < .001). Correlations within the prolonged abstinent group indicated pain tolerance was significantly improved as length of opioid abstinence increased (R = .37; p < .05); but duration of abstinence did not alter sensitivity (ns).
CONCLUSION: Among individuals with a history of prolonged opioid maintenance, there appears to be long-term differences in pain sensitivity that do not resolve with discontinuation of opioid maintenance. Although pain sensitivity does not change, pain tolerance does improve after opioid maintenance cessation. Implications for treating co-morbid opioid addiction and pain (acute and chronic) are discussed.
BACKGROUND: Recent studies have indicated that the 11-item Psychotic Depression Assessment Scale (PDAS), consisting of the 6-item melancholia subscale (HAM-D6) of the Hamilton Depression Rating Scale and 5 psychosis items from the Brief Psychiatric Rating Scale (BPRS), is a valid measure for the severity of psychotic depression. The aim of this study was to subject the PDAS, and its depression (HAM-D6) and psychosis (BPRS5) subscales to further validation.
METHODS: Patients diagnosed with psychotic depression at Danish psychiatric hospitals participated in semi-structured interviews. Video recordings of these interviews were assessed by two experienced psychiatrists (global severity rating of psychotic depression, depressive symptoms and psychotic symptoms) and by two young physicians (rating on 27 symptom items, including the 11 PDAS items). The clinical validity and responsiveness of the PDAS and its subscales was investigated by Spearman correlation analysis of the global severity ratings and the PDAS, HAM-D6, and BPRS5 total scores. The unidimensionality of the scales was tested by item response theory analysis (Mokken).
RESULTS: Ratings from 39 participants with unipolar psychotic depression and nine participants with bipolar psychotic depression were included in the analysis. The Spearman correlation analysis indicated that the PDAS, HAM-D6 and BPRS5 were clinically valid (correlation coefficients from 0.78 to 0.85, p < 0.001) and responsive (correlation coefficients from 0.72 to 0.86, p < 0.001) measures of psychotic depression. According to the Mokken analysis, all three scales were unidimensional.
CONCLUSIONS: The clinical validity, responsiveness and unidimensionality of the PDAS and its subscales were confirmed in an independent sample of patients with psychotic depression.
Psychophysiology of pain and opioid use: implications for managing pain in patients with an opioid use disorder
BACKGROUND: Opioid therapy is one component of an effective pain management regimen for patients with chronic pain and the majority of these patients use their medications responsibly. However, there are a growing number of these patients who develop an opioid use disorder and in some cases require opioid replacement therapy. Managing these patients is complex and the underlying mechanisms of pain and addiction are not well understood. Developing an effective interdisciplinary treatment program for the individual with pain and an opioid use disorder will depend on enhancing our knowledge of the psychophysiology of pain and addiction.
METHOD: Authors gathered key empirical and theoretical papers examining the psychophysiology of comorbid pain and opioid misuse disorders. RESULTS: This article reviews the current theory of the effect of pain on patients with pain and concomitant addiction, the psychophysiology of pain, opioid use and addiction, and future research in this area.
CONCLUSIONS: Individuals with a history of opioid misuse have greater levels of hyperalgesia which may be due to alterations in psychophysiological pathways. More research is needed into the psychophysiological biomarkers among individuals with comorbid pain and addiction in order to develop better treatment approaches and improve outcomes among this difficult to treat population.
Acceptance and commitment therapy smoking cessation treatment for veterans with posttraumatic stress disorder: a pilot study
OBJECTIVE: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking.
METHODS: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms.
RESULTS: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at three-month follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up.
CONCLUSIONS: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial.
OBJECTIVE: During the transition to adulthood, youths face challenges that may limit their likelihood of obtaining services for psychiatric problems. The goal of this analysis was to estimate changes in rates of service use and untreated psychiatric disorders during the transition from adolescence to adulthood.
METHODS: In a prospective, population-based study, participants were assessed up to four times in adolescence (ages 13-16; 3,983 observations of 1,297 participants, 1993-2000) and three times in young adulthood (ages 19, 21, and 24-26; 3,215 observations of 1,273 participants, 1999-2010). Structured diagnostic interviews were used to assess service need (participants meeting DSM-IV diagnostic criteria for a psychiatric disorder) and use of behavioral services in 21 service settings in the past three months.
RESULTS: During young adulthood, 28.9% of cases of psychiatric disorders were associated with some treatment, compared with a rate of 50.9% for the same participants during adolescence. This decrease included a near-complete drop in use of educational and vocational services as well as declines in use of specialty behavioral services. Young adults most frequently accessed services in specialty behavioral or general medical settings. Males, African Americans, participants with substance dependence, and participants living independently were least likely to get treatment. For cases of psychiatric disorders among young adults, insurance and poverty status were unrelated to likelihood of service use.
CONCLUSIONS: Young adults were much less likely to receive treatment for psychiatric problems than they were as adolescents. Public policy must address gaps in service use during the transition to adulthood.
Assessing psychopathy among justice involved adolescents with the PCL:YV: an item response theory examination across gender
This study used an item response theory (IRT) model and a large adolescent sample of justice involved youth (N = 1,007, 38% female) to examine the item functioning of the Psychopathy Checklist-Youth Version (PCL: YV). Items that were most discriminating (or most sensitive to changes) of the latent trait (thought to be psychopathy) among adolescents included "glibness/superficial charm," "lack of remorse," and "need for stimulation," whereas items that were least discriminating included "pathological lying," "failure to accept responsibility," and "lacks goals." The items "impulsivity" and "irresponsibility" were the most likely to be rated high among adolescents, whereas "parasitic lifestyle," and "glibness/superficial charm" were the most likely to be rated low. Evidence of differential item functioning (DIF) on 4 of the 13 items was found between boys and girls. "Failure to accept responsibility" and "impulsivity" were endorsed more frequently to describe adolescent girls than boys at similar levels of the latent trait, and vice versa for "grandiose sense of self-worth" and "lacks goals." The DIF findings suggest that 4 PCL: YV items function differently between boys and girls.
Case report about a complex case of perinatal psychiatric illness.
Contrary to popular perception, young adults-ages approximately 18-26 years-are surprisingly unhealthy. They are less healthy than adolescents, and they also show a worse health profile than those in their late 20s and 30s. The Affordable Care Act provisions to extend coverage for young adults are well known, and some states had already been pursuing similar efforts before the Affordable Care Act was enacted. These initiatives have resulted in important gains in young adults' heath care coverage. However, too little attention has been paid to the care that young adults receive once they are in the system. Given young adults' health problems, this is a critical omission. The Institute of Medicine and National Research Council recently released a report titled Investing in the Health and Well-Being of Young Adults. The report concludes that young adulthood is a critical developmental period and recommends that young adults ages 18-26 years be treated as a distinct subpopulation in policy, planning, programming, and research. The report also recommends action in three priority areas to improve health care for young adults: improving the transition from pediatric to adult medical and behavioral health care, enhancing preventive care for young adults, and developing evidence-based practices. Elsevier Inc. All rights reserved.
Predictors of outpatient mental health clinic follow-up after hospitalization among Medicaid-enrolled young adults
AIM: To assess demographic and clinical predictors of outpatient mental health clinic follow-up after inpatient psychiatric hospitalization among Medicaid-enrolled young adults.
METHODS: Using logistic regression and administrative claims data from the Maryland public mental health system and Maryland Medicaid for young adults ages 18-26 who were enrolled in Medicaid (N = 1127), the likelihood of outpatient mental health follow-up within 30 days after inpatient psychiatric hospitalization was estimated .
RESULTS: Only 51% of the young adults had any outpatient mental health follow-up visits within 30 days of discharge. Being black and having a co-occurring substance use disorder diagnosis were associated with a lower probability of having a follow-up visit (OR = 0.60, P < 0.01 and OR = 0.36, P < 0.01, respectively). In addition, those who utilized any outpatient public mental health services during the 180 days prior to their index hospitalization (N = 625, 55.4%) were more likely to have a follow-up visit than those without prior outpatient use (OR = 2.45, P < 0.01). Prior Medicaid-reimbursed primary care visits were not significantly associated with follow-up.
CONCLUSIONS: In this predominantly urban, low-income statewide sample of young adults hospitalized for serious psychiatric conditions, half did not connect with an outpatient mental healthcare provider following their discharge. Outpatient transition supports may be especially needed for young adults who were not receiving outpatient services prior to being admitted for psychiatric inpatient care, as well as for young adults with substance use disorders and African Americans.
In this short communication, attendees will: 1. Be able to recognize examples of successful collaboration between an academic health sciences library and the medical school curriculum 2. Discover methods to develop similar collaborative initiatives at other medical schools.
In 2010, the University of Massachusetts Medical School (UMMS) introduced a new, integrative curriculum. This curriculum includes a mandatory culminating experience called the Capstone Scholarship and Discovery Course (CSD). The CSD ensures that every graduating student completes an individualized, mentored, scholarly project that builds on their personal passion and medical school experience. Librarians in the Lamar Soutter Library (LSL) have become incorporated into the CSD in ways that capitalize on our research and information management skills. Most mentoring for the CSD occurs within one of five Learning Communities or "houses.” A librarian is assigned to each house so that every student has a “personal librarian” to consult as they formulate their hypothesis, conduct their literature review, and design their data management plan. In 2014, the LSL partnered with a 2nd year student to construct an online guide on effective scientific and scholarly writing for the CSD.
As each student begins their 1st year at UMMS, they are assigned to one of five houses. As they begin their CSD projects in year 1, they are encouraged to meet with their house librarian to develop research and data management plans. Students and faculty have welcomed this collaboration and have sought ways to continue to highlight this unique mentoring relationship. Two such initiatives were the creation of an online scientific writing guide and a video project where librarians discuss the importance of sound research methodologies in CSD projects.
The writing guide, launched at the start of the 2014-15 academic year, is prominently linked from the library's medical student portal. This portal is the third most visited of 46 existing subject guides which gives this content significant exposure going forward. The Lamar Soutter Library continually seeks ways to interact with our student body. This collaborative effort highlights how these relationships continue to be forged.
Normal bone remodeling depends upon a balance between the action of bone-resorbing cells, osteoclasts, and bone-forming cells, osteoblasts. When this balance is disrupted, as is seen in inflammatory diseases such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS), abnormal bone loss or bone formation occurs. In RA, proinflammatory cytokines induce osteoclast differentiation and inhibit osteoblast maturation, leading to articular bone erosions. In contrast, the inflammatory milieu in AS leads to excessive osteoblast activation and bone formation at sites of entheses. While much information exists about the effects of proinflammatory cytokines on osteoclast differentiation and function, more recent studies have begun to elucidate the impact of inflammation on the osteoblast. This review will summarize the mechanisms by which inflammation perturbs bone homeostasis, with a specific focus on the osteoblast.
Bone erosion is a central feature of rheumatoid arthritis and is associated with disease severity and poor functional outcome. Erosion of periarticular cortical bone, the typical feature observed on plain radiographs in patients with rheumatoid arthritis, results from excessive local bone resorption and inadequate bone formation. The main triggers of articular bone erosion are synovitis, including the production of proinflammatory cytokines and receptor activator of nuclear factor kappaB ligand (RANKL), as well as antibodies directed against citrullinated proteins. Indeed, both cytokines and autoantibodies stimulate the differentiation of bone-resorbing osteoclasts, thereby stimulating local bone resorption. Although current antirheumatic therapy inhibits both bone erosion and inflammation, repair of existing bone lesions, albeit physiologically feasible, occurs rarely. Lack of repair is due, at least in part, to active suppression of bone formation by proinflammatory cytokines. This Review summarizes the substantial progress that has been made in understanding the pathophysiology of bone erosions and discusses the improvements in the diagnosis, monitoring and treatment of such lesions.
As very effective targeted biological therapies have become available to treat rheumatoid arthritis (RA), remission is now the goal of treatment. Since 1981, efforts have been undertaken to develop criteria for clinical remission in RA. Although several different measures of disease activity have been proposed, many issues remain unresolved. Active joint inflammation, even if involving only a few joints, negatively impacts a patient's quality of life and may ultimately result in structural damage. Thus, a low disease activity state (LDAS), which has been adopted as the target in clinical trials of 'treat to target', may not be the optimal treatment target in clinical practice. Similarly, the definitions of remission used in clinical trials may not be appropriate for use in daily clinical practice because some allow for the presence of several tender and swollen joints. Measures of disease activity do not necessarily correlate with structural remission, which implies halting progression of radiographic evidence of damage over time. Because no single measure of RA disease activity fully quantifies the global burden of disease, rheumatologists must follow multiple parameters to assess disease activity thoroughly and to adjust treatment optimally.
Repair of bone erosions in rheumatoid arthritis has been considered a difficult goal to achieve. However—with better therapies at hand to control synovial inflammation—sensitive μCT imaging techniques now available confirm that repair of bone erosion is possible, and begins at the base of erosive lesions.
In rheumatoid arthritis (RA), cells within the inflamed synovium and pannus elaborate a variety of cytokines, including tumor necrosis factor (TNF) alpha, interleukin (IL)-1, IL-6, and IL-17, that contribute to inflammation, and may directly affect bone. The receptor activator of NF-kappaB (RANK) ligand/RANK/osteoprotegerin pathway plays a critical role in regulating osteoclastogenesis in articular bone erosions in RA. Proinflammatory cytokines can modulate this pathway, and may also affect the ability of the osteoblast to repair bone at sites of articular erosion. In this review, the authors discuss the current understanding of pathogenic mechanisms of bone erosion in RA and examine current therapeutic approaches to prevent this damage.
The past decade has observed an explosion of new information regarding the impact of inflammation on bone. In rheumatic diseases, several factors that act as both immune modulators and regulators of bone homeostasis have been shown to mediate an imbalance in bone resorption and bone formation resulting in joint degeneration. In rheumatoid arthritis (RA), focal bone loss is due to excess bone resorption by osteoclasts. Resorption is mediated in part by increased local expression of the cytokine receptor activator of nuclear factor-kappaB ligand (RANKL) compared with expression of its decoy receptor osteoprotegerin (OPG). Bone formation by osteoblasts is also impaired at erosion sites in RA, and inhibitors of the canonical Wingless (Wnt) signaling pathway, including DKK1, have been implicated in the suppression of normal osteoblast function at these sites. Inhibition of DKK1 in an animal model of RA attenuated bone erosion by increasing OPG expression as well as promoting bone formation. In contrast to RA, inflammation in the spondyloarthropathies often results in excess periosteal bone formation, highlighting that the net impact of inflammation on bone is specific to the site at which inflammation occurs, and the cell types, cytokines, and factors present within the local bone microenvironment. This fertile area of research bears watching for the identification of novel targets for the prevention of abnormal bone remodeling in inflammatory diseases.
Rheumatoid arthritis, juvenile idiopathic arthritis, the seronegative spondyloarthropathies including psoriatic arthritis, and systemic lupus erythematosus are all examples of rheumatic diseases in which inflammation is associated with skeletal pathology. Although some of the mechanisms of skeletal remodeling are shared among these diseases, each disease has a unique impact on articular bone or on the axial or appendicular skeleton. Studies in human disease and in animal models of arthritis have identified the osteoclast as the predominant cell type mediating bone loss in arthritis. Many of the cytokines and growth factors implicated in the inflammatory processes in rheumatic diseases have also been demonstrated to impact osteoclast differentiation and function either directly, by acting on cells of the osteoclast-lineage, or indirectly, by acting on other cell types to modulate expression of the key osteoclastogenic factor receptor activator of nuclear factor (NF) kappaB ligand (RANKL) and/or its inhibitor osteoprotegerin (OPG). Further elucidation of the mechanisms responsible for inflammation-induced bone loss will potentially lead to the identification of novel therapeutic strategies for the prevention of bone loss in these diseases. In this review, we provide an overview of the cell types, inflammatory mediators, and mechanisms that are implicated in bone loss and new bone formation in inflammatory joint diseases.