Treatment As Usual Group Research Articles

Post-traumatic growth in adult survivors of brain injury: a qualitative study of participants completing a pilot trial of brief positive psychotherapy

Purpose: Post-traumatic growth (PTG) can occur following acquired brain injury (ABI). It has been proposed that people experiencing psychological distress following ABI may benefit from a positive psychotherapy intervention (PPT) aimed at increasing well-being; PPT may also influence PTG. We aimed to investigate PTG experiences in participants of a positive psychotherapy pilot trial.Methods: ABI survivors who had received PPT or treatment as usual (TAU) were interviewed individually after the end of the trial. Thematic analysis was conducted, to code transcripts for known themes from PTG literature as well as newly emerging themes.Results: Four participants (age = 46–62; n = 3 male; months since injury = 11–20) from the PPT group and three (age = 58–74; n = 2 male; months since injury = 9–22) from the TAU group were interviewed. Six themes were shared across both groups: personal strength, appreciation of life, relating to others, optimism/positive attitude, feeling fortunate compared to others, and positive emotional/behavioral changes. Two themes were expressed by PPT participants only: lifestyle improvements and new possibilities. One TAU participant reported spiritual change.Conclusions: A greater understanding of the development of PTG following ABI may help rehabilitation clinicians to promote better adjustment by focusing on clients’ potential for positive change and enhancing their capacity for growth.Implications for RehabilitationPost-traumatic growth is “positive psychological change experienced as the result of the struggle with highly challenging life circumstances.”This is the first qualitative investigation of post-traumatic growth in participants in a positive psychotherapy trial following acquired brain injury.Several post-traumatic growth themes were shared by participants from the positive psychotherapy and treatment as usual study arms, with additional themes evident only in positive psychotherapy participants.A greater understanding of post-traumatic growth among rehabilitation professionals may help to promote adjustment following brain injury.

Using Problem-Solving Therapy to Reduce Depressive Symptom Severity Among Older Adult Methadone Clients

Objective: Treatment of older adults in methadone maintenance treatment (MMT) with comorbid mood disorders presents many challenges. The goal of this randomized controlled trial was to assess the combined effect of problem-solving therapy (PST) with treatment as usual (TAU) compared to TAU alone on decreasing depressive symptoms in opioid-addicted older adults in MMT. Methods: Sixty-four methadone clinic attendees, at least 50 years old, with moderate depressive symptom were randomized to PST + TAU ( n = 29) or TAU ( n = 35). PST is an intervention for depressed older adults with a focus on teaching problem-solving skills. Results: There was not a statistically significant difference in depression scores between the two treatment groups. However, there is evidence for a clinically meaningful decrease in symptoms in the PST + TAU group 7 months post treatment (Cohen’s d = .57) Conclusion: Clinical implications of PST + TAU in comparison to TAU on depressive symptom seemed to have lasting benefits at 6-month post treatment.

Rehabilitación del reconocimiento de emociones combinada con estimulación cognitiva para personas con enfermedad de Alzheimer. Eficacia sobre aspectos cognitivos y funcionales

The ability to recognize facial emotional expression is essential for social interactions and adapting to the environment. Emotion recognition is impaired in people with Alzheimer's disease (AD), thus rehabilitation of these skills has the potential to elicit significant benefits. To assess the efficacy of a combined treatment of rehabilitation of emotion recognition (RER) and cognitive stimulation (CS) for people with AD, due to its potential implications for more effective psychosocial interventions. 36 patients were assigned to one of three experimental conditions: an experimental group (EG) that received 20 sessions of RER and 20 sessions of CS; a control group (CG) that received 40 sessions of CS, and a treatment as usual group (TAU). 32 patients completed the treatment (77.53 ± 5.43 years). Significant differences were found in MMSE30 (F = 5.10; p = 0.013), MMSE35 (F = 4.16; p = 0.026), affect recognition (Z = -2.81; p = 0.005) and basic activities of daily living (Z = -2.27; p = 0.018) favouring the efficacy of the combined treatment. The TAU group showed a decline in depression (Z = -1.99; p = 0.048), apathy (Z = -2.30; p = 0.022) and anosognosia (Z = -2.19; p = 0.028). The combined treatment of RER + CS was more effective than TAU and CS alone for the treatment of patients with AD. This is the first study about the rehabilitation of affect recognition in AD.

Randomized, controlled trial of a brief family-centred care programme for hospitalized patients with bipolar disorder and their family caregivers.

Family interventions have been emphasized in the treatment of bipolar disorder (BPD) due to the bidirectional and entangled relationships between patients and the family system, and have benefits for patients' symptoms and health; however, the effects of family interventions on family function and caregivers' health-related outcomes have not been well investigated. This randomized, controlled trial with 47 hospitalized patients with BPD/family caregiver dyads at a medical centre in northern Taiwan compared the effects of a brief family-centred care (BFCC) programme with treatment as usual (TAU). All of the family caregivers in two groups were invited to attend a routine 60-min family discussion group about violence and suicide prevention. The TAU group without specific family interview for patient and family caregiver dyad. In the BFCC group, four 90-min BFCC programme sessions were additionally provided twice a week for each hospitalized family dyad. We hypothesized that, first, family caregivers in the BFCC group could increase their family function, and second, improve perceived health status and reduce caregiver's burdens compared to the TAU. The results showed that family caregivers in the BFCC group significant interaction effects in overall family function (P=0.03) and subscale conflict (P=0.04), communication (P=0.01), and problem-solving (P=0.04), but there were no significant interaction effects on the caregivers' perceived health status and caregivers' burdens. Our findings support both the feasibility of using the BFCC programme for inpatients and its specific benefits for family function. An intensive family intervention during hospitalization has been suggested in psychiatric practice to support patients with BPD and family caregivers.

The Effect of Pivotal Response Treatment in Children with Autism Spectrum Disorders: A Non-randomized Study with a Blinded Outcome Measure

Purpose of this quasi-experimental trial was to investigate the effect of Pivotal response treatment (PRT) versus treatment as usual (TAU) on autism symptoms. Children with autism spectrum disorder (ASD), aged 3–8 years, received either PRT (n = 11) or TAU (n = 13). Primary outcome measure was the total score on the Autism Diagnostic Observation Schedule at pre- and posttreatment. Additionally, general problem behavior and parental stress levels were measured. Children in the PRT condition improved on the primary outcome measure compared to the TAU group with a small effect size [partial η2 = 0.22 (95 % CI 0.00–0.46)]. Neither group demonstrated significant changes in the secondary outcomes. This study suggests that PRT may improve autism symptoms in children with ASD over TAU.

CBT for Ultra-High-Risk Patients Lowers Incidence of Psychosis

CBT for Ultra-High-Risk Patients Lowers Incidence of Psychosis

Effectiveness of Group Format Parent-Child Interaction Therapy Compared to Treatment as Usual in a Community Outreach Organization

ABSTRACTForty-four participants recruited from a community outreach organization were assigned to receive either group format Parent-Child Interaction Therapy (PCIT) or group format treatment as usual (TAU). The expected interaction between time and condition was such that participants in the PCIT group experienced a significantly greater decrease in internalizing and externalizing behavior problems compared to participants in the TAU group. This interaction was not significant regarding parenting stress or child abuse potential between the PCIT and TAU conditions. There was a significant increase in positive caregiver skills from pretreatment to posttreatment for the PCIT group; however, there was not a significant decrease in caregiver negative talk.

A Randomized Controlled Trial of the Say Yes to Life (SYTL) Positive Psychology Group Psychotherapy Program for Depression: An Interim Report

An RCT was conducted to evaluate the effectiveness of the Say Yes to Life (SYTL) positive psychology group psychotherapy program compared with treatment as usual (TAU). The current interim report is based on data from the first 82 cases recruited into the trial. There were 57 trial completers at post-treatment. At pretreatment on demographic and clinical variables, there were no significant differences between trial completers and dropouts in SYTL and TAU groups. There were two main significant (p < .01) findings. Compared with TAU treatment-completers, more than twice as many SYTL treatment-completers (28 vs. 72 %) were recovered 3 months after therapy using stringent recovery criteria (no longer meeting DSM-5 diagnostic criteria for major depressive disorder and scoring below clinical cut-off scores on the Beck Depression Inventory II, the Hamilton Rating Scale for Depression, and the Montgomery–Asberg Depression Rating Scale and showing reliable change on these three measures of depressive symptom severity). Second, the overall average service use cost per case in the SYTL group was significantly lower than that of the TAU group (€726 vs.€1187). This was largely due to the lower cost of the SYTL group therapy program compared with TAU which involved individual therapy. The pattern of results in an intention-to-treat analysis was similar to that in the completer analysis, though group difference did not reach significance due to inadequate statistical power and conservative missing data imputation procedures. It is planned to collect data on 100 trial completers, based on a power analysis.

A Developmental and Sequenced One-to-One Educational Intervention for Autism Spectrum Disorder: A Randomized Single-Blind Controlled Trial.

Individuals with autism spectrum disorder (ASD) who also exhibit severe-to-moderate ranges of intellectual disability (ID) still face many challenges (i.e., less evidence-based trials, less inclusion in school with peers). We implemented a novel model called the "Developmental and Sequenced One-to-One Educational Intervention" (DS1-EI) in 5- to 9-year-old children with co-occurring ASD and ID. The treatment protocol was adapted for school implementation by designing it using an educational agenda. The intervention was based on intensity, regular assessments, updating objectives, encouraging spontaneous communication, promoting skills through play with peers, supporting positive behaviors, providing supervision, capitalizing on teachers' unique skills, and providing developmental and sequenced learning. Developmental learning implies that the focus of training is what is close to the developmental expectations given a child's development in a specific domain. Sequenced learning means that the teacher changes the learning activities every 10-15 min to maintain the child's attention in the context of an anticipated time agenda. We selected 11 French institutions in which we implemented the model in small classrooms. Each institution recruited participants per dyads matched by age, sex, and developmental quotient. Patients from each dyad were then randomized to a DS1-EI group or a Treatment as usual (TAU) group for 36 months. The primary variables - the Childhood Autism Rating scale (CARS) and the psychoeducational profile (PEP-3) - will be blindly assessed by independent raters at the 18-month and 36-month follow-up. We enrolled 75 participants: 38 were randomized to the DS1-EI and 37 to the TAU groups. At enrollment, we found no significant differences in participants' characteristics between groups. As expected, exposure to school was the only significant difference [9.4 (±4.1) h/week in the DS1-EI group vs. 3.4 (±4.5) h/week in the TAU group, Student's t-test, t = 5.83, p < 0.001]. The protocol was authorized by the competent national regulatory authority (Agence nationale de sécurité du médicament et des produits de santé) and approved by the local Ethics Committee (Comité de Protection des Personnes) at the University Hospital Saint-Antoine (May 7, 2013). The findings will be disseminated through peer-reviewed journals and national and international conferences. ANSM130282B-31 (April 16 2013) and ACTRN12616000592448 (May 6 2016).

Factors influencing patients' recovery and the efficacy of a psychosocial post-discharge intervention: post hoc analysis of a randomized controlled trial.

The aim of this post hoc analysis was to examine self-reported recovery following a post-discharge intervention and to focus on the moderators of this intervention programme. RCT using parallel group block randomisation, including 151 patients with≤3 hospitalisations within the last 3years, a GAF score≤60, and aged 18-64years, assessed at two psychiatric hospitals from Zurich, Switzerland, between September 2011 and February 2014. In the present study, the main outcome was the OQ-45 as assessed prior to discharge from the index hospitalisation and at 12-month follow-up. Participants received either the post-discharge intervention provided by a social worker or treatment as usual (TAU). Patients in the intervention group showed substantially less recovery over the 12-month observation period than controls (d=0.44). In the TAU group, 15.6% remained clinically impaired at 12-month follow-up as opposed to 48.1% in the intervention group (p=0.001). Among participants in the intervention group, an interdisciplinary meeting of significant network members was associated with less recovery (d=0.46). Involuntary index admission (d=0.42) and high educational degree (d=0.52) were significant moderators of the intervention. Both factors related to less recovery over time in the intervention group relative to TAU. According to the OQ-45, this psychosocial post-discharge intervention revealed an unintended negative effect on self-reported recovery over time. Specifically, the meeting of significant network members related to a moderate deteriorating effect, suggesting that the involvement of some carers, relatives, or friends may cause harm to the patient. Considering with reservation pending replication, these findings could have important implications for brief interventions targeted at patients' social networks. This study was supported by a private foundation. ISRCTN58280620.

How did a Housing First intervention improve health and social outcomes among homeless adults with mental illness in Toronto? Two-year outcomes from a randomised trial.

ObjectivesWe studied the impact of a Housing First (HF) intervention on housing, contact with the justice system, healthcare usage and health outcomes among At Home/Chez Soi randomised trial participants in Toronto, a city with an extensive service network for social and health services for individuals who are experiencing homelessness and mental illness.MethodsParticipants identified as high needs were randomised to receive either the intervention which provided them with housing and supports by an assertive community treatment team (HF+ACT) or treatment as usual (TAU). Participants (N=197) had in-person interviews every 3 months for 2 years.ResultsThe HF+ACT group spent more time stably housed compared to the TAU group with the mean difference between the groups of 45.8% (95% CI 37.1% to 54.4%, p<0.0001). Accounting for baseline differences, HF+ACT group showed significant improvements over TAU group for community functioning, selected quality-of-life subscales and arrests at some time points during follow-up. No differences between HF+ACT and TAU groups over the follow-up were observed for health service usage, community integration and substance use.ConclusionsHF for individuals with high levels of need increased housing stability and selected health and justice outcomes over 2 years in a city with many social and health services.Trial registration numberISRCTN42520374.

Efficacy and cost-effectiveness of a specialist depression service versus usual specialist mental health care to manage persistent depression: a randomised controlled trial

Persistent moderate or severe unipolar depression is common and expensive to treat. Clinical guidelines recommend combined pharmacotherapy and psychotherapy. Such treatments can take up to 1 year to show an effect, but no trials of suitable duration have been done. We investigated the efficacy and cost-effectiveness of outpatient-based, specialist depression services (SDS) versus treatment as usual (TAU) on depression symptoms and function. We did a multicentre, single-blind, patient-level, parallel, randomised controlled trial (RCT), as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) study, in three mental health outpatient settings in England. Eligible participants were in secondary care, were older than 18 years, had unipolar depression (with a current major depressive episode, a 17-item Hamilton Depression Rating Scale [HDRS17] score of ≥16, and a Global Assessment of Function [GAF] score of ≤60), and had not responded to 6 months or more of treatment for depression. Randomisation was stratified by site with allocation conveyed to a trial administrator, with research assessors masked to outcome. Patients were randomised (1:1) using a computer-generated pseudo-random code with random permuted blocks of varying sizes of two, four, or six to either SDS (collaborative care approach between psychiatrists and cognitive behavioural therapists for 12 months, followed by graduated transfer of care up to 15 months) or to the TAU group. Intention-to-treat primary outcome measures were changes in HDRS17 and GAF scores between baseline and 6, 12, and 18 months' follow-up. We will separately publish follow-up outcomes for months 24 and 36. Clinical efficacy and cost-effectiveness were examined from health and social care persp ectives at 18 months, as recommended by the National Institute for Health and Care Excellence. This trial is registered at ClinicalTrials.gov (NCT01047124) and the ISRCTN registry (ISRCTN10963342); the trial has ended. 307 patients were assessed for eligibility between Dec 21, 2009, and Oct 31, 2012. 94 patients were assigned to TAU and 93 patients to SDS, and were included in intention-to-treat analyses. The changes from baseline to 6 months in HDRS17 and GAF scores did not significantly differ between treatment groups (mean change difference in HDRS17 score -1·01 [95% CI -3·30 to 1·28], p=0·385; and in GAF score 1·33 [-2·92 to 5·57], p=0·538). Primary outcome data were available for 134 (72%) patients at 12 months. We noted no differences at 12 months' follow-up between SDS and TAU for mean HDRS17 score (14·8 [SD 7·9] in the SDS group vs 17·2 [7·3] in the TAU group, p=0·056) or GAF score (60·4 [11·7] vs 55·8 [12·7], p=0·064), and the changes from baseline to 12 months in HDRS17 and GAF scores did not significantly differ between treatment groups (mean change difference in HDRS17 score -2·45 [95% CI -5·04 to 0·14], p=0·064; and in GAF score 4·12 [-0·11 to 8·35], p=0·056). The mean change in HDRS17 score from baseline to 18 months was significantly improved in the SDS group compared with the TAU group (13·6 [SD 8·8] in the SDS group vs 16·1 [6·6] in the TAU group; mean change difference -2·96 [95% CI -5·33 to -0·59], p=0·015), but the GAF scores showed no significant differences between the groups (61·2 [SD 13·0] vs 57·7 [11·9]; mean change difference 3·82 [-9·3 to 8·57], p=0·113). We reported no deaths, but one (1%) patient was admitted to hospital for myocardial infarction, and three episodes of self-harm were reported in three (2%) patients (two receiving TAU, one receiving SDS care). The incremental cost-effectiveness ratio of SDS versus TAU was £43 603 per quality-adjusted life-year. Compared with usual specialist mental health secondary care, SDS might improve depression symptoms for patients with persistent moderate to severe depression, but functional outcomes and economic benefits are equivocal. National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, UK Medical Research Council, Nottinghamshire Healthcare NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, Cambridgeshire and Peterborough NHS Foundation Trust, University of Nottingham.

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes.

Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95% CI = 89.6-92.9) vs. 88.3 (95% CI = 86.1-90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95% CI 68.3-78.5) for those housed none of the time; 91.1 (95% CI 89.2-93.0) for those housed some of the time; and 93.1 (95% CI 91.4-94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First.

Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.

The Wellness Theorem: A Test of the Hypothesis

Prior research indicates elevated but subclinical posttraumatic stress disorder (PTSD) symptoms as a risk factor for a later diagnosis of PTSD. This study examined the progression of symptoms in 21 subclinical veterans. Participants were randomized into a treatment as usual (TAU) wait-list group and an experimental group, which received TAU plus six sessions of clinical emotional freedom techniques (EFT). Symptoms were assessed using the PCL-M (Posttraumatic Checklist—Military) on which a score of 35 or higher indicates increased risk for PTSD. The mean pretreatment score of participants was 39 ± 8.7, with no significant difference between groups. No change was found in the TAU group during the wait period. Afterward, the TAU group received an identical clinical EFT protocol. Posttreatment groups were combined for analysis. Scores declined to a mean of 25 (−64%, P < .0001). Participants maintained their gains, with mean three-month and six-month follow-up PCL-M scores of 27 (P < .0001). Similar reductions were noted in the depth and breadth of psychological conditions such as anxiety. A Cohenʼs d = 1.99 indicates a large treatment effect. Reductions in traumatic brain injury symptoms (P = .045) and insomnia (P = .004) were also noted. Symptom improvements were similar to those assessed in studies of PTSD-positive veterans. EFT may thus be protective against an increase in symptoms and a later PTSD diagnosis. As a simple and quickly learned self-help method, EFT may be a clinically useful element of a resiliency program for veterans and active-duty warriors.

Face to face but not in the same place: A pilot study of prolonged exposure therapy

ABSTRACTThis pilot study examined use of smartphone technology to deliver prolonged exposure (PE) therapy to patients with posttraumatic stress disorder (PTSD) with geographic limitations hindering in-person therapy. The primary goal was to examine the feasibility and acceptability of using video teleconferencing (i.e., computer-based and iPhone 4 streaming technology), with a secondary goal of examining clinical outcomes of PE delivered via teleconferencing compared with treatment as usual (TAU) on PTSD and depressive/anxious symptom reduction. Rural veterans (N = 27) were randomized to receive PE by computer teleconferencing at a Veterans Administration community clinic, PE by an iPhone issued for the duration of the study, or TAU provided by a referring clinician. To examine the research goals, we collected data on the number of referrals to the study, number of patients entering the study, and number completing psychotherapy and documented pragmatic and technical issues interfering with the ability to use teleconferencing to deliver PE; results are discussed. In addition, measures of symptom change examined clinical outcomes. Results indicated decreases in PTSD symptoms in veterans who completed PE therapy via teleconferencing; however, there was significantly more attrition in these groups than in the TAU group.

EFT (Emotional Freedom Techniques) and Resiliency in Veterans at Risk for PTSD: A Randomized Controlled Trial

Prior research indicates elevated but subclinical posttraumatic stress disorder (PTSD) symptoms as a risk factor for a later diagnosis of PTSD. This study examined the progression of symptoms in 21 subclinical veterans. Participants were randomized into a treatment as usual (TAU) wait-list group and an experimental group, which received TAU plus six sessions of clinical emotional freedom techniques (EFT). Symptoms were assessed using the PCL-M (Posttraumatic Checklist-Military) on which a score of 35 or higher indicates increased risk for PTSD. The mean pretreatment score of participants was 39 ± 8.7, with no significant difference between groups. No change was found in the TAU group during the wait period. Afterward, the TAU group received an identical clinical EFT protocol. Posttreatment groups were combined for analysis. Scores declined to a mean of 25 (-64%, P < .0001). Participants maintained their gains, with mean three-month and six-month follow-up PCL-M scores of 27 (P < .0001). Similar reductions were noted in the depth and breadth of psychological conditions such as anxiety. A Cohen's d = 1.99 indicates a large treatment effect. Reductions in traumatic brain injury symptoms (P = .045) and insomnia (P = .004) were also noted. Symptom improvements were similar to those assessed in studies of PTSD-positive veterans. EFT may thus be protective against an increase in symptoms and a later PTSD diagnosis. As a simple and quickly learned self-help method, EFT may be a clinically useful element of a resiliency program for veterans and active-duty warriors.

How Strong is your “R Factor”?

Prior research indicates elevated but subclinical posttraumatic stress disorder (PTSD) symptoms as a risk factor for a later diagnosis of PTSD. This study examined the progression of symptoms in 21 subclinical veterans. Participants were randomized into a treatment as usual (TAU) wait-list group and an experimental group, which received TAU plus six sessions of clinical emotional freedom techniques (EFT). Symptoms were assessed using the PCL-M (Posttraumatic Checklist—Military) on which a score of 35 or higher indicates increased risk for PTSD. The mean pretreatment score of participants was 39 ± 8.7, with no significant difference between groups. No change was found in the TAU group during the wait period. Afterward, the TAU group received an identical clinical EFT protocol. Posttreatment groups were combined for analysis. Scores declined to a mean of 25 (−64%, P < .0001). Participants maintained their gains, with mean three-month and six-month follow-up PCL-M scores of 27 (P < .0001). Similar reductions were noted in the depth and breadth of psychological conditions such as anxiety. A Cohenʼs d = 1.99 indicates a large treatment effect. Reductions in traumatic brain injury symptoms (P = .045) and insomnia (P = .004) were also noted. Symptom improvements were similar to those assessed in studies of PTSD-positive veterans. EFT may thus be protective against an increase in symptoms and a later PTSD diagnosis. As a simple and quickly learned self-help method, EFT may be a clinically useful element of a resiliency program for veterans and active-duty warriors.

Brief acceptance and commitment therapy for psychotic inpatients: A randomized controlled feasibility trial in Sweden

Psychiatric inpatient care in Sweden is often described as lacking in content other than medication and mere containment. In an attempt to increase structured psychological content in the ward context, this study aims to investigate whether a brief form of acceptance and commitment therapy (ACT) is a feasible addition to standard care for psychotic inpatients. ACT has previously been administered to psychotic inpatients in the US, and the present study was an attempt at implementing this intervention in Sweden. In this feasibility study, 22 psychotic inpatients were randomized to one of two conditions: treatment as usual (TAU) or TAU plus an average of two ACT sessions. Measures of rehospitalization and values-based living were obtained before treatment, after treatment, and at four-month follow-up. Results indicate that participants in the TAU plus ACT group were rehospitalized at a lower rate than those who only received TAU (9% vs. 40%), though the difference was not statistically significant. Controlling for age, gender, and pretreatment values-based living scores, there was a significantly higher risk for TAU participants to be rehospitalized. There was a trend toward increased values-based living scores in the ACT group. These results suggest that it is feasible to add structured psychotherapeutic interventions to the existing care package at psychiatric inpatient wards in Sweden. However, the findings need to be explored in larger samples.

Mental Health Courts: Does Treatment Make a Difference?

Mental health courts (MHCs), a variant of problem-solving courts, have continued to proliferate, surprisingly without robust evidence of their effectiveness or for their mechanism of action. Broadly, the theory of action is that the court uses its moral authority to leverage privileged access to mental health and substance abuse services, enforce treatment adherence, and tightly monitor and sanction criminogenic behavior. Evidence is accumulating that clients under such a regime have fewer rearrests, but more elusive is the evidence that the behavioral health treatment itself makes a difference—that clients are less symptomatic, function better, and stay out of the trouble that is often attributed to their behavioral health conditions. As a result of these null findings of a treatment effect, some have suggested that behavioral health treatment and improved functioning may play a minimal role in the benefits seen among MHC participants and, rather, that informal counseling by court personnel and community corrections personnel may be the primary mechanism of action. In this issue, an article by Han and Redlich from the multisite, MacArthur MHC Project provides new evidence that treatment may make a difference. Until now, study investigators reported reduced rearrests at the four MHC sites but, vexingly, no detectable treatment effect. In this new study, arrestees in the MHC and treatment-as-usual groups selfreported the types of behavioral health services they received six months before and after MHC initiation. Both groups received increased behavioral health services in the six months after arrest, but that had no effect on rearrests in the treatmentas-usual group. In the MHC group, rearrests were reduced apparently as a result of increased service use, compared with the prearrest period, combined with improved medication compliance. This finding suggests that the court enhanced the benefit of treatment in reducing rearrest at least partially via enhanced medication compliance. Such a mechanism has been reported in studies of involuntary outpatient commitment, another form of mandated treatment, in which court involvement has been found to yield benefits in reducing hospital recidivism. In those studies, personswith severemental illness under court order were, like MHC participants, more treatment adherent and reported receiving reminders about adherence frommultiple sources: the court, casemanagers, and their families. Studies of involuntary outpatient commitment have also reported that one of its greatest benefits is the linkage to more intensive services. Indeed, the New York State assisted outpatient treatment programhas recognized this and stipulates that all participants receive either assertive community treatment or intensive case management, at a minimum. As a result, the court order not only enhances treatment adherence but also leverages the provision of more intensive treatment. Han and Redlich’s analysis also offers insights into the extent to which MHCs leverage privileged access to behavioral health services for participants with complex comorbid conditions. Here the findings, if generalizable, are very sobering. Participants at the four MHC sites may have received slightly more behavioral health services than the treatment-as-usual group—but vanishingly little more in absolute terms. In the six months postarrest, theMHC group received an average of 1.08 individual mental health counseling sessions, .68 sessions of group therapy, 1.28 medication management services, and nearly imperceptible amounts of substance abuse services—in a populationwith a prevalence rate of comorbid substance use disorders of roughly 75%. Despite evidence that cognitivebehavioral therapies can reduce criminogenic behavior, fewof the MHC participants could have been receiving such treatment. In some ways this is not surprising because MHCs typically do not have funds to purchase treatment and must compete with other priority populations for scant public treatment resources. Most MHC clients are indigent as well. One MHC judge reported, with some irony, that MHC treatment plans for her clients had to be preauthorized by the county’s managed behavioral health care vendor. In such a scenario, criminal justice involvement may not make a compelling case for behavioral health services under standard utilization review criteria. Advocates for MHCs and other diversion programs speak emphatically about the need to access evidence-based treatment for justice-involved clients. The good news is that better access to behavioral health services under court supervision canmake a difference. The sobering news is that access to reasonably adequate treatment is a longway away.Now thatMHCshave been firmly established in the growing list of interventions for persons with severe mental illness with criminal justice involvement, the focus needs to turn to how MHCs can effectively leverage evidence-based treatment for this important population.