Urban Mental Health Center Research Articles

Weaving Words and Music: Healing from Trauma for People with Serious Mental Illness

Weaving Words and Music: Healing from Trauma for People with Serious Mental Illness AbstractThis paper will present the development of music verbal trauma groups for people with serious mental illness. The work grew out the collaboration of an interdisciplinary trauma committee in an urban mental health center. Recognizing the high rates of childhood trauma histories in this population members of the committee recognized the importance of including music and creative arts in the treatment of complex trauma. We will outline the interdisciplinary collaboration and the structure of the groups. Elements of music as tools in trauma treatment are described along with using words to identify specific problems and solutions. Examples of our clinical work will be shared from this interweaving of words and music. Brief vignettes will demonstrate survivors’ journeys as they begin to identify and create safety, build healthy relationships, and maintain equilibrium while facing the challenges of their past traumatic experiences.

Barriers and Facilitators of Healthcare for People with Mental Illness: Why Integrated Patient Centered Healthcare Is Necessary

Understanding barriers and facilitators of healthcare for people with mental illness is essential for healthcare and mental healthcare organizations moving towards patient centered care. This paper presents findings of a measure on barriers and facilitators of healthcare completed by 204 patients being served at a co-located wellness center (primary healthcare clinic) located in an urban mental health center. The top 10 results show important findings for planning healthcare services that are responsive to the needs of people with mental illness. Basic structural issues as a result of poverty are extremely important (transportation, housing, payment) as well as difficulty with public healthcare that often involves long wait-times for appointments and at the doctor's office and hours that might not be convenient. Healthcare services that want to meet the needs of people with mental illness need to address these issues. What facilitates healthcare is not just removing the barriers to receiving healthcare services but instead involves more interpersonal aspects of healthcare such as liking your provider, being able to talk with your provider, feeling your provider cares about you and listens to you. Structural supports such as also being in mental health services, having systems for remembering appointments, and/or having appointment times that are convenient also facilitate seeking healthcare. Facilitating healthcare seeking also seems to involve a sense of agency—looking forward to taking charge of your health and feeling capable of following healthcare provider instructions. Healthcare systems for people with mental illness need to support these facilitators to give care-seekers the support they need. Key points are provided on how organizations and staff can work more effectively in implementing patient centered care.

Longitudinal Course of Clients With Co-occurring Schizophrenia-Spectrum and Substance Use Disorders in Urban Mental Health Centers: A 7-Year Prospective Study.

A previous longitudinal study in rural New Hampshire showed that community mental health center clients with co-occurring schizophrenia-spectrum and substance use disorders (SZ/SUD) improved steadily and substantially over 10 years. The current study examined 7 years of prospective clinical and functional outcomes among inner-city Connecticut (CT) community mental health center clients with SZ/SUD. Participants were 150 adults with SZ/SUD, selected for high service needs, in 2 inner-city mental health centers in CT. Initially, all received integrated mental health and substance abuse treatments for at least the first 3 years as part of a clinical trial. Assessments at baseline and yearly over 7 years measured progress toward 6 target clinical and functional outcomes: absence of psychiatric symptoms, remission of substance abuse, independent housing, competitive employment, social contact with non-users of substances, and life satisfaction. The CT SZ/SUD participants improved significantly on 5 of the 6 main outcomes: absence of psychiatric symptoms (45%-70%), remission of substance use disorders (8%-61%), independent housing (33%-47%), competitive employment (14%-28%), and life satisfaction (35%-53%). Only social contact with nonusers of substances was unimproved (14%-17%). Many urban community mental health center clients with SZ/SUD and access to integrated treatment improve significantly on clinical, vocational, residential, and life satisfaction outcomes over time, similar to clients with SZ/SUD in rural areas. Thus, the long-term course for people with SZ/SUD is variable but often quite positive.

Involvement in the criminal justice system among attendees of an urban mental health center

BackgroundIncarceration rates for people with serious mental illnesses are higher than the general population. However, research has been limited in regards to patterns of incarcerations for patients treated in public mental health settings. This study examines differences in lifetime imprisonment rates among patients of a U.S. urban Community Mental Health Center (CMHC) and national samples, within gender, race and education subgroups.FindingsParticipants were interviewed about their criminal history. Analyses compared lifetime incarceration history in this sample to a group with similar demographics. A majority (69.6%) of the sample had been incarcerated and 34.0% had been incarcerated with a felony charge as compared with 2.7% expected for the control sample.ConclusionWithin every racial and educational subgroup, incarceration rates were high compared to the general population. Though racial and educational factors partly explained added incarceration risk, presence of a serious mental disorder heightened the incarceration risk within all strata in this public sector setting.

Predictors of Incarceration Among Urban Adults With Co-Occurring Severe Mental Illness and a Substance Use Disorder

People with severe mental illness and a co-occurring substance use disorder (co-occurring disorders) who live in urban areas experience high rates of incarceration. This study examined sociodemographic, clinical, economic, and community integration factors as predictors of incarceration among people with co-occurring disorders. This secondary analysis used data from a randomized controlled trial of assertive community treatment versus standard case management. In the parent study, researchers interviewed 198 people with co-occurring disorders from two urban mental health centers in Connecticut at baseline and every six months for three years. Researchers tracked incarceration, clinical engagement and status, employment, living situation, social relationships, and substance use. The study reported here used bivariate analyses and logistic regression analyses to compare individuals who were incarcerated during the study period with those who were not. The overall incarceration rate was 38% during the study period. In multivariate analyses, prior incarceration predicted incarceration during the study period (odds ratio [OR]=3.26). Two factors were associated with a reduced likelihood of incarceration: friendships with individuals who did not use substances (OR=.19) and substance use treatment engagement (OR=.60). Positive social relationships and engagement in substance use treatment are promising service and policy targets to prevent incarceration in this high-risk population.

Associations of medical comorbidity, psychosis, pain, and capacity with psychiatric hospital length of stay in geriatric inpatients with and without dementia.

ABSTRACT Background: Geriatric psychiatry hospital beds are a limited resource. Our aim was to determine predictors of hospital length of stay (LOS) for geriatric patients with dementia admitted to inpatient psychiatric beds. Methods: Admission and discharge data from a large urban mental health center, from 2005 to 2010 inclusive, were retrospectively analyzed. Using the resident assessment instrument - mental health (RAI-MH), an assessment that is used to collect demographic and clinical information within 72 hours of hospital admission, 169 geriatric patients with dementia were compared with 308 geriatric patients without dementia. Predictors of hospital LOS were determined using a series of general linear models. Results: A diagnosis of dementia did not predict a longer LOS in this geriatric psychiatry inpatient population. The presence of multiple medical co-morbidities had an inverse relationship to length of hospital LOS - a greater number of co-morbidities predicted a shorter hospital LOS in the group of geriatric patients who had dementia compared to the without dementia study group. The presence of incapacity and positive psychotic symptoms predicted longer hospital LOS, irrespective of admission group (patients with dementia compared with those without). Conversely, pain on admission predicted shorter hospital LOS. Conclusions: Specific clinical characteristics generally determined at the time of admission are predictive of hospital LOS in geriatric psychiatry inpatients. Addressing these factors early on during admission and in the community may result in shorter hospital LOS and more optimal use of resources.

Best Practices: A Program to Support Shared Decision Making in an Outpatient Psychiatric Medication Clinic

This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

Pain Medication Use Among Patients With Posttraumatic Stress Disorder

The relationship of analgesic medication use with posttraumatic stress disorder (PTSD) diagnosis was investigated among a sample of 173 African Americans presenting for routine outpatient visits at an urban mental health center. Seventy-eight (43.5%) of the sample met DSM-IV PTSD criteria. Those with PTSD had significantly higher use of analgesic medication (both opiate and non-opiate), as compared with non-PTSD patients. PTSD symptoms, as measured by the Posttraumatic Symptom Scale, were significantly higher in subjects who were prescribed analgesics. The authors conclude that there may be a relationship between PTSD and use of pain medications warranting further examination of the endogenous opiate system in the pathophysiology of PTSD.

The criminogenic, clinical, and social problems of forensic and civil psychiatric patients.

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.

The work project survey: Consumer perspectives on work

Objective: Mental health consumers at an urban mental health center were surveyed about their motivations for working and perceived barriers to employment. Design: A survey was developed and administered by a consumer-led research team to 389 persons receiving case management and outpatient services. Results: Most consumers were either working (16%; n=59) or reported a desire to work (46%; n=170). The latter group constituted 55% of the 310 respondents who were not working at the time of the study. The most common perceived barrier was the fear of losing Social Security benefits. Consumers also reported concerns about receiving low pay and being ashamed of their job histories. Among the 38% of the total sample who expressed a reluctance or unwillingness to work, two-thirds (n=58) indicated that, if they did not have to worry about losing their Social Security benefits while working, they would try to obtain employment. A total of 179 (49%) respondents expressed a preference for receiving vocational services at their clinical sites, versus at a clubhouse location. Conclusions: Most consumers in this study were working or wanted to work. Consumers' motivations for work can be increased, especially if key barriers to work are described as removable. Preferences for types and locations of vocational services need to be considered in planning services.

Suicide amongst Alzheimer’s Disease Patients: A 10-Year Survey

Suicide is a major public health problem with advancing age being one of the factors associated with increased risk. It has been suggested that most DSM axis-I disorders contribute to increased suicidal risk while dementia is one of the few exceptions. We conducted a 10-year retrospective analysis of all elderly patients suffering from dementia admitted to a large urban mental health center. Between 1991 and 2000 there were 1,551 admissions to our center who were 65 years or older. Of these, 341 were diagnosed (DSM-IV criteria) as suffering from dementia and 215/341 as suffering from Alzheimer’s disease (AD). Sixteen AD patients (7.4% of all AD patients) were admitted immediately following a suicide attempt. The control group consisted of the next admission of an elderly AD patient matched for age and gender. The index group (suicidal patients) differed from controls in Clinical Dementia Rating scores (p = 0.017) and higher frequency of previous suicide attempts (p = 0.022). Lifetime psychopathology was not associated with higher rates of suicide attempts (p = 0.068). Physicians should be aware that suicide attempts are not rare in elderly AD patients. Higher level of daily functioning and previous suicide attempts are associated with increased suicidal risk.

Mining Treatment Termination Data in an Adolescent Mental Health Service

SUMMARY This study utilizes available clinical information from client records to explore patterns of termination from mental health treatment among adolescents at an urban outpatient mental health center. The analysis focuses on how and why adolescents terminate from treatment and identifies variables associated with “acknowledged” and “unacknowledged” terminations. Findings indicate that termination was acknowledged infrequently, often a brief process that occurred almost as frequently by telephone as in the context of treatment. Contrary to “practice wisdom” concerning treatment termination, adolescents who “dropped out” without a “clinical process” reported considerably more engagement in treatment than those who acknowledged the termination of treatment. Recommendations for a more “open door” policy and a more flexible practice with adolescents are discussed.

Adult Attachment as a Framework for Understanding Mental Health and American Indian Families

This article discusses three cases of American Indian families who presented for therapy at an urban mental health center. The framework of adult attachment is used to understand the cross-generational continuity of mental health concerns in these families, and American Indian families more generally, who present with mental health problems. The demographics of American Indian family life are presented, along with a background review of the adult attachment literature.

The Waiting-List Group

ABSTRACTThis report describes a pilot study of a waiting-list group (preliminary process group [PPG]) that provided treatment for applicants to a university affiliated, urban mental health center. All individuals on the treatment waiting list were informed of the PPG. This semistructured group, meeting weekly, began with members presenting their problems, followed by free discussion, and ending with goal setting for the next week. Approximately one seventh (35 out of 262) of the clinic's applicants during a 4½-month period chose to enter the PPG. They differed from those who chose not to particpate (wait list) by being older and less educated. Approximately 80% of both wait-list and PPG participants subsequently entered therapy. Significantly more PPG patients than those on the wait list entered group treatment. The PPG served clinic needs by providing prompt service for self selected individuals and by supporting the group therapy program.

Multiple Family Groups: An Alternative for Reducing Disruptive Behavioral Difficulties of Urban Children

Objective: This article presents an evaluation of a multiple family group intervention (MFG) designed to meet the mental health needs of low-income minority children and families. Method: Children participating in the MFG are compared with children demographically and clinically similar who received individual or family therapy services at an urban mental health center. Results: Of the children referred for MFG, 59% were still in service by the 16th group meeting. Of the children assigned to individual or family therapy, only 39% were in service after 16 weeks. Data from the subsamples that attended 16 weeks of MFG or therapy sessions were analyzed, and significant decreases in total disruptive behavior, conduct problems, learning difficulties, hyperactivity, and impulsivity were associated with MFG participation. Conclusion: Follow-up interviews revealed that 70% of MFG parents noted child improvements, in comparison to 54% of parents whose children received individual family therapy.

Posttraumatic stress disorder and service utilization among urban mental health center clients.

Although the urban poor are at high risk for exposure to trauma, community mental health clinics rarely diagnose clients with PTSD. Failure to diagnose PTSD may undermine the effectiveness of services provided. Our objectives were to (1) assess prevalence of traumatic experiences and PTSD, and (2) examine differences in service utilization between those who had PTSD and those who did not. Interview data were gathered from 181 urban psychiatric outpatients. A substantial number of clients had experienced at least one lifetime trauma (94%), and of those, 42% had PTSD during the past year. Analyses comparing service use between PTSD and nonPTSD clients supported our expectation that clients with PTSD would use more mental health services, and would be less satisfied with services than their nonPTSD counterparts.

Preventive health care for mentally ill women.

Utilization of preventive medical care was compared for two low-income groups--47 women with serious mental illness in an urban mental health center and 17 women patients at a primary care center. Appropriate preventive care was defined as at least one physical examination, a Pap test, and a breast examination in the past five years and a mammogram if the patient was over age 40. Receipt of preventive care by women in both settings was similar. Histories of physical and sexual abuse were prevalent in both groups, and a history of abuse was associated with less frequent receipt of preventive care. Results indicate that procedures to identify and provide services to women with abuse histories should be further developed.

Observations from the program on chronic mental illness.

The Robert Wood Johnson Foundation (RWJF) Program on Chronic Mental Illness has come to an end. Launched in December 1986, it was the foundation’s first multisite national venture into mental health care. The program sought to establish improved systems of care for persons with serious and long-term mental disorders in nine major cities across the country. Now, almost six years later, the grant period has ended, and it is time to take stock. The nine demonstration programs are still intact, with more than 250 staff in place at the sites. Throughout the program’s lifetime it received $22.5 million in RWJF grant funds, $9 million in foundation loan funds to stimulate housing development, and 1,200 Section 8 housing certificates, issued by the U.S. Department of Housing and Urban Development (HUD). One view of the impact of this program is offered by Howard Goldman and his colleagues, based on a formal evaluation funded by RWJF and a consortium of federal agencies.’ But there is another view of the program’s impact: the subjective impressions of the national program office staff and the staff at the nine demonstration sites. This perspective has been enriched by RWJF’s style of grant management, which is to fund a partnership between the national program office (typically in a university) and the demonstration sites. Instead of awarding the grant and coming back later to assess the results, RWJF requires that each demonstration site develop its program in collaboration with the national program staff. The national office maintains constant contact with the sites to monitor progress and solve immediate problems and carries out numerous site visits, with special conferences among the sites and other direct contact as needed. This management style affords the national program staff an intimate view of the demonstration sites and an opportunity to compare them as they face common situations.

Medication Compliance, Antidepressant Blood Levels, and

A study of medication compliance, side effects, and clinical change with the use of antidepressants in 32 Southeast Asian refugee patients seen at an urban mental health center is reported. Patients met criteria for either major depressive episode, posttraumatic stress disorder, or both. Only five of the 32 patients who stated that they were taking their medications regularly had antidepressant blood levels in the therapeutic range. Another 10 patients had subtherapeutic levels and the remaining 17 had undetectable blood levels. Patients with therapeutic blood levels had fewer side effects (p = 0.049) than patients with undetectable blood levels. Blood levels tended (p = 0.070) to be correlated with clinical improvement. The authors discuss cultural attitudes of Southeast Asian refugee patients toward medication use and side effects that appear to influence medication compliance.

Commonality of Diagnostic Categories for Students Assessed on the K-ABC and WISC-R

The K-ABC and the WISC-R were administered in a counterbalanced order as part of a psychoeducational battery to 164 children referred to an urban school mental health center for academic problems. The study compared the extent of agreement in the diagnoses of learning disability and mental retardation based on these instruments. Diagnoses were made by experienced clinicians who had access to only one of the two test profiles (K-ABC or WISC-R). While statistically significant overlap in diagnostic decisions between the K-ABC and WISC-R was found, a large number of children received different diagnoses based on the two tests. When different diagnostic decisions were made, the differences were likely to be conservative. For instance, Learning Disabled with one instrument became No Diagnosis with the second instrument, rather than Mentally Retarded. The most significant data for prediction of diagnosis were the cognitive measure (either WISC-R or K-ABC), plus a measure of achievement.