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1.  A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors 
Annals of surgery  2013;257(3):390-399.
To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.
Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.
The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined, care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at one-, three-, six-, nine-, and twelve-months after the index injury admission.
Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared to controls (group by time effect, CAPS, F(2, 185) = 5.50, P < 0.01; PCL-C, F(4, 185) = 5.45, P < 0.001). Clinically and statistically significant PTSD treatment effects were observed at the six-, nine-, and twelve-month post-injury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function (MOS SF-36 PCS main effect, F(1, 172) = 9.87, P < 0.01).
Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at United States trauma centers. (Trial Registration: identifier: NCT00270959)
PMCID: PMC3582367  PMID: 23222034
2.  Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for Alcohol at Trauma Centers Study Design 
General hospital psychiatry  2012;35(2):174-180.
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
PMCID: PMC3594343  PMID: 23273831
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
3.  Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma 
General hospital psychiatry  2011;33(2):123-134.
To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions.
We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.
Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers.
Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts.
PMCID: PMC3099037  PMID: 21596205
PTSD; stepped collaborative care; acute care; population impact; traumatic injury
7.  Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods 
A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.
The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.
This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.
Trial registration NCT00877331
PMCID: PMC3598998  PMID: 23237456
Problem drug use; Screening; Brief Intervention and Referral to Treatment (SBIRT); Motivational Interviewing (MI); Addiction Severity Index (ASI); Safety net; Public health benefit; Cost effectiveness
8.  Self-reported alcohol and drug use six months after brief intervention: do changes in reported use vary by mental-health status? 
Although brief intervention (BI) for alcohol and other drug problems has been associated with subsequent decreased levels of self-reported substance use, there is little information in the extant literature as to whether individuals with co-occurring hazardous substance use and mental illness would benefit from BI to the same extent as those without mental illness. This is an important question, as mental illness is estimated to co-occur in 37% of individuals with an alcohol use disorder and in more than 50% of individuals with a drug use disorder. The goal of this study was to explore differences in self-reported alcohol and/or drug use in patients with and without mental illness diagnoses six months after receiving BI in a hospital emergency department (ED).
This study took advantage of a naturalistic situation where a screening, brief intervention, and referral to treatment (SBIRT) program had been implemented in nine large EDs in the US state of Washington as part of a national SBIRT initiative. A subset of patients who received BI was interviewed six months later about current alcohol and drug use. Linear regression was used to assess whether change in substance use measures differed among patients with a mental illness diagnosis compared with those without. Data were analyzed for both a statewide (n = 828) and single-hospital (n = 536) sample.
No significant differences were found between mentally ill and non-mentally ill subgroups in either sample with regard to self-reported hazardous substance use at six-month follow-up.
These results suggest that BI may not have a differing impact based on the presence of a mental illness diagnosis. Given the high prevalence of mental illness among individuals with alcohol and other drug problems, this finding may have important public health implications.
PMCID: PMC3685518  PMID: 23186062
Brief intervention; Comorbid substance use and mental illness; Mental illness; Alcohol use; Binge drinking; Illicit drug use
9.  Deconstructing Proficiency in Motivational Interviewing: Mechanics of Skilful Practitioner Delivery During Brief Simulated Encounters 
Proficient delivery of motivational interviewing (MI) is often determined by global rating of relational elements or cumulative tallies of technical elements. Yet limited empirical evidence exists to clarify how relational and technical elements are associated, or if rates of skill indices and their constituent technical elements vary within a clinical encounter.
This study sought to document temporal variance in rates of MI skill indices and their constituent technical elements during brief clinical encounters with a standardized patient wherein delivery was “MI-proficient”, and to distinguish those temporal patterns from those observed in encounters with “MI-inconsistent” delivery.
Data were accessed from a large MI training trial wherein relational and technical elements of MI delivery were scored for 503 recordings of a simulated 20-minute clinical encounter. Notably, independent raters tallied technical elements in 5-minute segments, allowing evaluation of potential variance among the encounter’s quartile intervals. Global ratings of MI spirit identified subsets of recordings with MI-proficient (n = 49) and MI-inconsistent (n = 43) delivery for stratified analyses.
Analyses contrast temporal trajectories of technical aspects of MI-proficient and MI-inconsistent delivery, with the former characterized by: 1) elicitation and reflective listening as primary opening strategies; 2) increased depth of reflective listening as a predominant strategy in subsequent, focused therapeutic discussion; and 3) increased use of elicitation and information provision in change planning as the encounter approached conclusion.
Findings are generally consistent with seminal descriptions of MI (Miller and Rollnick, 1991, 2002), and document temporal aspects of skilful MI delivery in brief encounters.
PMCID: PMC3236613  PMID: 20615272
Motivational interviewing; psychotherapy process; addiction
10.  Agency context and tailored training in technology transfer: A pilot evaluation of motivational interviewing training for community counselors 
Few empirical studies are available to guide best practices for transferring evidenced-based treatments to community substance abuse providers. To maximize the learning and maintenance of new clinical skills, this study tested a context-tailored training model (CTT) which used standardized patient actors in role-plays tailored to agency clinical context, repetitive cycles of practice and feedback, and enhanced organizational support. This study reports the results of a randomized pilot evaluation of CTT for motivational interviewing (MI). Investigators randomly assigned community substance abuse treatment agencies to receive either CTT or a standard two-day MI workshop. The study also evaluated the effects of counselor-level and organizational-level variables on the learning of MI. No between-condition differences were observed on the acquisition and maintenance of MI skills, despite reported higher satisfaction with the more costly context tailored model. Analyses revealed that those counselors with more formal education and less endorsement of a disease model of addiction made the greatest gains in MI skills, irrespective of training condition. Similarly, agencies whose individual counselors viewed their organization as being more open to change and less supportive of autonomy showed greater average staff gains in MI skills, again, irrespective of training method. Post-training activities within agencies that supported the ongoing learning and implementation of MI mediated the effects of organizational openness to change. This pilot study suggests that tailored training methods may not produce better outcomes than traditional workshops for the acquisition of evidence-based practice and that efforts to enhance dissemination should be focused on characteristics of learners and ongoing organizational support of learning.
PMCID: PMC2737382  PMID: 19339139
11.  Geographic variation and localised clustering of congenital anomalies in Great Britain 
Environmental pollution as a cause of congenital anomalies is sometimes suspected because of clustering of anomalies in areas of higher exposure. This highlights questions around spatial heterogeneity (clustering) in congenital anomaly rates. If spatial variation is endemic, then any one specific cluster is less remarkable, though the presence of uncontrolled geographically clustered risk factors is suggested. If rates are relatively homogeneous across space other than around specific hazards, then evidence for these hazards causing the clusters is strengthened. We sought to estimate the extent of spatial heterogeneity in congenital anomaly rates in the United Kingdom.
The study population covered about one million births from five registers in Britain from 1991–1999. We estimated heterogeneity across four geographical levels: register area, hospital catchment, electoral ward, and enumeration district, using a negative binomial regression model. We also sought clusters using a circular scan statistic.
Congenital anomaly rates clearly varied across register areas and hospital catchments (p < 0.001), but not below this level (p > 0.2). Adjusting for socioeconomic deprivation and maternal age made little difference to the extent of geographical variation for most congenital anomaly subtypes. The two most significant circular clusters (of four ano-rectal atresias and six congenital heart diseases) contained two or more siblings.
The variation in rates between registers and hospital catchment area may have resulted in part from differences in case ascertainment, and this should be taken into account in geographical epidemiological studies of environmental exposures. The absence of evidence for variation below this level should be interpreted cautiously in view of the low power of general heterogeneity tests. Nevertheless, the data suggest that strong localised clusters in congenital anomalies are uncommon, so clusters around specific putative environmental hazards are remarkable when observed. Negative binomial models applied at successive hierarchical levels provide an approach of intermediate complexity to characterising geographical heterogeneity.
PMCID: PMC1939702  PMID: 17617898

Results 1-12 (12)