PTSD among Adults with SMI in the Public Sector

B. Christopher Frueh, Ph.D.Supported by: K08-MH01660; R01-HS11642; R01-MH65517; R21-MH065248

Collaborators (alphabetical)

George Arana, MD Kathleen Brady, MD Todd Buckley, PhD Victoria Cousins, BS Karen Cusack, PhD Jon Elhai, PhD Paul Gold, PhD Anouk Grubaugh, PhD Tom Hiers, PhD Terry Keane, PhD Matthew Kimble, PhD Rebecca Knapp, PhD Kathy Magruder, PhD

Chris Molner, PhD Jeannine Monnier, PhD Kim Mueser, PhD Carrie Randall, PhD Cynthia Robins, PhD Stan Rosenberg, PhD Julie Sauvageot, MSW Alberto Santos, MD Samantha Suffoletta-

Maierle, PhD Chris Wells, MEd Eunsil Yim, MS(Partial list)

The Public Sector: SCDMH

The Population

Indigent

Heavily minority

Underserved, understudied

Severe mental illness* *A mental illness resulting in persistent impairment in self-care, work, or social relationships; plus a past year history of DSM-IV Axis I diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder.

SCDMH Trauma Initiative

Trauma victimization is highly prevalent (51-98%) among persons with SMI

PTSD typically remains untreated due inadequate assessment and the lack of empirically validated treatments with SMI

SC DMH Trauma Initiative goals: Sensitize stakeholders to the impact of trauma Influence policies and administration Educate and train clinicians on empirically validated

assessment procedures and interventions Expand the relevant knowledge base by supporting a

strong empirical research platform

SCDMH Clinician Survey

Most clinicians (N = 245) received little training in trauma– only 30% had more than 6 hours of training in their career to date

Most clinicians underestimated the prevalence of trauma in their patients– less than 30% estimated that trauma prevalence was greater than 40%

(Frueh BC, Cusack KJ, Hiers TG, Monogan S, Cousins VC, Cavenaugh SD. Improving public mental health services for trauma victims in South Carolina. Psychiatric Services 2001; 52:812-814)

SCDMH Facility Survey

Most SCDMH facilities across state (N = 23) did not routinely evaluate trauma history in an adequate manner

Only 41% did None of the 41% did it well

Most facilities did not provide any specialized trauma-related services

(Frueh BC, Cousins VC, Hiers TG, Cavanaugh SD, Cusack KJ, Santos AB. The need for trauma assessment and related clinical services in a state public mental health system. Community Mental Health Journal 2002; 38:351-356)

Trauma History Screening in a CMHC

For those screened at a CMHC (N = 505) 91% with lifetime trauma history Number of traumatic events inversely

correlated with SF-12 functioning Per chart PTSD diagnoses was 19%,

compared with 5% before trauma history screening was implemented

Still no change in PTSD treatment services

(Cusack KJ, Frueh BC, Brady KT. Trauma history screening in a Community Mental Health Center. Psychiatric Services 2004; 155:157-162)

“Sanctuary” Trauma and Harm

“Sanctuary Trauma”: Events in psychiatric settings that meet DSM criteria for a traumatic event (A1 & A2).

“Sanctuary Harm”: Events in psychiatric settings that, while not meeting DSM criteria for trauma involve highly insensitive, inappropriate, neglectful or abusive actions by staff; and involve a response of fear, helplessness, distress, humiliation, or loss of trust in staff.

(Frueh BC, Dalton ME, Johnson MR, Hiers TG, Gold PB, Magruder KM, Santos AB. Trauma within the psychiatric setting: Conceptual framework, research directions, and policy implications. Administration and Policy in Mental Health 2000; 28:147-154)

“Sanctuary” Trauma/Harm: Pilot Data

Randomly identified SCDMH outpatients with inpatient histories at 5 CMHCs (N = 57)

Findings 47% reported at least one ST event 7% sexual assault 18% physical assault 22% witnessing physical assault 5% witnessing sexual assault 91% reported at least one negative institutional psychiatric

experience (e.g., 58% seclusion, 33% restraints)

(Cusack KJ, Frueh BC, Hiers TG, Suffoletta-Maierle S, Bennett S. Trauma within the psychiatric setting: A preliminary empirical report. Administration and Policy in Mental Health 2003; 30:453-460)

“Sanctuary” Trauma/Harm: Current Study Randomly identified SC DMH day-hospital patients with

inpatient histories (N = 142) Sanctuary Trauma 8.5% sexual assault 31% physical assault 63% witnessing traumatic events

Sanctuary Harm 82% reported at least one negative institutional psychiatric

experience (e.g., 65% handcuffed transport; 60% seclusion; 34% restraints)

Reported treatment compliance was significantly worse for those who reported witnessing traumatic sanctuary events, experiencing verbal intimidation, and humiliation.

(Frueh BC, Knapp RG, Cusack KJ, Grubaugh AL, Sauvageot JA, Cousins VC, Yim E, Robins CS, Monnier J, Hiers TG. Patient safety within the psychiatric setting. Under review/revision.Robins CS, Sauvageot JA, Cusack KJ, Suffoletta-Maierle S, Frueh BC. Consumers’ descriptions of sanctuary harm. Under review/revision)

A Proposed Cognitive-Behavioral Treatment ModelMulticomponent cognitive-behavioral treatment for

PTSD among public-sector consumers with SMI psychoeducation anxiety management training social skills training exposure therapy “homework” assignments

(Frueh BC, Buckley TC, Cusack KJ, Kimble MO, Grubaugh AL, Turner SM, Keane TM. Cognitive-behavioral treatment for PTSD among people with severe mental illness: A proposed treatment model.

Journal of Psychiatric Practice 2004; 10:26-38)

SCDMH Clinician Perspectives

Conducted 5 qualitative focus group discussions with clinicians and clinical supervisors (n = 33).

Four themes: There is consensus that trauma has a major impact on

the lives of persons with SMI Trauma has acquired a mystique that leaves clinicians

fearful of addressing it The proposal of a CBT approach for PTSD within this

population was well-received Suggestions for improving the feasibility and

acceptability of the proposed CBT program

(Frueh BC, Cusack KJ, Grubaugh AL, Sauvageot JA, Wells C, Monnier J. Clinician perspectives on cognitive-behavioral treatment for PTSD among public-sector consumers with severe mental illness. Under submission.)