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					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         Chris Molner, PhD
   Kathleen Brady, MD       Jeannine Monnier, PhD
   Todd Buckley, PhD        Kim Mueser, PhD
   Victoria Cousins, BS     Carrie Randall, PhD
   Karen Cusack, PhD        Cynthia Robins, PhD
   Jon Elhai, PhD           Stan Rosenberg, PhD
   Paul Gold, PhD           Julie Sauvageot, MSW
   Anouk Grubaugh, PhD      Alberto Santos, MD
   Tom Hiers, PhD           Samantha Suffoletta-
   Terry Keane, PhD          Maierle, PhD
   Matthew Kimble, PhD     Chris Wells, MEd
   Rebecca Knapp, PhD      Eunsil Yim, MS
   Kathy Magruder, PhD    (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 Model
Multicomponent 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.)

				
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