Kim T. Mueser - US grants

Substance use disorders (SUD) in persons with severe mental illness (SMI) are common and have a profound effect on the course of psychiatric illness. Despite the prominence of "dual disorders" among the SMI, no manualized, empirically validated treatments exist. There is a particular need for family work in this area because most dually diagnosed clients maintain contact with relatives, and the loss of family support is associated with housing instability and homelessness in this population. The proposed research will be a controlled evaluation of a new family intervention for dual disorders (FIDD) program, described in a treatment manual and supported by a pilot study. The study will take place at two typical public mental health centers, the North Suffolk Mental Health Association in Massachusetts and the San Fernando Mental Health Center in California. The research will be conducted by the joint effort of two well-established centers for mental health services and clinical trials research, the New Hampshire-Dartmouth Psychiatric Research Center and the UCLA Intervention Research Center. A total of 140 clients and their families (N=70 at each site) will be randomly assigned to either the FIDD program for 2 years (N=70), which includes both single family and multiple-family group formats, or family psychoeducation including 6 weekly sessions (N=70). Fidelity of clinicians to the FIDD program will be monitored with standardized measures. Routine assessments will be conducted over 2 years on all clients and relatives to evaluate a wide range of outcomes, including substance abuse, hospitalizations, psychiatric symptoms, legal problems, aggression, housing and homelessness, family burden, social support, and quality of life. Process measures of the FIDD program will include family knowledge of dual disorders and problem-solving skill. The results of the proposed research have important implications for improving the long-term outcomes of clients with dual disorders and lessening the impact of SUD on relatives. Enhancing the skills of families for coping with dual disorders is expected to be an effective strategy for treating SUD, decreasing hospitalizations, and decreasing caregiver burden. Improvements in these areas may the have long-term benefit of maintaining family involvement with dually diagnosed clients, thereby reducing housing instability and homelessness.

DESCRIPTION (provided by applicant): There is ample evidence documenting that persons with severe mental illness (SMI) are at increased risk for exposure to trauma and the development of posttraumatic stress disorder (PTSD). However, despite research showing that trauma and PTSD are related to worse functioning and a more severe course of SMI, no standardized interventions have been empirically validated for the treatment of PTSD in this population. The proposed research will be a randomized controlled trial of an individual cognitive-behavior therapy (CBT) program for PTSD designed for clients with SMI. The CBT intervention is 12-16 weeks long, has been manualized, and a pilot study supports its feasibility and suggests clinical benefits. A total of 88 clients with SMI (44 with major affective disorders, 44 with schizophrenia or schizoaffective disorder) and PTSD will be randomly assigned to either CBT or treatment as usual (TAU), with assessments conducted at baseline, posttreatment, and 3- and 6-month follow-ups. Primary hypotheses will focus on evaluating whether CBT is superior to TAU in improving PTSD diagnoses and symptoms, quality of life, self-perceived health, knowledge of PTSD, and distorted perceptions of the world. Secondary analyses will explore whether changes in PTSD are associated with improved outcomes for clients with SMI, as suggested by our interactive model of trauma, PTSD, and course of SMI. If our CBT program is effective at improving PTSD and associated outcomes, clinicians will have a valuable new tool for treating this common and distressing comorbid disorder in the SMI population, and potentially for improving the course of SMI.

[unreadable] DESCRIPTION (provided by applicant): The proposed research is the first resubmission a competing continuation of an R01 examining the effectiveness of a cognitive behavioral treatment (CBT) program for posttraumatic stress disorder (PTSD) in persons with severe mental illness (SMI). This research builds on the success of our first randomized controlled trial, in which CBT delivered by academically trained and employed (e.g., doctoral level) clinicians improved PTSD and related outcomes more than treatment as usual in clients with SMI living in rural New Hampshire and Vermont. The proposed research will extend these findings by: 1) having treatment provided by frontline (e.g., masters level) clinicians, 2) focusing on predominantly minority clients with SMI and PTSD living in urban New Jersey, and 3) comparing the CBT program with a brief pilot-tested Psychoeducation program for PTSD. Two-hundred clients with SMI and severe PTSD will be randomized to either the 12-16 session CBT program or the 3-session Psychoeducation program, with follow-up assessments conducted after treatment, and 6 and 12 months later. Analyses will focus on testing the hypotheses that CBT is more effective than Psychoeducation at improving PTSD severity and diagnosis, other symptoms, quality of life, community functioning, as well as decreased use of acute care services and direct treatment costs. [unreadable] Relevance: Trauma and PTSD are common problems in the lives of persons with SMI, and are associated with considerable distress and impairment in functioning. The CBT for PTSD program is the first standardized treatment for PTSD in this population shown to be effective in rigorous, randomized controlled research. The proposed research follows up these important findings by evaluating whether frontline clinicians can implement the CBT program with clients living in urban areas, and examining its impact on the long-term outcomes of quality of life and community functioning, as well as service utilization and costs. The results of this research will bring the field one step closer to having an evidence-based practice for trauma and PTSD in clients with SMI. [unreadable] [unreadable] [unreadable]