Anxiety Disorders: Cusack KJ

Frueh BC, Buckley TC, Cusack KJ, Kimble MO, Grubaugh AL, Turner SM, Keane TM. · Medical University of South Carolina and Veterans Affairs Medical Center, Charleston 29401-5799, USA. · J Psychiatr Pract. · Pubmed #15334985 No free full text.

Abstract: The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, "homework" assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.

Frueh BC, Grubaugh AL, Cusack KJ, Elhai JD. · The Menninger Clinic and Baylor College of Medicine, Houston, TX 77080, USA. · Behav Modif. · Pubmed #18723837 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care. Yet few public-sector mental health agencies routinely provide specialized services for PTSD. The purpose of the article is to describe strategies and efforts to disseminate trauma-focused empirically based practices in a public-sector mental health system. Identified challenges include limited resources and commitment; knowledge deficits, attitudes, and biases; and limited practice accountability at provider, facility, and system levels. Proposed strategies for overcoming these challenges are to set clear goals, nurture broad-based organizational commitment and key stakeholder involvement, implement specialty training efforts to provide information and change attitudes, provide ongoing supervision, conduct fidelity monitoring, and ensure accountability to the extent possible.

Cusack KJ, Morrissey JP, Ellis AR. · Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7590, USA. · Adm Policy Ment Health. · Pubmed #17999175 No free full text.

Abstract: National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.

Cusack KJ, Grubaugh AL, Yim E, Knapp RG, Robins CS, Frueh BC. · Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, CB 7590, 725 Martin Luther King, Chapel Hill, NC 27599-7590, USA. · Psychiatr Q. · Pubmed #17345158 No free full text.

Abstract: The current study examined racial differences in the reported frequency and distress associated with potentially harmful or traumatic experiences occurring within psychiatric settings. One hundred and forty-two (109 African-American; 32 Caucasian) randomly selected adult consumers recruited from a community psychosocial day program completed a battery of self-report measures to assess experiences in the psychiatric setting, lifetime trauma exposure, PTSD severity, and were the subject of a chart review. A subset of participants (20%) also completed a qualitative interview exploring their perceptions of events occurring in psychiatric settings. Few racial differences were noted in the reported frequency or distress associated with particular events in the psychiatric setting. However, we found differential patterns of association between adverse psychiatric events and lifetime trauma history, and racial differences in diagnosis and medications prescribed by the mental health center. These racial differences merit further attention to better understand their meaning and to improve mental health services provided to both African-Americans and Caucasian public-sector psychiatric patients.

Grubaugh AL, Elhai JD, Cusack KJ, Wells C, Frueh BC. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, and the Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina 29425, USA. · Depress Anxiety. · Pubmed #16892418 No free full text.

Abstract: There are few available data on how to accurately screen for and assess posttraumatic stress disorder (PTSD) among severely mentally ill adults, a group with high rates of unrecognized trauma and PTSD symptoms. We examined the diagnostic utility of a widely used screening instrument, the PTSD Checklist (PCL), for diagnosing PTSD among 44 traumatized, adult, public-sector mental health patients recruited through a community mental health program. Participants completed the PCL and the Clinician-Administered PTSD Scale (CAPS), which is considered the "gold standard" for determining PTSD diagnoses. Data provide preliminary support for the use of the PCL as a screening instrument in public psychiatric settings, indicating that the optimal cut-point for adults with severe mental illness is about 54 (with slightly higher or lower recommended cut-points depending on the clinical context and purpose of the PCL). Such data are critical to ensuring that public-sector mental health patients with trauma-related difficulties are identified and referred for appropriate services.

Cusack KJ, Grubaugh AL, Knapp RG, Frueh BC. · Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King, Chapel Hill, NC 27599-7590, USA. · Community Ment Health J. · Pubmed #16868841 No free full text.

Abstract: Lifetime prevalence of traumatic events and current PTSD was assessed among 142 mental health consumers with serious mental illness served by a psychosocial rehabilitation day program. Lifetime exposure to trauma was high (87%). The rate of PTSD based on the PTSD Checklist (PCL) was also high (19-30% depending on different scoring criteria). Overall, the PCL had strong internal reliability for this sample. Documentation of trauma and PTSD was exceptionally low in medical records. Results suggest that trauma and PTSD are significantly overlooked in the public mental health system. Improved recognition of trauma and PTSD are needed in order to provide meaningful services to this highly vulnerable population.

Frueh BC, Cusack KJ, Grubaugh AL, Sauvageot JA, Wells C. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, P.O. Box 250861, Charleston, South Carolina 29425, USA. · Psychiatr Serv. · Pubmed #16816289 links to  free full text

Abstract: OBJECTIVE: As an intermediate step in the development of a cognitive-behavioral posttraumatic stress disorder (PTSD) treatment program for persons with severe mental illness, a focus group gathered feedback from clinicians and clinical supervisors within a public-sector mental health system. METHODS: Five qualitative focus group discussions were held with 33 clinicians and clinical supervisors within a state-funded community mental health center system. RESULTS: Clinicians perceived trauma to be a significant adverse factor in the lives of their mental health services consumers, were reluctant to address trauma with them, and yet believed that cognitive-behavioral treatments for PTSD may be effective and appropriate for them. Clinicians also offered practical suggestions to improve the feasibility and acceptability of the proposed cognitive-behavioral treatment program. Examples include creating gender-specific treatment groups; ensuring that trust and rapport with clients are established before the discussion of traumatic experiences; developing careful safety precautions for clients, especially for the exposure therapy component; preparing for the possibility that some consumers will lack the cognitive ability to understand treatment; and collaborating with other care providers to ensure optimal integration with other aspects of care and minimize clinic disruptions. CONCLUSIONS: These findings provide information relevant to the development and implementation of PTSD interventions for patients with severe mental illness treated in public-sector settings.

Robins CS, Sauvageot JA, Cusack KJ, Suffoletta-Maierle S, Frueh BC. · Westat, Rockville, MD, USA. · Psychiatr Serv. · Pubmed #16148329 links to  free full text

Abstract: OBJECTIVE: Recent studies show a high prevalence of trauma symptoms among people with serious mental illness who are treated in public-sector mental health systems. Unfortunately, growing evidence suggests that many consumers have had traumatic or harmful experiences while being treated in various psychiatric settings. This study explores consumers' perceptions of such harmful inpatient experiences, events that the authors place under the rubric of "sanctuary harm." METHODS: The authors conducted semistructured qualitative interviews with 27 randomly selected mental health consumers to hear their descriptions of adverse events that they experienced while receiving psychiatric care. Our analysis of interview transcriptions focused on understanding consumers' narratives of harmful experiences-events that would not meet DSM-IV criteria for trauma but that nevertheless resulted in significant distress. RESULTS: Eighteen of 27 interviewees described harmful incidents that they had witnessed or experienced directly, many of which evoked strong emotional responses by consumers during their narration. Nearly all incidents described were hospital based and were clustered around two sets of themes. The first set related to the hospital setting, including the fear of physical violence and the arbitrary nature of the rules. The second set related to the narrators' interactions with clinical staff, including depersonalization, lack of fairness, and disrespect. CONCLUSIONS: The findings suggest that many mental health consumers have had a lifetime sanctuary experience that they perceived as harmful. They also offered suggestions for how the mental health service delivery system might reduce the potential for sanctuary harm experiences.

Frueh BC, Knapp RG, Cusack KJ, Grubaugh AL, Sauvageot JA, Cousins VC, Yim E, Robins CS, Monnier J, Hiers TG. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, 29425, USA. · Psychiatr Serv. · Pubmed #16148328 links to  free full text

Abstract: OBJECTIVE: This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector mental health system. METHODS: Participants were 142 randomly selected adult psychiatric patients who were recruited through a day hospital program. Participants completed a battery of self-report measures to assess traumatic and harmful events that occurred during the course of their mental health care, lifetime trauma exposure, and symptoms of posttraumatic stress disorder. RESULTS: Data revealed high rates of reported lifetime trauma that occurred within psychiatric settings, including physical assault (31 percent), sexual assault (8 percent), and witnessing traumatic events (63 percent). The reported rates of potentially harmful experiences, such as being around frightening or violent patients (54 percent), were also high. Finally, reported rates of institutional measures of last resort, such as seclusion (59 percent), restraint (34 percent), takedowns (29 percent), and handcuffed transport (65 percent), were also high. Having medications used as a threat or punishment, unwanted sexual advances in a psychiatric setting, inadequate privacy, and sexual assault by a staff member were associated with a history of exposure to sexual assault as an adult. CONCLUSIONS: Findings suggest that traumatic and harmful experiences within psychiatric settings warrant increased attention.

Cusack KJ, Frueh BC, Brady KT. · South Carolina Department of Mental Health, Charleston, South Carolina 29403, USA. · Psychiatr Serv. · Pubmed #14762240 links to  free full text

Abstract: OBJECTIVE: This study assessed the lifetime prevalence of traumatic events among consumers of a community mental health center by using a brief trauma screening instrument. This study also examined the relationship between trauma exposure and physical and mental health sequelae and determined whether the routine administration of a trauma screening measure at intake would result in increased diagnoses of posttraumatic stress disorder (PTSD) and in changes in treatment planning in a practice setting. METHODS: A 13-item self-report trauma screening instrument, a shortened version of the Trauma Assessment of Adults instrument, was incorporated into the intake assessment process at a community mental health center (CMHC). A total of 505 out of 515 consumers who presented to the CMHC consecutively were surveyed from May 1, 2001, to January 31, 2002. Data from the initial assessment on trauma exposure and on rate of PTSD diagnosis were examined, and a chart review was conducted on 97 cases (19 percent) to determine the extent to which CMHC services addressed trauma-related problems. RESULTS: Data indicated that 460 consumers (91 percent) had been exposed to one or more traumatic life experiences. The number of traumatic events was negatively correlated with physical and mental health functioning on the 12-item Short-Form Health Survey (SF-12). Subjects with a history of sexual abuse scored significantly higher on the SF-12, reflecting poorer physical and mental health. Although the rate of PTSD diagnosis increased after implementation of the trauma screening instrument, the rates of actual PTSD treatment services provided did not change. CONCLUSIONS: This study strongly suggests that screening for trauma history should be a routine part of mental health assessment and may significantly improve the recognition rate of PTSD. However, much work remains to be done in implementing appropriate treatment.

Cusack KJ, Frueh BC, Hiers T, Suffoletta-Maierle S, Bennett S. · South Carolina Department of Mental Health, USA. · Adm Policy Ment Health. · Pubmed #12940686 No free full text.

This publication has no abstract.

Frueh BC, Cousins VC, Hiers TG, Cavenaugh SD, Cusack KJ, Santos AB. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, USA. · Community Ment Health J. · Pubmed #12166921 No free full text.

Abstract: Previous data show that trauma is highly prevalent in public sector consumers and is associated with severe mental illness and high service use costs. Despite this, evidence suggests that trauma victims tend to go unrecognized and to receive inadequate mental health services. We surveyed all facilities (6 inpatient, 17 outpatient) within the South Carolina Department of Mental Health about their current services for trauma victims. Results indicate that most public mental health facilities do not routinely evaluate trauma history in an adequate manner or provide specialized trauma-related services. Implications and future directions are addressed, including the current trauma initiatives of many state-funded systems.

Frueh BC, Cusack KJ, Hiers TG, Monogan S, Cousins VC, Cavenaugh SD. · Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA. · Psychiatr Serv. · Pubmed #11376230 links to  free full text

Abstract: Studies have shown that trauma and posttraumatic stress disorder are highly prevalent among persons with serious mental illness who are treated in state-funded mental health systems. Nevertheless, there is strong evidence that many of these persons receive inadequate mental health services. South Carolina recently became one of at least 15 states whose departments of mental health have initiated efforts to better address these needs. The goals of this initiative are to sensitize stakeholders, influence policies, educate and train clinicians, and increase knowledge by supporting a strong empirical research platform. Current progress and future directions are described in this article.

Grubaugh AL, Cusack KJ, Zinzow HM. · No affiliation provided · Psychiatr Serv. · Pubmed #18832515 No free full text.

This publication has no abstract.

Cusack KJ, Frueh BC. · No affiliation provided · Psychiatr Serv. · Pubmed #11474062 links to  free full text

This publication has no abstract.