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This article reports the findings of an outcome study done at ALONGSIDE, a counseling-focused retreat center that offers three-week intensive outpatient programs for Christian leaders, the majority of whom are missionaries. Repeated measures research utilized the Outcome Questionnaire -45.2 (OQ-45.2) to explore whether or not clients participating in the three-week intensive outpatient program realized significant clinical progress and whether or not therapeutic gains were retained after the conclusion of the program. Missionaries and other Christian leaders took the inventory online a month before coming to ALONGSIDE, upon arrival, at the end of the three-week program, and three months after the program concluded. The results indicated that a month of time before arrival did not bring about a significant reduction in symptomatology among the 191 subjects, but three weeks of ALONGSIDE's intensive outpatient program resulted in significant clinical improvement which remained when the inventory was taken again three months post-program. This suggests that in a fairly short period of time, an intensive outpatient program consisting of psycho-education, group psychotherapy, and individual and/or marital counseling within a milieu of intentional Christian community can be a highly effective model for promoting enduring psychological healing. ********** When missionaries return Stateside to seek psychological treatment, they often go to centers specializing in offering treatment to missionaries. Several of these centers utilize some form of an intensive outpatient program (IOP). This can be an attractive option because of the relatively short timeframe that might be needed, thus taking missionaries away from their homes, their ministries--their very lives!--for a shorter period of time. Additionally, because these centers usually offer lodging--a great convenience when the missionary does not have a home readily available on short notice--going to such a center is sometimes the preferred approach to treatment for important logistical reasons. In any case, whether or not participation in an IOP is intentionally chosen, a substantial number of missionaries who return to the United States seeking psychological treatment go to specialized centers that do in fact utilize some form of an IOP. Three centers for missionaries that utilize an IOP (Link Care Center, Heartstream Resources, and ALONGSIDE) combined treat upwards of 200 missionaries a year. Therefore, it is important to establish whether or not IOP treatment is effective for a missionary population. There is great variability among programs claiming IOP status in terms of the number of hours a week and the number of weeks involved in the treatment program. The range includes from two to four hours a day, from three to five days a week, and from one week to many months. Some IOPs have beginning and end dates during which clients go through the IOP as a cohort group; others have an ongoing IOP which clients enter and exit as deemed appropriate with no stipulated length of stay. In general, intensive outpatient programs are most commonly associated with treating chemical dependency or eating disorders. Little research is available on IOPs with a more general psychiatric population. However, Wise (2003a) validated the efficacy of an IOP in a private-practice setting and specifically demonstrated the efficacy of using an IOP model to treat depression (Wise, 2005). He found the IOP to be "more effective than psychotherapy in clinically representative studies, randomized clinical trials, and controlled clinical trials as well as comparable to many widely used medical interventions" (Wise, 2003b, p. 203). In light of the high level of effectiveness that he found using an IOP, Wise (2003b) lamented the general underutilization of this model. It is encouraging, therefore, to note that the IOP model is not uncommonly used with missionaries who seek psychological treatment. …

Background Research has demonstrated that the combination of pharmacotherapy and psychological interventions in alcohol use disorder (AUD) treatment is superior to either alone. Despite this, medications remain highly underutilized in many outpatient treatment facilities. Pharmacists can serve as an excellent resource to aid in improving access to medications. Methods This study was a prospective, longitudinal evaluation of a pharmacist's role in a substance use disorder (SUD) clinic, specifically an intensive outpatient program (IOP). The primary objective was to determine if the addition of a clinical pharmacy specialist (CPS) as a bridge until next available provider appointment would improve access to AUD pharmacotherapy for patients in the IOP. Results A total of 43 patients were enrolled in the IOP during the study. Of these, 27 patients presented with a primary diagnosis of AUD, and only eight were receiving AUD pharmacotherapy at the start of the program. During this intervention, 11 patients expressed interest in initiating a medication for AUD while in the IOP. The average wait time for a medication evaluation appointment with the CPS was 1.4 days. By comparison, the average wait time for an addiction psychiatrist was approximately 44 days. Each patient was seen for an average of two 30-minute visits, including an initial medication evaluation and one follow-up. Upon completion of CPS services, patients were referred almost equally to an established non-addiction recovery services (ARS) mental health provider (36%), an ARS psychiatrist (36%), or a primary care provider (28%). Conclusion Our study highlights the role that pharmacists can play in improving access to evidence-based AUD pharmacotherapy, as well as in providing medication education to patients and providers. Long-term prospective research and pharmacoeconomic analysis are needed to determine the sustainability of this service, both at our facility and in other similar practice settings.

IntroductionPosttraumatic stress disorder (PTSD) negatively impacts service members at high rates, causing considerable physical and psychological consequences. Additionally, many service members experience subthreshold PTSD (i.e., experiencing PTSD symptoms that do not meet full diagnostic criteria), which has also been shown to cause significant functional impairment and can be a precursor to the development of full PTSD. Typically, treatment for PTSD at Walter Reed National Military Center facility includes weekly outpatient individual therapy over a three-month period or referral to an intensive outpatient program (IOP), which emphasizes group treatment. Inclusion in these programs is dependent on the severity of symptoms. Service members with subthreshold symptoms do not typically qualify for an IOP, and weekly outpatient therapy does not meet the needs of some service members or their commands.MethodsAs a result, we developed an alternative program with the intention of allowing service members with subthreshold PTSD to receive treatment and return to full-duty status more rapidly. The program emphasized bi-weekly evidenced-based PTSD therapies treatment adjusted to meet the needs of each service member along with the option of adjunct individual and group treatments.ResultsWhile this program is ongoing and we have not yet conducted outcome data analyses, the structure and pace of this program have the potential to produce quicker functional improvements, prevent the development of full PTSD symptoms, and reduce long-term or recurring healthcare utilization.ConclusionAlthough more research is needed, there exists preliminary empirical evidence of efficacy for an accelerated protocol of biweekly evidence-based therapy for service members with subthreshold PTSD.DisclaimerThe opinions expressed in this abstract are those of the authors and do not necessarily represent the opinions of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States Government. Additionally, the authors have no conflicts of interests to report.

Background Insomnia and other types of sleep disturbance are highly prevalent during withdrawal across many different types of substance use disorders (SUDs). It is largely unknown how sleep impacts SUD treatment outcomes, including treatment completion. Methods A retrospective chart review was conducted to obtain information about sleep disturbance and treatment completion in individuals beginning an intensive outpatient (IOP) SUD treatment program. Demographic data were collected along with number of sessions completed, treatment completion, comorbid psychiatric diagnosis, pertinent lab results, and scores on three self-reported measures of sleep: the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). Results Pertinent information was available for 110 individuals. The majority had clinically significant scores on the ISI and PSQI but not the ESS. ISI, but not PSQI or ESS, was associated with treatment completion, such that those with more insomnia were less likely to complete treatment. Conclusion The high prevalence of insomnia symptoms and poor sleep quality coupled with the relationship between insomnia severity and treatment completion may indicate that more severe symptoms of insomnia are a risk factor for treatment completion and subsequent relapse across many substance types. Applying evidence-based insomnia interventions in SUD treatment programs may have meaningful implications for outcomes.

Current work in multicultural competency has emphasized factors such as race and ethnicity, age, disability status, socioeconomic status, sexual orientation and gender. For those clinicians who work with military and veteran populations, grounding in military cultural competence is also critical as a prerequisite for providing quality care. We believe that engaging these populations from a specifically cognitive behavioural orientation allows bridging of cultural gaps and that there is a natural alignment between cognitive behavioural therapy (CBT) and many aspects of warrior culture. This paper outlines several factors related to the values of military culture and strategies of the CBT therapist to better understand and use these values effectively in clinical practice, including lessons learned from an intensive outpatient program providing speciality care to veterans and military service members.

Background In the context of the COVID-19 pandemic, many behavioral health services have transitioned to teletherapy to continue delivering care for patients with mental illness. Studies that evaluate the outcome of this rapid teletherapy adoption and implementation are pertinent. Objective This single-arm, nonrandomized pilot study aimed to assess the feasibility and initial patient-level outcomes of a psychiatric transitional day program that switched from an in-person group to a video teletherapy group during the COVID-19 pandemic. Methods Patients with transdiagnostic conditions who were at risk of psychiatric hospitalization were referred to the Adult Transitions Program (ATP) at a large academic medical center in the United States. ATP was a 3-week intensive outpatient program that implemented group teletherapy guided by cognitive and behavioral principles delivered daily for 3 hours per day. Feasibility was assessed via retention, attendance rate, and rate of securing aftercare appointments prior to ATP discharge. Patients completed standardized patient-reported outcome measures at admission and discharge to assess the effectiveness of the program for improving quality of mental health, depression, anxiety, and suicide risk. Results Patients (N=76) started the program between March and August of 2020. Feasibility was established, with 70 of the 76 patients (92%) completing the program and a mean attendance of 14.43 days (SD 1.22); also, 71 patients (95%) scheduled at least one behavioral health aftercare service prior to ATP discharge. All patient-level reported outcomes demonstrated significant improvements in depression (95% CI –3.6 to –6.2; Cohen d=0.77; P Conclusions Rapid adoption and implementation of a group-based teletherapy day program for adults at risk of psychiatric hospitalization appeared to be feasible and effective. Patients demonstrated high completion and attendance rates and reported significant improvements in psychosocial outcomes. Larger trials should be conducted to further evaluate the efficacy and effectiveness of the program through randomized controlled trials.

The main aim of this clinical study was to explore how adolescent patients with eating disorders and their parents report their perceived self-image, using Structural Analysis of Social Behavior (SASB), before and after treatment at an intensive outpatient program. Another aim was to relate the self-image of the young patients to the outcome measures body mass index (BMI) and Children's Global Assessment Scale (C-GAS) score.A total of 93 individuals (32 adolescents, 34 mothers, and 27 fathers) completed the SASB self-report questionnaire before and after family-based treatment combined with an individual approach at a child and youth psychiatry day care unit. The patients were also assessed using the C-GAS, and their BMI was calculated.The self-image (SASB) of the adolescent patients was negative before treatment and changed to positive after treatment, especially regarding the clusters self-love (higher) and self-blame (lower). A positive correlation between change in self-love and in C-GAS score was found, which rose significantly. Increased self-love was an important factor, explaining a variance of 26 %. BMI also increased significantly, but without any correlation to change in SASB. The patients' fathers exhibited low on the cluster self-protection. Mothers' profiles were in line with a non-clinical group.Results indicate that the self-image of adolescent patients change from negative to positive alongside with a mainly positive outcome of the ED after treatment. Low self-protection according to SASB among fathers suggests the need for greater focus on their involvement.

To investigate whether telephone-based continuing care (TEL) is a promising alternative to traditional face-to-face counseling for clients in treatment for substance abuse.Patients with alcohol and/or cocaine dependence who had completed a 4-week intensive outpatient program were randomly assigned through urn randomization into one of three 12-week interventions: standard continuing care (STD), in-person relapse prevention (RP), or telephone-based continuing care (TEL). This study performed cost, cost-effectiveness, and cost-benefit analyses of TEL and RP compared to STD, using results from the randomized clinical trial with two years of follow up (359 participants). In addition, the study examined the potential moderating effect of baseline patient costs on economic outcomes.The study found that TEL was less expensive per client from the societal perspective ($569) than STD ($870) or RP ($1684). TEL also was also significantly more effective, with an abstinence rate of 57.1% compared to 46.7% for STD (p0.05). Thus TEL dominated STD, with a highly favorable negative incremental cost-effectiveness ratio (-$1400 per abstinent year). TEL also proved favorable under a benefit-cost perspective.TEL proved to be a cost-effective and cost-beneficial contributor to long-term recovery over two years. Because TEL dominated STD care interventions, wider adoption should be considered.

This study examines the prospective relationship between insomnia symptoms and suicide attempts in high-risk youth. We obtained depressive symptoms, insomnia symptoms, and suicide ideation measures from clinical records of 206 adolescents ages 12–17 at entry and discharge from a suicide prevention intensive outpatient program. Information about whether the participant made a suicide attempt was available through six months after discharge. Patients were mainly girls (79.1%; n = 163) with depression (89.8%; n = 185). Associations between insomnia symptoms, attempts within 6 months of discharge, persistent insomnia symptoms, and suicide ideation at discharge were tested with multiple regression analyses. Entry insomnia symptoms were prospectively associated with attempts when controlling for age, sex, and previous attempts, but insomnia symptoms at discharge were not. Suicide ideation at discharge was associated both with entry insomnia symptoms and attempts within 6 months of discharge. When entry and discharge suicide ideation were controlled, the association between entry insomnia symptoms and attempts lost significance. However, the association between discharge ideation and attempts remained significant. Insomnia symptoms contribute indirectly to suicide attempt risk after discharge. Intensive treatment for ideation and reducing insomnia symptoms could reduce discharge suicide risk and subsequent suicide attempts.

Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3–4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel. Keywords: Posttraumatic stress disorder, Exposure therapy, Active duty military, Massed treatment, Trauma Management Therapy

Emerging research highlights the potential cognitive benefits of physical exercise (PE) programs for schizophrenia (SCZ). The few recent efficacy studies that examined augmenting cognitive training (CT) with PE suggest superior effects of the combination. The next step is to consider strategies to enhance adherence in real-world settings if this type of combined treatment is going to be effective. We present the first community effectiveness data for PE and CT that included a motivationally-enhancing, self-determined approach to exercise, in lieu of participant payment. Eighty-five outpatients with schizophrenia attending an intensive outpatient program were randomized to 18 h of either (A) self-determined PE regimen with choice from a menu of different activities; (B) tablet-based neurofeedback CT focused on processing speed (PS) and working memory (WM), or (C) a time-matched combination of PE and CT. Assessments were conducted at baseline, post, and follow-up (2 mo). All groups improved in WM from baseline to post, with greatest gains in the PE only group. At follow-up, cognitive gains originally observed in the PE-only group disappeared, while the PE + CT group evidenced improvements in WM and psychotic symptoms. Notably, attrition for PE was only 7%. Our data shows that combining PE and CT leads to lasting effects that are superior to those of either intervention alone. The low PE drop-out rate suggests a self-determined approach to the exercise regimen was tolerable, and may be an important component of future community implementation efforts. Keywords: Schizophrenia, Motivation, Physical exercise, Cognitive training

Background Mobile technologies hold potential for improving the quality of care and engagement of patients. However, there are considerable challenges in ensuring that technologies are relevant, useful, and engaging. While end users such as patients and providers are increasingly involved in the design of health technologies, there are limited examples of their involvement in directly creating technologies for their personal use. Objective We aim to evaluate the feasibility and acceptability of patients and providers creating mobile texting apps to support treatment goals. Methods In an 11-month usability study, we enrolled 4 providers and 28 patients in an intensive outpatient program for obsessive-compulsive disorder. Patients and providers created their own mobile texting apps using a visual app development platform. A subsample of 10 patients and 4 providers completed a usability measure. Results Participants created a total of 360 unique mobile text messages (1787 total messages sent). There were 4 types of messages identified, including personalized reminders, clinical exposures, interactive prompts, and encouraging/informational messages. A total of 9 out of 10 (90%) patients agreed that the messages were relevant to their recovery, and 8 out of 10 (80%) agreed that the messages were effective at helping complete treatment plans. Conclusions Enabling patients and providers to cocreate apps for their own use by using a visual application platform is feasible and holds potential for increasing the relevance, sustainability, and effectiveness of digital health technologies.

Objective The purpose of this study was to assess the incidence of adverse childhood experiences (ACEs) and the efficacy and feasibility of a trauma-informed screening for ACEs among individuals in a substance use disorder recovery program. Method Individual interviews, questionnaires, and postinterview survey and reflections were used in this cross-sectional clinical translation project. Descriptive statistics were used to analyze demographics, ACE scores, protective childhood experiences, self-reported diagnoses, and postintervention survey data. Postinterview reflections were reviewed and grouped into common ideas as shared by participants, as well as interesting impressions, insights, and responses to the interviews. Results Thirty clients participated in the interview process. Among the 29 participants who completed the questionnaires, all reported at least one ACE, and 82.8% reported six or more ACEs. In addition, 96.6% reported experiencing more than four protective factors. Twelve (40%) clients were referred for further mental health counseling after the interviews. Notable findings from the interviews were the general lack of awareness of the relationship between ACEs and current substance use disorder among participants. Gaining knowledge about the impact of ACEs on their recovery seemed to provide a sense of relief and a feeling that they were "normal." Conclusions The trauma-informed care approach is intended to promote mindfulness regarding the effect of ACEs on substance abuse in this population. Screening for ACEs is necessary if effective interventions are to be provided, with the goal of improving client outcomes.

Youth experiencing substance use disorders often are susceptible to relapse because traditional support systems can be expensive, geographically dispersed, operated on limited schedules and lacking in peer support. The continuity of care offered via the digital Addiction Comprehensive Health Enhancement Support System (ACHESS) system holds promise in preventing relapse because of its portability and capability to foster virtually anytime/anywhere, cost-effective access to supportive interventions. The aim of this mixed-methods study was to evaluate the utility and impact of ACHESS on treatment adherence among youth with substance use disorders in an intensive outpatient program in the US Midwest. Data on 28 clients using ACHESS during 2016–17 were compared to retrospective data on 28 carefully-matched others treated without ACHESS during 2014–16. Fifty-four percent of the study group successfully completed treatment as opposed to 42.9% of those in the comparison group. Staff focus group findings highlighted how some features of ACHESS were effectively integrated into the care model and appeared to positively impact outcomes, while other elements of the application offered little utility. We suggest further study of ACHESS among larger samples of youth with substance use disorders in intensive outpatient programs to assess its efficacy in supporting adherence to treatment.

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Although self-concept has been identified as salient to the psychosocial adjustment of adolescents dealing with a chronic illness (CI), little research has focused on its predictors it. Given that depression and parent-child attachment have been linked to self-concept in the population at large, the goal of this study was to evaluate these relationships longitudinally in a sample of adolescents with CI. Using participant data from the Mastering Each New Direction (MEND) program, a 3-month psychosocial, family based intensive outpatient program for adolescents with CI, we employed multilevel modeling to test longitudinal changes in self-concept, as predicted by depressive symptoms and parent-child attachment, in a sample of 50 youths (MAunque el autoconcepto se cosidera muy importante para la adaptación psicosocial de los adolescentes que sufren una enfermedad crónica (EC), pocas investigaciones se han centrado en qué lo predice. Teniendo en cuenta que la depresión y el apego entre padres e hijos se ha asociado con el autoncepto en la población en general, el objetivo de este estudio fue evaluar estas relaciones longitudinalmente en una muestra de adolescentes con EC. Utilizando datos de los participantes del programa Mastering Each New Direction (MEND), un programa ambulatorio psicosocial, familiar e intensivo de tres meses para adolescentes con EC, usamos modelos multinivel para evaluar los cambios longitudinales en el autoconcepto como los predicen los síntomas depresivos y el apego entre padres e hijos en una muestra de 50 jóvenes (Edad promedio = 14.56, desvío estándar = 1.82) que participaron en el programa MEND. Tanto el “tiempo pasado en el programa” como las disminuciones de los síntomas depresivos estuvieron asociados con aumentos en el autoconcepto con el paso del tiempo. Los niveles iniciales más altos de apego evasivo a la madre y al padre también estuvieron asociados con mayores niveles iniciales de autoconcepto. Enfocarse en los síntomas depresivos y apoyar los cambios adaptativos en el apego puede ser clave para promover un autoconcepto saludable en las poblaciones de pacientes pediátricos con enfermedades crónicas. La asociación entre el apego evasivo y los puntajes iniciales más altos de autoconcepto pueden reflejar diferencias en la autonomía, la autoconfianza o la depresión de los participantes. Entre las limitaciones del estudio se encuentran la variabilidad de la cantidad de tiempo pasado en el programa, la reducción de las valoraciones de los últimos intervalos de tiempo y la incapacidad de analizar y exponer completamente todas las posibles covariables debido a un tamaño muestral pequeño (p. ej.: poder).虽然自我概念已被确认为青少年应对慢性疾病心理社会调试的一个突出因素,然而很少有研究着重预测自我概念。鉴于抑郁和家长-儿童依恋在人群中和自我概念相关,该研究的目的即在一个有慢性病青少年样本中纵向评估这些关系。我们使用从”掌握每个新方向” (MEND)项目(一个为期三个月的针对有慢性病青少年的以家庭为基础的心理社会)中得来的参与者数据和多层面模型来测试自我概念在由50位参与MEND项目青少年(M

This study examined the influence of gender, post-treatment issue severities, and treatment participation rate on the post-treatment employment status of consumers with substance use disorders. The study analyzed the archival data of 100 unemployed and underemployed participants from a substance abuse intensive outpatient program. We found significant differences in the characteristics of gender, severity of alcohol use, drug use, psychiatric issues, and treatment participation rate. Female gender and low treatment participation rates negatively predicted employment. This study increased understanding about the interplay of alcohol, drug, and psychiatric influences on post-treatment employment status.

Background Intensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]). Method One-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention. Results Pre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation. Conclusion Intensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.

This was an investigation of the feasibility and effectiveness of a brief yoga intervention (one session) within an intensive outpatient program (IOP) for service recipients diagnosed with various psychiatric disorders. Participants (N = 26) completed the Toronto Mindfulness Scale (TMS) and the Positive and Negative Affect Schedule (PANAS). Data was collected before and after one yoga session and follow-up data was collected via mail after discharge from the IOP. Scores indicated that negative affect significantly decreased and positive affect significantly increased from pre to post yoga session. Mindfulness scores significantly increased from pre to post yoga session. Though the results of this study supported that a yoga intervention is both feasible and effective within an IOP, collection of follow-up data after discharge via mail was not as feasible. The results of this preliminary investigation support a larger and longitudinal study to further examine yoga as a treatment modality with this clinical population.

This chapter summarizes unique applications of the Pathways concepts. Several examples are provided, including applications of the Pathways Model in support groups, in intensive outpatient services, and in patients with lifestyle issues and patients with vague, diffuse symptoms, among others. When a group intervention is the most practical, then the Pathways principles are adapted to provide the best care. Some patients with complex psychiatric and medical comorbid chronic illnesses need more than weekly sessions, so an intensive outpatient program using the Pathways Model is detailed. Patients with medically unexplained symptoms often search for ways to cope with their daily suffering, but also the negative reactions of medical professionals to them. This chapter will also attempt to project the Pathways Model into the future, particularly to anticipate what advances people with chronic illness can expect. The use of technology, self-help programs, and better understanding of the biological basis of illness hold great promise for those who struggle every day with pain or depression. Finally, the chapter described the application of the Pathways Model for those who are biologically and psychologically healthy—“not sick”—but who desire to be fully well, mentally, emotionally, and spiritually, with suggestions for implementation.

This article describes and investigates initial findings from the Esperanza Mental Health Services (EMHS) Program, which is an intensive outpatient program that provides individual and group mental health services for students with “dual diagnosis” or developmental disabilities and co-occurring mental health problems. Previous research substantiates that the mental health needs of this population are significant, yet often go unaddressed in school settings. Preliminary outcomes for a sample of 61 children ages 4–22 suggest improvements in important school indicators, such as suspensions and absences during the year of program implementation, as well as positive changes in parent-reported mental health functioning. Lastly, parent satisfaction regarding these services and supports was high. The implications of these results for a proposed school-based mental health service delivery model within a multi-tiered system of prevention and intervention are discussed.

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.

Prospective study. The objective of this study was to determine whether an integrated and an intensive outpatient program would result in functional improvement of spinal cord injury (SCI) patients with American Spinal Injury Association Impairment Scale (AIS) A injuries as measured by the Spinal Cord Independence Measure (SCIM III). Patient recruitment and evaluations were conducted at the Brain and Spinal Injury Repair Research Centre (BASIR), Tehran, Iran. Observed SCIM III scores and SCI Ability Realization Measurement Index changes were used to measure the change in 134 patients with complete SCI (AIS A), after participation in an outpatient rehabilitation program consisting of a bimonthly multidisciplinary education program, combined with a twice-weekly occupational therapy, physical therapy and home nursing as a rehabilitation package for a 6-month period. A significant increase in median total SCIM III scores following comparison of ‘pre-treatment’ scores and final ‘post-treatment’ scores (9.5 score, P

Objective The goal of this study was to provide pilot clinical data on the effectiveness of an intensive outpatient treatment model for adolescent eating disorders that combines Maudsley-based family therapy and group dialectical behavior therapy skills training. Method Measures of physical and psychological status were gathered upon admission, discharge, and at 3 follow-up intervals. Results Adolescents who completed the program gained a significant amount of weight and experienced a significant decrease in eating disorder psychopathology. At the 1-year follow-up, 64% of adolescents were weight restored and menstruating normally. Measures of eating disorder psychopathology continued to improve up to a year after treatment. Conclusions This pilot, multimodal program warrants further investigation and may be an effective intermediate level of care treatment option for adolescent eating disorders.

Obsessive-Compulsive Disorder (OCD) is prevalent among children and adults across racial and ethnic groups, causing significant and pervasive impairment in home life, work, and relationships. This article includes a review of the literature surrounding utilization of mental health care and barriers to treatment for OCD in four specific ethnoracial minority groups, followed by an examination of minority participation in a large intensive/residential OCD treatment facility. Participants included 924 children or adults diagnosed with OCD at Rogers Memorial Hospital between 1999 and 2012. The overwhelming majority of participants were non-Hispanic White (93.3%), indicating a significant mental health disparity. Patients were: 2.4% Hispanic/Latino American, 1.2% Asian American, 0.9% African American, 0.8% biracial/multiracial, 0.7% Indian American, 0.6% other, 0.1% Native American, and 0.1% Pacific Islander. Minority patients required significantly longer stays, despite no differences in mean OCD severity pre- or post treatment. The percentage of minority patients significantly increased over a 13-year span. Implications of findings and recommendations for increasing minority participation are discussed.

This article examines the prevalence and consequences of alcohol and other drug (AOD) use in Ukraine, and the counseling modalities and resources that are available to address the issue. The authors consider the need for a suitable service initiative involving intensive outpatient AOD counseling, focusing on the North American Intensive Outpatient Program (IOP; Wise, American Journal of Orthopsychiatry, 73, 405–410, 2003b) as well as the likely challenges and solutions to implementing such a model.

An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA's ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations.

Emerging adults (18–25 years old) are often poorly retained in substance use disorder treatment. Office-based buprenorphine often enhances treatment retention among people with opioid dependence. In this study, we examined the records of a collaborative care buprenorphine treatment program to compare the treatment retention rates of emerging adults versus older adults. Subjects were 294 adults, 71 (24%) aged 18–25, followed in treatment with buprenorphine, nurse care management, and an intensive outpatient program followed by weekly psychosocial treatment. Compared to older adults, emerging adults remained in treatment at a significantly lower rate at 3 months (56% versus 78%) and 12 months (17% versus 45%), and were significantly more likely to test positive for illicit opioids, relapse, or drop out of treatment. Further research into factors associated with buprenorphine treatment retention among emerging adults is needed to improve treatment and long-term outcomes in this group.

The goal of this study was to determine which cocaine dependent patients engaged in an intensive outpatient program (IOP) were most likely to benefit from extended continuing care (24 months). Participants (N=321) were randomized to: IOP treatment as usual (TAU), TAU plus Telephone Monitoring and Counseling (TMC), or TAU plus TMC plus incentives for session attendance (TMC+). Potential moderators examined were gender, stay in a controlled environment prior to IOP, number of prior drug treatments, and seven measures of progress toward IOP goals. Outcomes were: (1) abstinence from all drugs and heavy alcohol use, and (2) cocaine urine toxicology. Follow-ups were conducted at 3, 6, 9, 12, 18, and 24 months post-baseline. Results indicated that there were significant effects favoring TMC+ over TAU on the cocaine urine toxicology outcome for participants in a controlled environment prior to IOP and for those with no days of depression early in IOP. Trends were obtained favoring TMC over TAU for those in a controlled environment (cocaine urine toxicology outcome) or with high family/social problem severity (abstinence composite outcome), and TMC+ over TAU for those with high family/social problem severity or high self-efficacy (cocaine urine toxicology outcome). None of the other potential moderator effects examined reached the level of a trend. These results generally do not suggest that patients with greater problem severity or poorer performance early in treatment on the measures considered in this report will benefit to a greater degree from extended continuing care.

Importance Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes. Objective To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients’ costs, health care utilization, and experience. Design, Setting, and Participants Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care. Interventions The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services. Main Outcomes and Measures Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention’s effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants’ satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months. Results Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] −$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03). Conclusions and Relevance Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings. Trial Registration clinicaltrials.gov Identifier:NCT02932228

Research suggests a high comorbidity between chronic pain and substance use disorder (SUD), particularly within a military population. Optimal clinical treatment for those with chronic pain and SUD is believed to be multidisciplinary care. However, limited research has been conducted on this topic within the military health care system (MHS). This quality improvement project examines short-term outcomes for a joint-SUD and chronic pain intensive outpatient program (IOP). Active duty, veterans, and dependents were enrolled in a 6-week Joint-IOP at WRNMMC. The multidisciplinary team included addiction social workers, physical therapists, nurses, and clinical psychologists. Patients received a breathalyzer and urine drug screen at the time of treatment initiation and periodically throughout. Participants filled out the following validated questionnaires pre- and post-treatment: Defense and Veterans Pain Rating Scale (DVPRS), Pain Outcomes Questionnaire (POQ), Brief Addiction Monitor (BAM), World Health Organization Quality of Life-Brief (WHOQOL-BREF) and Pain Catastrophizing Scale (PCS). Fifty-eight patients completed the joint-IOP. Paired T-tests suggest a reduction in DVPRS worst pain scores (p=0.013), reduced POQ total impairment (p=0.034) and improved POQ vitality (p=0.024) from pre- to post-treatment. Paired T-tests suggest a trend toward decreased alcohol and substance use as measured by the BAM (p=0.056). Both WHO quality of life and pain catastrophizing showed no significant change. This project suggests that patients suffering from chronic pain and SUD within the MHS have improved pain and SUD outcomes at the completion of a 6-week joint-IOP. Implications of this project suggest the importance of concurrently treating chronic pain and SUD within the MHS.

Introduction Every eight seconds a Baby Boomer turns 60 (Rao, Praveena, & Rao, 2010). The number of people over age 65 in the United States with a mental illness is expected increase to 15 million persons in 2030 (McGovern, Lee, Johnson, & Morton, 2008). Mental health services in the U.S. are insufficient due to lack of providers and limited options. The scenario worsens when you add factors such as rural and geriatric populations. Mendenhall, MS is indicative of this phenomena. There are few mental health services in Simpson County and even fewer options for geriatric patients. The county has two hospitals with Simpson General Hospital (SGH) in Mendenhall housing a ten bed geriatric psychiatric unit but the need is much greater. Mendenhall's census is 2,509 residents with 17.7% being over age 64. Simpson county has a census of 27, 463 residents with 15.6% being over age 65 (United States Census Bureau, 2015). The hospital is plagued by a revolving door syndrome with multiple readmissions in the midst of congress’ mandate that the Centers for Medicare and Medicaid Services (CMS) penalize hospitals with 30-day readmission rates. An Intensive Outpatient Program was implemented in Mendenhall, MS in conjunction with SGH. The program provided outpatient mental health treatment for 12 geriatric patients with multiple 30 day readmissions throughout the previous year. Methods The subjects for this study were patients with 3 to 6 readmissions within 30 days within one year from the geriatric psychiatric unit. Twelve patients participated and were part of a convenience sample. The study was conducted by use of comparison of readmission rates in 30 days between the intervention(implementation of outpatient program) and pre-intervention archival data that showed readmission rates monthly for one year prior to readmission rates. Data during intervention were collected via daily sign in sheets and hospital daily census records. Results Prior to the intervention, the number of admissions per month ranged from 11 to 16 per month, and readmissions ranged from 4 to 8. The average pre-intervention readmission rate was 43.6%. During the month of the intervention program, only one readmission occurred relative to the 18 total admissions, which resulted in a clinically substantial reduced rate of only 5.6%. A Fisher's exact test was conducted to compare the average pre-intervention readmission rate to the intervention rate, and showed a statistically significant reduction in the 30-day readmission rate (p = 0.012). Conclusions Offering programs such as Intensive Outpatient Mental Health Services can reduce costly readmission rates and penalties while increasing available services to geriatric patients in rural Mendenhall, MS. This research was funded by Funding was supplied from host hospital, Simpson General Hospital in Mendenhall, MS. Participation in the program was paid through Medicare reimbursement. Monthly hospital readmission rates.

R. Lindsay Bergman, Associate Director of the UCLA Child OCD and Anxiety Program and Director of the Pediatric OCD Intensive Outpatient Program at Resnick Neuropsychiatric Hospital at UCLA, is Asso...

Background and Objectives: Historically patients consulted for the substanceabusetreatmentfromthemedicalsurgical floorshaveavery low show rate for the substance abuse treatment. The authors performed retrospective chart review to find predictors of substance abuse treatment outcome in hospitalized veterans at Atlanta VA Medical Center. Methods: The medical records from all the patients who were admitted to the medical/surgical floor with substance abuse consults from January‐December 2009 were reviewed. A total of 235 consults were received. Those records were examined to find the predictors for substance abuse treatment. Results: Multiple variables were tested for significance – patient demographics, housing status, employment, reason for hospitalization, toxicology screens, co‐morbid psychiatric and medical conditions, physician visits, and patients on waiting list. All variables were given cut‐off point for the p‐value of .10. These variables were then included in the logistic regression model. It was found that homelessness (x2 ¼ 16.14 and p < .0001) was the only individual variable that showed a statistically significant correlation with starting the program. It was found that homelessness (x2 ¼ 19.21 and p < .0001) was the only individual variable that showed statistically significant correlation with completing the program. Conclusions and Scientific Significance: Our study supports that for veterans with substance abuse, housing was the only consistent predictor to enter intensive outpatient program (IOP), complete IOP, and start aftercare. Our study demonstrates the need for and potential benefit of providing stable housing for the homeless veterans. (Am J Addict 2013;XX:1–8)

This study examined the moderating role of shyness mindset on the reduction of social anxiety during exposure-based treatment. Participants (N = 60) in an intensive outpatient program for anxiety disorders were assessed at pre- and post-treatment. Social performance anxiety decreased dramatically during treatment, but the amount of decrease differed as a function of pre-treatment shyness mindset. At one standard deviation above the mean on both the social performance anxiety and shyness mindset measures, an average reduction of 15 points on the social performance anxiety measure was observed. At one standard deviation above the mean on the social performance anxiety measure and one standard deviation below the mean on the shyness mindset measure, an average reduction of 27 points on the social performance anxiety measure was observed. These results suggest that targeting shyness mindset during exposure-based treatments for social anxiety disorder might increase the effectiveness of treatment for individuals with a high shyness mindset.

Background and Objectives There are limited investigations of brief interventions to facilitate treatment entry among individuals with substance use disorders. This study investigated the effectiveness of brief motivational feedback (BMF) for increasing entry into intensive substance abuse treatment in veteran patients. Methods Veteran patients (N = 84) with substance use disorders referred for an intake assessment in a substance abuse specialty clinic received either (i) intake assessment plus BMF or (ii) intake assessment as usual (AAU). BMF consisted of brief motivational enhancement feedback pertaining to estimates of alcohol and drug consumption, money spent on drugs and alcohol, and self-reported problems due to substance abuse. Primary outcome was entry in treatment groups in an intensive outpatient program for substance abuse. Results Patients in BMF and AAU conditions did not significantly differ on indices of treatment entry. However, among patients with comorbid substance dependence and psychiatric disorders, those who received BMF were significantly more likely to enter outpatient treatment groups. Conclusions and Scientific Significance The addition of motivational feedback to a standard intake assessment enhanced substance abuse treatment entry among veteran patients with comorbid substance use disorders and psychiatric disorders. These preliminary findings extend the use of motivational feedback to facilitate entry into substance abuse treatment among veteran patients with comorbid substance use and psychiatric disorders. Furthermore, they suggest opportunity for more effective patient-treatment matching based on initial motivation and other individual factors such as psychiatric comorbidity. (Am J Addict 2013;22:132-135)

In an effort to increase engagement in effective treatment, we offered a choice of alternate evidence-based treatments to 137 alcohol- or cocaine-dependent adults (110 males, 27 females) who entered an intensive outpatient program (IOP) but disengaged within the first 8 weeks. We hypothesized that disengaged patients would choose and subsequently attend alternatives to IOP when given the chance, that their choices would be consistent with their previously-stated preferences, and that demographic and clinical characteristics would be predictive of alternatives chosen. Of 96 participants reached by phone, 19% chose no treatment; 49% chose to return to IOP; 24% chose individual psychotherapy; 6% chose telephone counseling; 2% chose naltrexone with medication management. There were few relationships between participant characteristics and choices made upon disengagement. Participants who chose alternative treatments were equally likely to attend their chosen treatment as those who chose IOP. Limited interest in alternative treatments may reflect allegiance to IOP, which was initially chosen by all participants. Implications for implementation of patient-centered adaptive treatment are discussed.

Objective To evaluate the efficacy of an intensive outpatient program designed to improve functioning and reduce psychological impairment in chronic headache patients. Background Chronic headaches, occurring 15 or more days per month, for three or more months, may arise from multiple International Classification of Headache Disorders diagnoses: Chronic Migraine, Chronic Tension Type Headache, New Daily Persistent Headache, Chronic Post Traumatic Headaches, and Medication Overuse Headache. Several interdisciplinary programs that treat patients with chronic headaches have reported decreases in headache frequency. This study sought to evaluate the effect of a 3 week interdisciplinary treatment program for patients with chronic headache disorders on headache severity, functional status, and psychological impairment. Methods Subjects were 379 patients admitted to an outpatient chronic headache treatment program. Assessments of headache severity, psychological status, and functional impairment were completed by 371 (97.8%) of these at the time of admission. At discharge, 340 subjects (89.7%) provided assessment data, and 152 (40.1%) provided data at 1-year follow-up. Results Subjects' mean ratings on a 0-10 scale for their headache pain in the prior week declined, and these improvements were maintained at follow-up. (Estimated marginal means on a 0-10 scale for Average pain: admission 6.1, discharge 3.5, follow-up 3.3; for Least pain: admission 3.2; discharge 1.5; follow-up 1.3; for Worst pain: admission 8.2; discharge 6.4; follow-up 5.7), and similar results were found for current pain (admission 4.7; discharge 2.8; follow-up 2.4): Measures of functional impairment also improved following treatment, and these gains were maintained at 12 month follow up (Estimated marginal mean Headache Impact Test-6 score: admission 66.1, discharge 55.4, follow-up 51.9; Estimated marginal mean Pain Disability Index score: admission 36.2, discharge 14.1, follow-up 11.6). As measured by the Depression, Anxiety and Stress Scale, anxiety and reactivity to stress decreased following treatment, and remained improved at follow-up (Estimated marginal mean score for Anxiety: admission 8.7, discharge 5.2, follow-up 4.4; Estimated marginal mean score for stress: admission 14.9, discharge 7.2, follow-up 7.6). Depression decreased with treatment, but while 1-year follow-up depression scores remained significantly lower than at admission, they were also significantly higher than at discharge (Estimated marginal means: admission 13.3, discharge 4.1, follow-up 6.6). Conclusions The study supports the efficacy of the treatment model. Limitations of the study and suggestions for future research are also discussed.

Objectives Intensive outpatient programs (IOPs) have become increasingly common for treating highly distressed patients, and a burgeoning number of IOPs are based on, or informed by, dialectical behavior therapy (DBT). The goal of the present study was to evaluate the effectiveness of DBT in a community mental health center IOP for patients with heterogeneous diagnoses. Method Using a within-subjects design, we examined changes in depression, anxiety, mindfulness, and hope during DBT treatment in a community mental health center in the Midwestern United States. The final sample comprised 56 participants (59% female) ranging in age from 18 to 73 years, with a mean age of 36.8 years (standard deviation = 13.7). The majority of participants (80%) met criteria for a mood disorder, just over half met criteria for an anxiety disorder, and 20% met criteria for comorbid substance abuse or dependence. Over half met criteria for more than one diagnosis. Length of treatment varied based on the needs of the individual patient; treatment ranged from 2 to 16 weeks, with an average stay of 6 weeks. Results Depression and anxiety scores decreased significantly and hope scores increased significantly over the course of treatment (all p's < .001). Mindfulness scores did not increase significantly, although changes did occur in the predicted direction. In addition, the extent to which hope and mindfulness increased over the course of treatment predicted final depression and anxiety scores after controlling for baseline symptom levels. Conclusions Results suggest that this DBT-informed intervention was effective in reducing depression and anxiety and increasing hope. Because of the move away from inpatient hospitalizations over the last few decades, it is incumbent on the field to find alternative ways to treat patients in need of more acute, intensive care. Moreover, these treatments must be cost effective, as many of these patients have limited financial resources. Group therapy formats might provide an appropriate and needed bridge for this coverage gap. The results of this study suggest that a DBT-informed IOP might be an amenable treatment for this population.

Background Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs). Methods In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs’ (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Results The literature review ( n =9 studies) and analyses of interviews ( n =15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals , including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers. Conclusions Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs. Implications Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs. Level of evidence V.

An empirically derived prediction model was developed in a private practice setting to monitor on-track and off-track weekly treatment progress in an intensive outpatient program (IOP).The predictive equation was derived as a function of the baseline measure and time. The formulae for the predictive equations were derived from two groups of psychiatric patients (N = 400 each) in an IOP diagnosed with major depression. Each equation was cross-validated between these two psychiatric IOP samples and a dual diagnosis sample (N = 198) using κ, the reliable change index (RCI), receiver operating characteristic curves, and Youden's J.Using varying RCI classifications, approximately 66-75% of both samples reliably improved, 23-24% were indeterminant, and only 1-3% deteriorated. Of patients identified as off-track, which included patients classified as indeterminant and deteriorated, 83% were correctly identified. Of those identified as on-track, 85% were correctly classified. Those identified as on-track (85%) are highly likely to respond to treatment as expected.The overall efficiency index (hit rate) for the correct classification of all patients was 85%. Implications for using this predictive model as a clinical support decision tool with relatively homogeneous populations in other practice settings are discussed.

Compulsive hoarding patients have been found in previous studies to have substantial disability and functional impairment. However, no prior study has examined subjective and objective quality of life (QOL) in patients with compulsive hoarding. This present study compared compulsive hoarders and non-hoarding OCD patients across a variety of QOL domains. Subjects were 171 consecutive adult patients (34 compulsive hoarders, 137 non-hoarding patients with DSM-IV OCD) treated openly between 1998 and 2004 in the UCLA OCD Partial Hospitalization Program (OCD PHP), a specialized, intensive, multi-modal treatment program for treatment-refractory patients. Scores on the Quality of Life Scale and other symptom severity measures on admission were compared between compulsive hoarders and non-hoarding OCD patients. Compulsive hoarders were older and had lower global functioning than non-hoarding OCD patients. Both groups had low overall QOL scores across multiple domains. Compulsive hoarders had significantly lower levels of satisfaction with their safety than non-hoarding OCD patients, were more often the victims of both violent and non-violent crime, felt less safe in their neighborhoods, and felt less protected against attack. Compulsive hoarders were also much less satisfied with their living arrangements than non-hoarding OCD patients. No differences were found on financial variables, but the vast majority of patients in both groups were unemployed. Compulsive hoarders have lower QOL than non-hoarding OCD patients in the domains of safety and living situation. Psychosocial rehabilitation that focuses on problems with victimization, safety, employment, and financial areas may be a beneficial augmentation to treatment for compulsive hoarding.

Introduction/Background To compare the effectiveness of three treatment strategies for chronic low back pain with varying biomechanical intensity and multidisciplinary approach. Material and method A monocentric controlled trial with a 12-months follow-up, conducted in the French Valley Loire region from May 2009 to April 2013. Participants were working-aged patients with chronic low back pain referred to a French chronic low back pain care-network to support medical and occupational issues. Three treatment strategies, each for five weeks were compared: (i) intensive and multidisciplinary program conducted in a rehabilitation center; (ii) less intensive outpatient program conducted by a trained private physiotherapist; (iii) mixed strategy combining the same outpatient program associated with a weekly multidisciplinary intervention. The effects of treatment conditions were compared using an “intention to treat” approach: Number of days’ sick leave during the 12-months following treatment, and quality of life and social ability assessed by auto-questionnaires. Results A total of 349 patients (52.2% men, 42.5 ± 8.7 years old, median duration of sick leave = 206.0 days (92.0–301.0)) were included. Sick leave duration significantly decreased during the 12-months following treatment in the three groups. Physical capacity improved in intensive program and mixed strategy groups. There was no significant difference for the evolution of participants’ quality of life, social ability, and personal beliefs between the three groups. Conclusion This study confirms that disparate treatments might show similar effectiveness because they could all work through concomitant changes in beliefs, attitudes, and coping mechanisms. The original mixed strategy can treat a larger number of chronic low back pain patients, at a lower cost and provide local community-based care.

The purpose of this study is to demonstrate the effectiveness of a freestanding intensive outpatient program (IOP) in a private practice setting for the treatment of dual diagnosis substance-abusing patients. Pre- and post-treatment Symptom Checklist 90–Revised, Global Assessment of Functioning, and patient functional rating scales were analyzed. Reliable change indices and clinically significant change measures were utilized. Trajectories of change for depression and number of days substances were used were analyzed, based on weekly Brief Symptom Inventory and substance use data reported by patients. Client satisfaction was also assessed at the end of treatment. Although patients started treatment with psychiatric symptoms comparable to those found in inpatient settings and 56% presented with suicidal or homicidal ideation, all symptom scales, functional impairments, and number of days used were significantly reduced by the end of treatment. Effect size statistics, reliable change indices, and statistica...

One of the pressing needs in the treatment of substance use disorders is the identification of adjunctive services or interventions that can be added to “treatment as usual” to improve outcomes. At this point, there is evidence that the provision of services to address psychiatric, family, employment, and housing problems can bring about improvements in these areas, and in some cases, in substance use outcomes (Friedmann, Hendrickson, Gerstein, & Zhang, 2004; McLellan et al., 1997, 1998; O'Farrell, Choquette, & Cutter, 1998). Continuing care, which serves to extend the duration of treatment, has also been shown to improve substance use outcomes (McKay, 2005). However, it can be difficult to deliver adjunctive interventions to patients in standard outpatient treatment due to the high drop out rates in these programs. For example, recent data from a national survey of addictions treatment programs indicated that the median length of stay in intensive outpatient programs was 46 days, with only 36% of admissions completing treatment (SAMHSA, 2008). One intervention that has shown considerable promise as a means to both increase retention and improve substance use outcomes is contingency management (CM), which provides incentives linked to performance. CM interventions, most notably in the form of voucher-based reinforcement therapy (VBRT) for abstinence, have demonstrated efficacy in the treatment of substance use disorders, as documented in several recent meta-analyses (Dutra, Stathopoulou, Basden, Leyro, Powers, & Otto, 2008; Lussier, Heil, Mongeon, Badger, & Higgines, 2006, Prendergast, Podus, Finney, Greenwell, & Roll, 2006). Notably, CM interventions have also proved effective in community settings (Petry, Alessi, Marx, Austin, & Tardif, 2005; Petry, Alessi, & Hanson, 2007). The majority of trials utilizing CM for drug abstinence have focused on initiating abstinence early in treatment. What has been much less frequently addressed is whether CM works as an adjunctive relapse prevention intervention in individuals who have achieved initial engagement in treatment and already sharply reduced or stopped using drugs. Another intervention that, at least theoretically, should promote better outcomes in initially stabilized patients with substance use disorders is relapse prevention, or RP (Marlatt & Gordon, 1985). Most RP interventions make use of techniques from cognitive-behavioral and social skills therapies to increase awareness of situations in which the individual has been particularly likely to use drugs (i.e., “high risk situations”) and improve coping responses for these situations through rehearsal and homework assignments (Annis & Davis, 1989; Carroll, 1998; Marlatt & Gordon, 1985). Improvements in these areas are thought to increase self-efficacy, which in term promotes further improvements in coping abilities. Although CBT-based interventions are widely seen as evidence-based (Carroll, 1996), recent research has suggested they are not more effective than other bona fide treatments for substance use disorders, whether delivered as a primary treatment or as a form of continuing care (Dutra et al., 2008; Irvin, Bowers, Dunn, & Wang, 1999; Longabaugh & Morgenstern, 1999; McKay et al., 1999; McKay, Lynch, Shepard, & Pettinati, 2005; Morgenstern & McKay, 2007; Rawson et al., 2006). Therefore, it is not clear that supplementing standard addiction treatment with RP for patients who have achieved initial engagement will in fact lead to better outcomes. There is also mixed evidence regarding possible additive effects for interventions that combine RP/CBT and CM over RP/CBT or CM alone. Epstein, Hawkins, Covi, Umbricht, and Preston (2003) reported that CM alone was more effective in decreasing cocaine use in methadone maintenance patients than CM+CBT during treatment, but additive effects favoring the CM+CBT condition over CM alone emerged at 12 months. Shoptaw et al. (2005) found that methamphetamine dependent participants had better drug use outcomes in CM+CBT than in CBT alone, but the combination condition was not more effective than CM alone. Finally, in studies with methadone maintenance and methamphetamine dependent patients, Rawson and colleagues found that while shorter term outcomes favored CM over CBT or control conditions, longer term outcomes in CBT conditions were not different from those in CM conditions. Moreover, there were no additive effects for CM+CBT over CM or CBT (Rawson et al., 2002; Rawson et al., 2006). It should be noted that all of these studies were done as abstinence-initiation projects, rather than as continuing care or relapse prevention projects. Another important consideration in the selection of adjunctive interventions to reduce relapse in stabilized patients is whether the effects of the intervention persist into the post-treatment period. There is some evidence that RP/CBT interventions can exhibit sleeper effects, where the positive effects of the intervention in relation to comparison conditions does not become apparent until after the interventions are over (Carroll et al., 1994; McKay et al., 1999; Rawson et al., 2002; Rawson et al., 2006), although this is not the case in all studies. Until recently, most studies of CM did not have post-treatment follow-ups. However, a number of newer studies have included post-treatment follow-ups, usually out to 12 months. The results have been mixed, with some studies showing evidence of sustained voucher effects (Alessi, Hanson, Wieners, & Petry, 2007; Epstein et al., 2003; Higgins, Wong, Badger, Ogden, & Dantona, 2000; Higgins et al., 2003; Higgins et al., 2006), and other studies showing no sustained effects (Milby et al., 2003; Petry et al., 2005; Petry et al., 2006; Rawson et al., 2002; Rawson et al., 2006; Shoptaw et al., 2005). This paper presents results from a program of research on the effectiveness of enhancements to improve continuing care in outpatient specialty care for drug and alcohol dependence. Participants were recruited from cocaine-dependent patients attending a publicly funded intensive outpatient program (IOP) in Philadelphia, who had successfully engaged in IOP for at least two weeks and met other study inclusion criteria. They also reported that they had been abstinent for an average of 44 consecutive days at entrance into the study, although abstinence was not a requirement for participation. The study featured a 2 × 2 design, which crossed contingency management (CM; yes/no) with relapse prevention (RP; yes/no). The CM protocol used in the study was modeled after the protocol developed by Silverman et al. (1996), which in turn was adapted from work by Higgins and colleagues (1993). Participants earned vouchers for cocaine-free urines on an escalating schedule over a 12 week period, with a total maximal value of $1,150 if all urines were cocaine-free. The vouchers could be redeemed for goods and services consistent with recovery. The cognitive-behavioral RP protocol (Annis & Davis, 1989) was delivered in up to 20 weekly individual sessions. Participants in the condition that provided both CM and RP were required to be attending their RP sessions for the first 12 weeks in order to be eligible to participate in the CM procedures during that time. The primary goal of the study was to determine whether providing CM, RP, or the combination of CM and RP to participants who had achieved initial engagement in intensive outpatient treatment would produce better cocaine use outcomes than treatment as usual (TAU) over an 18 month follow-up period. We predicted that significant main effects for CM and RP would be obtained, and the best outcomes would be found in the CM+RP condition. These predictions were tested through an examination of main and interaction effects in the 2 × 2 design and post hoc contrast analyses that compared the four treatment conditions.

The Center for Drug and Alcohol Programs (CDAP) at the Medical University of South Carolina (MUSC) focuses on research and clinical services for substance use disorders. CDAP is comprised of both inpatient and outpatient services. Outpatient services include an intensive program with daily group meetings and an individualized treatment program where patients are able to take part in one-on-one counseling. Approximately 1200 outpatients are seen in the CDAP clinics annually, 300 of which are in the intensive outpatient program. The patients seen in CDAP have a range of substance use disorders which include alcohol and opioid dependence, among others. Given the patient population, there is a significant demand for extended-release intramuscular naltrexone (ERIN), but the CDAP clinics are neither staffed nor structured for medication administration or storage. A previously established pharmacist-run clinic exists at MUSC for the purpose of administering long-acting injectable antipsychotics and monitoring the patients who receive them. An explanation of the financial impact of the antipsychotic injection clinic to our institution is described by Phan and Vandenberg. With the increasing patient and physician demand, a protocol was developed to allow pharmacists to administer ERIN in the pharmacist-run clinic.