Bonnie Green – Research Abstracts

  • Impact of PTSD co-morbidity on one-year outcomes in a depression trial.

Low-income African American, Latino, and White women were screened and recruited for a depression treatment trial in social service and family planning settings. Those meeting full criteria for major depression (MDD; N = 267) were randomized to cognitive behavior therapy (CBT), antidepressant medication, or community mental health referral.  All randomly assigned participants were evaluated by baseline telephone and clinical interview, and followed by telephone for one year.  PTSD comorbidity was assessed at baseline and one-year follow-up in a clinical interview. At baseline, 33% of the depressed women had current comorbid PTSD.  These participants had more exposure to assaultive violence, had higher levels of depression and anxiety, and were more functionally impaired than women with depression alone.  Depression in both groups improved over the course of one year, but the PTSD subgroup remained more impaired throughout the one-year follow-up period.  Thus, evidence-based treatments (antidepressant medication or structured psychotherapy) decrease depression regardless of PTSD comorbidity, but women with PTSD were more distressed and impaired throughout.  Including direct treatment of PTSD associated with interpersonal violence may be more effective in alleviating depression in those with both diagnoses.  

  • Primary care providers’ experiences with trauma patients: A qualitative study.

The goal of this study was to increase knowledge about provider perspectives on provision of healthcare to trauma patients in primary care settings for underserved clients, to inform the development of effective interventions for patients and providers.  Thirty-one primary care providers (PCPs) working with low-income primary care patients participated in focus group interviews exploring attitudes and strategies for working with trauma and mental health patients.  Transcripts were analyzed using an iterative coding process.  PCPs described frequent contact with trauma and mental health patients. They sometimes developed appropriate short-term management strategies, and many were aware of indications that their patients had experienced trauma.  However, they felt unprepared to deal with these issues.  Lack of formal training plus strong emotional reactions to some trauma patients may undermine PCP effectiveness and contribute to job stress.  Additional training and appropriate treatment models could allow these dedicated providers to increase their effectiveness and job satisfaction.

  • A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care.

This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care.

  • Trauma-Informed Medical Care: A CME communication training for primary care providers. 

BACKGROUND AND OBJECTIVES:  Trauma exposure predicts mental disorders, medical morbidity, and healthcare costs. Yet trauma-related impacts have not received sufficient attention in training primary care providers (PCPs). This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), and evaluated its efficacy.  METHODS: We randomized PCPs to training or wait-list (delay) conditions; waitlist groups were trained after reassessment. The primary outcome was a patient-centeredness score derived from Roter Interactional Analysis System ratings of 90 taped visits between PCPs and standardized patients.  The secondary outcome comprised a survey of 400 of PCPs’ actual patients.  PCPs were Family Medicine residents (n=17) and community physicians (n=13; 83% Family Medicine specialty), from four sites. The mostly minority patients recruited from two community and two residency clinics completed surveys before or after their provider received training. RESULTS: Immediately trained PCPs trended toward a larger increase in patient-centeredness than did the delayed PCPs (p < .09), with a large effect size (.66).  The combined trained PCP groups showed a significant increase in patient-centeredness pre to post training, p < .01, Cohen’s D = .61.  Actual patients rated PCPs significantly higher post-training on a composite encompassing partnership issues.  Breakdowns showed lower scores for those with trauma or PTSD symptoms, and non-significant but positive pre-post changes for these subgroups. CONCLUSIONS:  This is a promising approach to supporting relationship-based trauma-informed care among PCPs to help promote better patient health and higher compliance with medical treatment plans. 

  • Trauma experiences and mental health among incarcerated women. Psychological Trauma: Theory, Research, Practice, and Policy

Objective: Female offenders have different risk factors for offending than do male offenders, and elevated rates of interpersonal victimization such as physical, emotional, and sexual abuse, and family and community violence, are common in histories of incarcerated women.  We used factor analysis to examine patterns of traumatic events experienced by women in jail and explored how these patterns were associated with four psychiatric disorders (PTSD, major depression, bipolar disorder, and substance use disorder) observed in this sample.   Method: A total of 464 women from nine jails in four geographic regions in the USA comprised the sample.  Women participated in diagnostic interviews to assess trauma exposure and psychiatric disorders.  Results: Three factors described the observed patterns of trauma exposure: Family Dysfunction (FD), Interpersonal Violence (IPV) and External Events (EE). Life Events were analyzed as a separate group of items.  FD and IPV each contributed independently to the odds of having each of the four mental disorders studied; significant odds ratios were in the range of 1.38 – 2.05. All three factors contributed to the diagnosis of bipolar disorder.  The only diagnosis to which stressful Life Events made a unique contribution was to the likelihood of having PTSD.  Conclusion: This work provides further support for the importance of assessing trauma exposure of women in jail, especially the family context, as well as mental health. Implementation and testing of evidence-based treatment approaches that address trauma-related distress in correctional settings are warranted.