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Biomedical subjects

Paul B Gold

Publications and source records attributed to Paul B Gold.

At least 19 recordsLinked to original sources
PubMed2006

Demographic characteristics and employment among people with severe mental illness in a multisite study.

People with psychiatric disabilities experience disproportionately high rates of unemployment. As research evidence is mounting regarding effective vocational programs, interest is growing in identifying subgroup variations. Data from a multisite research and demonstration program were analyzed to identify demographic characteristics associated with employment outcomes, after adjusting for the effects of program, services, and study site. Longitudinal analyses found that people with more recent work history, younger age, and higher education were more likely to achieve competitive employment and to work more hours per month, while race and gender effects varied by employment outcome. Results provide strong evidence of demographic subgroup variation and need.

Adolescent↗
PubMed2006

Estimated payments to employment service providers for persons with mental illness in the Ticket to Work program.

OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.

Adolescent↗
PubMed2006

Challenges to implementing and sustaining comprehensive mental health service programs.

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

Advisory Committees↗
PubMed2005

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness.

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Adolescent↗
PubMed2005

Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness.

CONTEXT: National probability surveys indicate that most individuals with schizophrenia and other severe mental illnesses are not employed. This multisite study tested the effectiveness of supported employment (SE) models combining clinical and vocational rehabilitation services to establish competitive employment. METHODS: We randomly assigned 1273 outpatients with severe mental illness from 7 states in the United States to an experimental SE program or to a comparison or a services-as-usual condition, with follow-up for 24 months. Participants were interviewed semiannually, paid employment was tracked weekly, and vocational and clinical services were measured monthly. Mixed-effects random regression analysis was used to predict the likelihood of competitive employment, working 40 or more hours in a given month, and monthly earnings. RESULTS: Cumulative results during 24 months show that experimental group participants (359/648 [55%]) were more likely than those in the comparison programs (210/625 [34%]) to achieve competitive employment (chi(2) = 61.17; P<.001). Similarly, patients in experimental group programs (330/648 [51%]) were more likely than those in comparison programs (245/625 [39%]) to work 40 or more hours in a given month (chi(2) = 17.66; P<.001). Finally, participants in experimental group programs had significantly higher monthly earnings than those in the comparison programs (mean, US 122 dollars/mo [n=639] vs US 99 dollars/mo [n=622]); t(1259) = -2.04; P<.05). In the multivariate longitudinal analysis, experimental condition subjects were more likely than comparison group subjects to be competitively employed, work 40 or more hours in a given month, and have higher earnings, despite controlling for demographic, clinical, work history, disability beneficiary status, and study site confounders. Moreover, the advantage of experimental over comparison group participants increased during the 24-month study period. CONCLUSION: The SE models tailored by integrating clinical and vocational services were more effective than services as usual or unenhanced services.

Adult↗
PubMed2005

Screening offenders with histories of mental illness and violence for supportive housing.

This article describes a community mental health agency's process of screening supportive housing applicants with histories of violent felonies and serious mental illness. The agency adopted its corporate intranet as a tool so that geographically dispersed senior staff could participate in information gathering in order to ensure expert input in admissions decisions. This broad-based participation was designed to maintain community safety, while making the agency's residential resources available to people with mental illness and criminal histories. Considering the high recidivism rate of ex-offenders with mental illness and lack of clearly established best practices to serve them in the community, the authors believe that it is timely for housing providers to reevaluate how to better serve these individuals.

Adult↗
PubMed2005

Clinical factors associated with employment among people with severe mental illness: findings from the employment intervention demonstration program.

Research has shown that supported employment programs are effective in helping psychiatric outpatients achieve vocational outcomes, yet not all program participants are able to realize their employment goals. This study used 24 months of longitudinal data from a multisite study of supported employment interventions to examine the relationship of patient clinical factors to employment outcomes. Multivariate random regression analysis indicated that, even when controlling for an extensive series of demographic, study condition (experimental versus control), and work history covariates, clinical factors were associated with individuals' ability to achieve competitive jobs and to work 40 or more hours per month. Poor self-rated functioning, negative psychiatric symptoms, and recent hospitalizations were most consistently associated with failure to achieve these employment outcomes. These findings suggest ways that providers can tailor supported employment programs to achieve success with a diverse array of clinical subpopulations.

Adolescent↗
PubMed2005

Integration of psychiatric and vocational services: a multisite randomized, controlled trial of supported employment.

OBJECTIVE: Although large-scale surveys indicate that patients with severe mental illness want to work, their unemployment rate is three to five times that of the general adult population. This multisite, randomized implementation effectiveness trial examined the impact of highly integrated psychiatric and vocational rehabilitation services on the likelihood of successful work outcomes. METHOD: At seven sites nationwide, 1,273 outpatients with severe mental illness were randomly assigned either to an experimental supported employment program or to a comparison/services-as-usual condition and followed for 24 months. Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis. RESULTS: Subjects served by models that integrated psychiatric and vocational service delivery were more than twice as likely to be competitively employed and almost 1(1/2) times as likely to work at least 40 hours per month when the authors controlled for time, demographic, clinical, and work history confounds. In addition, higher cumulative amounts of vocational services were associated with better employment outcomes, whereas higher cumulative amounts of psychiatric services were associated with poorer outcomes. CONCLUSIONS: Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.

Adult↗
PubMed2005

Effects of job development and job support on competitive employment of persons with severe mental illness.

OBJECTIVES: Few studies have sought to determine which specific supported employment services improve employment outcomes for people with pyschiatric disabilities. This study examined the effects of job development and job support among other services on acquisition and retention of competitive employment. METHODS: Data used in the analysis came from seven sites of the Employment Intervention Demonstration Program. Employment data were collected weekly for a period up to 24 months for 1,340 participants. A random-effects meta-analysis was conducted. RESULTS: Job development increased the probability of obtaining competitive employment. The effects of job development on job acquisition remained after the effects of other factors were controlled for. Job support was associated with more months in the first competitive job but not total hours worked. However, no evidence for the causal role of job support was found in analyses that tested the effects of job support after the job support was provided. The causal role of job support alone was also cast in doubt by the fact that a substantial overlap existed between individuals who received job support and vocational counseling. CONCLUSIONS: Job development is a very effective service when the goal is job acquisition. Job support is associated with retention of a first competitive job, but its causal role is questionable.

Adult↗
PubMed2004

Comparison of self-report versus agency records of service utilization in a community sample of individuals with alcohol use disorders.

Health services research has become an important area for evaluating the cost effectiveness of interventions. When used in treatment outcome research, the accuracy of self-report data is essential. The reliability and validity of self-report service utilization among alcohol and drug addicted individuals is questionable and largely unexplored. This study assessed the accuracy of self-report utilization of services compared to service record abstraction in a sample of treatment seeking individuals with alcohol use disorders. The results of the comparative analysis found that the level of agreement for some services, particularly medical, psychiatric and substance abuse inpatient admissions, and social service involvement was good. There was less agreement in emergency room visits and arrests. Factors related to discrepancies between self-report and records were explored.

Adult↗
PubMed2004

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment.

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

Adult↗
PubMed2004

Effectiveness of naltrexone in a community treatment program.

OBJECTIVE: In several large, well-designed, randomized, double-blind studies, the opiate antagonist naltrexone demonstrated efficacy in the treatment of alcohol dependence. Specifically, when combined with certain psychosocial therapies, naltrexone reduces the number of drinking days, heavy drinking, and time to relapse to alcohol use in alcohol-dependent individuals. Whether this efficacy can be generalized to individuals who have alcohol use disorders and present for treatment at front-line community treatment programs has not been well established. METHODS: A total of 145 patients who presented for treatment at a rural community substance abuse treatment center were randomized to receive naltrexone 50 mg daily plus usual program treatment (n = 54), placebo plus usual treatment (n = 43), or usual treatment alone (n = 48) for 12 week. A total of 133 participants had at least one follow-up visit. Primary outcome measures included percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days (four or more for women and six or more for men), and time to first heavy drinking day. Secondary measures included changes in serum biological markers (alkaline phosphatase, alanine transaminase, aspartate transaminase, and gamma-glutamyltransferase), craving, and psychosocial functioning. RESULTS: In the intention-to-treat analysis, there were no between-group differences for any of the primary drinking outcomes at 12 weeks. In post hoc exploratory analyses, the entire sample of participants was divided into two new groups: (1) people who drank during the 2 weeks before the start of medication (entry drinkers) and (2) people who did not drink during this interval (entry abstainers). Entry abstainers were at an advantage at study entry in that they were significantly more likely to have an inpatient hospitalization immediately before entry into outpatient treatment. Mixed-model analysis of variance revealed a main effect for entry group at the 12-week treatment endpoint on the primary outcome measures of percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days, and time to first heavy drinking day. Participants in any of the randomized groups who were entry abstainers had significantly better improvement on all of the primary outcome measures. The abstainer groups that were randomized to placebo and usual treatment had significantly better outcomes than the entry drinkers in those perspective groups. However, for the naltrexone-treated group, entry drinkers and entry abstainers had similar improvement in drinking-related outcomes. CONCLUSIONS: These data suggest that naltrexone may offer particular benefit to patients who continue to drink during the early stages of the trial as compared with those who have achieved abstinence before treatment entry.

Adult↗
PubMed2003

Disability compensation seeking among veterans evaluated for posttraumatic stress disorder.

OBJECTIVE: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). METHODS: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. RESULTS: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans. CONCLUSIONS: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.

Adolescent↗
PubMed2003

Service use and satisfaction among elderly former prisoners of war in South Carolina.

OBJECTIVE: This project was developed to evaluate the use of and satisfaction with Veteran's Affairs (VA) medical services and disability benefits among surviving elderly prisoners of war (POWs) in South Carolina. METHOD: A single-assessment quantitative survey strategy was implemented to learn more about the service use patterns and satisfaction with care of two groups of male former POWs (N = 87): those who were members of a national POW service organization and those who were not. RESULTS: Data show that the majority of these POWs had used the VA for medical care in the previous year, received disability compensation through the VA, and were satisfied with VA primary care medical services. Furthermore, differences between these two POW groups were minimal. CONCLUSIONS: Results provide preliminary evidence that many former POWs rely heavily upon the VA for provision of primary medical and specialty care and disability compensation and that POWs are generally satisfied with the VA services and benefits they receive.

Aged↗
PubMed2002

Naturalistic, self-assignment comparative trial of bupropion SR, a nicotine patch, or both for smoking cessation treatment in primary care.

The effectiveness of bupropion SR, a nicotine patch, or both, when co-administered with cognitive-behavioral therapy, on smoking cessation was evaluated under treatment-as-usual conditions in a primary care smoking cessation clinic. Consecutive consenting patients (n = 189) assigned themselves to one of three treatments according to personal preference: nicotine patch (NTP; n = 27), bupropion SR (B; n = 101), and bupropion SR plus nicotine patch (B + NTP; n = 61). Six-month self-reported abstinence rates were 14.8%, 27.7%, and 34.4%, respectively. Odds ratios for 6-month abstinence, with NTP as reference, were 2.2 (CI = 0.7-5.9; p = .19) for B, and 3.0 (CI = 0.9-9.9; p = .07) for B + NTP. Resemblance of abstinence pattern and magnitude between this naturalistic study and randomized clinical trials of bupropion SR may support tentative inferences of stability and generalizability of clinical trial efficacy findings.

Administration, Cutaneous↗
PubMed2002

Patient satisfaction among combat veterans receiving specialty PTSD treatment.

BACKGROUND: Despite the difficulties with successfully developing effective treatments for posttraumatic stress disorder (PTSD), very little research has been conducted on veterans' perceptions of satisfaction with the treatments they receive through the VA. OBJECTIVE: Our objective was to evaluate combat veterans' satisfaction with Veterans Affairs (VA) services and to evaluate the reliability and preliminary validity of a measure of patient satisfaction, the Charleston Psychiatric Outpatient Satisfaction Scale-VA PTSD Version, which was originally designed for general psychiatric outpatients. METHOD: Fifty-one combat veterans currently receiving specialty mental health care at a VA outpatient PTSD clinic were asked to complete two instruments designed to assess their satisfaction with services provided within the VA mental health and primary care clinics. RESULTS: Data show that the reliability (alpha = 0.96 and 0.95) and validity of these two measures of patient satisfaction were good and indicate that veterans receiving specialty mental health care for PTSD rate their mental health and primary care quite positively. CONCLUSIONS: These results provide preliminary support for the internal reliability and convergent validity of a novel measure of patient satisfaction for use with combat veterans suffering from PTSD and treated within a VA hospital specialty mental health clinic; the results also support the satisfaction of these patients with mental health and primary care services received through the VA.

Journal Article↗
PubMed2002

The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combat-related PTSD.

Researchers have identified difficulties associated with the use of traditional Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity scales with survivors of traumatic events. A new scale, the Infrequency-Posttraumatic Stress Disorder scale (Fptsd), was created from MMPI-2 items that were infrequently endorsed by 940 male combat veterans presenting for treatment at the posttraumatic stress disorder (PTSD) clinics of 2 Veterans Affairs Medical Centers. A variety of statistical methods were implemented that preliminarily established Fptsd's validity with a validation sample of 323 additional PTSD-diagnosed combat veterans. Results indicate that, relative to previously established validity and overreporting scales (F, Fb, and Fp), Fptsd was significantly less related to psychopathology and distress and better at discriminating simulated from genuinely reported PTSD. Clinical implications are discussed concerning the use of Fptsd to assess disability-seeking veterans suspected of overreporting PTSD symptoms.

Adult↗