Genotypic drug resistance testing could facilitate the choice of initial ART in areas with rising transmitted drug resistance TDR and enable care-providers to determine which individuals with virological failure VF on a first- or second-line ART regimen require a change in treatment. An inexpensive near point-of-care POC genotypic resistance test would be useful in settings where the resources, capacity, and infrastructure to perform standard genotypic drug resistance testing are limited. A POC genotypic resistance test is likely to involve the use of allele-specific point mutation assays for detecting drug-resistance mutations DRMs. One or more of these six DRMs was present in
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Abstract Patients hospitalized for psychiatric reasons exhibit significantly elevated risk of suicide, yet the research literature contains very few outcome studies of interventions designed for suicidal inpatients. This pilot study examined the inpatient feasibility and effectiveness of The Collaborative Assessment and Management of Suicidality CAMS , a structured evidence-based method for risk assessment and treatment planning Jobes, The study used an open-trial, case-focused design to assess an inpatient adaptation of CAMS, spread over a period averaging 51 days.
The intervention was provided via individual therapy to a convenience sample of 20 patients 16 females and four males, average age Although these findings must be considered preliminary due to the lack of a randomized control group, they merit attention from clinicians working with patients at risk for suicide. This study also supports the feasibility of implementing a structured, suicide-specific intervention for at-risk patients in inpatient settings.
This is especially true in the case of inpatient treatment; for example, a review of the literature on treatment of suicidal individuals Linehan, listed only two outcome studies of inpatient treatments for suicidal patients.
However, recent years have seen the introduction and testing of new therapies focused on suicide. For example, Linehan and associates tested a therapy designed specifically for suicidal patients with borderline personality disorder Dialectical Behavior Therapy [DBT] and found it superior to community treatment by experts CTBE; Linehan et al.
The comparison group was treated with enhanced usual care EUC , which included tracking and referral services. These and other studies have contributed to a growing body of evidence indicating that outpatient therapies targeting psychological vulnerabilities and suicidal behaviors are effective and produce benefits superior to conventional therapies Ellis, These therapies view the suicidal coping response as the primary focus of treatment, rather than as a symptom of an illness that, when treated, will eliminate suicide risk as well.
The picture regarding inpatient treatment, however, is less clear. For example, Bohus et al. However, the suicide-related behavior of interest in this study was parasuicide deliberate self-harm without intent to die , so the question of reduction in ideation and behavior associated with a wish to die still awaits study. A recently developed protocol adapts the cognitive therapy intervention used in the Brown et al.
Emphases include development of a collaborative therapeutic alliance, construction of a cognitive— behavioral conceptualization, instilling hope, practicing alternate coping skills, and developing explicit relapse prevention plans.
This intervention is currently in early stages of feasibility testing. In addition to therapies specifically tailored to the vulnerabilities of suicidal patients, Jobes has developed a system that serves both as a means of assessing risk in suicidal patients and as a platform for developing the kind of therapeutic relationship needed for working effectively with patients who often have low motivation for accepting help Ellis, The emphasis in Collaborative Assessment and Management of Suicidality on collaborative assessment dovetails with current trends in the assessment literature.
Sitting side-by-side, the patient and therapist assess several key contributors to the suicidal state: psychological pain, stress, agitation, hopelessness, and self-hate. Patients rate pertinent scales and provide narrative responses for these items.
Thus, the assessment process is intrinsically psychotherapeutic. Moreover, in CAMS, the results of the assessment are immediately transparent to the patient. CAMS investigates the extent of ambivalence about life and death while inviting the patient to refrain from acting on the suicidal wish as other options are explored. As we have described elsewhere Allen, , this collaborative, inquisitive approach to understanding the suicidal state of mind exemplifies the stance of mentalizing.
The purpose of the present study was to assess the feasibility and performance of the CAMS system in the treatment of psychiatric inpatients with current or recent suicidal ideation and behavior. Our goal was to determine whether patients treated with CAMS showed reduced levels of suicidal ideation, and whether they also experienced reduced levels of symptoms associated with suicide risk, particularly depression, hopelessness, and self-hate. Our purpose was to establish feasibility of implementation and to obtain preliminary data regarding changes in suicidal ideation and related variables over the course of treatment.
Method Participants The initial group consenting to participation consisted of 24 inpatients at The Menninger Clinic, a bed, private psychiatric hospital that specializes in the treatment of patients with multiple, treatment-resistant disorders. Average length of stay is 6 to 8 weeks. Among the initial sample, four patients failed to complete the protocol defined as at least four, minute individual therapy sessions due to premature discharge, resulting in a final sample size of They were hospitalized with suicidal ideation as a significant aspect of their reasons for admission.
The average number of previous psychiatric hospitalizations was 2. Of the five participants without a recent suicide attempt i. Of these five, the first participant reported a strong wish to die, had devised a plan, and had obtained the means to carry it out; the second had multiple suicide risk factors and had been prevented by family members from walking in front of a car; the third reported recent suicidal ideation in the context of bipolar disorder, cocaine abuse, and prior attempts by overdose; the fourth had a history of five prior attempts, was stockpiling pills, and had begun writing farewell notes to loved ones; and the fifth had obtained a gun with the intent of killing himself, but was interrupted by a visitor.
All were judged at significant risk of suicide by their treatment teams and expressed agreement that suicide was a significant issue in their illness and treatment. The four participants without a mood disorder diagnosis had primary diagnoses of bulimia nervosa, panic disorder, anxiety disorder NOS, and post-traumatic stress disorder. All participants had histories of suboptimal response to prior treatments, including inpatient and outpatient psychotherapy and pharmacotherapy.
No suicide attempts or acts of nonsuicidal self-harm occurred during the course of the study. The CAMS team met weekly to review use of the approach and discuss cases. Jobes and a senior-level doctoral student in clinical psychology using the CAMS Rating Scale previous research had established their interrater reliability of the adherence approach, Comtois et al. Procedure The study used an open-trial, case series design. Although a majority of patients participating in the study had histories of suicide attempts, patients without recent attempts were considered eligible for the study if current suicidal ideation was a significant part of their reason for admission.
Inclusion criteria otherwise were deliberately broad; among patients with suicidal ideation, only those who were actively psychotic or under age 18 were excluded. Availability of CAMS was made known to hospital clinicians through an assortment of channels, including professional discipline meetings and in-service training programs. In addition, a member of the research team also serves as coordinator of individual therapy services and was able to monitor availability of study therapists and make matches with appropriate patients.
Patients were informed of the study by the therapist during an early session, given a copy of the consent form, and asked to review it and let the therapist know their decision at the next therapy session.
Patients were informed that receiving CAMS was not contingent upon their consenting to the study; they would receive CAMS if they wished, and the consent merely allowed the researchers to collect assessment data for the purpose of analysis and publication. In addition to CAMS-M, patients participated in a therapeutic milieu and received the standard array of services for Menninger inpatients. Although these vary somewhat depending on patient need and program enrollment, services generally include group psychotherapy, psychoeducational groups e.
Addictions and eating disorder tracks are also available according to patient need. There were no exceptions to this rule in this study sample; all were taking psychotherapeutic medications on admission, and all but one were receiving multiple medications.
All study participants were taking multiple psychotherapeutic medications at discharge. The first session following consent was devoted to completion of the initial SSF Jobes, All other measures were administered biweekly. Each item is rated on a Likert scale from 0 to 3, with higher scores indicating more severe levels of depressive symptoms.
Higher scores on the BHS indicate greater hopelessness severity. Previous studies have reported BHS means of 2. Items are scored on a Likert scale ranging from 0 to 2, with higher scores indicating more severe suicidal ideation. Previous studies have reported BSS means of 2. Items are scored on a Likert scale of 0 to 5, with higher scores indicating greater levels of suicidal cognitions. Rudd et al.
Inventory items are rated on a Likert scale of 1 never to 7 always , with higher scores indicating a greater perceived alliance. The SSF is a multifaceted instrument; at its core are five items asking for subjective ratings 0 —5 of negative states: psychological pain, stress, agitation, hopelessness, and self-hate.
In an inpatient sample of suicidal patients, means for each of the items were as follows: pain: 3. It is intended to build a strong clinical alliance and increase patient motivation and engagement in care. Ongoing CAMS care includes routine suicide risk assessment, further crafting of the Crisis Response Plan, and use of problem-focused interventions to target and treat suicidal drivers.
Collaborative Problem-Focused Interventions—treating identified suicidal drivers within clinical interventions or referral to external resources.
Collaborative Development of Existential Purpose and Meaning—working with the patient to develop a life worth living. To further illustrate the use of CAMS in clinical practice, Table 1 provides brief examples of clinician statements that are emblematic of the five components of CAMS adherence.
I would like to understand more about your pain and despair. May I take a seat next to you so we can complete this assessment tool together? Perhaps that way we can get a deep understand of your suicidal pain and suffering. We can also start addressing issues that cause you to want to kill yourself.
Then, if we can get you back into AA and using your sponsor again, perhaps we can reduce the role that alcohol plays in getting you into a suicidal crisis. Coping is really important. Now, I wonder if we can turn to how you can have more purpose and meaning in your life—even beyond your marriage—so that you have a brighter future and a life more worth living?
CAMS-based problem-focused interventions for various suicidal drivers may include targeting and treating hopelessness, emotional dysregulation, interpersonal isolation, impulsivity, symptoms of PTSD, or difficulties imagining and planning for the future.
CAMS-based care often leads to the engagement and coordination of related auxiliary services e. Unlike other evidence-based suicide-relevant treatments, CAMS is not a new psychotherapy, nor is it limited to a particular therapeutic orientation such as cognitive therapy or psychodynamic therapy. Rather, it is an organizational clinical framework—a therapeutic platform—for maintaining a collaborative focus on the elimination of suicidal ideation and behavior as a means of coping.
CAMS does not prescribe the specific interventions that the clinician must use. Instead, the CAMS clinician is free to use his or her own expertise and experience to select and implement effective clinical interventions.
The psychometric assessment properties of the SSF have been established and replicated Conrad et al. There are now five published correlational studies supporting the feasibility and clinical value of CAMS and the SSF with suicidal outpatients Arkov et al. A recent randomized clinical trial of CAMS both replicates and extends previous correlational support of the approach Comtois et al.
In this study, CAMS led to rapid and sustained reductions in suicidal ideation and overall symptom distress while increasing reasons for living, optimism, and hope in comparison to treatment as usual. Critically, this clinical trial found that the effectiveness of CAMS in follow-up assessments was most pronounced 12 months after the initial engagement in CAMS care, suggesting both effectiveness and sustained therapeutic impact.
Results Participants completed an average of Average length of hospital stay was Because of a decreasing sample size over each round of repeated measures due to variations in length of stay and occasional missed assessments , there was not an adequate sample size to support a repeated-measures analytic strategy.
Thus, t tests of pre- versus post-treatment scores were calculated using the first and last assessment score available on each measure i. The three variables with the largest effect sizes depressive symptoms, psychological pain, and self-hate were examined using repeated-measures ANCOVA analyses to examine for possible confounding effects of age and gender.
Results for depressive symptoms were consistent with t test analyses and these covariates were nonsignificant. Psychological pain and self-hate were reduced to nonsignificance in this model, although age and gender were also nonsignificant in both analyses. Due to the small sample size, these analyses were underpowered, but overall suggest that age and gender were not significant confounding variables.
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