High levels of stress, anxiety, and depression (SAD) can adversely influence physical health, psychological well-being, and academic and clinical performance of nursing students. Numerous studies have identified the factors associated with SAD; however, a paucity of empirical research addresses the relationship of SAD with campus connectedness (CC), perceived social support (PSS), and coping. The purpose of this quantitative cross-sectional study, guided by Lazarus and Folkman's theory of stress, coping, and adaptation, was to determine the prevalence of SAD and examine its relationship with CC, PSS, and coping among undergraduate nursing students of Nepal. Survey research was conducted using depression anxiety stress scale, campus connectedness scale, the multidimensional scale for perceived social support, and brief cope inventory. Among 680 nursing students analyzed, the 51.7% reported moderate to extremely severe levels of SAD. A one-way multivariate analysis of variance revealed a statistically significant relationship among CC, PSS, and coping with SAD (p < .001). A discriminant analysis indicated that depression best discriminated the levels of CC and PSS. The levels of coping were found to be best discriminated by anxiety. The findings can be sourced to create awareness among educators and administrators of nursing colleges about the roles that campus connectedness, social support, and coping strategies play in the occurrence SAD. Future studies can focus on the need to establish mental health screening and social support services, such as counseling centers in nursing colleges, which may bring about a positive social change in the lives of nursing students.

In a Department of Veterans Affairs hospital on the East Coast of the United States, behavioral outbursts result in 2 out of 10 veterans dismissed from a posttraumatic stress disorder (PTSD) unit prior to completing the 6-week program. The purpose of this evidence-based quality improvement project was to create a clinical practice guideline (CPG) based on social cognitive theory (SCT) to provide new strategies for managing veterans with PTSD and to improve the confidence of the nurses in managing outbursts. The Star Model guided the project development with the Delphi method to achieve participant consensus, the AGREE II to assess the CPG quality, and the Generalized Self-Efficacy (GSE) scale to measure the change in participant knowledge and confidence. The literature was searched, compiled, assessed, and shared with 10 participants, registered nurses on the PTSD unit. Through the Delphi process, the participants achieved consensus (8/10) for the CPG, with two neutral participants. The GSE was administered pre- and post-test and analyzed using a paired t test to measure the mean differences of the GSE scores. The data was normally distributed to different scores to gauge the impact of the CPG development process on improving nursing knowledge and confidence was normally distributed [t(9) = -4.188, p < 0.05, &, t(9) = -2.714, p =0.003]. The data indicated a significant increase in participant knowledge about role of SCT, and confidence toward implementing the CPG into clinical practice. This project contributes to positive social change as nurses identified a clinical practice problem, transferred evidence about strategies from the literature into their clinical practice through a CPG, and implemented the CPG with the knowledge and confidence to impact patient care.

Repeated exposure to media images that portray women as sex objects can have negative long-term effects on self-esteem beginning in preadolescence. Negative effects include decreased feelings of competence, increased focus on appearance, increased body dissatisfaction, and limited achievement in domains not related to appearance. There is a gap in the literature examining if media literacy training can mitigate the negative effects of exposure to sexualized media content. Festinger's social comparison theory and Vygotsky's theory of cognitive development provided the framework for this study. A quasi-experimental pre-post-test design was used to examine the interaction of media literacy training and time of measurement, on self-esteem and body-satisfaction in preadolescent girls. Archival data from 73 5th grade girls were obtained from a media literacy group with the addition of data from 14 5th grade girls collected to form a non-media literacy comparison group to control for confounding variables and bias. Two separate 2-way, mixed-model, factorial ANOVAs were conducted. The analyses failed to show a significant interaction between literacy group and time of measurement on self-esteem and/or body-satisfaction. However, the potential effectiveness of media literacy skills in neutralizing the negative impact of sexualized media imagery on preadolescent girls' self-esteem and body-satisfaction was observed in the between-group analyses. Positive social change may occur when society continues to identify and incorporate positive self-esteem influences and media literacy skills into the lives of preadolescent girls as to mitigate negative long-term effects of media sexualization.

Prior to the 1990s, bipolar disorder, a behavioral disorder characterized by severe mood fluctuations, was not considered an suitable diagnosis for children. However, in recent decades, an increase in pediatric bipolar disorder (PBD) diagnosis has occurred in the U.S. The purpose of this study was to explore the perceptions and lived experiences of licensed mental health clinicians regarding their decision-making processes used during assessment and diagnosis of PBD. This phenomenographic study utilized individual, semi-structured interviews to explore the perceptions and lived experiences of 14 licensed clinicians in the Commonwealth of Massachusetts who assess and diagnose PBD. Data were collected with a 7-question face to face interview. Using NVivo 10 software several key phrases and words were identified, coded, and used to locate patterns, themes, and concepts. Data analysis revealed that significant issues related to PBD assessment and diagnosis may exist, including: inconsistencies in assessment/diagnostic processes; reticence to diagnose the disorder; failure to use available assessment instruments; a lack of attention to comorbidities; and trouble differentiating between PBD symptoms and other issues, such as trauma or dysfunctional family dynamics. Given the reluctance of these mental health professionals to diagnose PBD, implications for social change underscore the important role of education, training, and ongoing clinical supervision to help other mental health professionals accurately assess and diagnose PBD. Recommendations emanating from study findings suggest further research on PBD assessment and diagnosis to help professionals develop more effective diagnostic frameworks for clinical training and practice.

The rate of DV for AA women is higher than other groups and often more severe; however, some AA women are successful in leaving the violence for good. Researchers continue to examine how victims move beyond their former life and into an abuse free environment by directing more attention on positive dynamics of victims of DV. One area is the study of resilience; however, little is known about the lived experience of resilience. The purpose of this phenomenological study was to explore the lived experiences of resilience in AA women who successfully abandoned an abusive relationship. The interview questions were used assist the participants in describing the lived experience of resilience. The survivor theory (ST) was used to demonstrate the participants' active role in leaving the relationship. ST was also used to dispute past research that indicated victims give up hope and therefore remain in the abusive relationship. Ten AA women from the Bell County, Texas area who are at least 18-years-old and have been free of an abusive relationship for 2 years were interviewed. Participants' perceptions were extracted and analyzed for patterns and themes using face-to-face interviews and written surveys. Data analysis procedures included the process of reducing participants' similar themes and statements in search of meaning. Results revealed three common themes that include having a positive mindset, establishing a strong relationship with God, and taking various forms of actions toward gaining control. Implications for social change include using the findings toward increasing education, intervention, and other supportive means used by those who provide services to victims.

Quality substance abuse treatment is needed to help fight the battle against drug addiction. This qualitative study was designed to explore some of the approaches to eye movement desensitization (EMDR) therapy that therapists trained in Parnell's adapted EMDR model use in conjunction with treatment for addictions. The purpose of this narrative inquiry was to investigate the experience of therapists who incorporate substance abuse treatment with Parnell's adapted EMDR model when treating trauma and substance use disorders. The population studied comprised licensed mental health therapists who had completed Parnell's EMDR training and implemented Parnell's modified EMDR protocol in their professional practice. The data from 9 participant interviews were coded and NVIVO data analysis software was used to identify key concepts and themes including deviations from Parnell's modified protocol, incorporating addiction treatment within the modified protocol, and the importance of the resourcing phase in the modified protocol. The study findings provided a deeper understanding of the types of addiction therapies that therapists are using in conjunction with Parnell's EMDR model. The results also showed that that participants perceived Parnell's EMDR model, combined with addiction therapeutic techniques and approaches, as beneficial in treating those with trauma and substance use disorders. By integrating addiction therapies with Parnell's EMDR protocol, EMDR certified trainers may better educate EMDR trainees about useful strategies for treating dual diagnosed clients. The strategies may shorten the client's time in treatment and provide a strong foundation for therapists as they conduct therapy for dual diagnosed people.

The overarching aim of this dissertation is to use health services research methods to address three problems in behavioral health services. This dissertation seeks to address the knowledge gaps in behavioral health services through the generation of evidence intended to support evidence-based practices (EBP). Previous work has examined epidemiology of behavioral health disorders in the ED, but they have not attempted to examine disorders by the cause of injury. Chapter 2 examines the epidemiology of psychiatric disorders among adults who seek care in the emergency department (ED) by cause of injury. Data from a national hospital discharge survey was analyzed using logistic and multinomial regression. Estimates are given as average marginal effects (AME) to simplify the interpretation and application. Intentionally-caused injury and undetermined cause of injury are significantly associated with psychiatric disorders. Patients with undetermined cause of injury were more likely to be diagnosed with anxiety disorders, depressed mood, and psychoses relative to patients with unintentional injuries Since there are several treatment options for obsessive-compulsive disorder (OCD), including cognitive behavioral therapy (CBT), serotonin reuptake inhibitors (SRIs), and combinations of these, a comparison of treatment effects denominated in dollars is helpful when comparing risks and benefits. Chapter 3 builds on previous randomized control trials of treatments for OCD in children and adolescents by ranks the cost-benefits of first-line treatments. The analysis aggregates treatment effects from published trials in meta-analytic framework and a Monte Carlo simulation of 100,000 hypothetic children and adolescents to derive ranked cost-benefit. Treatments strategies starting with CBT, but not CBT and SRIs concurrently, were the most cost-beneficial. The relationship between cost-sharing and utilization of behavioral health services has been studied in the aggregate, but there has been little work examining the relationship by disorder and treatment modality. The aim of Chapter 4 is to examine the association between cost-sharing and utilization of psychotherapy and adherence to pharmacotherapy among insured adults with OCD. This chapter utilizes the Truven MarketScan Commercial Claims and Encounters dataset to perform zero-inflated negative binomial regression and logistic regression analyses. Increased cost-sharing was significantly, negatively associated with psychotherapy intensity and dose, but not associated with SRI adherence. This dissertation examined three different research questions to address gaps in the behavioral health services research. The findings of these chapters have implications for patients, clinicians, insurers, and policymakers. The results can be used to improve aspects of cost, quality, access, and efficiency of behavioral health services.

Post Intensive Care Syndrome-Family (PICS-F) refers to acute and chronic psychological effects of critical illness on family members of patients in intensive care units (ICU). Evidence about the increase and persistence of PICS-F warrants the need for prevention interventions. This study evaluated the feasibility of providing Sensation Awareness Focused Training (SĀF-T) during the ICU stay for spouses of mechanically ventilated patients. Methods: A randomized controlled trial of SĀF-T versus a control group was conducted (n=10) to assess safety, acceptability, feasibility, and effect size of the intervention on PICS-F symptoms. Symptoms assessed as outcome measures included stress, anxiety, depression, posttraumatic stress disorder, and sleep efficiency. Those randomly assigned to SĀF-T received one session daily over 3-days in the ICU. Repeated measures (day 1, day 3, day 30, and day 90) of PICS-F symptoms in both groups were analyzed. Results: Mean age was 58 ± 12 years; 70% were female. Feasibility success criteria were met in weekly recruitment (8 ± 3.5), enrollment rate (67%), SĀF-T acceptability (100% of doses received, no adverse events) with significantly lower post SĀF-T stress levels (p<.05) compared to pre SĀF-T stress levels, ActiWatch acceptability rate (90% agreed to wear, no adverse events) with no significant difference in sleep efficiency between groups (p>.05), and repeated measures completion rate (>90%). Conclusions: This study provided guidance for modifications to protocol outcome measures and evidence of a large effect size, which will inform a larger clinical trial to assess the effectiveness of the SĀF-T intervention in reducing PICS-F.

A growing literature suggests that experiencing positive emotions provides psychological benefits (e.g., Coifman et al. 2007), and interventions increasing positive emotions may reduce depression risk (Geschwind et al., 2011). The present study tested whether reminiscence, a method of positive emotion savoring (Quoidbach et al., 2010), can mitigate depression risk by increasing positive emotions in an unselected sample and a subsample of at-risk anxious individuals. Female participants (n=336) were randomized to a reminiscence or control condition and asked to complete daily mental imagery exercises focusing on a positive memory (reminiscence) or a neutral laboratory memory (control) for one week. As expected, reminiscence exercises produced immediate positive emotion increases compared to control exercises. Contrary to prediction, reminiscence participants did not report higher positive affect or lower depression symptoms at the end of the study week or one month follow up period compared to controls. Future studies in treatment-seeking samples are needed before strong conclusions can be drawn about the long term affective benefits of reminiscence in at-risk or clinical populations. Findings in the anxious subsample revealed no greater benefit of reminiscence versus neutral mental imagery for those with high anxiety. However, across both conditions, anxiety was a strong predictor of positive emotional functioning, with high anxiety predicting low positive emotions even after accounting for depression symptoms. These findings add to prior work suggesting anxiety can blunt positive emotional functioning, and warrant future studies to further elucidate the impact of anxiety on positive emotional functioning and the potential utility of intervening on positive emotions in anxious individuals.

Schools need accurate and efficient ways to identify youth with mental health problems, in part to provide services to such students whose mental health concerns pose barriers to learning. The present study involved an investigation of the accuracy of one method--relying on educators (teachers, a team of school-based mental health professionals, and a school nurse) to identify early adolescents who self-report elevated levels of anxiety or depression. With respect to teachers as screening agents, the possible variability in rates of accurate identification as a function of number of teachers involved in the process (i.e., pooling nominations from multiple subject area teachers for a single student rather than from a single subject area teacher) was examined. The present study also included an examination of the demographic and psychological features of students who are more likely to be missed (i.e., self-report elevated symptoms but are not detected) or misidentified (i.e., self-reported symptoms in the typical range but were incorrectly identified as symptomatic) by educators. Participants included 233 middle school students in grades 7 to 8, 19 teachers, and 6 school-based mental health professionals. Approximately 15.5% and 12% of student participants twice-reported at-risk levels of anxiety and depression, respectively. At-risk was defined as T-scores more than one standard deviation from the norm group mean on psychometrically sound narrowband measures of anxiety and depression. Teachers correctly identified 58.33% of these anxious students and 32.14% of the students with elevated depression, but misidentified 34.52% of non-symptomatic students for anxiety and 23.41% for depression. The school-based mental health staff was largely less accurate than the teachers. The team of school-based mental health professionals accurately identified 12.50% of students for anxiety and 26.32% for depression, and falsely identified 10.31% for anxiety and 25.49% for depression. The school nurse correctly identified 14.81% of students for anxiety and 14.29% for depression, and misidentified 16.26% for anxiety and 17.83% for depression. Taken together, the use of educator nominations in identification of internalizing middle school students appears most defensible when relying on teacher judgments to identify youth with elevated anxiety. The combined group of core subject area teachers (language arts, math, and social studies) was more accurate than teachers from a single subject area, suggesting that teacher nominations should be elicited from multiple groups of core subject area teachers, particularly math and language arts. Rather than nominating students themselves, school-based mental health professionals may be better situated to deliver professional development to teachers regarding the identification of anxiety and depression. Additionally, although several demographic (i.e., gender, race/ethnicity, socioeconomic status) and psychological features (i.e., symptom severity, symptom type; also socially desirable responding and life satisfaction) were examined for students who were missed and misidentified, few differences emerged between the pairs of groups with similar self-reported levels of symptoms. Exceptions included that students who were misidentified reported higher levels of depressive symptoms (albeit still in the typical range) and less satisfaction with their lives than students who were not nominated by teachers. Thus, teachers may detect some mild mood or quality of life differences among students that do not align with students' self-report of symptoms. The practical implications of all study findings, as well as directions for future research, are discussed