Title without typo: Visual Analysis of Within-Subject Data: A Comparison Within and Across Certification Levels The field of behavior analysis has relied on the visual inspection of data to draw conclusions about the effects of experimental manipulations on dependent variables (Baer, Wolf, & Risley, 1968; Baer, Wolf, & Risley 1987; Kazdin, 1982). Although previous researchers have consistently found low levels of interrater agreement when manipulating the statistical parameters of graphs (e.g., DeProspero & Cohen, 1979; Ottenbacher, 1986), research conducted by Kahng et al. (2010) disagrees with the finding that poor interrater agreement is common among applied behavior analysts. The purpose of the current study was to replicate and extend the findings of Kahng et al. In Experiment 1, Editors of several applied behavior analysis journals and BCBA-Ds provided a dichotomous response and numerical rating to the question whether a set of simulated ABAB graphs displayed experimental. High levels of agreement were found for Experiment 1. In Experiment 2, Masters-level BCBAs were also asked to reply to a set of simulated ABAB graphs similar to those presented in Experiment 1. Low levels of agreement were found for Experiment 2. Additionally, In Experiment 3 the effects of multiple exemplar training on participant interrater agreement were examined. Improved performance across all three participants was observed. However, an increasing trend in responding was observed across baseline, training, and generalization suggesting repeated exposure to the ABAB graphs led to improvement. Taken together, the findings of Experiment 1 and Kahng et al. suggest that consistent analysis of intrasubject data is possible under certain circumstances.

There is a lack of treatment guidelines for how to address the impact of nutrition on clients’ mental health. Prior research is limited regarding psychologists’ practices of nutrition counseling and has mostly focused on practices of dieticians and medical doctors. The purpose of this study was to examine psychologists’ beliefs and attitudes about nutrition counseling, amount of training and use of nutrition counseling, self-rated knowledge in the use of nutrition counseling and perceived benefits and barriers to using nutrition counseling. Data was collected using an online survey of 76 licensed psychologists’ training in nutrition and use of nutrition counseling. Findings show that most of the psychologists talk to their clients about nutrition, nearly half report using nutrition counseling, but few received training in nutrition while in graduate school. A statistically significant difference was found between those who use nutrition counseling and those who do not regarding self-reported knowledge, belief about therapy, benefit of outcome, importance of nutrition in the context of mental health, importance of discussing nutrition with clients and confidence as a barrier to using nutrition counseling in practice. A statistically significant difference was found between those who have training in nutrition and those who do not regarding self-reported knowledge, benefit of outcome, and importance of discussing nutrition with clients. The relationship between use of nutrition counseling and training in nutrition was statistically significant. As might be expected, a larger proportion of those who have training in nutrition use nutrition counseling than the proportion of those without training. The result highlights the need for a collaborative approach to client care. Psychologists reported several themes, including need for more training and guidelines for psychologists’ use of nutrition counseling.

The purpose of the present study was to investigate the influence of pain causal attributions on patient pain-related functioning, treatment engagement, and clinical outcomes. Additionally, the impact of discordant pain causal attributions between patients and their providers as well as between interdisciplinary providers was examined. Patients rated their pain functioning and causal pain attributions during a regular clinic visit. Following the patient’s visit both the behavioral medicine provider and internal medicine resident provided ratings of similar pain-related functioning domains and causal attributions. Follow-up data were collected from the electronic medical record three months following that clinic visit. Overall, results revealed that patients’ chronic pain attributions did influence pain-related functioning, however the impact was relatively small. There was insufficient evidence to conclude that chronic pain attributions influence a patient’s readiness to adopt self-management coping strategies and their subsequent treatment engagement. Additionally, results confirmed that different health care disciplines attribute the cause of patients’ chronic pain in distinct ways and these unique perspectives can lead to discrepant pain-related functioning assessments between providers. Discordant ratings between providers were shown to influence referring patterns for interdisciplinary services and the patient’s overall opioid dose. Similarly, discrepancies between patients and their providers influenced subsequent referral for behavioral health services, the patient’s attendance at those visits, and their overall morphine equivalent doses. Together the results indicate the important role pain attributions can play in chronic pain management and highlight the central role of the patient-provider and provider-provider relationship.

Adolescence and young adulthood are the periods of development associated with the highest amount of risk-taking. One theory, the Dual-Systems model, suggests that this could be due to an imbalance in the maturation of two brain systems: reward appraisal, which matures first, and cognitive control, which matures later. This imbalance may be the cause of adolescents’ tendency to favor immediate rewards, disregarding consequences. Depressed adolescents, however, behave differently. While it is not exactly clear whether they take more risks or fewer risks, depressed adolescents display different interactions and decision making with their peers than non-depressed adolescents. This study attempted to use these patterns of behavior already identified in previous research to predict where an adolescent would fall on a depression continuum based on their Self-Focused and Other-Focused risk behaviors. Results did not find a link between depression and either type of risk. Results may be inconclusive due to issues within the data and data collection process.

Mental illness is not only the leading cause of disability among adults, but there is also an emerging public health crisis in childhood mental illness. A majority of parents do not recognize symptoms of psychological disorder in their children, and current policies and programs for mental health service delivery are not sufficiently responsive to the early help-seeking dynamics of families. Using a concurrent mixed methods design, this study explored how parents in the Pikes Peak region of Colorado learned to recognize their child's mental illness. Phenomenological interviews, augmented by poetic inquiry and quantitative measurements, were used to discover factors that inhibited or enhanced five mothers' recognitions. These factors were then evaluated using a frequency distribution analysis and a rank-order correlation. The phenomenon of recognition was, for these mothers, a process of waiting to hear that â??normalâ?? had stopped, wherein they miscategorized symptoms as normal behaviors in a passing developmental phase. Prior experience with mental illness appeared to significantly decrease both the length of time and the level of distress necessary for recognition. Ultimately, recognition did not occur until someone in their social network validated their concerns and provided explicit confirmation, which galvanized them to seek treatment. Governance network collaborations can facilitate positive social change by standardizing guidance on how to differentiate symptoms of a disorder from normal childhood development. Public policies and programs such as universal mental health screening, mental health literacy, and more supportive and responsive school policies can foster dialogue for parental recognition in Colorado and throughout the country.

Male mortality rates exceeded female rates in every death type and the sex differential increased from 1970 to 1980 in every death type except homicides. The findings in this study suggest that marital and employment factors contribute to sex differences in mortality for suicidal and accidental deaths. Being employed was associated with fewer suicidal and accidental deaths for females than for males. Being married was associated with fewer suicidal and accidental deaths for males, while marital status had no relationship to suicidal and accidental deaths for females. Due to these relationships it might be inferred that the expanding sex differential in suicidal and accidental mortality rates is associated with the spiraling divorce rate and the dramatic increase in female employment. Results relative to homicidal deaths appear ambiguous and do not offer support for the hypothesis that marital and employment factors contribute to the observed sex differences in homicidal death rates.

This paper examines the correspondence, manuscripts, and speeches of ex-mental patient activists. I chronicle the activities of the emergent psychiatric survivors movement from its beginnings in the early 1970’s focusing on the work of the Boston based activist, Judi Chamberlin (1944-2010). This paper examines how mental patients in post-war America began to organize in order to have their voices included in the process of their own recovery. I present Chamberlin’s experience as a mental patient as being representative of the “rootlessness” that many post-war women experienced. Chamberlin’s work as an ex-patient activist presented one aspect of the overall struggle on the part of mental patients to claim their place in a wider society. I also pay attention to interdisciplinary scholarly analyses of madness to investigate how discussion of the subject influenced ex-patient activists, as well as whether or not the ex-patients’ narrative reciprocally influenced the scholarly discussion about madness. In the final chapters, I also look at how the successes of this social movement ironically led to the prevalence of today’s diagnostic models of treatment that rely heavily on pharmacological methods and highly regimented evidence-based psychotherapies while still excluding patients’ voices. The voices of mental patients both in the asylum era and today have been excluded from the treatment process.

Both diabetes and behavioral health disorders (mental and substance use disorders) are significant health issues in the United States. While previous studies have shown worse health outcomes in people with diabetes and co-occurring behavioral health disorders (BHDs) than those with diabetes alone, it is unclear whether the quality of diabetes care was poorer in the presence of co-occurring BHDs. Although previous research has observed a trend of positive outcomes in people with comprehensive diabetes care, there is a lack of evidence about whether that mode of care delivery can improve outcomes in people with co-occurring BHDs. Therefore, further studies are necessary. Using a combined dataset from Medicare and Medicaid claims for Massachusetts residents, this study compared the quality of diabetes care (e.g., having at least 1 hemoglobin A1c test) and diabetes outcomes (e.g., eye complications) among Medicare and Medicaid beneficiaries with diabetes and co-occurring BHDs to those with diabetes alone in Massachusetts in 2005. The results showed a mixed picture on the relationships between BHDs and diabetes outcomes. While substance use disorders had adverse impact on adherence to quality measures (e.g., 20% less likely to attain full adherence, p0.05). Findings from this dissertation research suggest that disparities exist in the quality of diabetes care and health outcomes between people with substance use disorders and those without. The mode of care delivery needs to be further examined so that interventions can be designed to improve the outcomes of people with diabetes.

Background: The Veterans Health Administration (VHA) encourages depression screening and treatment for pregnant veterans; however, rates of depression symptoms and treatment utilization during pregnancy have not been well-studied. Methods: We used data from the Maternity Care Coordination for Women Veterans cohort study. Specifically, our aims were to: 1) examine rates and correlates of depression symptoms in a sample of pregnant veterans; 2) understand mental health care treatment utilization and explore the experiences of veterans accessing mental health care at the VHA during pregnancy; and 3) examine VHA mental health provider's perspectives on depression screening and treatment in the perinatal period. Findings: Depression symptoms were present in 28% of pregnant veterans in our sample. Social support and employment decreased odds of symptoms; history of anxiety, antidepressant use, and active duty service resulted in increased odds of symptoms. Nearly 70% of women veterans with prenatal depression symptoms received at least one mental health visit or antidepressant prescription during pregnancy. However, symptomatic pregnant women without a history of depression were less likely to receive care. Mental health providers identified absence of screening protocols and referral procedures and variability in risk/benefit conversations surrounding antidepressant use as areas of weakness for VHA mental health care during the perinatal period. Conclusions: Depression symptoms were present in nearly one in every three pregnant veterans. Depression treatment during pregnancy is complex, requiring individualized care. Policies for depression screening, referrals to providers, and medication review could be better encouraged to improve standardized care across the VHA.

Background: Major depression is one of the most prevalent, disabling, and costly illnesses worldwide. Despite a 400% increase in antidepressant medication use since 1988, fewer than half of treated depression patients experience a clinically meaningful reduction in symptoms and uncertainty exists regarding how to successfully obtain symptom remission. Identifying homogenous subgroups based on clinically observable characteristics could improve the ability to efficiently predict who will benefit from which treatments. Methods: Latent class analysis and latent transition analysis (LTA) were applied to data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study to explore how to efficiently identify subgroups comprised of the multiple dimensions of depression and examine changes in subgroup membership during treatment. The specific aims of this dissertation were to: 1) evaluate latent depression subgroups for men and women prior to antidepressant treatment; 2) examine transitions in these subgroups over 12 weeks of citalopram treatment; and 3) examine differences in functional impairment between women’s depression subgroups throughout treatment. Results: Four subgroups of depression were identified for men and women throughout this work. Men’s subgroups were distinguished by depression severity and psychomotor agitation and retardation. Severity, appetite changes, insomnia, and psychomotor disturbances characterized women’s subgroups. Psychiatric comorbidities, especially anxiety disorders, were related to increased odds of membership in baseline moderate and severe depression subgroups for men and women. After 12 weeks of citalopram treatment, depression severity and psychomotor agitation were related to men’s chances of improving. Severity and appetite changes were related to women’s likelihood of improving during treatment. When functional impairment was incorporated in LTA models for women, baseline functional impairment levels were related to both depression subgroups at baseline and chances of moving to a different depression subgroup after treatment. Conclusion: Depression severity, psychomotor disturbances, appetite changes, and insomnia distinguished depression subgroups in STAR*D. Gender, functional impairment, comorbid psychiatric disorders, and likelihood of transitioning to subgroups characterized by symptom improvement differed between these subgroups. The results of this work highlight how relying solely on summary symptom rating scale scores during treatment obscures changes in depression that might be informative for improving treatment response.