Interventions focused on diabetes, hypertension, and drug or alcohol dependence/abuse across the county may be effective for preterm birth reduction. We identified several modifiable risk and resilience factors across the reproductive life course that can be addressed to reduce preterm birth rates. Given the complex clinical and social determinants that influence preterm birth, cross-sector collaborative efforts that take into account place-based contextual factors may be helpful and are actively being pursued in Fresno County. Ultimately, refining our understanding of risk and resilience and how these factors vary across a geography are fundamental steps in pursuing a precision public health approach to achieve health equity. Individuals with psychotic disorders were for many decades not considered appropriate candidates for psychotherapy. The first case reports detailing the use of cognitive behavioral techniques to treat psychosis were published in the 1980s , while the first randomized controlled trial of cognitive‐behavioral therapy for psychosis originated in the United Kingdom in the 1990s . Presently, CBT is listed as a preferred treatment for psychosis by the Schizophrenia Patient Outcome Research Team in the United States, a set of strictly evidenced‐based treatment guidelines . A combination of anti-psychotics and structured therapy has been shown to improve both positive and negative symptoms and result in global functional improvement . The CBT focus on cognitive restructuring, normalizing, behavioral self‐monitoring, and activity scheduling promotes social engagement . In one community‐based study, CBT improved positive symptoms, general mental health problems, and depression, as well as reduced admission rates following treatment . The PORT guidelines also recommend social skills training , which targets social cognitive processes, psycho‐education,life management skills , and relapse prevention skills . Cognitive Behavioral Social Skills Training combines both social skills training and cognitive‐ behavioral therapy to improve real‐world functioning . In one RCT,wholesale indoor plant grow rack individuals who engaged in CBSST demonstrated better rates of achieving functional milestones as compared to individuals who received goal‐ focused supportive contact .

Participants also showed greater improvement in experiential negative symptoms and defeatist performance attitudes. In another RCT of middle‐aged and older adults with schizophrenia, individuals who received CBSST demonstrated superior self‐ reported community living skills and a lower dose of psychotropic medications at 12‐month follow‐up compared to treatment as usual . Here we present data from a recently developed CBSST‐based program for adult patients with primary psychotic disorders—the UCLA Thought Disorders Intensive Outpatient Program . In addition to CBSST, participants received group‐modality self‐care and life skills training, medication management, case coordination, and brief individual supportive psychotherapy. We aimed to assess the TD IOP’s feasibility from a program development perspective as well as to assess the impact of this program on improving participants’ psychotic symptoms.CBSST is delivered in three modules, each lasting 2 weeks. The group is limited to 10 participants. The program is expected to last at least 6 weeks, longer if more treatment is clinically indicated. The program is held 3 days weekly from 1 p.m. through 4 p.m. Each day consists of 1 hour of CBSST as well as 2 hours of additional group therapy. Group‐modality treatment focuses on sleep hygiene, self‐ esteem building, time management, medication side‐ effect management, diet, and mindfulness, among others. Social workers meet with participants at least weekly to address participant concerns and provide brief individual supportive psychotherapy as well as any case management needs. Participants also meet regularly with their psychiatrist for medication management. Nurses are available for consultation regarding diet and nutrition; they also regularly measure vital signs, including weight. Family meetings are held as indicated with the participant and his or her social worker and psychiatrist.The primary measurement tool used to assess the effectiveness of the program was the Clinician‐Rated Dimensions of Psychosis Symptom Severity scale. The CRDPSS scale was developed by the American Psychiatric Association as a patient assessment tool to assist with evaluating severity of mental health symptoms important across psychotic disorders and monitoring treatment progress . Symptoms are categorized into eight domains , as follows: DI, hallucinations; DII, delusions; DIII, disorganized speech; DIV, abnormal psychomotor behavior; DV, negative symptoms; DVI, impaired cognition; DVII, depression; and DVIII, mania.

Each domain is scored by the clinician on a scale of 0 through 4 . Detailed descriptors are included that correspond to each value on the scale. The scale was administered by licensed clinical social workers each week from intake through discharge. Demographics and clinical characteristics were obtained by chart review for each participant.The present study evaluated the impact of an intensive outpatient program designed specifically to treat individuals with thought disorders. Our study showed that participants demonstrated statistically significant improvement in five out of eight psychosis symptom domains, as measured by a clinician‐rated scale. Additionally, most participants completed the program either with a reduction or no change in anti-psychotic dose, indicating improvements cannot be attributed to medication alone. In addition, the program was simple in design, feasible to incorporate under the umbrella of an existing general intensive outpatient program, required minimal resources for training and planning, and was effectively implemented by Master’s‐level clinicians. Although cognitive therapy has been frequently included in recent years as a standard recommended treatment for psychosis , few studies have evaluated the effectiveness of cognitive therapy for psychotic patients in non‐research‐based community mental health settings. An effectiveness study from Australia did not find significant improvement in symptoms in those receiving CBT for psychosis compared with controls; this was thought to be due to several factors, including the high quality of mental health services received by controls . Other studies have shown more positive results. One study showed that individual cognitive therapy provided to adults with psychotic disorders by clinical psychologists or nurse therapists in a community setting was associated with statistically significant improvements in positive symptoms, general mental health problems, and depression . In another small study in a community setting, one‐third of patients receiving up to 13 cognitive therapy sessions reported reduction in delusional conviction . One UK‐based study showed that delivery of six CBT sessions to a community sample of schizophrenia patients by mental health nurses, who were trained in CBT over just a 10‐day period, resulted in statistically significant improvements in negative symptoms and insight at 1‐year follow‐up .

Several randomized controlled trials have evaluated the role of CBSST in the treatment of adults with psychoticdisorders. One study showed that middle‐aged and older patients with schizophrenia performed activities related to social functioning significantly more frequently than those who received treatment as usual, with improved self‐ reported functioning at 12‐month follow‐up . In a study of non‐geriatric adults with schizophrenia or schizo affective disorder, those randomly assigned to receive CBSST experienced significantly greater functional improvement as well as greater engagement in educational activities when compared with those receiving goal‐ focused supportive contact only . CBSST has also been shown to benefit a first‐episode population, with significant functional gains observed among young patients with schizophrenia who had received less than 6 months of treatment . To our knowledge, ours is the first study to evaluate the delivery of CBSST in a community setting. In addition, our study adds to the evidence base showing the effectiveness of CBSST in treating adult, non‐geriatric patients in various stages of illness. Of particular interest from a cost reduction perspective is the potential decrease in healthcare costs associated with CBSST. Previous studies examining the cost‐ effectiveness of individual CBT for psychosis have shown mixed results, with one showing increased initial healthcare costs though savings over time due to decreased service utilization , two showing neither cost benefit nor deficit , and one showing higher cost though better outcome in the CBT group . As a group‐based modality, CBSST requires far fewer therapist hours in comparison with the equivalent delivery of individual therapy. Prior studies have shown that the “dose” of CBSST sessions required to provide results was fewer than anticipated. For example, in one study,grow table number of CBSST sessions attended was not significantly associated with outcome, with participants receiving an average of only 12 out of 36 offered sessions ; in another, there was no significant benefit from repeating CBSST modules a second time . Our study showed that significant gains were achieved even without program completion, suggesting again that patients can benefit from even brief engagement in CBSST. Our study population was clinically acute, as 60% of participants were referred directly from an inpatient hospital and almost all had a history of at least one psychiatric hospitalization, with 64% having a history of two or more prior hospitalizations. Despite the acuity of our study population, most participants completed the program. Our population appears like that described in the study by Farhall et al., in which patients randomized to receive CBT for psychosis had a median of 25 inpatient days and an average of 2.2 inpatient admissions prior to baseline assessment. In that study, the acuity of the population was thought to contribute to no significant symptom change between the control and treatment as usual groups . In contrast, our study suggests that even very ill patients with psychotic disorders can benefit from intensive outpatient treatment built on talk‐based therapy. Furthermore, these patients endorsed high subjective satisfaction with the program.

A major strength of our study is its naturalistic design. The TD IOP program at UCLA was conceived as an inclusive treatment option for adults of all ages and in all stages of a psychotic illness. Non‐naturalistic studies for talk therapy in psychosis tend to focus on specific populations, such as geriatric or non‐geriatric adults, or adults who are experiencing their first episode of psychosis. In addition, our CBSST providers were non‐doctoral level therapists, most of whom had no significant prior experience working with psychotic disorders, though they did have extensive knowledge of delivery of CBT. They were able to effectively work with the study population after only 11 h of training in CBSST. Given the primary barrier to program attendance related to transport, community implementation of CBSST programs would confer significant value. Our study had several limitations. The sample size was limited to a single treatment arm. As unblinded, there is the potential for rater bias towards positive study results. New as of DSM‐5, the inter‐rater reliability and convergent validity of the CRDPSS remains under explored. One study found low inter‐rater reliability scores except for the delusions domain. Positive associations, however, were found between CRDPSS and Positive and Negative Syndrome Scale , indicating convergent validity . A self‐reported measure of psychosis is not included. We did not follow‐up individually with patients outside of chart review; as such, no conclusion may be drawn if gains achieved in the program persisted or if treatment resulted in reduced number of future inpatient admissions. Treatments that improve the quality of life of individuals with psychosis is a matter of great significance to public health. Our data indicate that improved socialization and functioning are concerns shared by affected individuals and clinicians alike. CBSST appears to be an effective intervention to address these concerns that requires minimal resources and a relatively brief treatment interval, making it ideally suited to adaptation to a variety of clinical settings. Future studies will compare CBSST to standard outpatient care with a focus on additional outcomes, including quality of life and healthcare utilization.The acute respiratory distress syndrome affects at least 10% of patients in the intensive care unit and carries a high mortality rate of approximately 40%.1 There have been effective advances in supportive care, but there are as yet no consistently proven effective pharmacologic treatments for ARDS.2 One approach to addressing this problem is to target the heterogeneity of ARDS by understanding patient factors that impact response to treatment once ARDS has already developed. For example, secondary analyses of randomized clinical trials demonstrate that ARDS sub-phenotypes respond differentially to simvastatin therapy.Another important facet is early intervention in hospitalized patients at risk of ARDS.However, clinicians and researchers should also focus on identifying preventable patient exposures that increase the risk for ARDS, as demonstrated by a growing body of research. This review summarizes the current literature on environmental exposures and ARDS development and outcomes, discusses underlying mechanisms, and outlines the implications for patient management and policy-guided solutions.According to the World Health Organization, the pollutants with the greatest effect on human health are ozone, sulfur dioxide , nitrogen dioxide , and particulate matter .