Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine.

BACKGROUND AND OBJECTIVES: There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine. METHODS: This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38). RESULTS: Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study. DISCUSSION AND CONCLUSIONS: Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling. SCIENTIFIC SIGNIFICANCE: This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.

Intersectionality in Intervention Development: Insights From Formative Work on a Tailored Tobacco Cessation Program for LGBTQIA+ Young Adults.

Tailored tobacco cessation interventions focusing on minoritized communities are proliferating, but the extent to which these interventions address the needs of individuals with multiple minoritized social identities is unclear. We developed Empowered, Queer, Quitting, and Living (EQQUAL), an avatar-led digital smoking cessation intervention tailored for lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more (LGBTQIA+) young adults based on acceptance and commitment therapy (ACT), via a multistage user-centered design process. The purpose was to evaluate feedback from EQQUAL development activities using an intersectional lens. Intersectionality is a paradigm created by Kimberlé Crenshaw illustrating the multiple social identities each person possesses along with the marginalization of these different social identities. We conducted a rapid deductive content analysis focused on intersectional design gaps using interviewer notes from user testing (n = 7), a diary study (n = 8), and treatment satisfaction responses from a single-arm trial of the EQQUAL intervention (n = 22). Feedback related to intersectional design fell under three broad themes: (a) inadequate representativeness of the avatar, (2) inadequate representativeness within the program broadly, and (3) non-inclusive ACT intervention content. Feedback on inclusiveness included reference to socioeconomic status, race/ethnicity, religious/cultural affiliation, and ability/disability. Although we previously found that EQQUAL was highly acceptable and showed promise in terms of efficacy in a single-arm pilot trial, we identified several gaps in intersectional design as the iterative intervention development proceeded. Because intersectional design is a critical part of developing interventions with a health equity focus, applying standardized procedures for intersectional design and analysis could improve intervention design and better address tobacco cessation treatment needs of individuals who may experience multiple forms of marginalization.

Correlates of Obtaining Employment among Veterans Receiving Treatment for Severe PTSD in Specialized Intensive Programs.

Severe Post-Traumatic Stress Disorder (PTSD) has been identified as a significant impediment to employment. However, little is known about correlates of employment recovery after a period of not working among veterans with severe PTSD treated in specialized intensive treatment programs. This study examines rates and correlates of transitioning from not being employed at admission to working four months after discharge using national Veterans Health Administration (VHA) program evaluation data on veterans engaged in specialized intensive PTSD treatment (N = 27,339). Results suggest that only 5.68% of the sample made the transition to employment while 10.6% lost employment, 8.9% worked both at admission and following discharge, and 74.9%, did not work either at admission or following discharge. Multinomial regression analysis found that compared to other groups, veterans who became employed were younger, less likely to receive service-connected disability payments, and experienced a significantly greater reduction in PTSD symptoms. Findings from this study highlight that this distinct population has very poor employment outcomes and deserves more attention, and that reducing PTSD symptoms can lead to improved employment outcomes. Efforts to integrate evidence-based vocational rehabilitation practice into residential PTSD treatment targeting PTSD symptoms is encouraged.

Pilot Randomized Controlled Trial of Web-Delivered Acceptance and Commitment Therapy Versus Smokefree.gov for Smokers With Bipolar Disorder.

INTRODUCTION: Smokers with bipolar disorder (BD) are less successful at quitting than the general population. In this study, we evaluated in a pilot randomized controlled trial a novel, targeted, web-based intervention for smokers with BD based on acceptance and commitment therapy (ACT) and designed for reach and disseminability. AIMS AND METHODS: Daily smokers (n = 51) with bipolar I or II disorder were recruited from four US sites and randomly assigned to one of two web-based smoking cessation interventions-ACT-based WebQuit Plus (n = 25) or Smokefree.gov (n = 26) over a 10-week treatment period. All participants received nicotine patch for 8 weeks. Key outcomes were trial design feasibility, intervention acceptability, and cessation at end of treatment and 1-month follow-up. RESULTS: We screened 119 to enroll 51 participants (target sample size = 60) over 24 months. The most common reason for ineligibility was the inability to attend study appointments. Retention was 73% at end of treatment and 80% at follow-up, with no differences by arm. The mean number of logins was twice as high for WebQuit Plus (10.3 vs. 5.3). The usefulness of program skills was rated higher for WebQuit Plus (75% vs. 29%). Biochemically confirmed, 7-day abstinence at end of treatment was 12% in WebQuit Plus versus 8% in Smokefree.gov (odds ratio = 1.46, 95% confidence interval = 0.21 to 9.97). At follow-up, abstinence rates were 8% in both arms. CONCLUSIONS: Trial design produced favorable retention rates, although alternative recruitment methods will be needed for a larger trial. At end of treatment, acceptability and estimated effect size of WebQuit Plus relative to Smokefree.gov were promising and support continued program refinement and evaluation. IMPLICATIONS: In this first randomized controlled trial of a targeted intervention for smokers with BD, we found that the ACT-based WebQuit Plus intervention, delivered in combination with the nicotine patch, had promising acceptability and cessation outcomes relative to Smokefree.gov. The observed signals for acceptability and cessation suggest that the WebQuit Plus program should be refined based on participant feedback and evaluated in a larger trial. Feasibility findings from this study also provide direction for refining trial procedures to enhance the recruitment of smokers with BD.

Gambling-related cognitive distortions predict level of function among US veterans seeking treatment for gambling disorders.

BACKGROUND AND OBJECTIVES: Gambling Disorder (GD) is characterized by recurrent gambling behavior that is associated with significant impairment and distress, high psychiatric comorbidities, and high functional disability. The military veteran population appears particularly susceptible to developing the disorder, but relatively little has been studied among this population. The purpose of the present study is to investigate the clinical psychopathologies and comorbidities of veterans seeking treatment for problem gambling and how problem gambling may impact functioning. METHODS: Treatment-seeking veterans meeting criteria for GD (N = 61) underwent a structured clinical interview and completed the South Oaks Gambling Screen (SOGS), the Gambling Symptom Assessment Scale (G-SAS), the Yale-Brown Obsessive-Compulsive Scale for Gambling Disorder (PG-YBOCS), the Gambling Belief Questionnaire (GBQ), the Barratt Impulsiveness Scale (BIS-11), and the Sheehan Disability Scale (SDS). RESULTS: Veterans seeking treatment for GD had high rates of psychiatric and addiction disorder comorbidities. Few veterans had previously sought treatment and most reported substantive challenges in social and occupational functioning. When determining how gambling-related characteristics (ie, severity and cognitive distortions) impact function, severity of cognitive distortions was the strongest statistical predictor of overall functional disability. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The findings from this study indicate that there is high comorbidity between GD and other psychiatric and addictive disorders, as well as social and occupational functioning. In addition, cognitive distortions related to gambling relate importantly to overall functioning and should be considered in the development of interventions for veterans with GD. (Am J Addict 2018;27:108-115).

Co-occurring tobacco use and posttraumatic stress disorder: Smoking cessation treatment implications.

BACKGROUND AND OBJECTIVES: PTSD and cigarette smoking frequently co-occur for reasons that are not well understood. The current behavioral and pharmacological treatments and emerging new treatment targets for smoking cessation are discussed. METHODS: Here we describe recent research on PTSD and smoking with an emphasis on 1) the clinical characteristics of smokers with PTSD, 2) smoking treatment trials that specifically targeted smokers with PTSD, 3) recent research on stress-response and affect regulation pathways that might link the two disorders and 4) potential ways to leverage new findings on stress response systems and affect regulation mechanisms to improve treatment outcomes for smokers with PTSD. RESULTS: Smokers with PTSD have higher rates of smoking compared to the general population and have greater difficulty quitting compared to smokers without PTSD. There have been several studies of adjunctive and integrated smoking cessation interventions for smokers with PTSD, but fewer tailored interventions that intensively target stress-response pathways or affect regulation related to both tobacco use and PTSD. Stress-response pathways and affect regulation appear to be important mechanisms involved in the development and maintenance of smoking in individuals with PTSD. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Additional research that focuses on smokers with PTSD is warranted given that successful tobacco treatment response is low and the negative health effects of each disorder can be greatly amplified.

Acceptance and commitment therapy smoking cessation treatment for veterans with posttraumatic stress disorder: a pilot study.

OBJECTIVE: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking. METHODS: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms. RESULTS: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at three-month follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up. CONCLUSIONS: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial.

Anxiety and smoking cessation outcomes in alcohol-dependent smokers.

INTRODUCTION: Anxiety-related characteristics, including anxiety sensitivity and trait anxiety, are elevated in individuals with alcohol and nicotine dependence and associated with greater difficulties with quitting smoking. However, little is known about how anxiety-related characteristics are related to smoking cessation outcomes in alcohol-dependent smokers. The present study, part of a larger smoking cessation clinical trial, examined associations between anxiety sensitivity, trait anxiety, nicotine withdrawal symptoms, smoking urges, and smoking cessation outcomes in a sample of 83 alcohol-dependent smokers. METHODS: Participants were enrolled in concurrent alcohol and tobacco treatment as part of a substance-abuse intensive outpatient program. Smoking cessation treatment was administered in a 3-week cognitive-behavioral format that included 8 weeks of open-label nicotine patch treatment. Information on nicotine withdrawal, smoking urges, and CO-confirmed smoking consumption rates was collected at baseline, quit date, end of behavioral treatment, and at a 1-month follow-up. RESULTS: Higher levels of anxiety sensitivity were associated with more smoking urges due to anticipation of negative affect relief at quit date. Higher levels of trait anxiety were associated with more smoking urges due to positive reinforcement and anticipation of relief of negative affect at quit date, as well as more severe nicotine withdrawal symptoms at the end of treatment. Levels of anxiety sensitivity and trait anxiety were not associated with Cox regression survival times to relapse. CONCLUSION: These results indicate that for alcohol-dependent smokers, levels of anxiety sensitivity and trait anxiety are important to consider in the assessment and treatment of nicotine dependence.

An Avatar-Led Web-Based and SMS Text Message Smoking Cessation Program for Socioeconomically Disadvantaged Veterans: Pilot Randomized Controlled Trial.

BACKGROUND: Despite the declining prevalence of cigarette smoking in the United States, socioeconomically disadvantaged veterans receiving care from the Veterans Health Administration have a high prevalence of smoking. Currently, available treatment options for these veterans focus on tobacco users who are ready to quit and have limited reach. Consequently, there is a great need for accessible, effective smoking cessation interventions for veterans at all levels of readiness to quit smoking. OBJECTIVE: To address these needs, we developed Vet Flexiquit, a web-based Acceptance and Commitment Therapy program for veterans, and evaluated its acceptability (primary aim), efficacy, and impact on theory-based change processes relative to the National Cancer Institute's SmokefreeVET program in a pilot randomized controlled trial. METHODS: Participants (N=49) were randomized 1:1 to receive either the Vet Flexiquit (n=25) or SmokefreeVET (n=24) web program. Both groups received SMS text messages as part of the intervention for 6 weeks. Both interventions are fully automated and self-guided. Primary outcome data were collected at 3 months after the randomization. Self-reported smoking abstinence was biochemically verified using saliva cotinine. Multivariable logistic regression, negative binomial regression, and linear regression models were used to evaluate the association between the treatment arm and outcomes of interest. RESULTS: Acceptability, as measured by overall treatment satisfaction, was high and similar across treatment arms: 100% (17/17) for Vet Flexiquit and 95% (18/19) for SmokefreeVET. Acceptability, as measured by utilization, was more modest (log-ins: M=3.7 for Vet Flexiquit and M=3.2 for SmokefreeVET). There were no statistically significant differences between treatment arms for any acceptability measures. Similarly, there were no statistically significant differences between treatment arms in the secondary outcomes of smoking cessation or change in Acceptance and Commitment Therapy's theory-based processes. In open-ended survey responses, some veterans in both treatment arms expressed interest in having support from a professional or peer to enhance their experience, as well as an expanded SMS text messaging program. CONCLUSIONS: Both programs had high ratings of acceptability, limited utilization, and a similar impact on cessation and cessation processes. Taken together with the qualitative data suggesting that additional support may enhance participants' experience of both programs, these preliminary findings suggest that the programs may have similar outcomes among veterans who are looking for a digital cessation treatment option and that integrating provider or peer support and enhancing the SMS text messaging program holds promise as a means of boosting engagement and outcomes for both programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04502524; https://clinicaltrials.gov/ct2/show/NCT04502524.

An Online Acceptance and Mindfulness Intervention for Chronic Pain in Veterans: Development and Protocol for a Pilot Feasibility Randomized Controlled Trial.

BACKGROUND: In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain-related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning. OBJECTIVE: The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20). METHODS: This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system. RESULTS: This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023. CONCLUSIONS: The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning. TRIAL REGISTRATION: ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45887.

Chronic pain and problematic substance use for veterans during COVID-19: the moderating role of psychological flexibility.

Background: Chronic pain and problematic substance use are commonly co-occurring and highly detrimental issues that are especially prevalent in U.S. veteran populations. Although COVID-19 made clinical management of these conditions potentially difficult, some research suggests that certain veterans with these conditions did not experience this period as negatively as others. It is thus important to consider whether resilience factors, such as the increasingly-studied process of psychological flexibility, might have led to better outcomes for veterans managing pain and problematic substance use during this time of global crisis. Methods: This planned sub-analysis of a larger cross-sectional, anonymous, and nationally-distributed survey (N = 409) was collected during the first year of the COVID-19 pandemic. Veteran participants completed a short screener and battery of online surveys assessing pain severity and interference, substance use, psychological flexibility, mental health functioning, and pandemic-related quality of life. Results: For veterans with chronic pain and problematic substance use, the pandemic resulted in a significant lowering of their quality of life related to meeting basic needs, emotional health, and physical health compared to veterans with problematic substance use but no chronic pain diagnosis. However, moderation analyses revealed that veterans with these comorbid conditions experienced less negative impacts from the pandemic on quality of life and mental health when they reported greater psychological flexibility. For veterans with problematic substance use only, psychological flexibility was also related to better mental health functioning, but did not significantly correlate with their quality of life. Conclusion: Results highlight how COVID-19 differentially impacted veterans with both problematic substance use and chronic pain, such that this group reported particularly negative impacts of the pandemic on multiple areas of quality of life. However, our findings further emphasize that psychological flexibility, a modifiable resiliency process, also buffered against some of the negative impacts of the pandemic on mental health and quality of life. Given this, future research into the impact of natural crises and healthcare management should investigate how psychological flexibility can be targeted to help increase resiliency for veterans with chronic pain and problematic substance use.

Direct and indirect photolysis of the phytoestrogens genistein and daidzein.

Genistein and daidzein are two estrogenic compounds derived from plants, especially legumes. This research begins to explore their environmental fate, focusing on direct and indirect photolysis. UV-visible spectra for both compounds at varying pH values were taken, the pK(a) values for both compounds were measured, and UV-visible spectra for each protonation state were determined. The loss of both compounds in deionized water was observed upon exposure to natural sunlight, and the quantum yields were determined for each protonation state. In Mississippi River water, direct photolysis does not account for all of the loss of genistein and daidzein. The mechanism of indirect photolysis was probed using quenchers and sensitizers, and results suggest that daidzein is transformed mainly via direct photolysis and singlet oxygenation, while genistein is transformed mainly via reaction with triplet-state natural organic matter. The parameters determined in this study will allow for estimation of the concentration of genistein and daidzein in sunlit surface waters, which will allow for assessment of any risks posed to aquatic wildlife.

A Randomized Pilot Study of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD.

Veterans with PTSD often have substantial interpersonal difficulties and low levels of social support, which puts them at increased risk of mortality, but few treatments address global social impairment for veterans with PTSD. This study is a pilot randomized trial of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD (ACT-SS), a psychotherapy that targets social avoidance and eroded social relationships, compared to Person-Centered Therapy (PCT), a non-directive psychotherapy. Participants were randomized to twelve sessions of either ACT-SS (n = 21) or PCT (n = 19). The results showed that veterans with PTSD had high ratings of satisfaction for both treatments. Contrary to the PCT group, participants in the ACT-SS group showed a significant improvement in the quality of social relationships, engagement in social and leisure activities, and PTSD symptoms from the baseline assessment to the end of treatment and a three-month follow-up. Veterans in the ACT-SS group, but not the PCT group, also showed significant improvements in mindfulness and valued living and a reduction in experiential avoidance from baseline to the end of treatment, with sustained improvements in valued living at the three-month follow-up. Overall, the present study demonstrated the feasibility, acceptability, and positive preliminary outcomes of ACT-SS for veterans with PTSD.

A quantitative and qualitative examination of the impacts of the COVID-19 pandemic on U.S. veterans with self-reported anxiety and alcohol use disorder.

Introduction: The COVID-19 pandemic generated concerns about rising stress and alcohol use, especially in U.S. veterans who experience high rates of anxiety disorders (ADs), alcohol use disorder (AUD), and dual AD+AUD diagnoses. This study investigated differences among these diagnostic groups in a veteran population related to their concern about COVID-19, impacts of COVID-19 on quality of life, and self-reported changes to urge to drink and drinking frequency. Methods: A nationally administered online survey was given to a sample of U.S. veterans reporting substance use issues during the pandemic. Differences in the level of concern about COVID-19, impacts of COVID-19 on quality of life, and drinking behaviors were examined in those self-reporting AD (n = 98), AUD (n = 46), or AD+AUD (n = 67). Consensual qualitative research was used to analyze an open-ended question about COVID-19's impact on substance use, health, and quality of life. Results: Veterans with AD+AUD experienced significant increases in urge to drink and alcohol consumption compared to veterans with AD only. Greater urge and frequency of drinking were associated with greater negative impacts of COVID-19 on quality of life. There were no differences among groups in global negative impact on quality of life or level of COVID-19 concern. However, respondents described specific COVID-19 worries, with qualitative findings revealing that those with AD+AUD reported a disproportionate psychosocial burden due to the pandemic. Discussion: Special attention in screening and treatment should be given to those with a dual AD+AUD diagnosis who may be experiencing both an increase in alcohol use and psychosocial burden as stress increases due to the pandemic.

The Impact of COVID-19 on Self-Reported Substance Use, Well-Being, and Functioning Among United States Veterans: A Cross-Sectional Study.

As the COVID-19 pandemic sweeps the globe, many veterans with substance use issues have faced the closure of treatment facilities, mandates to shelter in place, and social distancing measures. To better understand their pandemic experiences, substance use changes, and functioning, a survey was nationally administered to a sample of United States veterans reporting substance use issues during the pandemic. The purpose of this cross-sectional online survey for veterans (N = 409) was to report on COVID-19 experiences, safety behaviors, and infection experiences while also investigating the relationship among addictive behaviors, mental and physical health, and COVID-19 impact. Measures also assessed specific substance use concerns, pandemic-related loneliness, and functioning. Though few veterans reported personally receiving a confirmed COVID-19 medical diagnosis (10.5%), the impact of pandemic stressors was evident, with a majority reporting anxiety related to contracting COVID-19 (61.4%) or fear of a family member or close friend contracting COVID-19 (58.7%). Participants reported increased use of alcohol (45.3%), sedatives (36.6%), inhalants (35.7%), tobacco (35.0%), and cannabis (34.9%), attributed specifically to the pandemic. Regression analyses revealed that even when controlling for the contribution of problematic substance use issues, negative pandemic impacts and self-reported COVID-19 related loneliness were related to more impaired physical and mental health functioning during the pandemic. Findings from this sample of veterans with addiction issues add to the growing literature suggesting unique and adverse effects of COVID-19 stressors on functioning while also revealing specific pandemic impacts for this group.

Use of a Rapid Qualitative Method to Inform the Development of a Text Messaging Intervention for People With Serious Mental Illness Who Smoke: Formative Research Study.

BACKGROUND: People with serious mental illness are disproportionately affected by smoking and face barriers to accessing smoking cessation treatments in mental health treatment settings. Text-based interventions are cost-effective and represent a widely accessible approach to providing smoking cessation support. OBJECTIVE: We aimed to identify key factors for adapting text-based cessation interventions for people with serious mental illness who smoke. METHODS: We recruited 24 adults from mental health programs who had a serious mental illness and currently smoked cigarettes or had quit smoking within the past 5 years. We then conducted virtual qualitative interviews between November 2020 and August 2021. Data were analyzed using the rapid thematic analytic approach. RESULTS: We identified the following 3 major themes: (1) interplay between smoking and having a serious mental illness, (2) social contextual factors of smoking in adults with serious mental illness, and (3) smoking and quitting behaviors similar to the general population. Participants reported barriers and facilitators to quitting across the 3 themes. Within the "interplay between smoking and having a serious mental illness" theme, barriers included smoking to manage stress and mental health symptoms, and facilitators to quitting included the awareness of the harm of smoking on mental health and patient-provider discussions on smoking and mental health. In the "social contextual factors of smoking in adults with serious mental illness" theme, barriers included high social acceptability of smoking among peers. Positive support and the combined social stigma of smoking and having a mental health condition outside of peer groups motivated individuals to quit. Some participants indicated that low exposure to other smokers during the COVID-19 pandemic helped them to engage in cessation efforts. In the "smoking and quitting behaviors similar to the general population" theme, barriers included smoking after eating, having coffee, drinking alcohol, and experiencing negative social support, and facilitators included health concerns, improvement in the general quality of life, and use of evidence-based tobacco treatments when available. CONCLUSIONS: People with serious mental illness often smoke to cope with intense emotional states, manage mental health symptoms, or maintain social bonds. Text message content emphasizing equally effective and less harmful ways for stress reduction and mental health symptom management may improve quit rates in individuals with serious mental illness.

The effects of loneliness and psychological flexibility on veterans' substance use and physical and mental health functioning during the COVID-19 pandemic.

During the COVID-19 pandemic, social isolation was a common experience as people were trying to keep themselves and others safe from infection. Veterans with problematic substance use are at particular risk of the consequences of social isolation. This study evaluated the nature of social interactions during the COVID-19 pandemic and the effects of loneliness and psychological flexibility on self-reported substance use and physical and mental health functioning among U.S. veterans who reported problematic substance use. Data from 409 veterans with self-reported substance use concerns were obtained via a cross-sectional online survey. Results showed that many veterans who engaged in problematic substance use during the COVID-19 pandemic reported a number of social supports during this period and frequent communication with others, but still felt lonelier during the pandemic. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning. Psychological flexibility demonstrated significant unique variance in explaining mental health functioning during the pandemic after accounting for loneliness, but not for substance use or physical functioning. For veterans with high levels of loneliness, high levels of psychological flexibility were associated with a lower negative impact on quality of life due to the pandemic, but for veterans with low levels of loneliness, differing levels of psychological flexibility were not significantly associated with the negative impact of COVID-19. Overall, loneliness and psychological flexibility appear to be highly associated with the negative impact of COVID-19 on veterans with problematic substance use.

Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review.

Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder.

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.