Tailored vs. General COVID-19 prevention for adults with mental disabilities residing in group homes: a randomized controlled effectiveness-implementation trial.

BACKGROUND: People with serious mental illness (SMI) and people with intellectual disabilities/developmental disabilities (ID/DD) are at higher risk for COVID-19 and more severe outcomes. We compare a tailored versus general best practice COVID-19 prevention program in group homes (GHs) for people with SMI or ID/DD in Massachusetts (MA). METHODS: A hybrid effectiveness-implementation cluster randomized control trial compared a four-component implementation strategy (Tailored Best Practices: TBP) to dissemination of standard prevention guidelines (General Best-Practices: GBP) in GHs across six MA behavioral health agencies. GBP consisted of standard best practices for preventing COVID-19. TBP included GBP plus four components including: (1) trusted-messenger peer testimonials on benefits of vaccination; (2) motivational interviewing; (3) interactive education on preventive practices; and (4) fidelity feedback dashboards for GHs. Primary implementation outcomes were full COVID-19 vaccination rates (baseline: 1/1/2021-3/31/2021) and fidelity scores (baseline: 5/1/21-7/30/21), at 3-month intervals to 15-month follow-up until October 2022. The primary effectiveness outcome was COVID-19 infection (baseline: 1/1/2021-3/31/2021), measured every 3 months to 15-month follow-up. Cumulative incidence of vaccinations were estimated using Kaplan-Meier curves. Cox frailty models evaluate differences in vaccination uptake and secondary outcomes. Linear mixed models (LMMs) and Poisson generalized linear mixed models (GLMMs) were used to evaluate differences in fidelity scores and incidence of COVID-19 infections. RESULTS: GHs (n=415) were randomized to TBP (n=208) and GBP (n=207) including 3,836 residents (1,041 ID/DD; 2,795 SMI) and 5,538 staff. No differences were found in fidelity scores or COVID-19 incidence rates between TBP and GBP, however TBP had greater acceptability, appropriateness, and feasibility. No overall differences in vaccination rates were found between TBP and GBP. However, among unvaccinated group home residents with mental disabilities, non-White residents achieved full vaccination status at double the rate for TBP (28.6%) compared to GBP (14.4%) at 15 months. Additionally, the impact of TBP on vaccine uptake was over two-times greater for non-White residents compared to non-Hispanic White residents (ratio of HR for TBP between non-White and non-Hispanic White: 2.28, p = 0.03). CONCLUSION: Tailored COVID-19 prevention strategies are beneficial as a feasible and acceptable implementation strategy with the potential to reduce disparities in vaccine acceptance among the subgroup of non-White individuals with mental disabilities. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04726371, 27/01/2021. https://clinicaltrials.gov/study/NCT04726371 .

NiH-Catalyzed Proximal-Selective Hydroamination of Unactivated Alkenes with Anthranils.

The regioselective hydroamination of unactivated alkenes is a long-standing challenge in organic synthesis. Herein, we report a NiH-catalyzed proximal-selective hydroamination of unactivated alkenes with 8-aminoquinoline (AQ) as a bidentate auxiliary and anthranils as aminating reagents. A wide range of primary aryl amines bearing an ortho-carbonyl group were installed in both terminal and internal unactivated alkenes, delivering a variety of valuable ß- and γ-amino acid building blocks, respectively, with excellent regiocontrol. The utility of this transformation was further demonstrated by the conversion of the multifunctionalized aryl amines into useful N-heterocycles.

E-Cigarette Provision to Promote Switching in Cigarette Smokers With Serious Mental Illness-A Randomized Trial.

BACKGROUND: High cigarette smoking prevalence and low quit rates in people with serious mental illness (SMI) contribute to disparate rates of chronic disease and premature death. This prospective trial tested the impact of switching to a potentially lower-harm nicotine-containing product on smoking in this population. AIMS AND METHODS: A total of 240 cigarette smokers with SMI who tried but were currently unwilling to quit were randomly assigned to receive disposable e-cigarettes for 8 weeks or not, with assessments at baseline, 2, 4, 6, 8, 13, and 26 weeks. Generalized linear mixed models examined the effects of e-cigarette provision on e-cigarette appeal, cigarettes per day (CPD), breath carbon monoxide (CO), nicotine dependence, and side effects. Clinical Trial registration: NCT03050853. RESULTS: Self-reported smoking was similar between groups at baseline (mean = 18.7 CPD). By week 2, 79% of the e-cigarette group were using e-cigarettes daily. During weeks 2-8, CPD and CO decreased in the e-cigarette versus assessment-only group (eg, 7.5 CPD [95% CI = 5.9, 9.2] vs. 18.1 CPD [CI = 16.4, 19.8] and 16.4 ppm [CI = 13.4, 19.5] vs. 25.4 ppm [CI = 22.4, 28.9], respectively, at week 2). Additionally, 19%-22% in the e-cigarette group reported smoking no cigarettes in weeks 2-8 compared to 0% in the assessment-only group. By 13 and 26 weeks, group differences in CPD, but not CO, remained significant. Nicotine dependence did not increase and side effects were minor. CONCLUSIONS: Providing e-cigarettes for 8 weeks to smokers with SMI resulted in substantial reductions in CPD and CO. Enhancing and maintaining switching from cigarettes to e-cigarettes warrant further study. IMPLICATIONS: This was the first prospective study to compare e-cigarette provision with assessments only to evaluate the appeal and impact of e-cigarettes on smoking behavior, carbon monoxide exposure, and nicotine dependence among smokers with SMI who had tried but were unable to quit and were not currently interested in cessation treatment. The finding that e-cigarette provision led to significant reductions in smoking and carbon monoxide without increasing nicotine dependence has implications for reducing harm not only among the millions of smokers with SMI who struggle to quit, but also for other vulnerable smokers who cannot achieve cessation.

Cognitive Enhancement Therapy vs social skills training in schizophrenia: a cluster randomized comparative effectiveness evaluation.

BACKGROUND: Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST). METHODS: The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES. DISCUSSION: Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians' ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning. TRIAL REGISTRATION: ClinicalTrial.gov NCT04321759 , registered March 25, 2020.

Virtual Learning Collaborative Compared to Technical Assistance as a Strategy for Implementing Health Promotion in Routine Mental Health Settings: A Hybrid Type 3 Cluster Randomized Trial.

BACKGROUND: Despite widespread use of learning collaboratives, few randomized trials have evaluated their effectiveness as a strategy for implementing evidence based practices. This randomized trial evaluated the effectiveness of a virtual learning collaborative (VLC) in the implementation of a health promotion program for persons with serious mental illness (SMI) aimed at reducing cardiovascular risk reduction in routine mental health settings, compared to routine technical assistance (TA). METHODS: Fifty-five mental health provider organizations were recruited to participate in a Hybrid Type 3 cluster randomized implementation-effectiveness trial of the InSHAPE health promotion program for persons with SMI. Sites were stratified by size and randomized prior to implementation to an 18-month group-based VLC with monthly learning sessions or individual site TA with four scheduled conference calls over 18 months. Primary implementation and service outcomes were InSHAPE program fidelity, participation, and reach. Primary clinical outcomes were weight loss, cardiorespiratory fitness, and cardiovascular risk reduction (≥ 5% weight loss or > 50 m increase on the 6-Minute Walk Test). Program fidelity was assessed at 6, 12, and 24 months; program participation and participant-level outcomes were assessed at 3, 6, 9, and 12 months. RESULTS: VLC (N = 27) and TA (N = 28) sites were similar in organizational characteristics (all p > 0.05). At 12-month follow-up mean program fidelity score was higher in VLC compared to TA (90.5 vs. 79.1; p = 0.002), with over double the proportion with good fidelity (VLC = 73.9% vs. TA = 34.8%; p = 0.009). Over half of individuals in both VLC and TA achieved cardiovascular risk-reduction at 6-month follow-up (VLC: 51.0%; TA: 53.5%; p = 0.517) and at 12-month follow-up (62% VLC and TA; p = 0.912). At 12-month follow-up VLC compared to TA was associated with greater participation (VLC 69.5% vs. TA 56.4% attending at least 50% of sessions, p = 0.002); larger caseloads (VLC = 16 vs. TA = 11; p = 0.024); greater reach consisting of 45% greater number of participants receiving InSHAPE (VLC = 368 vs. TA = 253), and 58% greater number of participants achieving cardiovascular risk reduction (VLC = 150 vs. TA = 95). CONCLUSION: Virtual learning collaboratives compared to routine technical assistance as an implementation strategy for evidence-based health promotion promote greater intervention fidelity, greater levels of intervention participation, greater reach, and a greater number of participants achieving clinically significant risk reduction outcomes, while achieving similarly high levels of intervention effectiveness for participants who completed at least 6 months of the program.

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.

Correlation Database of 60 Cross-Disciplinary Surveys and Cognitive Tasks Assessing Self-Regulation.

Self-regulation is studied across various disciplines, including personality, social, cognitive, health, developmental, and clinical psychology; psychiatry; neuroscience; medicine; pharmacology; and economics. Widespread interest in self-regulation has led to confusion regarding both the constructs within the nomological network of self-regulation and the measures used to assess these constructs. To facilitate the integration of cross-disciplinary measures of self-regulation, we estimated product-moment and distance correlations among 60 cross-disciplinary measures of self-regulation (23 self-report surveys, 37 cognitive tasks) and measures of health and substance use based on 522 participants. The correlations showed substantial variability, though the surveys demonstrated greater convergent validity than did the cognitive tasks. Variables derived from the surveys only weakly correlated with variables derived from the cognitive tasks (M = .049, range = .000 to .271 for the absolute value of the product-moment correlation; M = .085, range = .028 to .241 for the distance correlation), thus challenging the notion that these surveys and cognitive tasks measure the same construct. We conclude by outlining several potential uses for this publicly available database of correlations.

Brief Web-Based Interventions for Young Adult Smokers With Severe Mental Illnesses: A Randomized, Controlled Pilot Study.

Significance: About 50% of young adults with schizophrenia, bipolar disorder, and other severe mental illnesses smoke tobacco, but few studies have evaluated interventions for this group. Methods: We conducted a randomized pilot study among 58 young adult smokers with severe mental illnesses comparing a brief interactive web-based motivational tool, Let's Talk About Smoking, to computerized standard education from the National Cancer Institute. An additional 23 subjects received minimal tobacco assessment at baseline and no intervention, providing a comparison condition for naturalistic cessation behavior. All participants (total n = 81) were assessed for smoking and breath carbon monoxide at baseline and 14 weeks and had access to standard cessation treatments. Results: The 81 participants were stable outpatients ages 18-30 (mean 24.8 years): 43.2% were diagnosed with schizophrenia-spectrum disorders, the remainder with severe mood and anxiety disorders. They smoked 14.6 ± 10.2 cigarettes per day. All participants completed their assigned intervention; 83.4% of Let's Talk About Smoking users and 71.4% of standard education users rated their intervention "good" or "very good." At 14 weeks, less than 15% of participants in all conditions had used additional cessation treatment. Let's Talk About Smoking users were more likely to have biologically verified abstinence at 14 weeks than standard education users (14.8% vs. 0%; X2 = 3.7, p = .05). None of the participants in the naturalistic comparison condition were abstinent at 14 weeks. Conclusions: Interactive, web-based motivational interventions are feasible and promising for smoking cessation among young smokers with severe mental illnesses. Such interventions warrant further study among this group of smokers. Implications: Young adult smokers with severe mental illnesses are a vulnerable population that, without intervention, goes on to experience disparate morbidity and mortality. Brief, easily disseminable interventions are needed to facilitate cessation in this group. This pilot research indicates that brief, technology-delivered, motivational interventions that are tailored for this group may be able to activate a significant number to quit without additional cessation intervention.

Analyzing Long-Duration and High-Frequency Data Using the Time-Varying Effect Model.

With the rapid development of methods for electronic data capture, longitudinal data sets with many assessment points have become common in mental health services and addiction research. These data typically exhibit complex and irregular patterns of change, and the relationship between variables may also change over time. Existing statistical methods are not flexible enough to capture this complexity, but a new method, the time-varying effect model (TVEM), permits modeling nearly any shape of change, and allows the effect of an independent variable on outcome to change over time. This paper introduces TVEM and illustrates its application using data from a 16-year study of 223 participants with serious mental illness and substance abuse.

The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD.

OBJECTIVE: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). METHOD: A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression. RESULTS: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. CONCLUSIONS: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness.

BACKGROUND: A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS: To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD: In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS: There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS: Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers.

INTRODUCTION: Smoking cessation pharmacotherapy is underutilized by people with mental illnesses, who smoke at high rates and die prematurely of smoking-related diseases. Educational outreach can improve prescribing, but distances impede widespread use of this practice. Little research has assessed whether videoconference can effectively deliver educational outreach. We conducted a randomized, controlled trial of in-person versus videoconference educational outreach for smoking cessation pharmacotherapy across a state mental health system. METHODS: We randomly assigned clinics to receive in-person or videoconference educational outreach with audit and feedback for cessation pharmacotherapy. Prescribers completed brief questionnaires before and after the intervention. With segmented regression analysis of interrupted time series, we evaluated prescribing trends in Medicaid pharmacy claims for nicotine replacement therapy (NRT) and varenicline, with interaction terms for the effect of intervention type (in-person vs. videoconference). RESULTS: With interaction terms in the model, filled NRT prescriptions increased after the intervention compared to before (p < .01). The pattern of fills after the intervention were different at centers receiving in-person compared to videoconference educational outreach (p < .02) without clearly favoring one over the other. Additionally, filled varenicline prescriptions increased after the intervention compared to before (p = .04), but type of intervention delivery did not influence varenicline fills. Prescriber satisfaction with the educational intervention was high and prescriber attitudes became more positive in both groups. CONCLUSION: This study suggests that single session educational outreach with audit and feedback can increase cessation pharmacotherapy utilization, and that videoconference delivery could be an effective, scalable approach to improve workforce capacity in systems serving mentally ill smokers.

The impact of addiction medications on treatment outcomes for persons with co-occurring PTSD and opioid use disorders.

BACKGROUND AND OBJECTIVES: Previous research has been inconclusive about whether adding psychosocial treatment to medication assisted treatment (MAT) improves outcomes for patients with co-occurring psychiatric and opioid use disorders. This study evaluated the impact of MAT and psychosocial therapies on treatment outcomes for patients with co-occurring opioid use disorders and PTSD. METHODS: Patients meeting criteria for PTSD and substance use disorders were randomly assigned to one of three treatment conditions: Standard Care (SC) alone, Integrated Cognitive Behavioral Therapy (ICBT) plus SC, or Individual Addiction Counseling (IAC) plus SC. Substance use and psychiatric symptoms were assessed at baseline and 6 months. Only patients with opioid use disorders were included in the present analyses (n = 126). Two-way ANOVAS and logistic regression analyses were used to examine associations between treatment conditions and MAT, for substance use and psychiatric outcomes. RESULTS: MAT patients receiving ICBT had significantly decreased odds of a positive urine drug screen, compared to non-MAT patients receiving SC alone (OR = .07, 95% CI = .01, .81, p = .03). For PTSD symptoms, a significant MAT by psychosocial treatment condition interaction demonstrated that MAT patients had comparable declines in PTSD symptoms regardless of psychosocial treatment type (F(2, 88) = 4.74, p = .011). Non-MAT patients in ICBT had significantly larger reductions in PTSD. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: For patients with co-occurring opioid use disorders and PTSD, MAT plus ICBT is associated with more significant improvement in substance use. For non-MAT patients, ICBT is most beneficial for PTSD symptoms.

Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes.

BACKGROUND: The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented. OBJECTIVES: This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes. METHODS: Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up. RESULTS: Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity. CONCLUSIONS: The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.

The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders.

Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.

Antipsychotic Cardiometabolic Side Effect Monitoring in a State Community Mental Health System.

Antipsychotic medications can cause serious cardiometabolic side effects. No recent research has broadly evaluated monitoring and strategies to improve monitoring in U.S. public mental health systems. To address this knowledge gap, we evaluated education with audit and feedback to leaders to improve cardiometabolic monitoring in a state mental health system. We used Chi square statistics and logistic regressions to explore changes in monitoring recorded in randomly sampled records over 2 years. In 2009, assessment of patients on antipsychotics was 29.6 % for cholesterol, 40.4 % for glucose, 29.1 % for triglycerides, 54.3 % for weight, 33.6 % for blood pressure, and 5.7 % for abdominal girth. In 2010, four of ten mental health centers improved their rate of adult laboratory monitoring. Overall monitoring in the state did not increase. Education for prescribers with audit and feedback to leaders can improve monitoring in some settings, but more intensive and/or prolonged interventions may be required.

Long-term outcomes of a randomized trial of integrated skills training and preventive healthcare for older adults with serious mental illness.

OBJECTIVE: This report describes 1-, 2-, and 3-year outcomes of a combined psychosocial skills training and preventive healthcare intervention (Helping Older People Experience Success [HOPES]) for older persons with serious mental illness. METHODS: A randomized controlled trial compared HOPES with treatment as usual (TAU) for 183 older adults (age ≥ 50 years [mean age: 60.2]) with serious mental illness (28% schizophrenia, 28% schizoaffective disorder, 20% bipolar disorder, 24% major depression) from two community mental health centers in Boston, Massachusetts, and one in Nashua, New Hampshire. HOPES comprised 12 months of weekly skills training classes, twice-monthly community practice trips, and monthly nurse preventive healthcare visits, followed by a 1-year maintenance phase of monthly sessions. Blinded evaluations of functioning, symptoms, and service use were conducted at baseline and at a 1-year (end of the intensive phase), 2-year (end of the maintenance phase), and 3-year (12 months after the intervention) follow-up. RESULTS: HOPES compared with TAU was associated with improved community living skills and functioning, greater self-efficacy, lower overall psychiatric and negative symptoms, greater acquisition of preventive healthcare (more frequent eye exams, visual acuity, hearing tests, mammograms, and Pap smears), and nearly twice the rate of completed advance directives. No differences were found for medical severity, number of medical conditions, subjective health status, or acute service use at the 3-year follow-up. CONCLUSION: Skills training and nurse facilitated preventive healthcare for older adults with serious mental illness was associated with sustained long-term improvement in functioning, symptoms, self-efficacy, preventive healthcare screening, and advance care planning.

Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity.

BACKGROUND: Prescription opioids are the most rapidly growing category of abused substances, and result in significant morbidity, mortality and healthcare costs. Co-occurring with psychiatric disorders, persons with prescription opioid problems have negative treatment outcomes. Data are needed on the prevalence of co-occurring prescription opioid abuse and specific disorders, such as posttraumatic stress disorder (PTSD), to better inform clinical practice. OBJECTIVE: To determine prevalence rates of current co-occurring prescription opioid use problems and PTSD symptom severity among patients in community addiction treatment settings. METHODS: We abstracted administrative and chart information on 573 new admissions to three addictive treatment agencies during 2011. Systematic data were collected on PTSD symptoms, substance use, and patient demographics. RESULTS: Prescription opioid use was significantly associated with co-occurring PTSD symptom severity (OR: 1.42, p < 0.05). Use of prescription opioids in combination with sedatives (OR: 3.81, p < 0.01) or cocaine (OR: 2.24, p < 0.001) also were associated with PTSD severity. The odds of having co-occurring PTSD symptoms and prescription opioid use problem were nearly three times greater among females versus males (OR: 2.63, p < 0.001). Younger patients (18-34 years old) also were at higher risk (OR: 1.86, p < 0.01). CONCLUSIONS: Prescription opioid use problems are a risk factor for co-occurring PTSD symptom severity. Being female or younger increase the likelihood of this co-morbidity. Further research is needed to confirm these finding, particularly using more rigorous diagnostic procedures. These data suggest that patients with prescription opioid use problems should be carefully evaluated for PTSD symptoms.

Gender differences in psychotic disorders with concurrent substance use.

OBJECTIVE: We conducted a comparative analysis of gender differences in patients with primary psychotic disorders with concurrent substance use and in those with substance-induced psychoses. METHODS: A total of 385 individuals admitted to psychiatric emergency departments with early-onset psychosis and recent substance use were interviewed at baseline and at six-month intervals for two years. Using a standardized research diagnostic assessment instrument, we classified patients at baseline into primary and substance-induced psychosis groups and analyzed the effects of gender on demographic, family, and clinical characteristics at baseline, the interaction of gender and diagnosis, and gender main effects on illness course, adjustment, and service use over the two-year follow-up period. RESULTS: Women had better premorbid adjustment, less misattribution of symptoms, and a later age at onset of regular drug use compared to men. Women, however, showed greater depression and histories of abuse compared to men. Men had greater arrest histories. No interactions between gender and diagnosis were significant. Both genders in the primary and substance-induced psychosis groups showed clinical and functional improvement over the follow-up period despite the overall minimal use of mental health and substance abuse treatment services. CONCLUSIONS: Women and men with psychosis and substance use differ on several dimensions. Our findings suggest the need for gender-specific treatment programming across both diagnostic groups.