Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study.

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Adherence to guideline creation recommendations for suicide prevention in the emergency department: A systematic review.

OBJECTIVES: Suicide rates in the United States rose 35.2% from 1999-2018. As emergency department (ED) providers often have limited training in management of suicidal patients and minimal access to mental health experts, clinical practice guidelines (CPGs) may improve care for these patients. However, clinical practice guidelines that do not adhere to quality standards for development may be harmful both to patients, if they promote practices based on flawed evidence, and to ED providers, if used in malpractice claims. In 2011, the Institute of Medicine created standards to determine the trustworthiness of CPGs. This review assessed the adherence of suicide prevention CPGs, intended for the ED, to these standards. Secondary objectives were to assess the association of adherence both with first author/organization specialty (ED vs non-ED) and with inclusion of recommendations on substance use, a potent risk factor for suicide. METHODS: This is a systematic review of available suicide-prevention CPGs for the ED in both peer-reviewed and gray literature. This review followed the PRISMA standards for reporting systematic reviews. RESULTS: Of 22 included CPGs, the 7 ED-sponsored CPGs had higher adherence to quality standards (3.1 vs 2.4) and included the highest-rated CPG (ICAR2E) identified by this review. Regardless of specialty, nearly all CPGs included some mention of identifying or managing substance use. CONCLUSIONS: Most suicide prevention CPGs intended for the ED are written by non-ED first authors or organizations and have low adherence to quality standards. Future CPGs should be developed with more scientific rigor, include a multidisciplinary writing group, and be created by authors working in the practice environment to which the CPG applies.

Substance use in a sexual context: The association of sex-related substance use motives with substance choice and use behaviors.

BACKGROUND: Substance use before sex is associated with riskier behaviors. Sex-related substance use motives may explain pre-sex substance use. We explored what sex-related motives are associated with alcohol versus drug use, and which motives underlie heavier use. METHODS: A sample of 936 participants (50% male, 80% White) completed an Internet survey about sexuality. Those who drank before sex (n=657) reported on six sex-related drinking motives; those who used drugs before sex (n=271) reported on six (parallel) sex-related drug use motives. The frequency of endorsement of each motive between drinkers and drug users was compared with z-distributions. Logistic regressions assessed whether motives were associated with substance use frequency and intoxication before sex. RESULTS: Substance use to relax and to get a sex partner to use were more commonly endorsed for alcohol than drugs; substance use to improve performance and enhance experience were more commonly endorsed for drugs. Most motives were associated with alcohol frequency and intoxication before sex. None were associated with drug frequency; some were associated with drug intoxication. CONCLUSIONS: Alcohol was generally used to facilitate sex, and drugs to enhance sex. Sex-related drinking motives were associated with drinking before sex; sex-related drug use motives were less predictive.

Physical Health Disparities Across Dimensions of Sexual Orientation, Race/Ethnicity, and Sex: Evidence for Increased Risk Among Bisexual Adults.

Accumulating evidence suggests that sexual minority individuals are at increased risk for physical health conditions compared to heterosexual individuals. However, we know little about physical health disparities affecting bisexual individuals, a population at increased risk for psychiatric and substance use conditions compared to both heterosexual and lesbian/gay populations. Using a large, nationally representative sample, we examined physical health disparities for bisexual individuals. To advance research on sexual minority health disparities, we further: (1) compared prevalence rates of physical health conditions across three dimensions of sexual orientation (i.e., identity, attractions, behavior) and (2) examined whether disparities differed by sex and race/ethnicity. Results indicated that sexual minority individuals were at increased risk for many physical health conditions. Notably, individuals with bisexual identity, attractions, and/or behavior were at increased risk for more physical health conditions than other sexual minority groups. The number and types of physical health disparities affecting bisexually identified individuals and individuals with same- and opposite-sex attractions and/or sexual partners varied across sex and race/ethnicity, with the most consistent disparities emerging for individuals who reported same- and opposite-sex sexual partners. Our findings highlight the substantial physical health disparities affecting sexual minorities and the heightened risk conferred by all facets of bisexuality.

Substance Use Disorders and Poverty as Prospective Predictors of Adult First-Time Suicide Ideation or Attempt in the United States.

This study examined whether substance use disorders (SUD) and poverty predicted first-time suicide ideation or attempt in United States national data. Respondents without prior histories of suicide ideation or attempt at Wave 1 of the NESARC (N = 31,568) were analyzed to determine the main and interactive effects of SUD and poverty on first-time suicide ideation or attempt by Wave 2, 3 years later. Adjusted for controls, poverty (AOR = 1.35, CI = 1.05-1.73) and drug use disorders (AOR = 2.10, CI = 1.07-4.14) independently increased risk for first-time suicide ideation or attempt at Wave 2. SUD and poverty did not interact to differentially increase risk for first-time suicide ideation or attempt, prior to or after adjustment for controls. This study reinforces the importance of SUD and poverty in the risk for first-time suicide ideation or attempt. Public health efforts should target messages to drug users and the impoverished that highlight their increased risk for first-time suicide.

Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults: Results from a randomized controlled trial.

BACKGROUND: Homeless young adults are more likely than their never-homeless counterparts to abuse alcohol and engage in risky sexual behaviors, yet no interventions to simultaneously reduce both these behaviors among this vulnerable population have been systematically designed and evaluated. We therefore developed a brief intervention (BI) to reduce both alcohol use and sexual risk behaviors among homeless young adults. The results of a randomized trial testing the BI against an education comparison (EC) are presented. METHOD: Young adults (N=61; age 17-22 years) from an urban, Northeastern crisis shelter were randomly assigned to either the 2-session, individual-level BI or a time-matched, 2-session, individual-level EC. Generalized linear mixed models for repeated measures determined effects of treatment condition on outcomes. RESULTS: The BI significantly increased participant readiness to change alcohol use. However, it did not significantly decrease primary alcohol or HIV sexual risk outcomes, independently or relative to EC (all ps>.05). Participants in the EC reduced times engaged in unprotected sex between baseline and post-intervention to a significantly greater extent (p<.01) than those in the BI condition. Participants in both conditions reported satisfaction with respective interventions. CONCLUSIONS: Findings suggest that the BI was acceptable and successful in getting participants to consider changing their drinking. However, lack of change in alcohol and sexual behavior outcomes indicates the need for further research to determine how to translate readiness to change into actual behavioral change among homeless young adults.

Regularly Drinking Alcohol Before Sexual Activity in a Nationally Representative Sample: Prevalence, Sociodemographics, and Associations With Psychiatric and Substance Use Disorders.

OBJECTIVES: We addressed regular drinking before sex and its associated risk factors. METHODS: From the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative adult US sample (fielded 2004-2005), we determined the 12-month prevalence of regularly drinking alcohol before sexual activity. Among 17,491 sexually active drinkers, we determined the sociodemographic, psychiatric, and substance use correlates of regularly drinking before sex. RESULTS: Regular presex drinking's 12-month prevalence was 1.8%. Significant bivariate sociodemographic correlates were age, gender, race/ethnicity, education, family income, marital status, and employment status. Generalized anxiety disorder and alcohol dependence were associated with significantly increased odds of being a regular presex drinker after controlling for covariates. CONCLUSIONS: We estimate that 4.3 million American adults are regular presex drinkers. Future research should examine this public health issue at the population level, with particular focus on pathways that link it to psychopathology.

Substance-use disorders and poverty as prospective predictors of first-time homelessness in the United States.

OBJECTIVES: We examined whether substance-use disorders and poverty predicted first-time homelessness over 3 years. METHODS: We analyzed longitudinal data from waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions to determine the main and interactive effects of wave 1 substance use disorders and poverty on first-time homelessness by wave 2, among those who were never homeless at wave 1 (n = 30,558). First-time homelessness was defined as having no regular place to live or having to live with others for 1 month or more as a result of having no place of one's own since wave 1. RESULTS: Alcohol-use disorders (adjusted odds ratio [AOR] = 1.34), drug-use disorders (AOR = 2.51), and poverty (AOR = 1.34) independently increased prospective risk for first-time homelessness, after adjustment for ecological variables. Substance-use disorders and poverty interacted to differentially influence risk for first-time homelessness (P < .05), before, but not after, adjustment for controls. CONCLUSIONS: This study reinforces the importance of both substance-use disorders and poverty in the risk for first-time homelessness, and can serve as a benchmark for future studies. Substance abuse treatment should address financial status and risk of future homelessness.

Parental Divorce, Maternal-Paternal Alcohol Problems, and Adult Offspring Lifetime Alcohol Dependence.

This study examined the influences of parental divorce and maternal-paternal histories of alcohol problems on adult offspring lifetime alcohol dependence using data from the 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Parental divorce and maternal-paternal alcohol problems interacted to differentially influence the likelihood of offspring lifetime alcohol dependence. Experiencing parental divorce and either maternal or paternal alcohol problems doubled the likelihood of alcohol dependence. Divorce and history of alcohol problems for both parents tripled the likelihood. Offspring of parental divorce may be more vulnerable to developing alcohol dependence, particularly when one or both parents have alcohol problems.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department.

OBJECTIVE: The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED). METHODS: Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results. RESULTS: The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits. CONCLUSIONS: Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Smartphone intervention to optimize medication-assisted treatment outcomes for opioid use disorder: study protocol for a randomized controlled trial.

BACKGROUND: Opioids accounted for 75% of drug overdoses in the USA in 2020, with rural states particularly impacted by the opioid crisis. While medication-assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD and (2) evaluate the role of specific OptiMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention. METHODS: We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence. DISCUSSION: This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone app-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05336188 , registered March 21, 2022.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms.

BACKGROUND: In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options. METHODS/DESIGN: Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective. DISCUSSION: Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05023317.

Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial.

Objective: The emergency department (ED) is an important site for suicide prevention efforts, and safety planning has been identified as a best practice for suicide prevention among ED patients at increased suicide risk. However, few ED clinicians are prepared to assess suicide risk or guide patients in the creation of safety plans. This study was a pilot randomized controlled trial of the feasibility, acceptability, and preliminary effects of safety planning by individuals with lived experience of suicide attempt or of severe suicidal ideation but without medical training (i.e., peers) in the ED. Methods: Patients at risk for suicide in a general ED were randomly assigned to receive peer-delivered or mental health provider­delivered safety planning. Intervention feasibility measures included ED length of stay, safety plan completeness, and safety plan quality. Acceptability measures included patient satisfaction. Preliminary effects were assessed as number of ED returns within the 3 months after the ED visit. Results: Data from 31 participants were available for analysis. Compared with participants with provider-delivered safety planning, participants with peer-delivered safety planning had similar ED lengths of stay, higher safety plan completeness, and higher safety plan quality. Acceptability of the safety planning process was similar for the two groups. Compared with participants receiving provider-delivered safety planning, participants receiving peer-delivered planning had significantly fewer ED visits during the subsequent 3 months than during the 3 months preceding the ED visit. Conclusions: Peer-delivered safety planning is feasible and acceptable and may result in fewer return ED visits. These findings provide preliminary support for peer-delivered safety planning in the ED.

Acceptability of a Game-Based Intervention to Prevent Adolescent Prescription Opioid Misuse.

Objective: This study assessed the initial acceptability of SafeUse, a game-based opioid misuse prevention intervention for delivery via smartphone among adolescents. Evidence-based educational and refusal skills training materials were adapted, and game design elements were applied to clinically and scientifically informed scenarios in which opioids are typically introduced to adolescents using standard product development methods to create the SafeUse prototype. Materials and Methods: In a mixed-methods study, 14 adolescents were assessed on their knowledge and perceptions of opioids before and following 5-7 days of access to SafeUse. Participants provided feedback in focus groups on the acceptability, relevance, and understandability of SafeUse and made suggestions for its improvement. Feedback was coded and summarized as to playability, acceptability, appropriateness, content development, and knowledge transfer. Pre- and post-access quantitative data were analyzed using Wilcoxon matched pairs signed-rank tests. Results: Overall, participants liked SafeUse, its characters, graphics, and approach, finding it more appealing than lectures/reading materials and appropriate for school settings. They moderately to extremely "liked the game," "would like to play more game modules," "liked playing through the decisions," thought the game was realistic/relevant and fun, and they learned new information about opioids. Participants reported increased confidence to refuse opioids and decreased likelihood of accepting opioids from someone they know. Knowledge about opioids increased (P < 0.006), and adolescent perception that prescription drugs are safer than illegal drugs decreased (P < 0.003) after playing SafeUse. Conclusion: Findings suggest that SafeUse is acceptable and likely educational to adolescents and worthy of further development and research.

Utility of a controlled amphetamine withdrawal paradigm among adults who use methamphetamine: A pilot clinical trial.

BACKGROUND: The continued increase in prevalence of methamphetamine use in the United States has resulted in a significant increase in the number of patients entering treatment for methamphetamine use. However, no robustly efficacious pharmacologic treatment for methamphetamine use or withdrawal has been identified to date after stopping methamphetamine use. AIMS: Given the association between methamphetamine withdrawal and relapse during early treatment, this study tested a controlled d-amphetamine withdrawal paradigm among methamphetamine-using individuals. METHODS: Treatment-seeking adults who used methamphetamine (N = 34; 47% female; 100% white) were enrolled in a 4-week, randomized, double-blind, placebo-controlled trial in a residential setting, in which all participants were maintained on d-amphetamine (30 mg BID) during week 1, then half were switched to placebo during weeks 2-3. All participants received placebo during week 4. Outcomes included vital signs, withdrawal, cravings for methamphetamine, mood, and cognition. Bivariate analyses tested treatment group differences on baseline demographic and outcome variables. Repeated measures models examined main and interaction effects of treatment over time. RESULTS/OUTCOMES: Participants were successfully randomized and safely stabilized on d-amphetamine. Craving for methamphetamine increased during weeks 2-3 in the placebo group relative to those on d-amphetamine. Interactions with age and heart rate were noted. CONCLUSIONS/INTERPRETATION: To our knowledge, this is the first double-blind, placebo-controlled trial measuring pharmacologic effects of abruptly stopping controlled d-amphetamine administration in adults who use methamphetamine. Results support the potential of this withdrawal paradigm to further examine the efficacy of pharmacologic agents in ameliorating methamphetamine withdrawal symptoms.

"This Pandemic Is Making Me More Anxious about My Welfare and the Welfare of Others:" COVID-19 Stressors and Mental Health.

COVID-19 and subsequent social distancing guidelines have changed many aspects of people's daily lives including the way that they interact within their social environment. Pandemics are inherently social phenomena, and public health measures intended to curtail transmission of COVID-19 (e.g., quarantine and social distancing) have consequences for individuals with anxiety and depression. Using qualitative methods, respondents with previously diagnosed anxiety or depression identified ways in which COVID-19 affected their symptoms at multiple levels of the social ecological model (SEM). Key themes reported were organized following the SEM. Emergent themes at the individual level are isolation/loneliness, fear of contracting COVID-19, and uncertainty about the future. Themes at the interpersonal level are: fears of family contracting COVID-19, separation from family members, and domestic relationships. Themes at the level of community and societal stressors are: employment, community and societal systems, media, and the COVID-19 pandemic. Our findings demonstrate the ways that mental health, physical health/safety, and social environments are interrelated in the experience of COVID-19 for individuals diagnosed with anxiety or depression. These findings make a significant contribution to the literature as this is the first article to document mental health stressors related to the COVID-19 pandemic among individuals with diagnosed anxiety and depressive disorders.

The role of depression in the differential effect of childhood parental divorce on male and female adult offspring suicide attempt risk.

In previous studies by our group, we found that female offspring of parental divorce and parental remarriage are more susceptible to suicide attempt than male offspring. In this study, we examine whether these findings remain even after controlling for offspring depression. The sample consists of respondents from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. Multivariable regressions controlled for offspring depression, parental depression, age, race/ethnicity, income, and marital status. Our previous findings that female offspring of parental divorce and parental remarriage are more likely to report a lifetime suicide attempt than male offspring remained even after controlling for offspring depression. Findings suggest that focusing on engaging female offspring who demonstrate symptoms of depression is not sufficient to reduce suicide attempt risk in this group as many at risk individuals will remain unrecognized.

Smartphone application plus brief motivational intervention reduces substance use and sexual risk behaviors among homeless young adults: Results from a randomized controlled trial.

Homeless young adults are more likely than their never-homeless counterparts to abuse substances and engage in sexual risk behaviors. This study evaluated the feasibility and preliminary effectiveness of OnTrack, a smartphone application to self-monitor substance use and sexual risk behaviors, plus a brief motivational intervention (BMI), in reducing substance use and sexual risk among homeless young adults. A randomized controlled pilot trial (N = 60) compared OnTrack + BMI to treatment as usual (TAU) at an inner-city crisis shelter for homeless young adults (aged 18-21 years). Participants were assessed at baseline and 2 weeks, 4 weeks, and 6 weeks after baseline to evaluate substance use and sexual risk behaviors. Kruskal-Wallis tests determined differences between baseline and postintervention assessments. Logistic regression models examined treatment effect on change in outcomes between baseline and postintervention follow-up assessment, controlling for baseline levels. Participants in OnTrack + BMI significantly reduced past 2-week number of drinks (p = .023), times used marijuana (p = .046), times engaged in unprotected sex (p = .012), and times used drugs before sexual activity (p = .019). No reductions of substance use or sexual risk behaviors were found among participants in TAU (all ps > .05). After adjusting for baseline levels of substance use and sexual risk, participants in OnTrack + BMI had significantly lower odds than those in TAU for drinking alcohol (adjusted OR = 0.14; p = .01) and having unprotected sex (adjusted OR = 0.151; p = .032). OnTrack + BMI is feasible and effective in reducing past 2-week alcohol use and unprotected sex among homeless young adults. A larger randomized trial is warranted to replicate and extend present results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Parental divorce, parental depression, and gender differences in adult offspring suicide attempt.

Research suggests parental divorce during childhood increases risk of suicide attempt for male but not female offspring. The negative impact on offspring associated with parental divorce may be better explained by parental psychopathology, such as depression. We examined whether adult offspring of parental divorce experience elevated risk of suicide attempt, controlling for parental history of depression, and whether the risk varies by the gender of the offspring. Using the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the sample consists of respondents who experienced parental divorce (N = 4895). Multivariable regressions controlled for age, race/ethnicity, income, marital status, and parental history of depression. Females living with their fathers were significantly more likely to report lifetime suicide attempts than females living with their mothers, even after controlling for parental depression. Findings suggest that childhood/adolescent parental divorce may have a stronger impact on suicide attempt risk in female offspring than previously recognized.