Socioecological factors associated with multiple nicotine product use among U.S. youth: Findings from the population assessment of tobacco and health (PATH) study 2013-2018.

OBJECTIVE: This study utilized a socioecological approach to prospectively identify intrapersonal, familial, and environmental factors associated with single nicotine product use (NPU) and multiple NPU among U.S. youth. METHODS: Participants were 10,029 youths (ages 12-17 years) who had completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments and data on past 30-day nicotine product use. Multinomial logistic regression was fit for the 3-level outcome (no use, single NPU, multiple NPU) to estimate adjusted associations between the predictors and the outcome. RESULTS: The current study found that intrapersonal (sex, age, race/ethnicity, internalizing symptoms, sensation seeking, harm perceptions, lifetime history of using two or more tobacco products), familial (parental discussion about not using tobacco and living with someone who uses tobacco products) and environmental factors (exposure to tobacco advertising) commonly associated with tobacco use differentiated between individuals who later reported past 30-day NPU (either multiple or single NPU) from those who did not report past 30-day NPU. One familial factor only differentiated between lifetime users who were single NPUs from those who reported no NPU: non-combustible tobacco product use allowed anywhere in the home. Intrapersonal factors differentiated multiple NPU from single NPU: older age, being male, lifetime history of using nicotine product and less harm perceptions. CONCLUSIONS: This study identified factors that may be studied to prevent any NPU, along with factors that may be studied to promote harm reduction by preventing escalation of single NPU to problematic patterns of multiple NPU.

A randomized controlled trial of potential tobacco policies prohibiting menthol flavor in cigarettes and e-cigarettes: a study protocol.

BACKGROUND: Menthol cigarette use remains a large public health problem and disproportionately affects Black adults in the United States. The Food and Drug Administration has proposed prohibiting menthol flavor in cigarettes to protect public health. However, e-cigarettes are available in menthol flavor and are a popular alternative product adults might switch to if menthol is prohibited in cigarettes. Research is needed to understand how availability of menthol (vs. tobacco) flavored e-cigarettes could impact cigarette use among adults who smoke menthol cigarettes. METHODS: We will recruit 150 adults who currently smoke menthol cigarettes and will randomize them to 1 of 3 conditions modeling different regulatory scenarios. We will recruit equal numbers of participants identifying as Black vs. non-Black and will stratify randomization by race. To promote standardization and adherence, cigarette and e-cigarette products will be provided for 8 weeks based on the assigned condition: (A) no menthol restriction (menthol cigarette and menthol flavored e-cigarette), (B) menthol prohibited in cigarettes only (non-menthol cigarette and menthol flavored e-cigarette), (C) menthol prohibited in both cigarettes and e-cigarettes (non-menthol cigarette and tobacco flavored e-cigarette). A follow-up visit will occur at week 12 to assess tobacco use status. The study aims are to (1) examine the impact of prohibiting menthol flavor in cigarettes and e-cigarettes on smoking behavior and (2) investigate whether outcomes differ by race to understand the impact of menthol policies on Black (vs. non-Black) individuals given high rates of menthol cigarette use in this population. The primary outcome will evaluate changes in the number of cigarettes smoked per day during the 8-week study period and will examine differences by regulatory scenario. Secondary outcomes will compare percent days smoke-free, changes in nicotine dependence, and motivation, confidence, and intentions to quit smoking by the regulatory scenarios. We will examine whether changes in the outcomes differ by Black vs. non-Black participants to compare the magnitude of the effect of the various menthol policy scenarios by race. DISCUSSION: Results will contribute critical information regarding menthol in cigarettes and e-cigarettes to inform regulatory policies that maximize reductions in cigarette smoking and reduce tobacco-related health disparities. TRIAL REGISTRATION: NCT05259566. Yale IRB protocol #2000032211, last approved 12/8/2023.

Developing Researchers with Expertise in Sex as a Biological Variable through SCORE Career Enhancement Core Center Programs.

There is a critical need for interdisciplinary and translational scientists to apply sex as a biological variable (SABV) research to address knowledge gaps in the health of women. In 2018, the Office of Research on Women's Health (ORWH) partnered with several National Institute of Health (NIH) Institutes and Centers to expand the Specialized Centers of Research (SCOR) Excellence (SCORE) Programs (together referred to as SCOR/E) with an important feature-the Career Enhancement Core (CEC). The SCORE CEC mentors early career investigators to become the next generation of biomedical and behavioral researchers focused on SABV and women's health. In this article, we outline our approach at the Yale University SCORE to support early career trajectories through the provision of salary support, educational curricula, translational mentorship, pilot project funding, and professional development. Using the Yale-SCOR/E CEC Programs as instructional models, we highlight critical measures of academic success, namely grant funding and publications, among early career investigators. At Yale University, 12 pilot projects funded by the SCOR/E Programs resulted in 14 extramural grants, amounting to an $80 return on every $1 invested in "seed" funding. So far, our SCOR/E Programs have resulted in 129 publications, 83% of which were first-authored by trainees, and 100% of trainees continued research careers with an emphasis on SABV. Finally, we provide recommendations on how biomedical scientists can apply SABV in their studies of major medical conditions in an interdisciplinary and integrative way.

Clinical and Financial Outcomes Associated With a Workplace Mental Health Program Before and During the COVID-19 Pandemic.

Importance: Investment in workplace wellness programs is increasing despite concerns about lack of clinical benefit and return on investment (ROI). In contrast, outcomes from workplace mental health programs, which treat mental health difficulties more directly, remain mostly unknown. Objective: To determine whether participation in an employer-sponsored mental health benefit was associated with improvements in depression and anxiety, workplace productivity, and ROI as well as to examine factors associated with clinical improvement. Design, Setting, and Participants: This cohort study included participants in a US workplace mental health program implemented by 66 employers across 40 states from January 1, 2018, to January 1, 2021. Participants were employees who enrolled in the mental health benefit program and had at least moderate anxiety or depression, at least 1 appointment, and at least 2 outcome assessments. Intervention: A digital platform that screened individuals for common mental health conditions and provided access to self-guided digital content, care navigation, and video and in-person psychotherapy and/or medication management. Main Outcomes and Measures: Primary outcomes were the Patient Health Questionnaire-9 for depression (range, 0-27) score and the Generalized Anxiety Disorder 7-item scale (range, 0-21) score. The ROI was calculated by comparing the cost of treatment to salary costs for time out of the workplace due to mental health symptoms, measured with the Sheehan Disability Scale. Data were collected through 6 months of follow-up and analyzed using mixed-effects regression. Results: A total of 1132 participants (520 of 724 who reported gender [71.8%] were female; mean [SD] age, 32.9 [8.8] years) were included. Participants reported improvements from pretreatment to posttreatment in depression (b = -6.34; 95% CI, -6.76 to -5.91; Cohen d = -1.11; 95% CI, -1.18 to -1.03) and anxiety (b = -6.28; 95% CI, -6.77 to -5.91; Cohen d = -1.21; 95% CI, -1.30 to -1.13). Symptom change per log-day of treatment was similar post-COVID-19 vs pre-COVID-19 for depression (b = 0.14; 95% CI, -0.10 to 0.38) and anxiety (b = 0.08; 95% CI, -0.22 to 0.38). Workplace salary savings at 6 months at the federal median wage was US $3440 (95% CI, $2730-$4151) with positive ROI across all wage groups. Conclusions and Relevance: Results of this cohort study suggest that an employer-sponsored workplace mental health program was associated with large clinical effect sizes for employees and positive financial ROI for employers.

Examining the potential role of e-cigarettes to reduce health disparities associated with menthol cigarette use: Characterizing e-cigarette use, flavors, and reasons for use among US adults smoking menthol cigarettes.

INTRODUCTION: Menthol cigarette use contributes to disproportionate tobacco-related health disparities amongst minoritized race/ethnic groups. E-cigarettes are available in flavors such as menthol and may be a less harmful substitute among adults who smoke. Yet little is known about e-cigarette flavor preference and reasons for use by race/ethnicity among adults who smoke menthol cigarettes. METHODS: Nationally representative PATH wave 4 adult data (Dec. 2016-Jan. 2018) were used to examine how menthol cigarette status and race/ethnicity were associated with past 30-day e-cigarette use, flavors used, and reasons for use with adjusted logistic regression models. RESULTS: Menthol (vs. non-menthol) cigarette use was associated with higher odds of e-cigarette use (AOR=1.33, 95%CI=1.16-1.52). However, non-Hispanic (NH) Black and Hispanic individuals (vs. NH White) had lower odds of e-cigarette use (p's ≤ 0.004). In terms of flavor used, adults smoking menthol cigarettes and NH Black and Hispanic individuals had greater odds of using menthol/mint-flavored e-cigarettes (p's ≤ 0.02), and older adults (vs. 18-24-year-olds) had lower odds of using sweet-flavored e-cigarettes (p's < 0.0001). Regarding reasons for use, adults smoking menthol cigarettes had higher odds of reporting using e-cigarettes due to liking flavors (AOR=1.63, 95%CI=1.30-2.04), while NH Black adults had lower odds of liking flavors (AOR=0.64, 95%CI=0.43-0.96), and Hispanic adults had lower odds of using e-cigarettes to cut down on cigarette smoking (AOR=0.59, 95%CI=0.42-0.83). CONCLUSIONS: Findings suggest menthol flavored e-cigarettes may be important for adults who smoke menthol cigarettes, although racial disparities in current e-cigarette use and reasons for use may exacerbate tobacco-related health disparities.

Longitudinal Trajectories of Multiple Nicotine Product Use Among Youths in the Population Assessment of Tobacco and Health Study.

Importance: Multiple nicotine product use (MNPU) among youths is a significant public health concern. Much remains unknown about the patterns of MNPU in youths, including how socioecological factors influence trajectories of MNPU, which may inform targeted prevention. Objective: To identify longitudinal trajectories of MNPU and characterize them according to socioecological factors associated with tobacco use. Design, Setting, and Participants: This US-based longitudinal survey study used data from waves 1 (September 12, 2013, to December 14, 2014) through 4 (December 1, 2016, to January 3, 2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 10 086 youths (aged 12-17 years) at wave 1, with follow-up data at waves 2 to 4 (assessed approximately 1 year apart) in the youth or adult data sets. Data were analyzed from January 15, 2020, to December 22, 2021. Exposures: Socioecological factors at wave 1. Main Outcomes and Measures: Outcome variables were days of use in the past 30 days of 4 products: cigarettes, e-cigarettes, cigars, and smokeless tobacco. Factors associated with use of the nicotine products that were collected at wave 1 included sociodemographic factors, internalizing and externalizing symptoms, living with a tobacco user, rules about tobacco use at home, conversations with parents about not using tobacco, tobacco accessibility, and exposure to advertising. Multitrajectory latent class growth analysis was used to identify distinct subgroups with similar patterns of use over time. Multinomial logistic regression models were used to investigate factors associated with class membership. Weights were applied to all data except frequencies to account for the complex survey design. Results: Of the 10 086 youths included in the analysis, 5142 (51.2%) self-identified as male; 4792 (54.7%) were non-Hispanic White; and 5315 (50.6%) were aged 12 to 14 years. Six latent trajectory classes were identified: nonuse (8056 [78.2%]), experimentation (908 [9.8%]), increasing e-cigarette/cigarette use (359 [4.0%]), increasing cigarette/cigar use (320 [3.3%]), decreasing cigarette/e-cigarette/cigar use (302 [3.2%]), and stable smokeless tobacco/cigarette use (141 [1.6%]). Compared with the nonuse class, being older (odds ratio [OR] range, 2.54 [95% CI, 1.94-3.32] to 9.49 [95% CI, 6.03-14.93]), being female (OR range, 0.06 [95% CI, 0.03-0.14] to 0.71 [95% CI, 0.53-0.94]), living with a tobacco user (OR range, 1.43 [95% CI, 1.11-1.83] to 4.94 [95% CI, 3.43-7.13]), and having relaxed rules about noncombustible tobacco product use at home (OR range, 1.41 [95% CI, 1.02-1.94] to 3.42 [95% CI, 1.74-6.75]) were associated with classification in all the use classes. A high degree of difficulty accessing tobacco was associated with lower odds of membership in the increasing cigarette/cigar use vs nonuse classes (OR, 0.62 [95% CI, 0.40-0.98]). Conclusions and Relevance: These survey results highlight the heterogeneity of longitudinal pathways of MNPU in US youths and suggest directions for future prevention and regulatory efforts directed at tobacco use behaviors in this population.

Association of Vaping and Respiratory Health among Youth in the Population Assessment of Tobacco and Health (PATH) Study Wave 3.

The purpose of this study is to evaluate the association of electronic nicotine product (ENP) use and its respiratory manifestations in a nationally representative sample of adolescents in the US. Cross-sectional evidence from 9750 adolescents in wave 3 (October 2015-October 2016) of the Population Assessment of Tobacco and Health (PATH) survey was used. Adjusting for demographics, lifetime number of cigarettes and cigars used, home rules about tobacco use, and tobacco used by other household members, we used logistic regression models to examine associations between ENP use and its respiratory manifestations in the past year. Among 9750 adolescents, 12% (n = 1105) used ENP in the past year. Compared to non-users, past-year ENP-users had 37% higher odds of wheezing in general (Adjusted Odds Ratio (AOR) = 1.37, 95% Confidence interval (CI): 1.11-1.71, p = 0.005) and higher odds of wheezing 4-12 times or >12 times per year versus no wheezing (AOR = 1.57, 95% CI: 1.01-2.46, p = 0.05 and AOR = 2.58, 95% CI: 1.04-6.41, p = 0.04, respectively). Additionally, odds of dry cough at night were 23% higher among ENP-users than among non-users (AOR = 1.23, 95% CI: 1.04-1.46, p = 0.02). There was no association between past-year ENP use and exercise-induced wheezing or asthma diagnosis. Among those with asthma, there was no evidence of an association between ENP use and long-acting inhaler or quick-relief inhaler use. ENP use among adolescents is associated with increased frequency of wheezing and dry cough. Early recognition of pulmonary clinical manifestations among young ENP users should be critical considerations in regulatory and prevention efforts to protect public health, and clinical efforts to prevent progression to serious pulmonary complications.

Prospective association of e-cigarette and cigarette use with alcohol use in two waves of the Population Assessment of Tobacco and Health.

BACKGROUND AND AIMS: Prior cross-sectional research finds that electronic cigarette (e-cigarette) use clusters with higher rates of harmful alcohol consumption in the United States adult population. The current study examined prospectively the association between e-cigarette use, cigarette use and the combined use of e-cigarettes and tobacco cigarettes and alcohol use outcomes. DESIGN: A nationally representative multi-wave cohort survey (wave 1: September 2013-December 2014, wave 2: October 2014-October 2015). SETTING: United States. PARTICIPANTS: A representative sample of civilian, non-institutionalized adults who completed waves 1 and 2 of the Population Assessment of Tobacco and Health survey (n = 26 427). MEASUREMENTS: Participants were categorized into exposure groups according to their e-cigarette and cigarette use during wave 1. Past 30-day alcohol use outcomes were (1) National Institute on Alcohol Abuse and Alcoholism (NIAAA)-defined hazardous alcohol use, (2) total alcohol drinks consumed and (3) alcohol-related consequences. FINDINGS: After controlling for socio-demographic risk factors and alcohol use at wave 1, all exposure groups showed higher odds of hazardous alcohol use [adjusted odds ratios (aORs) = 2.05-2.12, all P < 0.001] and reported higher past-month total drinks (B = 0.46-0.70, all P < 0.001) and more alcohol consequences (B = 0.63-0.89, all P ≤ 0.10) at wave 2 compared with non-users. Cigarette users (B = 0.24, P = 0.038) and dual e-cigarette/cigarette users (B = 0.32, P = 0.038) reported higher past-month total drinks compared with e-cigarette users. There was no conclusive evidence that non-daily use of e-cigarettes or cigarettes predicted poorer alcohol use outcomes compared with daily use. CONCLUSIONS: In the United States between 2013 and 2015, after adjustment for socio-demographic characteristics, cigarette and e-cigarette use were associated with alcohol use 1 year later.

Transitions across tobacco use profiles among adolescents: results from the Population Assessment of Tobacco and Health (PATH) study waves 1 and 2.

BACKGROUND AND AIMS: To estimate progression to polytobacco use (PTU) over 1 year among a sample of US youth. DESIGN: Prospective survey with two waves 1 year apart: wave 1 (2013-14) and wave 2 (2014-15). We conducted latent transition analysis (LTA) to identify latent class transitions and examine socio-demographic predictors of transition types. SETTING: United States. PARTICIPANTS: A total of 11, 996 people who were aged 12-17 years at wave 1. MEASUREMENTS: Publicly available data were used from the Population Assessment of Tobacco and Health (PATH) study, a nationally representative sample of US civilian, non-institutionalized population aged 12 years and older. Tobacco use status was assessed and classified in terms of: never use, non-current (not in the past 30 days) and current (past 30-day) use of cigarettes, cigars, e-cigarettes, hookah and smokeless tobacco. Other nicotine products were excluded because rates of use were either too low to model (e.g. pipe) or the product was not assessed in the PATH youth sample (e.g. nicotine replacement products). FINDINGS: We identified three distinct patterns: class 1, non-use (wave 1 prevalence = 86%; wave 2 prevalence = 78%); class 2, ever use of cigarettes and e-cigarettes (wave 1 prevalence = 11%; wave 2 prevalence = 14%); and class 3, current PTU (wave 1 prevalence = 4%; wave 2 prevalence = 7%). Probability of progression from non-use to ever use of cigarettes and e-cigarettes was 0.06 and ever use of cigarettes and e-cigarettes to current PTU was 0.32. Non-users were more likely to transition to ever use of cigarettes and e-cigarettes if they were older (versus younger), white (versus non-white) or if their parental education level was high school or less (versus more than high school); and ever users of cigarettes and e-cigarettes to current PTU if they were older, male or white. CONCLUSIONS: US youth who had previously tried e-cigarettes and cigarettes at wave 1 (2013-14) had a 32% chance of transitioning to current use of two or more tobacco products within 1 year.

Tobacco use increases risk of food insecurity: An analysis of continuous NHANES data from 1999 to 2014.

Tobacco use is a major health disparities issue in the United States; it is much more common in less-educated and lower-income groups. These groups also experience a higher prevalence of food insecurity. Previous studies analyzing the association between tobacco use and food insecurity have focused on only cigarettes. We assessed the relationship between food insecurity and use of cigarettes, alternative tobacco products (cigars, electronic cigarettes, smokeless tobacco), any tobacco product, and multiple tobacco products. Using National Health and Nutrition Examination Survey data from 1999 to 2014, we built multinomial logistic regression models predicting degree of food security (i.e., food security, low food security, very low food security) for use of different tobacco product types, any product, and multiple products. After adjustment, use of any product, relative to no use, was significantly associated with increased odds of both food insecurity outcomes: low (adjusted odds ratio (AOR) = 1.2, 95% confidence interval (CI): 1.0-1.4) and very low (AOR = 1.8, 95% CI: 1.6-2.2) food security. In a separate model, single product use, relative to no use, was significantly associated with increased odds of low (AOR = 1.5, 95% CI: 1.3-1.7) and very low (AOR = 2.2, 95% CI: 1.9-2.6) food security. For multiple product use the magnitude of association was higher for very low food security (AOR = 2.7, 95% CI: 1.8-4.0). The significant associations identified here can inform researchers and policymakers developing interventions to prevent tobacco- and food insecurity-related diseases. To be effective in reducing either health risk, interventions may need to target both tobacco use and food insecurity.

Predicting Barriers to Treatment for Depression in a U.S. National Sample: A Cross-Sectional, Proof-of-Concept Study.

OBJECTIVE: Even though safe and effective treatments for depression are available, many individuals with a diagnosis of depression do not obtain treatment. This study aimed to develop a tool to identify persons who might not initiate treatment among those who acknowledge a need. METHODS: Data were aggregated from the 2008-2014 U.S. National Survey on Drug Use and Health (N=391,753), including 20,785 adults given a diagnosis of depression by a health care provider in the 12 months before the survey. Machine learning was applied to self-report survey items to develop strategies for identifying individuals who might not get needed treatment. RESULTS: A derivation cohort aggregated between 2008 and 2013 was used to develop a model that identified the 30.6% of individuals with depression who reported needing but not getting treatment. When applied to independent responses from the 2014 cohort, the model identified 72% of those who did not initiate treatment (p<.01), with a balanced accuracy that was also significantly above chance (71%, p<.01). For individuals who did not get treatment, the model predicted 10 (out of 15) reasons that they endorsed as barriers to treatment, with balanced accuracies between 53% and 65% (p<.05 for all). CONCLUSIONS: Considerable work is needed to improve follow-up and retention rates after the critical initial meeting in which a patient is given a diagnosis of depression. Routinely collected information about patients with depression could identify those at risk of not obtaining needed treatment, which may inform the development and implementation of interventions to reduce the prevalence of untreated depression.

Posttraumatic stress disorder diagnosis and gender are associated with accelerated weight gain trajectories in veterans during the post-deployment period.

BACKGROUND: Veterans are disproportionately affected by overweight/obesity and growing evidence suggests that post-deployment is a critical period of accelerated weight gain. OBJECTIVE: We explored the relationship between posttraumatic stress disorder (PTSD) diagnosis, gender, and post-deployment weight trajectories among U.S. Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. DESIGN: We used Veterans Affairs electronic health record data from 248,089 veterans (87% men) who, after their last deployment, had at least one medical visit between October 2001 and January 2009 and more than one BMI recorded through September 2010. We analyzed repeated BMI measurements using linear mixed models, with demographics, PTSD and other relevant psychiatric diagnoses as predictors. RESULTS: At the first recorded BMI, veterans' median age was 29, and 59% of women and 77% of men were overweight/obese. They had a median of 6 BMI measurements during a median follow-up of 2.4 years. Controlling for potential confounders, women with a PTSD diagnosis had a yearly BMI growth rate of 0.11 kg/m2 (95% CI 0.09 to 0.13, p < 0.001) higher than women without PTSD. For men, the corresponding PTSD effect was also significant, but slightly lower: 0.07 kg/m2 ((95% CI 0.05 to 0.09, p < 0.001); women-men difference: 0.03 (95% CI 0.01 to 0.06) kg/m2, p = 0.006). CONCLUSIONS: The post-deployment period is critical for weight gain, particularly for veterans diagnosed with PTSD and women veterans with PTSD. Efforts are needed to engage post-deployment veterans in weight management services, and to determine whether tailored recruitment/treatment interventions will reduce disparities for veterans with PTSD.

See One, Do One, Order One: a study protocol for cluster randomized controlled trial testing three strategies for implementing motivational interviewing on medical inpatient units.

BACKGROUND: General medical hospitals provide care for a disproportionate share of patients who abuse or are dependent upon substances. This group is among the most costly to treat and has the poorest medical and addiction recovery outcomes. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance use problems in that patients are accessible, have time for an intervention, and are often admitted for complications related to substance use that renders hospitalization a "teachable moment." METHODS/DESIGN: This randomized controlled trial will examine the effectiveness of three different strategies for integrating motivational interviewing (MI) into the practice of providers working within a general medical inpatient hospitalist service: (1) a continuing medical education workshop that provides background and "shows" providers how to conduct MI (See One); (2) an apprenticeship model involving workshop training plus live supervision of bedside practice (Do One); and (3) ordering MI from the psychiatry consultation-liaison (CL) service after learning about it in a workshop (Order One). Thirty providers (physicians, physician assistants, nurses) will be randomized to conditions and then assessed for their provision of MI to 40 study-eligible inpatients. The primary aims of the study are to assess (1) the utilization of MI in each condition; (2) the integrity of MI when providers use it on the medical units; and (3) the relative costs and cost-effectiveness of the three different implementation strategies. DISCUSSION: If implementation of Do One and Order One is successful, the field will have two alternative strategies for supporting medical providers' proficient use of brief behavioral interventions, such as MI, for medical inpatients who use substances problematically. TRIAL REGISTRATION: Clinical Trials.gov ( NCT01825057 ).

Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients.

BACKGROUND: Mental illness correlates with an increased length of stay (LOS) for patients hospitalized for medical conditions. While psychiatric consultations help manage mental illness among those hospitalized for medical conditions, consultations initiated by nonpsychiatric mental disease may lack maximum effectiveness. METHODS: In a before-and-after design, in 2 contiguous years LOS for internist-initiated, conventional consultation (CC) as usual treatment was compared to LOS of a proactive, mental health professional-initiated, multidisciplinary intervention delivered by the behavioral intervention team (BIT) on the same units. The patient populations included general medical patients with a variety of illnesses. Patients were treated in 3 different inpatient settings with a total capacity of 92 beds serving 15,858 patient visits over 3 comparison years. BIT comprised a psychiatrist, a nurse, and a social worker, each of whom performed the specific tasks of their professional discipline, while collaborating among themselves and their health-care colleagues. BIT provided timely, appropriate, and effective patient care alongside consultative advice and education to their corresponding professional peers. BIT was compared to CC on the outcome of LOS. RESULTS: There was a statistically significant reduction of LOS favoring BIT over CC for patients with an LOS of <31 days which persisted while controlling for multiple co-morbid factors. Also, a statistically significant spillover effect was suggested by the overall improvement of LOS on units implementing BIT. CONCLUSION: BIT is a promising means of lowering LOS on general medical units while providing a high level of care and staff support.

Reducing the duration of untreated psychosis and its impact in the U.S.: the STEP-ED study.

BACKGROUND: Early intervention services for psychotic disorders optimally interlock strategies to deliver: (i) Early Detection (ED) to shorten the time between onset of psychotic symptoms and effective treatment (i.e. Duration of Untreated Psychosis, DUP); and (ii) comprehensive intervention during the subsequent 2 to 5 years. In the latter category, are teams ('First-episode Services' or FES) that integrate several empirically supported treatments and adapt their delivery to younger patients and caregivers. There is an urgent need to hasten access to established FES in the U.S. Despite improved outcomes for those in treatment, these FES routinely engage patients a year or more after psychosis onset. The Scandinavian TIPS study was able to effectively reduce DUP in a defined geographic catchment. The guiding questions for this study are: can a U.S. adaptation of the TIPS approach to ED substantially reduce DUP and improve outcomes beyond existing FES? METHODS/DESIGN: The primary aim is to determine whether ED can reduce DUP in the US, as compared to usual detection. ED will be implemented by one FES (STEP) based in southern Connecticut, and usual detection efforts will continue at a comparable FES (PREP(R)) serving the greater Boston metropolitan area. The secondary aim is to determine whether DUP reduction can improve presentation, engagement and early outcomes in FES care. A quasi-experimental design will compare the impact of ED on DUP at STEP compared to PREP(R) over 3 successive campaign years. The campaign will deploy 3 components that seek to transform pathways to care in 8 towns surrounding STEP. Social marketing approaches will inform a public education campaign to enable rapid and effective help-seeking behavior. Professional outreach and detailing to a wide variety of care providers, including those in the healthcare, educational and judicial sectors, will facilitate rapid redirection of appropriate patients to STEP. Finally, performance improvement measures within STEP will hasten engagement upon referral. DISCUSSION: STEP-ED will test an ED campaign adapted to heterogeneous U.S. pathways to care while also improving our understanding of these pathways and their impact on early outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02069925 . Registered 20 February 2014.

Rates of violence in patients classified as high risk by structured risk assessment instruments.

BACKGROUND: Rates of violence in persons identified as high risk by structured risk assessment instruments (SRAIs) are uncertain and frequently unreported by validation studies. AIMS: To analyse the variation in rates of violence in individuals identified as high risk by SRAIs. METHOD: A systematic search of databases (1995-2011) was conducted for studies on nine widely used assessment tools. Where violence rates in high-risk groups were not published, these were requested from study authors. Rate information was extracted, and binomial logistic regression was used to study heterogeneity. RESULTS: Information was collected on 13 045 participants in 57 samples from 47 independent studies. Annualised rates of violence in individuals classified as high risk varied both across and within instruments. Rates were elevated when population rates of violence were higher, when a structured professional judgement instrument was used and when there was a lower proportion of men in a study. CONCLUSIONS: After controlling for time at risk, the rate of violence in individuals classified as high risk by SRAIs shows substantial variation. In the absence of information on local base rates, assigning predetermined probabilities to future violence risk on the basis of a structured risk assessment is not supported by the current evidence base. This underscores the need for caution when such risk estimates are used to influence decisions related to individual liberty and public safety.

Inter-rater reliability and concurrent validity of DSM-IV opioid dependence in a Hmong isolate using the Thai version of the Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA).

Because isolated populations offer relative genetic and environmental homogeneity, they are important resources for mapping genes for complex traits. Reliable and valid phenotypic characterization of the disease in the population studied is essential. We examined diagnostic reliability and concurrent validity of DSM-IV opioid dependence (OD) in a Hmong population in Thailand with historically high rates of opium (and heroin) use. 578 Thai-speaking Hmong individuals were assessed for lifetime OD, using Thai versions of both the Semi-Structured Assessment for Drug Dependence and Alcoholism (Thai SSADDA) and the Mini-Neuropsychiatric Interview (Thai MINI; adapted for lifetime diagnoses). In a subsample of 123 individuals, two raters interviewed each subject independently within a 2-week period. Chance-corrected agreement on the OD diagnosis was assessed between raters and instruments. Results showed excellent agreement for the DSM-IV diagnosis of OD both for the SSADDA (κ=0.97) and MINI (κ=1.00) and between the SSADDA and MINI (κ=0.97). Consistent with reliability assessments of English versions, our data demonstrate high reliability for Thai versions of the SSADDA and MINI in the diagnosis of OD. The high concordance between instruments supports the concurrent validity of the diagnosis. Either interview provides reliable, valid OD diagnoses in Thai-speaking Hmong individuals.

The impact of occupation on self-rated health: cross-sectional and longitudinal evidence from the health and retirement survey.

BACKGROUND: The objective of this study is to estimate occupational differences in self-rated health, both in cross-section and over time, among older individuals. METHODS: We use hierarchical linear models to estimate self-reported health as a function of 8 occupational categories and key covariates. We examine self-reported health status over 7 waves (12 years) of the Health and Retirement Study. Our study sample includes 9,586 individuals with 55,389 observations. Longest occupation is used to measure the cumulative impact of occupation, address the potential for reverse causality, and allow the inclusion of all older individuals, including those no longer working. RESULTS: Significant baseline differences in self-reported health by occupation are found even after accounting for demographics, health habits, economic attributes, and employment characteristics. But contrary to our hypothesis, there is no support for significant differences in slopes of health trajectories even after accounting for dropout. CONCLUSIONS: Our findings suggest that occupation-related differences found at baseline are durable and persist as individuals age.

Length of prenatal participation in WIC and risk of delivering a small for gestational age infant: Florida, 1996-2004.

OBJECTIVE: To assess the association between length of prenatal participation in WIC and a marker of infant morbidity. By focusing on small for gestational age, we consider one of the possible pathways through which prenatal nutrition affects fetal growth. DESIGN/METHODS: The study sample consists of 369,535 matched mother-infant pairs drawn from all singleton live births in Florida hospitals from 1996 to 2004. All subjects received WIC and Medicaid-funded prenatal services during pregnancy. We controlled for selection bias on observed variables using a generalized propensity scoring approach and performed separate analyses by gestational age category to control for simultaneity bias. RESULTS: Ten percent increase in the percent of time in WIC was associated with 2.5% decrease (95% CI: 2.1-3.0%) in the risk of a full-term an SGA infant. The risk was also significantly decreased for very preterm and late preterm infants (29-33 and 34-36 weeks gestation) but not for extremely preterm infants (23-28 weeks gestation). CONCLUSIONS: The observed small negative dose response relationship between percent of pregnancy spent in WIC and fetal growth restriction implies that longer participation in the program confers a small measure of protection against delivering an SGA infant.

A risk assessment screening test for very low birth weight.

OBJECTIVES: To develop a risk-assessment screening tool for very low birth weight (VLBW) and to compare our empirically derived tool to the nonempirically derived screening tool used by the State of Florida. METHODS: Birth records from the State of Florida Vital Statistics between 04/01/92 and 12/07/94 were matched with State Healthy Start prenatal records, reported from 04/01/92 through 03/31/94. Known and additional potentially important risk factors were identified from both sources. Generalized Linear Modeling techniques were used to estimate associations between risk factors and VLBW. A risk assessment system was then developed using the estimated model. The resulting screening test was compared with the one used by the Florida State Department of Health in terms of sensitivity and specificity on an independent validation sample. RESULTS: The proposed screening tool had comparable specificity to the Healthy Start screening tool but significantly better sensitivity. Both instruments are simple and easy to implement. CONCLUSIONS: Identification of women at high risk for VLBW would be improved using the model-based screening tool developed in this paper. Public health policy makers should use statistical methods in addition to expert opinion to improve existing risk assessment methods. The actual value of an improved screening instrument is dependent on the availability of effective intervention programs.