Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators.

INTRODUCTION: Transitional-aged youth (TAY) with mental health and/or addictions (MHA) concerns and their families experience significant challenges finding, accessing, and transitioning through needed MHA care. To develop appropriate supports that assist TAY and their families in navigating MHA care, their experiences of transitions in the MHA care system must be better understood. This scoping review identifies and explores the needs, barriers, and facilitators for TAY and their families when transitioning through MHA care. METHODS: This scoping review commenced with a search of five relevant databases. Three research team members were involved in title, abstract, and full-text scanning and data extraction. Sources focusing on TAY anywhere between the ages of 12-29 years and meeting the study objectives were included. Extractions compiled background and narrative information about the nature and extent of the data. Analysis and synthesis of findings involved numerical description of the general information extracted (e.g., numbers of sources by country) and thematic analysis of narrative information extracted (e.g., family involvement in TAY help-seeking). RESULTS: A total of 5894 sources were identified. Following title and abstract scanning, 1037 sources remained for full-text review. A total of 66 sources were extracted. Findings include background information about extracted sources, in addition to five themes that emerged pertaining to barriers and facilitators to access and transitions through care and the needs and roles of TAY and families in supporting help-seeking and care transitions: holistic supports, proactive preparation, empowering TAY and families, collaborative relationships, and systemic considerations. These five themes demonstrate approaches to care that can ensure TAY and families' needs are met, barriers are mitigated, and facilitators are enhanced. CONCLUSION: This review provides essential contextual information regarding TAY with MHA concerns and their families' needs when seeking care. Such findings lend to an enhanced understanding of how MHA programs can support this population's needs, involve family members as appropriate, reduce the barriers experienced, and work to build upon existing facilitators.

Enforcement of the Mental Health Parity and Addiction Equity Act: State Insurance Commissioners' Statutory Capacity.

OBJECTIVE: State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. METHODS: Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. RESULTS: The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. CONCLUSIONS: Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.

Disparities in Addiction Treatment: Learning from the Past to Forge an Equitable Future.

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

Digital gaming interventions: a novel paradigm in mental health? Perspectives from India.

The mental health gap has been a persistent concern globally, especially in low and middle-income countries (LMIC). In an attempt to mitigate resource limitations, the psychiatric practice has been undergoing a paradigm shift into digitalized mental health interventions. One such innovation involves digital gaming utilizing the principles of 'gamification' to incorporate both the playfulness component of online gaming as well as the domain-targeted design of gaming elements. Digital gaming-based interventions have been to deliver psychotherapy, biofeedback, cognitive training and rehabilitation, as well as behavioural modification and social skills training. Research shows their utility in autism spectrum disorders, attention deficit disorders, schizophrenia, depression, anxiety disorders, post-traumatic stress, eating disorders, neurocognitive disorders and also to promote healthy aging. Though promising in scope, these interventions face pragmatic challenges for implementation in developing countries. Even though increased use of technology, internet penetration and growing digital literacy have enhanced their accessibility and feasibility, various factors like socio-cultural diversity, lack of standardization, poor infrastructural support, bandwidth issues and lack of practice can impair their use and acceptability. Keeping this in the background, this commentary critically discusses the scope, applications and challenges of digital gaming in mental healthcare delivery in one of the rapidly globalizing LMIC nations, India.

Assessment of the Effectiveness of Group Cognitive Behavioural Therapy in Reducing Pathological Gambling.

Pathological gambling is a developmental disorder usually associated with a continuous loss of control over gambling; it also involves a preoccupation with gambling and with obtaining money for the same purpose of gambling, irrational thinking, and a continuation of the behaviour despite being aware of its adverse consequences. This study examined the effectiveness of group cognitive-behavioural therapy (GCBT) on pathological gambling among Nigerian students. The study used a group randomised controlled trial design to assign participants to intervention and control groups. A total of 40 undergraduate students, aged 18-30, were classified as pathological gamblers (participants) in this study. Participants completed self-report scales titled South oaks gambling screen and Gambling Symptom Assessment Scale at three-time points. The intervention lasted for 8 weeks. The data collected were statistically analysed using repeated-measures ANOVA. Results revealed that GCBT has a significant effect in decreasing the symptoms of pathological gambling among the participants in GCBT compared to those in the control group and that the improvements were maintained at follow-up. The study concluded that group cognitive-behavioural therapy is impactful therapy in reducing pathological gambling among students. It has also validated the effectiveness of cognitive-behavioural therapy in altering erroneous thoughts and replacing it with a better alternative realistic way of thinking.

Measuring capital in active addiction and recovery: the development of the strengths and barriers recovery scale (SABRS).

BACKGROUND: The international Life In Recovery (LiR) surveys have provided an important message to the public and policy makers about the reality of change from addiction to recovery, consistently demonstrating both that there are marked gains across a range of life domains and that the longer the person is in recovery the better their recovery strengths and achievements. However, to date, no attempt has been made to quantify the Life In Recovery scales and to assess what levels of change in removing barriers and building strengths is achieved at which point in the recovery journey. METHODS: The current study undertakes a preliminary analysis of strengths and barriers from the Life in Recovery measure, using data from a European survey on drug users in recovery (n = 480), and suggests that the instrument can be edited into a Strengths And Barriers Recovery Scale (SABRS). The new scale provides a single score for both current recovery strengths and barriers to recovery. RESULTS: The resulting data analysis shows that there are stepwise incremental changes in recovery strengths at different recovery stages, but these occur with only very limited reductions in barriers to recovery, with even those in stable recovery typically having at least two barriers to their quality of life and wellbeing. Greater strengths in active addiction are associated with greater strengths and resources in recovery. CONCLUSION: As well as demonstrating population changes in each of the domains assessed, the current study has shown the potential of the Life In Recovery Scale as a measure of recovery capital that can be used to support recovery interventions and pathways.

Excessive Spending in a "Free-to-Play" Smartphone Game.

BACKGROUND AND OBJECTIVES: Although gaming disorder is increasingly recognized, there has been limited consideration of the impact of free-to-play games with in-game purchases, also called microtransactions. METHODS: Case report (n = 1). RESULTS: A patient with posttraumatic stress disorder, major depressive disorder in remission, polysubstance use disorders in remission, and opioid use disorder on buprenorphine/naloxone developed gaming disorder (based on International Classification of Diseases, 11th revision) and spent up to 40% of his monthly income on microtransactions within a smartphone game. Treatment consisted of relinquishing access to electronic payment mechanisms, motivational interviewing, and couples therapy. DISCUSSION AND CONCLUSIONS: The case highlights how in-game purchases may cause patients with gaming disorder to experience financial consequences, and the need for further characterization of the clinical ramifications of microtransactions. SCIENTIFIC SIGNIFICANCE: To the best of our knowledge, this is the first report in the medical literature of a patient with gaming disorder developing excessive in-game spending from expenditures on microtransactions. (Am J Addict 2020;29:528-530).

Psychometric Properties of the Assessment of Recovery Capital (ARC) Instrument in a Diverse Low-Income Sample.

Background: Recovery capital is a theoretical construct elucidating the resources that support recovery from addiction. The 50-item Assessment of Recovery Capital (ARC) instrument and related brief-format versions are the predominant measures of this construct. However, some of the ARC's psychometric properties are not well-established, particularly in racially and economically diverse populations. Objectives: We aimed to determine if the ARC is a valid and reliable measure of recovery capital in a diverse sample. Methods: Paper-and-pencil survey data were collected between March 2017 and May 2018 from a low-income, racially diverse sample of adults in recovery (N = 273). Participants were recruited from nontreatment community settings throughout a mid-sized northeastern U.S. city. They completed the ARC and sociodemographic questions. To determine the ARC's reliability and factor structure, we used item-level analyses and Cronbach's alpha, followed by confirmatory and exploratory factor analyses. Results: Several items performed poorly, having means close to response extremes and problematically small variances. Cronbach's alpha for the full measure was α = .92; however, alphas for the majority of subscales were below .70. The a priori 10-factor model solution failed, preventing interpretation of the confirmatory factor analysis results. Exploratory factor analysis revealed that although the 10-factor model marginally fit the data, items did not load together as proposed. Not once did all five subscale items load highly on the same factor. Conclusions/Importance: The ARC has substantial weaknesses in its theoretical alignment, item performance, and psychometric properties with diverse populations. We recommend the development of a new multidimensional, theory-aligned measure, following a rigorous measurement development protocol.

Making EGMs Accountable: Can an Informative and Dynamic Interface Help Players Self-regulate?

Electronic gaming machines (EGMs) are recognised as one of the most harmful gambling forms, because they promote high-speed repetitive gambling and automatically reinvest winnings. These features, amongst others, make it difficult for EGM gamblers to keep track of their play. Tools to assist gamblers exist, but have limited effectiveness because they require user registration and manual activation, leading to low uptake. The present study aimed to evaluate the effect of a more informative interface (including removal of automatic reinvestment of winnings) and pop-up messages on gambling behaviour, and on player experience. A total of 213 Australian participants, recruited through social media, played a simulated online EGM. The experiment was a two (standard vs. informative interface) × two (pop-ups absent vs. present) between-subjects design. The informative interface: promoted keeping track of spins played; increased accurate estimation of amount spent (as did pop-up messages) and time played; and provided game usage figures which acted as cues to quit play. Once the initial deposit (but not winnings) was expended, informative interface users could opt to reinvest their winnings, although many opted to exit at that point. No difference in total spending or dissociation was observed between experimental groups. Informative interface users reported no reduction in enjoyment. Pop-up messages reduced enjoyment with the standard interface, but increased enjoyment when paired with an informative interface. These findings indicate that a more informative interface and pop-up messages may be useful in reducing the harmful nature of EGMs.

Recovery from addiction: Behavioral economics and value-based decision making.

Behavioral economics provides a general framework to explain the shift in behavioral allocation from substance use to substance-free activities that characterizes recovery from addiction, but it does not attempt to explain the internal processes that prompt those behavioral changes. In this article we outline a novel analysis of addiction recovery based on computational work on value-based decision making (VBDM), which can explain how people with addiction are able to overcome the reinforcement pathologies and decision-making vulnerabilities that characterize the disorder. The central tenet of this account is that shifts in molar reinforcer preferences over time from substance use to substance-free activities can be attributed to changes in evidence accumulation rates and response thresholds in the context of choices involving substance use and substance-free alternatives. We discuss how this account can be reconciled with the established mechanisms of action of psychosocial interventions for addiction and demonstrate how it has the potential to empirically address longstanding debates regarding the nature of impairments to self-control in addiction. We also highlight conceptual and methodological issues that require careful consideration in translating VBDM to addiction and recovery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Systematic review of addiction recovery mutual support groups and Indigenous people of Australia, New Zealand, Canada, the United States of America and Hawaii.

BACKGROUND: Addictions contribute significantly to the overall disease burden for Indigenous peoples of colonised countries. Mutual support groups are one of the most common addiction recovery resources, however their effectiveness for Indigenous peoples is unclear. METHODS: A PRISMA-informed search was performed to retrieve empirical studies on addiction recovery mutual support groups for Indigenous peoples of Australia, New Zealand, Canada, United States of America and Hawaii. Databases searched were: MEDLINE, CINAHL Plus, PsychINFO, PsychARTICLES, SocINDEX, Cochrane Database of Systematic Reviews, PubMed, Scopus and UlrichsWeb, Informit Collections, Australian Indigenous HealthInfonet and Lowitja Institute electronic databases. Exclusion criteria were: 1) not an Indigenous focus; 2) not an addiction focus (i.e. including alcohol, other drug, gambling); 3) not a mutual support group focus; 4) not an original study; 5) not a complete study; 6) not published in English language. RESULTS: Four studies published between 2001 and 2006 met review criteria. All studies were conducted in the United States of America with Native American Indian peoples (n = 1600) and featured Alcoholics Anonymous only. Study designs were: a retrospective analysis of survey data, a cross-sectional survey report, a clinical case study and an ethnographic study. Methodological differences precluded meaningful translation of results. CONCLUSION: There is a lack of empirical knowledge on the acceptability and outcomes of addiction recovery mutual support groups for Indigenous peoples of Australia, New Zealand, Canada, United States of America and Hawaii. This review suggests recommendations for future research.

Mental health services in the Northwest Territories: a scoping review.

The impacts of colonization have had significant impacts on the mental health and community wellness Indigenous peoples in the Northwest Territories (NWT). It is important that all communities in the NWT have access to key services in a culturally relevant way in achieving mental and community wellness. A scoping review was conducted to identify mental health services available in the NWT. To guide the understanding of the landscape of mental health services in the NWT, the information on health services gathered was organized using the First Nations Mental Wellness Continuum (FNMWC) Model's Continuum of Essential Services. Documents accessed included grey literature, consisting of government documents, practice guidelines, education materials, community wellness reports, internet searches and expert consult interviews to collect data on mental health and wellness services in the NWT. 68 mental health services were included in this review, from 23 different sources. Results were summarized and described the Continuum of Essential Services from the FNMWC Model. This guided approach was found to be useful for mapping mental health services for communities in the NWT. The findings highlight and catagorize existing mental health services and gaps in relation to a First Nation's perspective using the FNMWC Model. Specific areas examined included the Continuum of Essential Services, Key Partners, Culture as a Foundation, and Indigenous Social Determinants of Health. Findings can guide communities and health authorities in planning, implementing and coordinating a full range of optimized mental health services in the NWT.

Mental Health Parity and Addiction Equity Act and the Use of Outpatient Behavioral Health Services in the United States, 2005-2016.

Objectives. To assess the impact of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) on mental and substance use disorder services in the private, large group employer-sponsored insurance market in the United States. Methods. We analyzed data from the IBM MarketScan Commercial Database from January 2005 through September 2015 by using population-level interrupted time series regressions to determine whether parity implementation was associated with utilization and spending outcomes. Results. MHPAEA had significant positive associations with utilization of mental and substance use disorder outpatient services. A spending decomposition analysis indicated that increases in utilization were the primary drivers of increases in spending associated with MHPAEA. Analyses of opioid use disorder and nonopioid substance use disorder services found that associations with utilization and spending were not attributable only to increases in treatment of opioid use disorder. Conclusions. MHPAEA is positively associated with utilization of outpatient mental and substance use disorder services for Americans covered by large group employer-sponsored insurance. Public Health Implications. These trends continued over the 5-year post-MHPAEA period, underscoring the long-term relationship between this policy change and utilization of behavioral health services.

An Old Treatment for an Even Older Problem: Does Psychoanalysis Have a Role in the Treatment of Addictive Disorders? A Review of the Literature.

The fact that addictive disorders have a significant negative impact on the health of the global population is well documented in contemporary health literature. What is less well documented is the uncomfortable realization that the tools in our armament to help individuals who struggle with addictive disorders are limited. Many individuals will spend their lives "cycling" through the addiction treatment continuum only to again be met with relapse. Third-party reimbursement for addiction treatment has focused on time-limited treatments and "brief" therapies with an additional emphasis on support group attendance (aka "free" services) with minimal focus on the fact that brief therapies have poor evidence for efficacy. In this article, we explore an alternative to brief therapies by reaching back to the earliest and most comprehensive treatment we have for behavioral change-psychoanalysis. This article engages in a literature review to determine whether sufficient evidence exists for the use of psychoanalysis as a treatment for addictive disorders. Implications for advanced practice psychiatric nurses are discussed.

Hospital-Based Addiction Medicine Healthcare Providers: High Demand, Short Supply.

: Substance use disorders account for a significant burden of disease and place an enormous strain on the health care system in the United States and beyond. Despite death tolls climbing, a myriad of evidence-based medications exist to effectively treat many substance use disorders including nicotine, alcohol, and opioid use disorders. To date, hospitals have largely been overlooked as a setting ripe for the delivery of specialized addiction care. This occurs despite a high lifetime prevalence of a substance use disorder (50%) occurring among hospitalized individuals. A potential barrier to this is the lack of addiction medicine training that currently exists in undergraduate and graduate medical education. Consequently, a paucity of existing physicians report feeling competent to adequately screen for, diagnose or treat substance use disorders. Given the prevalence, cost and potentially lethal consequences of substance use disorders, a critical need exists to improve its identification and evidence-based management in hospital settings.

Mindfulness-based interventions for addictions among diverse and underserved populations.

Mindfulness-based interventions (MBIs) show strong promise for treating addictions, but there is much work to be done to ensure that they are culturally appropriate, accessible, and optimally effective for priority populations who could potentially have the most to gain. This article briefly highlights research on MBIs for addictions among diverse and underserved populations and proposes next steps for increasing their potential to target addiction-related health disparities. Future directions include: 1) Prioritize diversity in clinical trials and conduct appropriately powered moderation analyses; 2) Consider treatment adaptations; 3) Examine underlying mechanisms to optimize MBIs for specific populations; 4) Improve implementation in community-based and other appropriate settings; and 5) Consider use of technology to provide just-in-time support and increase scalability for diverse populations.

A randomized controlled trial of a manual-only treatment for reduction and cessation of problematic caffeine use.

BACKGROUND: Caffeine Use Disorder was added to DSM-5 as a diagnosis for further research, but few studies have been conducted to identify effective treatments. This randomized, controlled clinical trial examined the efficacy of a manual-only treatment program for caffeine cessation and reduction among individuals seeking treatment for problematic caffeine use. METHODS: Individuals meeting at least two proposed DSM-5 diagnostic criteria for Caffeine Use Disorder were randomly assigned to receive either immediate treatment or treatment delayed by 7 weeks. The treatment consisted of a manual containing information about caffeine and instructions for gradually reducing caffeine consumption over a period of 6 weeks, with no counseling or additional support. Caffeine consumption and caffeine-related distress were assessed before treatment, 7 weeks after receiving the treatment manual (end-of-treatment), and 20 weeks post-treatment. RESULTS: The manual-only treatment resulted in significant reductions in participants' self-reported caffeine consumption and caffeine-related distress at end-of-treatment that were sustained at 20-weeks post-treatment. Salivary caffeine levels and community observers corroborated the self-reported reductions in caffeine consumption. Comparisons between the immediate and delayed treatment groups suggest the reductions in caffeine consumption were attributable to the manualized treatment rather than spontaneous with the passage of time. CONCLUSIONS: The present study provides evidence that a gradual caffeine reduction and cessation program may be successfully implemented using a manual-only approach. This time- and cost-effective intervention may be easily adopted by practitioners with limited time or experience with behavioral interventions who want to encourage their patients to reduce caffeine consumption.