Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Attitudes Towards Gambling, Gambling Problems, and Treatment Among Hispanics in Imperial County, CA.

Gambling problems are associated with a wide range of serious negative personal, social, health, and mental health consequences and are an important public health concern. Some data suggest that gambling problems may be more prevalent among Hispanics, but few studies have been conducted in this community. The aim of the current study was to gather community-based, gambling-related data in order to increase understanding of gambling problems and their treatment in the Hispanic community. We conducted a mixed-methods study of gambling behavior and attitudes towards gambling, those with gambling problems, and professional treatment for gambling problems in a publicly funded health center serving a primarily Hispanic clientele. Study participants included clinic staff and clinic patients. All participants completed a brief, self-report survey; however, staff participated in a focus group on gambling issues and patients were interviewed individually about gambling issues. Nearly 80 % of patients had gambled in the past month, as compared to about 36 % of clinic staff. Survey data showed that patients had many risk factors for gambling problems. Focus group and interview information indicated that most viewed gambling problems as a form of addiction, the elderly were seen as being at increased risk for gambling problems, and gambling outings represented one of the few recreational opportunities in the region. The majority of both staff and patients believed that there was a need for gambling-related treatment services in the county; however, a notable minority of patients said that they would first seek help from a trusted relative or family member. Possible avenues to increase awareness of, screening for, and treatment for gambling problems may include collaborations with publicly funded health care centers and the training of promotoras to serve as an interface between health services and the community.

A Longitudinal Examination of Depression Among Gambling Inpatients.

Problem and pathological gamblers demonstrate high levels of depression, which may be related to coping styles, reactive emotional states, and/or genetics (Potenza et al., Arch Gen Psychiat 62(9):1015-1021, 2005; Getty et al., J Gambl Stud 16(4):377-391, 2000). Although depression impacts treatment outcomes (Morefield et al., Int J Men Healt Addict 12(3):367-379, 2013), research regarding depression among gamblers in residential treatment is particularly limited. This study attempts to address this deficit by examining the course of depressive symptoms among clients at a residential gambling program in the Western United States. Forty-four adults were administered a weekly measure of depression (Beck Depression Inventory-II, BDI-II) for eight consecutive weeks. Levels of depression were classified into three groups based on standard scoring criteria for the BDI-II: no/minimal, mild/moderate, and severe depression. Results from a mixed-model analysis indicated a main effect for group and time, as well as an interaction between group and time. Examination of the slopes for the rate of change for the three depression groups indicated no change in the non-depressed group and a decrease in depression scores over time for both the mild/moderate and severely depressed groups. The slopes for the two symptomatic depression groups were not significantly different, indicating a similar rate of change. We speculate that reductions in depression symptoms may be related to feelings of self-efficacy, environmental containment/stabilization, and therapeutic effects of treatment. These results help to illuminate the role of significant processes in residential treatment, including initial stabilization, insight, self-efficacy, and termination.

Crystalizing the role of traditional healing in an urban Native American health center.

A needs assessment surveying American Indians and Alaska Natives (AIs/ANs) at an AI/AN health center in the Midwestern United States was conducted, with an emphasis on traditional Native healing. Data from this study included qualitative material from interviews of community members (N = 27; age 12-82) and service providers (N = 11; age 26-70). Respondents emphasized the path to wellness includes physical, spiritual and mental health and that traditional healing can restore various imbalances. Furthermore, traditional healing was considered a complement to Western medicine. Third, traditional medicine as a tool in healthcare settings was conceptualized on a continuum.

Documentation of psychiatric disorders and related factors in a large sample population of HIV-positive patients in California.

This retrospective cohort study examined electronic medical records of HIV-positive patients in California (N = 7,834) to find the prevalence of any psychiatric condition and the associations between several factors and the likelihood of these disorders. Approximately 53 % of the patients in this study had a documented psychiatric condition, including 23 % who had a mood disorder, 19 % who had a substance-related disorder, and 16 % who had an anxiety disorder. After controlling for potential confounders, significant positive associations (p < 0.001) were found between female gender and the presence of any mood disorder (adjusted odds ratio [95 % confidence interval, 95 %CI] = 1.58 [1.26-1.99]) or anxiety disorder (AOR = 1.54 [1.18-2.02]) and between homosexual orientation and the presence of any psychiatric condition (AOR = 1.33 [1.15-1.55]), mood disorder (AOR = 1.71 [1.42-2.07]), or anxiety disorder (AOR = 1.41 [1.22-1.88]). There were also significant negative associations between African-American race and the presence of any psychiatric condition (AOR = 0.68 [0.60-0.77]), mood disorder (AOR = 0.74 [0.64-0.86]), anxiety disorder (AOR = 0.43 [0.36-0.52]), or substance-related disorder (AOR = 0.78 [0.67-0.91]) and between state/federal insurance and the presence of any psychiatric condition (AOR = 0.70 [0.62-0.79]), mood disorder (AOR = 0.71 [0.62-0.80]), or anxiety disorder (AOR = 0.77 [0.66-0.89]).

Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R).

The purpose of this study is to investigate the relationship between sleep disturbances and gambling behavior. Data from the National Comorbidity Survey-Replication (NCS-R) was used to examine the relationship between three specific sleep complaints (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]) and gambling behavior. Bivariate logistic regression models were used to control for potentially confounding psychiatric disorders and age. Almost half of respondents with problem gambling behavior (45.9%) and two thirds (67.7%) of respondents with pathological gambling behavior reported at least one sleep compliant. Compared to respondents with no gambling pathology, respondents with pathological gambling were significantly more likely to report at least one sleep complaint (Adjusted Odds Ratio [AOR] = 3.444, 95% CI = 1.538-7.713), to report all sleep complaints (AOR = 3.449, 95% CI = 1.503-7.914), and to report any individual complaint (DIS: OR = 2.300, 95% CI = 1.069-4.946; DMS: AOR = 4.604, 95% CI = 2.093-10.129; EMA: AOR = 3.968, 95% CI = 1.856-8.481). The relationship between problem gambling and sleep complaints were more modest (any sleep complaint: AOR = 1.794, 95% CI = 1.142-2.818; all three sleep complaints: AOR = 2.144, 95% CI = 1.169-3.931; DIS: AOR = 1.961, 95% CI = 1.204-3.194; DMS: AOR = 1.551, 95% CI = 0.951-2.529; EMA: AOR = 1.796, 95% CI = 1.099-2.935). Given the individual and societal ramifications linked with the presence of sleep problems, this study presents another health-related repercussion associated with gambling pathology rarely discussed in the literature.

Facets of perfectionism in a sample of hypersexual patients.

This study investigated the role of perfectionism in a treatment-seeking sample (N = 136) of adult men and women using the Perfectionism Inventory (PI) and the Hypersexual Behavior Inventory (HBI). Several facets of perfectionism were positively correlated with hypersexuality, with the concern over mistakes scale from the PI accounting for most of the predictive variance in patterns of hypersexual behavior measured by the HBI. Items associated with concern over mistakes closely parallel the construct of shame noted in other studies of hypersexual patients. To a lesser degree, the PI scale planfulness also showed a negative relationship with hypersexuality, suggesting tendencies of impulsivity in the current patients. These data reinforce the findings in other studies that patterns of harsh self-criticism and impulsivity seem to strongly influence hypersexual behavior.

Self-reported differences on measures of executive function in a patient sample of pathological gamblers.

Patients seeking help for pathological gambling often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with gambling. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive deficits. Evidence of executive deficits have been confirmed in pathological gamblers using objective neurocognitive tests, however, it remains to be seen if such findings will emerge in self-report measures of executive control. These observations led to the current investigation of differences between a group of pathological gamblers (n = 62) and a comparison group (n = 64) using the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). Significant differences between the groups emerged over all nine subscales of executive functioning with the most dramatic differences on BRIEF-A subscales Inhibit, Plan/Organize, Shift, Emotion Control, Self-Monitor, and Initiate among the pathological gamblers. These results provide evidence that support findings among pathological gamblers using objective neuropsychological measures and suggest that the BRIEF-A may be an appropriate instrument to assess possible problems with executive control in this population.

Screening for addictive disorders within a workers' compensation clinic: an exploratory study.

We conducted a cross-sectional study investigating the extent of addictive disorders within a workers' compensation (WC) clinic. We also examined the feasibility of substance abuse screening within the same clinic. In 2009 , 100 patients were asked to complete the World Health Organization's Alcohol, Smoking, Substance Involvement Screening Test (WHO-ASSIST) and the Current Opioid Misuse Measure (COMM). According to the WHO-ASSIST, we found that 46% of WC patients required intervention for at least one substance-related disorder (25% tobacco, 23% sedatives, 8% opioids), and according to the COMM, 46% screened positive for prescription opioid misuse. Importantly, the addition of this screening was brief, economical, and well accepted by patients. Further research should analyze the costs and benefits of detection and intervention of substance-related disorders in this setting.

Problem and pathological gambling in a sample of casino patrons.

Relatively few studies have examined gambling problems among individuals in a casino setting. The current study sought to examine the prevalence of gambling problems among a sample of casino patrons and examine alcohol and tobacco use, health status, and quality of life by gambling problem status. To these ends, 176 casino patrons were recruited by going to a Southern California casino and requesting that they complete an anonymous survey. Results indicated the following lifetime rates for at-risk, problem, and pathological gambling: 29.2, 10.7, and 29.8%. Differences were found with regards to gambling behavior, and results indicated higher rates of smoking among individuals with gambling problems, but not higher rates of alcohol use. Self-rated quality of life was lower among pathological gamblers relative to non-problem gamblers, but did not differ from at-risk or problem gamblers. Although subject to some limitations, our data support the notion of higher frequency of gambling problems among casino patrons and may suggest the need for increased interventions for gambling problems on-site at casinos.

Differences in cortical activity between methamphetamine-dependent and healthy individuals performing a facial affect matching task.

As individuals who abuse methamphetamine (MA) often exhibit socially maladaptive behaviors such as violence and aggression, it is possible that they respond abnormally to social cues. To investigate this issue, we exposed 12 MA-dependent participants (abstinent 5-16 days) and 12 healthy comparison participants to fearful and angry faces while they performed an affect matching task during functional magnetic resonance imaging (fMRI). Although the groups did not differ in task performance, the healthy participants showed more task-related activity than the MA-dependent participants in a set of cortical regions consisting of the ventrolateral prefrontal cortex (VLPFC), temporoparietal junction (TPJ), anterior and posterior temporal cortex, and fusiform gyrus in the right hemisphere, and the cuneus in the left hemisphere. In contrast, the MA-dependent participants showed more task-related activity than the healthy participants in the dorsal anterior cingulate cortex (dACC). As expected, the task elicited activation of the amygdala in both groups; however, contrary to expectation, we found no difference between groups in this activation. Dorsal ACC hyperactivity, along with high self-ratings of hostility and interpersonal sensitivity in the MA-dependent group, suggest a hyper-sensitivity to socially threatening cues in the MA-dependent participants, while lower VLPFC activation could point to a deficit in integrating socio-emotional information and/or regulating this limbic hyperactivity. Additional activation differences in neural circuitry related to social cognition (TPJ, anterior, and posterior temporal cortex) suggest further socio-emotional deficits. Together, the results point to cortical abnormalities that could underlie the socially inappropriate behaviors often shown by individuals who abuse MA.

Social and behavioral problems among five gambling severity groups.

Gambling has been associated with various social and behavioral problems, but previous analyses have been limited by sample bias regarding gambling symptom severity range and the role of antisocial personality disorder (ASPD). This study utilized a nationally representative data set and examined various characteristics of behavioral problems and ASPD among five gambling severity groups. Participants were 42,038 individuals who took part in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and provided information on social and behavioral problems, ASPD, and gambling. Using DSM-IV criteria, we derived five gambling groups from the total sample: non-gambling, low-risk, at-risk, problem, and pathological gambling. Associations between all problematic behaviors and nearly every gambling severity level were significant prior to adjustment for sociodemographic variables and ASPD. Following the adjustment, all significant associations persisted, with the exception of sexual coercion. In the adjusted model, the financially oriented behaviors had the strongest associations with gambling. All gambling severity levels were associated with an increased risk for a number of problematic behaviors and social problems in comparison to non-gamblers.Further examination of gambling problems in financial and criminal justice settings is recommended.

Treatment of patients with schizophrenia and substance abuse disorders.

Approximately half of patients with schizophrenia have a lifetime diagnosis of substance abuse disorders. These dual diagnosis patients are more likely to have poorer outcomes, including more severe psychiatric symptoms with increased hospitalizations, higher utilization of services and frequent homelessness. Assessment and treatment of dually diagnosed patients has evolved over the last twenty years. To date, the strongest evidence for effective management of dual diagnosis patients has been utilization of integrated treatment services, which combines both mental health and substance abuse treatments concurrently. Strategies commonly used include a combination of pharmacological treatment, intensive case management, motivational interviewing, individual and group psychotherapy, and family participation. This chapter summarizes the treatment options available for this population.

A preliminary 6-month prospective study examining self-reported religious preference, religiosity/spirituality, and retention at a Jewish residential treatment center for substance-related disorders.

Although there is a substantial amount of research suggesting that higher levels of religiosity/spirituality (R/S) are associated with better treatment outcomes of substance-related disorders, no studies have explored this relationship at a faith-based residential treatment center. The objective of this prospective study is to explore the relationship between R/S, self-reported religious preference, and retention at a Jewish residential treatment center for substance-related disorders. Using the Daily Spiritual Experience Scale, R/S levels were assessed for 33 subjects at baseline, 1 month, 3 months, and 6 months. Results demonstrated a significant relationship between baseline R/S level and retention at 6 months, while R/S levels were unchanged during the course of treatment. Notably, no relationship was found between self-reported religious affiliation and retention. This study demonstrates that patients' R/S level, rather than religious affiliation, is a possible predictor for better outcome at faith-based residential centers for substance-related disorders.

Shame, rumination, and self-compassion in men assessed for hypersexual disorder.

A number of studies have linked maladaptive shame to higher levels of hypersexual behavior and tendencies to ruminate. However, little research has examined factors that may attenuate the negative impact that shame and rumination may have on hypersexuality. Drawing on data collected from male patients (N=172) assessed for hypersexual disorder in a DSM-5 field trial, path analysis was used to explore relationships among shame, rumination, self-compassion, and hypersexual behavior. The findings from this study showed that self-compassion partially mediated the relationship between shame and rumination and hypersexual behavior. The implications of these results are discussed and directions for future research are offered.

Gambling and the onset of comorbid mental disorders: a longitudinal study evaluating severity and specific symptoms.

While the association between gambling disorders and comorbid mental disorders has been extensively studied, only a few studies have used longitudinal data or evaluated the association across different levels of gambling behavior and specific gambling-related symptoms. In this study, longitudinal data from waves 1 and 2 of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) were used to determine whether different levels of gambling behavior and gambling-related symptoms were associated with the onset of psychiatric disorders. Although NESARC used DSM-IV diagnoses, for this study, the recently published DSM-5 diagnostic criteria for gambling disorder were used to group the NESARC respondents (N=34,653) into three levels of gambling (gambling disorder, sub-threshold gambling disorder, and recreational gambling) and one non-gambling comparison group. Three years after the initial intake interview, compared to the non-gamblers, those reporting any gambling behavior at baseline were at increased risk to have any mood, anxiety, or substance use disorders (recreational gambling: adjusted odds ratio [AOR]=1.16, 95% confidence interval [CI]=1.10-1.23; sub-threshold gambling disorder: AOR 1.77, 95% CI 1.63-1.92; gambling disorder: AOR 2.51, 95% CI 1.83-3.46). Similar graded relationships were found for a number of specific disorders. In addition, multiple specific gambling-related symptoms were associated with comorbid disorders, possibly suggesting the interaction of different mechanisms linking gambling disorder and the onset of comorbid psychopathology. In conclusion, a graded or dose-response relationship exists between different levels of gambling and the onset of comorbid psychopathology. Among gambling groups, those with a gambling disorder were at the highest risk for the new onset of comorbid conditions and those with recreational gambling were at the lowest risk, while the risk among participants with sub-threshold gambling disorder fell between these two groups.

Psychometric properties of the Barratt Impulsiveness Scale in patients with gambling disorders, hypersexuality, and methamphetamine dependence.

Although the Barratt Impulsiveness Scale (BIS; Patton, Stanford, & Barratt, 1995) is a widely-used self-report measure of impulsivity, there have been numerous questions about the invariance of the factor structure across clinical populations (Haden & Shiva, 2008, 2009; Ireland & Archer, 2008). The goal of this article is to examine the factor structure of the BIS among a sample consisting of three populations exhibiting addictive behaviors and impulsivity: pathological gamblers, hypersexual patients, and individuals seeking treatment for methamphetamine dependence to determine if modification to the existing factors might improve the psychometric properties of the BIS. The current study found that the factor structure of the BIS does not replicate in this sample and instead produces a 12-item three-factor solution consisting of motor-impulsiveness (5 items), non-planning impulsiveness (3 items), and immediacy impulsiveness (4 items). The clinical utility of the BIS in this population is questionable. The authors suggest future studies to investigate comparisons with this modified version of the BIS and other impulsivity scales such as the UPPS-P Impulsive Behavior Scale in clinical populations when assessing disposition toward rash action.

Investigating facets of personality in adult pathological gamblers with ADHD.

The present study explored facets of personality in a sample of pathological gamblers with ADHD (n = 52) and without ADHD (n = 43). Participants were assessed for psychopathology and gambling disorders using the Mini International Neuropsychiatric Interview, the National Opinion Research Center DSM Screen for Gambling Problems, and the Adult ADHD Self-Report Scale. Facets of personality were assessed using the NEO Personality Inventory-Revised. Group differences emerged across several facets of personality when analyzed using multivariate statistics. Although both groups experienced difficulties in several areas compared with norming data (e.g., greater depression, higher impulsivity, lower self-esteem and lower self-discipline), these facets of personality were more pronounced in pathological gamblers with ADHD. Most notable among these differences are tendencies for gamblers with ADHD to experience greater levels of emotional instability, interpersonal sensitivity and stress proneness. Pathological gamblers with ADHD also appear to experience lower self-esteem, greater difficulty being assertive and lower levels of self-discipline. Surprisingly, both groups were comparable on facets of impulsivity. These findings suggest that pathological gamblers diagnosed with adult ADHD may experience additional challenges compared with pathological gamblers without ADHD.

Behavioral addictions: where to draw the lines?

Behavioral addictions can present in a variety of subtle and deceptive patterns. Because of the intense shame, guilt, and embarrassment felt by patients, it may fall to providers to utilize screening tools and deeper interviewing techniques to uncover the extent of these behaviors. Identifying when the line is crossed from recreation/habit to psychopathology relies on understanding current diagnostic criteria and consideration of cultural, ethnic, and local community standards. Individuals are also likely to cross back and forth between this line of pathology and habit, further clouding provider's opinions of diagnosis; therefore, tracking and monitoring these symptoms over time is critical to establishing patterns of use and documenting ongoing consequences. Treatment for these conditions is emerging slowly, and treatment outcomes for these conditions appear to be similar to those with other addictive disorders.

Exploring facets of personality in a patient sample of hypersexual women compared with hypersexual men.

This study explored group differences among a treatment-seeking sample of hypersexual women (n = 31) and hypersexual men (n = 47) across facets of personality using the NEO-Personality Inventory-Revised and the Hyper sexual Behavior Inventory. A number of striking parallels emerged between the two groups, including similar levels of impulsivity, emotional dysregulation, and difficulties coping with stress. Hypersexual women, compared to men, exhibited higher levels of distrust toward others, lower levels of self-confidence and ambition, and a greater preference for excitement and stimulation. These findings suggest that several common facets of personality precipitate or perpetuate hypersexual behavior in men and women, with some variations across genders. The implications of these findings for treatment interventions are discussed.