Increased Smoking Cessation Among Veterans With Large Decreases in Posttraumatic Stress Disorder Severity.

INTRODUCTION: Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. AIMS AND METHODS: Veterans Health Affairs (VHA) medical record data (2008-2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2 years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. RESULTS: On average, patients were 39.4 (SD = 12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with versus without clinically meaningful PTSD improvement stopped smoking (n = 36, cumulative incidence = 40.5% vs. 111, cumulative incidence = 30.8%, respectively). After controlling for confounding, patients with versus without clinically meaningful PTSD improvement were more likely to stop smoking within 2 years (hazard ratio = 1.57; 95% confidence interval: 1.04-2.36). CONCLUSIONS: Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. IMPLICATIONS: Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking-related disease.

The association between depression and type of treatments received for chronic low back pain.

BACKGROUND: Depression is associated with receipt of opioids in non-cancer pain. OBJECTIVES: To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments. METHODS: Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments. RESULTS: Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609). CONCLUSION: There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

Impact of adherence to antidepressants on long-term prescription opioid use cessation.

BACKGROUND: Depression contributes to persistent opioid analgesic use (OAU). Treating depression may increase opioid cessation. Aims To determine if adherence to antidepressant medications (ADMs) v. non-adherence was associated with opioid cessation in patients with a new depression episode after >90 days of OAU. METHOD: Patients with non-cancer, non-HIV pain (n = 2821), with a new episode of depression following >90 days of OAU, were eligible if they received ≥1 ADM prescription from 2002 to 2012. ADM adherence was defined as >80% of days covered. Opioid cessation was defined as ≥182 days without a prescription refill. Confounding was controlled by inverse probability of treatment weighting. RESULTS: In weighted data, the incidence rate of opioid cessation was significantly (P = 0.007) greater in patients who adhered v. did not adhered to taking antidepressants (57.2/1000 v. 45.0/1000 person-years). ADM adherence was significantly associated with opioid cessation (odds ratio (OR) = 1.24, 95% CI 1.05-1.46). CONCLUSIONS: ADM adherence, compared with non-adherence, is associated with opioid cessation in non-cancer pain. Opioid taper and cessation may be more successful when depression is treated to remission. Declaration of interest None.

The influence of prescription opioid use duration and dose on development of treatment resistant depression.

Long-term prescription opioid use is associated both with new-onset and recurrence of depression. Whether chronic opioid use interferes with depression management has not been reported, therefore we determined whether patients' longer duration of opioid use and higher opioid dose are associated with new-onset treatment resistant depression (TRD) after controlling for confounding from pain and other variables. Data was obtained from Veteran Health Administration (VHA) de-identified patient medical records. We used a retrospective cohort design from 2000-2012. Eligible subjects (n=6169) were 18-80years of age, free of cancer and HIV, diagnosed with depression and opioid-free for the 24-month interval prior to the observation period. Duration of a new prescription for opioid analgesic was categorized as 1-30days, 31-90days and >90days. Morphine-equivalent dose (MED) during follow-up categorized as ≤50mg versus >50mg per day. Pain and other sources of confounding were controlled by propensity scores and inverse probability of treatment weighting. Cox proportional hazard models were computed to estimate the association between duration and dose of opioid and onset of TRD. After controlling for confounding by weighting data, opioid use for 31-90days and for >90days, compared to 1-30days, was significantly associated with new onset TRD (HR=1.25; 95% CI: 1.09-1.45 and HR=1.52; 95% CI: 1.32-1.74, respectively). MED was not associated with new onset TRD. The risk of developing TRD increased as time spent on opioid analgesics increased. Long-term opioid treatment of chronic pain may interfere with treatment of depression.

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations.

PURPOSE: Recent results suggests the risk of a new onset of depression increases with longer duration of opioid analgesic use. It is unclear whether new-onset depression related to opioid analgesic use is a function of the dose prescribed or the duration of use or both. METHODS: Using a retrospective cohort design, we collected patient data from 2000 to 2012 from the Veterans Health Administration (VHA), and from 2003 to 2012 from both Baylor Scott & White Health (BSWH) and the Henry Ford Health System (HFHS). Patients (70,997 VHA patients, 13,777 BSWH patients, and 22,981 HFHS patients) were new opioid users, aged 18 to 80 years, without a diagnosis of depression at baseline. Opioid analgesic use duration was defined as 1 to 30, 31 to 90, and more than 90 days, and morphine equivalent dose (MED) was defined as 1 to 50 mg/d, 51 to 100 mg/d, and greater than 100 mg/d of analgesic. Pain and other potential confounders were controlled for by inverse probability of treatment-weighted propensity scores. RESULTS: New-onset depression after opioid analgesic use occurred in 12% of the VHA sample, 9% of the BSWH sample, and 11% of the HFHS sample. Compared with 1- to 30-day users, new-onset depression increased in those with longer opioid analgesic use. Risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from hazard ratio [HR] = 1.18 (95% CI, 1.10-1.25) in VHA to HR = 1.33 (95% CI, 1.16-1.52) in HFHS; in opioid analgesic use of more than 90 days, it ranged from HR = 1.35 (95% CI, 1.26-1.44) in VHA to HR = 2.05 (95% CI, 1.75-2.40) in HFHS. Dose was not significantly associated with a new onset of depression. CONCLUSIONS: Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression. Opioid analgesic use, not just pain, should be considered a potential source when patients report depressed mood.

New depression diagnosis following prescription of codeine, hydrocodone or oxycodone.

PURPOSE: Longer duration of prescription opioid use is associated with risk of major depression after controlling for daily morphine equivalent dose and pain. It is not known if risk of depression varies as a function of the type of opioid prescribed. METHODS: A retrospective cohort design was used to model onset of new depression diagnosis among 11 462 Veterans Health Administration (VA) patients who were prescribed only codeine, only hydrocodone or only oxycodone for >30 days. Patients were free of prevalent opioid use and depression at baseline (2000-2001). Follow-up was 2002-2012. Propensity scores and weighting were used to balance covariates across opioid type. Cox-proportional hazard models were computed, using weighted data and additional adjustment for morphine equivalent dose (MED), duration of use, and pain after opioid initiation, to estimate the risk of new depression diagnosis among patients prescribed only codeine, only oxycodone vs. those prescribed only hydrocodone. RESULTS: After controlling for confounding, we observed that patients prescribed codeine, compared to hydrocodone, were significantly more likely to have a new depression diagnosis (HR = 1.27; 95%CI: 1.12-1.43). Oxycodone was significantly associated with onset of new depression diagnosis when exposure was modeled as total days exposed in post-hoc analysis, but not when exposure was duration of incident period of use. CONCLUSIONS: Although codeine is a less potent opioid, after controlling for MED, chronic use of this agent is associated with nearly a 30% greater risk of depression compared to hydrocodone. Additional research is needed to determine the mechanisms for this association. Copyright © 2016 John Wiley & Sons, Ltd.

Antidepressant medication use and glycaemic control in co-morbid type 2 diabetes and depression.

OBJECTIVE: Depression is prevalent in diabetes and is associated with increased risks of hyperglycaemia, morbidity and mortality. The effect of antidepressant medication (ADM) on glycaemic control is uncertain owing to a paucity of relevant data. We sought to determine whether the use of ADM is associated with glycaemic control in depressed patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A retrospective cohort study (n = 1399) was conducted using electronic medical record registry data of ambulatory primary care visits from 2008 to 2013. Depression and type 2 diabetes were identified from ICD-9-CM codes; ADM use was determined from prescription orders; and glycaemic control was determined from measures of glycated haemoglobin (A1c). Good glycaemic control was defined as A1c < 7.0% (53 mmol/mol). Generalized estimating equations were used to determine the effect of depression and ADM use on glycaemic control. RESULTS: Good glycaemic control was achieved by 50.9% of depressed subjects receiving ADM versus 34.6% of depressed subjects without ADM. After adjusting for covariates, depressed patients receiving ADM were twice as likely as those not receiving ADM to achieve good glycaemic control (odds ratio = 1.95; 95% confidence interval: 1.02-3.71). CONCLUSIONS: In this retrospective cohort study of a large sample of primary care patients with type 2 diabetes, ADM use was associated with improved glycaemic control.

Racial differences in the association between nonmedical prescription opioid use, abuse/dependence, and major depression.

BACKGROUND: African Americans (AAs) have lower rates of depressive disorders and are less likely to receive opioid analgesics for chronic pain than whites. Given the evidence that prescription opioid use is associated with depression, we hypothesized that the opioid abuse/dependence and depression comorbidity would be less common among AAs compared with whites. METHODS: A cross-sectional secondary analysis of the public use files for the 2012 (n = 55,268) and 2013 (n = 55,160) National Survey on Drug Use and Health (NSDUH) was used to obtain past-year, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria diagnoses of nonmedical prescription opioid use (NMPOU), abuse/dependence, and major depressive episode (MDE). Covariates included anxiety disorder, alcohol and illicit drug abuse/dependence, smoking, age, gender, education, marital status, health insurance, county urbanicity, and income. Logistic regression models estimating the association between opioid use and MDE were computed before and after adjusting for covariates and separately for AAs and whites. RESULTS: AAs and whites had similar past-year prevalence of NMPOU (3.5% vs. 3.7%) and abuse/dependence (0.7% vs. 0.9%). MDE was significantly more prevalent among whites (7.4% vs. 5.5%; P < .0001). Among whites, NMPOU and abuse/dependence were associated with MDE (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.12-1.64 and OR = 2.22, 95% CI = 1.67-2.94, respectively). Among AAs, there were no significant associations between NMPOU, abuse/dependence, and MDE (OR range: 0.80-0.95). CONCLUSIONS: In a nationally representative sample, co-occurrence of past-year depression, NMPOU, and abuse/dependence was determined in whites but not AAs. Additional research is needed to establish the contribution of pain and temporal relationships.

Depression leads to incident vascular disease: evidence for the relevance to primary care.

BACKGROUND: Depression is a known risk factor for vascular disease in community cohorts and in large, system-wide, health care databases. It is not known if the association between depression and incident vascular disease exists when patient data is restricted to depression presenting in primary care. METHODS: Data were from a medical record registry capturing all primary care encounters at a large academic medical practice from 2008 to 2013. From 27,225 registry patients, we identified 7383 patients free of vascular disease for 18 months prior to baseline. ICD-9-CM codes were used to define depression and vascular disease. Volume of health care use, demographics and comorbid diagnoses were obtained from the patient data registry. Cox proportional hazard models with time dependent covariates were computed to measure the association between depression and incident vascular disease before and after adjusting for covariates. RESULTS: Of the 7383 patients initially free of vascular disease, 14% were diagnosed with depression and 8.6% developed vascular disease. Incident vascular disease was significantly (P < 0.01) higher among patients with depression (12.7%) compared to those without depression (7.9%). In the unadjusted model, depression was associated with a 49% increased risk of developing vascular disease (odds ratio [OR] = 1.49; 95% confidence interval [CI]: 1.19-1.86) and this association remained significant after adjusting for all potential confounders (OR = 1.28; 95% CI: 1.02-1.62). CONCLUSIONS: The association between depression and incident vascular disease is observed in patients diagnosed and managed by primary care physicians. Primary care physicians have an opportunity to impact this association. Guidelines for primary care providers are needed to prompt aggressive depression treatment and vascular disease screening.

Family Medicine Clerkship Directors' Perspectives on USMLE Pass/Fail Scoring: A CERA Study.

INTRODUCTION: Reports on the effects of changing the United States Medical Licensing Exam (USMLE) Step 1 examination scoring to pass/fail are evolving in the medical literature. This Council of Academic Family Medicine Educational Research Alliance family medicine clerkship directors' study seeks to describe family medicine clerkship directors' perceptions on the impact of incorporation of Step 1 pass/fail score reporting on students' family medicine clerkship performance. METHODS: Ninety-six clerkship directors responded (56.8% response rate). After exclusion of Canadian schools, we analyzed 88 clerkship directors' responses from US schools. We used descriptive statistics for demographics and responses to survey questions. We used ꭓ2 analysis to determine statistically significant associations between survey items. RESULTS: Clerkship directors did not observe changes in students' overall clinical performance after Step 1 pass/fail scoring (60.8%). Fifty percent of clerkship directors reported changes in Step 1 timing recommendations in the past 3 years. Reasons included curriculum redesign (30.5%), COVID (4.5%), change in Step 1 to pass/fail (11.0%), and other reasons (3.7%). Forty-five percent of these clerkship directors did not observe a change in students' clinical medical knowledge after Step 1 went to pass/fail. Eighty-four percent of these clerkship directors did not compare student performance on clerkship standardized exams before and after Step 1 score changes. We found no significant relationship between Step 1 timing and student performance. CONCLUSIONS: This study represents an early description of family medicine clerkship directors' perceived observations of the impact of Step 1 scoring changes on student performance. Continued investigation of the effects of USMLE Step 1 pass/fail scoring should occur.

Pursuing Scholarship: Creating Effective Conference Submissions.

Medical educators are expected to disseminate peer-reviewed scholarly work for academic promotion and tenure. However, developing submissions for presentations at national meetings can be confusing and sometimes overwhelming. Awareness and use of some best practices can demystify the process and maximize opportunities for acceptance for a variety of potential submission categories. This article outlines logistical steps and best practices for each stage of the conference submission process that faculty should consider when preparing submissions. These include topic choice, team composition, consideration of different submission types, and strategies for effectively engaging participants.

Adverse Childhood Experiences and Diabetes: Testing Violence and Distress Mediational Pathways in Family Medicine Patients.

Type 2 diabetes mellitus (diabetes) is increasing in frequency and creating a significant burden on the United States healthcare system. Adverse childhood experiences (ACE) and interpersonal violence (IV) have been shown to have detrimental effects on mental and physical health. How ACE can influence IV as an adult and how this can influence the management of diabetes is not known. The purpose of the current study is to understand the relationship between violence and social determinants of health (SDoH), and its effect on patients with type 2 diabetes mellitus. A practiced-based research network (PBRN) of family medicine residency programs was utilized to collect cross-sectional data from seven family medicine residency program primary care clinics. In total, 581 participants with type 2 diabetes were recruited. A serial/parallel mediation model were analyzed. The majority of participants (58.3%) had a Hemoglobin A1c (HbA1c) that was not controlled. ACE was associated with an increase in Hurt-Insult-Threaten-Scream (HITS) scores, which in turn was positively associated with an increase in emotional burden, and finally, emotional burden decreased the likelihood that one's HbA1c was controlled (Effect = -.054, SE = .026 CI [-.115, -.013]). This indirect pathway remained significant even after controlling for several SDoH and gender. The impact of ACE persists into adulthood by altering behaviors that make adults more prone to experiencing family/partner violence. This in turn makes one more emotionally distressed about their diabetes, which influences how people manage their chronic condition. Family physicians should consider screening for both ACE and family/partner violence in those patients with poorly controlled diabetes.

Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination.

OBJECTIVES: The purpose of this study was to examine the perspectives of primary care physicians in Texas around vaccine acceptance and potential patient barriers to vaccination. National surveys have shown fluctuating levels of acceptance for COVID-19 vaccination, and primary care physicians could play a crucial role in increasing vaccine uptake. DESIGN: This study employed a cross-sectional anonymous survey design to collect data using an online questionnaire. Participants were asked about vaccination practices and policies at their practice site, perceptions of patient and community acceptance and confidence in responding to patient vaccine concerns. SETTING: From November 2020 to January 2021, family medicine physicians and paediatricians completed an online questionnaire on COVID-19 vaccination that was distributed by professional associations. PARTICIPANTS: The survey was completed by 573 practising physicians, the majority of whom identified as family medicine physicians (71.0%) or paediatricians (25.7%), who are currently active in professional associations in Texas. RESULTS: About three-fourths (74.0%) of participants reported that they would get the vaccine as soon as it became available. They estimated that slightly more than half (59.2%) of their patients would accept the vaccine, and 67.0% expected that the COVID-19 vaccine would be accepted in their local community. The majority of participants (87.8%) reported always, almost always or usually endorsing vaccines, including high levels of intention to recommend COVID-19 vaccination (81.5%). Participants felt most confident responding to patient concerns related to education about vaccine types, safety and necessity and reported least confidence in responding to personal or religious objections to COVID-19 vaccination. CONCLUSIONS: The majority of the physicians surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were confident in their ability to respond to patient concerns. With additional education, support and shifting COVID-19 vaccinations into primary care settings, primary care physicians can use the trust they have built with their patients to address vaccine hesitancy and potentially increase acceptance and uptake.

Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion.

PURPOSE: Faculty promotion is important for retention and has implications for diversity. This study provides an update on recent trends in faculty promotion in U.S. medical schools. METHOD: Using data from the Association of American Medical Colleges Faculty Roster, the authors examined trends in faculty promotion over 10 years. Promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 inclusive was followed from January 1, 2010 to January 1, 2019. The authors used bivariate analyses to assess associations and promotion rates by sex, race/ethnicity, department, tenure status, and degree type. RESULTS: The promotion rate for assistant professors was 44.3% (2,330/5,263) in basic science departments, 37.1% (17,232/46,473) in clinical science departments, and 33.6% (131/390) in other departments. Among clinical departments, family medicine had the lowest rate of promoting assistant professors (24.4%; 484/1,982) and otolaryngology the highest rate (51.2%; 282/551). Faculty members who were male (38.9%; 11,687/30,017), White (40.0%; 12,635/31,596), tenured (58.7%; 98/167) or tenure-eligible (55.6%; 6,653/11,976), and holding MDs/PhDs (48.7%; 1,968/4,038) had higher promotion rates than, respectively, faculty who were female (36.3%; 7,975/21,998), minorities underrepresented in medicine (URM; 31.0%; 1,716/5,539), nontenured (32.5%; 12,174/37,433), and holding other/unknown degrees (20.6%; 195/948; all P < .001). These differences were less pronounced among associate professors; however, URM and nontenured faculty continued to have lower promotion rates compared with White, Asian, or tenured faculty at the associate professor level. CONCLUSIONS: Promotion rates varied not only by faculty rank but also by faculty sex, race/ethnicity, department, tenure status, and degree type. The differences were more pronounced for assistant professors than associate professors. URM faculty members, particularly assistant professors, were promoted at lower rates than their White and Asian peers. More research to understand the drivers of disparities in faculty promotion seems warranted.

Emergency department presentation of opioid use disorder and alcohol use disorder.

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

Identifying and overcoming barriers to trauma screening in the primary care setting.

Introduction: Underrecognition of trauma exposure and PTSD has a significant impact on psychiatric health, physical health, and health behaviors. The purpose of this study is to explore barriers and opportunities for trauma screening in primary care. Methods: Primary care physicians (PCPs) and their patients were interviewed about the acceptability of trauma screening and brief treatment in primary care. Interview transcripts were coded and analyzed for themes using Atlas v. 7.0. Results: Data showed PCPs informally screen for trauma but were hampered by organizational constraints including time, availability of behavioral health providers, and knowledge of trauma-informed-care practices. Most patients with trauma history met with behavioral health providers during their lifetimes, but still did not believe it was the PCPs' role to address trauma exposure, had fears of "appearing crazy," or were ambivalent about seeking treatment. Discussion: Findings suggest an enormous complexity involved in screening for trauma in primary care service delivery. Trauma screening appears to work best within the course of relationship building where patients can begin to see that their physician is capable of playing an important role in managing trauma, depression, and PTSD symptoms. We address how trauma discussion can take place within existing trauma informed care guidelines. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data.

BACKGROUND: Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization. METHODS: We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits. RESULTS: The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits. CONCLUSIONS: Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.

Trends in Tenure Status in Academic Family Medicine, 1977-2017: Implications for Recruitment, Retention, and the Academic Mission.

PURPOSE: Tenure status has important implications for medical school faculty recruitment and retention and may affect educational quality, academic freedom, and collegiality. However, tenure trends in academic family medicine are unknown. This study aimed to describe trends in tenure status of family medicine faculty overall and by gender and status of minorities underrepresented in medicine (URM) in Liaison Committee on Medical Education-accredited medical schools. METHOD: Association of American Medical Colleges Faculty Roster data were used to describe trends in tenure status of full-time family medicine faculty, 1977 to 2017. Bivariate and trend analyses were conducted to assess associations and describe patterns between tenure status and gender, race, and ethnicity. Interdepartmental variations in tenure trends over the years were also examined. RESULTS: Among family medicine faculty, the proportions of faculty tenured or on a tenure track dropped more than threefold from 1977 (46.6%; n = 507/1,089) to 2017 (12.7%; n = 729/5,752). Lower proportions of women and URM faculty were tenured or on a tenure track than male and non-URM faculty, respectively. But the gaps among them were converging. Compared with other clinical departments, family medicine had the highest proportion of faculty (74.6%; n = 4,291/5,752) not on a tenure track in 2017. CONCLUSIONS: Proportion of tenure positions significantly decreased among family medicine faculty in U.S. medical schools. While gaps between male and female faculty and among certain racial/ethnic groups remained for family medicine tenure status, they have decreased over time, mainly because of a substantial increase in nontenured positions.

Childhood Trauma, Social Networks, and the Mental Health of Adult Survivors.

The purpose of this study was to investigate the relationship of childhood trauma to the quality of social networks and health outcomes later in adulthood. Data were obtained from a convenience sample of 254 adults seen in one of 10 primary care clinics in the state of Texas. Standardized measures of adverse childhood experiences (ACEs), stressful and supportive social relationships, medical conditions, anxiety, depression, and health-related quality of life were administered. Using latent class analysis, subjects were assigned to one of four ACE classes: (a) minimal childhood abuse (56%), (b) physical/verbal abuse of both child and mother with household alcohol abuse (13%), (c) verbal and physical abuse of child with household mental illness (12%), and (d) verbal abuse only (19%). Statistically significant differences across the four ACE classes were found for mental health outcomes in adulthood. Although respondents who were physically and verbally abused as children reported compromised mental health, this was particularly true for those who witnessed physical abuse of their mother. A similar relationship between ACE class and physical health was not found. The quality of adult social networks partly accounted for the relationship between ACE classes and mental health outcomes. Respondents exposed to ACEs with more supportive social networks as adults had diminished odds of reporting poor mental health. Conversely, increasing numbers of stressful social relationships contributed to adverse mental health outcomes. Although efforts to prevent childhood trauma remain a critical priority, the treatment of adult survivors needs to expand its focus on both strengthening social networks and decreasing the negative effects of stressful ones.