Suicide prevention for substance using youth experiencing homelessness: study protocol for a randomized controlled trial.

BACKGROUND: While research on substance using youth experiencing homelessness (YEH) is increasing, there is a dearth of information regarding effective prevention interventions for these youth. Suicide is the leading cause of death among YEH and most youth do not access services that may be available to them. Therefore, this study seeks to address this gap in the research literature with the goal to identify an effective suicide prevention intervention that can be readily adopted by communities that serve these youth. METHODS: Three hundred (N = 300) YEH with recent substance use and suicidal ideation or a recent suicide attempt will be recruited from the streets as well as a drop-in center serving YEH. After the baseline assessment, all youth will be randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Services as Usual (SAU) (N = 150) or to SAU alone (N = 150). SAU includes outreach, advocacy, and service linkage whereas YEH who receive CTSP will also receive ten CTSP sessions and an optional nine booster sessions. Follow-up assessments will be conducted at 3, 6, 9, and 12 months post-baseline. Theoretically derived mediators (e.g., cognitive distortions) will be tested to shed light on mechanisms associated with change, and the moderating effects of sex, race, sexual orientation, and baseline service connection will be examined. In order to ease future dissemination of the intervention to agencies serving YEH, we will rigorously assess acceptability, feasibility, fidelity, and cost associated with the delivery of our intervention approach using a mixed-methods approach. DISCUSSION: This study adds to a very small number of clinical trials seeking to prevent lethal suicide among a very high-risk group by addressing suicidal ideation directly rather than underlying conditions. It is hypothesized that youth receiving CTSP + SAU will show greater reductions in suicidal ideation (primary outcome), substance use, and depressive symptoms (secondary outcomes) over time compared to SAU alone, as well as improved risk and protective factors. TRIAL REGISTRATION: NCT05994612. Date of Registration: August 16, 2023.

Lessons learned from housing first, rapid rehousing trials with youth experiencing homelessness.

BACKGROUND: Youth, 18 to 24 years, experiencing homelessness (YEH) are recognized as having developmental challenges dissimilar to older adults. Yet, research on efforts to end homelessness and prevent or intervene in drug use and mental health problems among youth have lagged behind that of adults. The Housing First (HF) Model which underlies Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH) has become preferred over treatment-first models. METHODS AND RESULTS: We provide an overview of PSH and RRH studies to date and summarize our current understanding of their utility for use with YEH. Finally, we review our team's current and past randomized trials testing RRH with YEH, providing lessons learned and recommendations. CONCLUSION: Current research efforts to guide best practices are hampered by a lack of fidelity to HF principles, lack of randomized design, and lack of focus on youth. Lessons learned and recommendations from our work are offered to facilitate the future work of those who seek to end homelessness and address drug use and mental health problems among youth.

Housing and supportive services for substance use and self-efficacy among young mothers experiencing homelessness: A randomized controlled trial.

AIMS: Homeless mothers with young children in their care contend with high rates of substance use and low self-efficacy. However, a limited number of studies have examined these outcomes associated with housing and supportive services. DESIGN: Participants were randomly assigned to: (1) housing + support services (n = 80), (2) housing-only (n = 80), or (3) services as usual (SAU) (n = 80) and were re-assessed at 3-, 6-, 9- and 12-months postbaseline. SETTINGS: The study recruited a community-based sample from homeless service agencies and advertisements in a large Midwestern city. PARTICIPANTS: The study recruited two hundred forty (N = 240) women between the ages of 18 to 24 years, experiencing homelessness and with a substance use disorder (SUD) who also had a biological child under the age of 6 years in their care. MEASUREMENTS: We measured frequency of alcohol and drug use using the Form 90 semi-structured interview, and self-efficacy using Pearlin and Schooler's (1978) 7-item Mastery Scale. FINDINGS: Overall, mothers showed significant improvement in substance use and self-efficacy over time in each condition. However, as expected, patterns of change differentiated intervention groups with more mothers showing better substance use and self-efficacy outcomes in housing + supportive services than in SAU. Unexpectedly, more mothers in SAU showed better outcomes than those in housing-only. CONCLUSIONS: Substance use decreased and self-efficacy increased over time, but patterns of change characterized the intervention groups. In particular, findings suggest that when providing housing to this population, supportive services should also be offered.

Housing, opportunities, motivation and engagement (HOME) for homeless youth at-risk for opioid use disorder: study protocol for a randomized controlled trial.

BACKGROUND: Homeless youth experience high rates of substance use disorders, exposures to violence, mental and physical health conditions, and mortality. They have been particularly affected by the opioid crisis. However, no study to date has used a randomized controlled design to test preventive interventions of opioid and other drug use among this vulnerable population. Resolution of youth homelessness through housing and supportive services including prevention services, often referred to as "Housing First," has great potential to reduce the likelihood for the development of an opioid use disorder as well as other problem behaviors associated with living on the streets. Housing First has been tested through randomized trials among homeless adults with mental health and substance use disorders, but has not been empirically tested for opioid prevention among homeless youth. METHODS: Homeless youth will be recruited from a drop-in shelter site frequented by disconnected youth; they will be screened for eligibility, including current homelessness, age 18-24 years, and not currently meeting criteria for opioid use disorder (OUD). In a controlled trial, 240 youth will then be randomized to one of two conditions, (1) housing + opioid and related risk prevention services, or (2) opioid and related risk prevention services alone. This project utilizes existing efficacious models of prevention to address opioid-related risks, including motivational interviewing, strengths-based outreach and advocacy, and an HIV risk preventive intervention. Follow-up will be conducted at 3, 6, 9 and 12-months post-baseline. The economic cost of each intervention will be determined to support implementation decisions with other providers and their funders. DISCUSSION: This study will provide essential information for researchers and providers on the efficacy of housing + opioid and related risk prevention services in an RCT for effects on opioid use and mechanisms underlying change. Because youth experiencing homelessness are at increased risk for a variety of adverse outcomes, the proposed intervention may produce substantial health care benefits to the youths and society at large. Trial registration ClinicalTrials.gov, NCT04135703, Registered October 13, 2019, https://clinicaltrials.gov/ct2/show/NCT04135703?term=NCT04135703&draw=2&rank=1#contacts.

Virtual Reality Meditation Among Youth Experiencing Homelessness: Pilot Randomized Controlled Trial of Feasibility.

BACKGROUND: Homelessness among youth is devastating, with high rates of substance use disorders and mental health comorbidity. Mindfulness-based interventions that include meditation and mindfulness skills training reduce stress and symptoms of anxiety or depression. However, engaging high-risk youth in interventions is challenging. Virtual reality is a more flexible platform for delivering meditation and may be appealing to youth. OBJECTIVE: The study objectives were to evaluate the feasibility of delivering virtual reality meditation and of collecting outcome measures, including anxiety and physiologic stress. METHODS: A sample of 30 youth experiencing homelessness was enrolled in the study. Youth were randomized to receive 10 minutes of one of three interventions: (1) virtual reality meditation, (2) audio meditation (through a web-based platform), or (3) virtual reality imagery of historical pictures and text. Subjects who consented to the study attended two research visits. The first visit collected survey measures of demographics, mental health, and substance use, and oriented subjects to the intervention platforms. The second visit (1-3 days later) delivered the intervention and collected pre and post outcome measures of anxiety and physiologic stress (salivary cortisol). Changes in anxiety and cortisol at the second visit were compared across groups using a linear regression model in which the primary analysis compared virtual reality meditation to audio meditation and secondary analyses compared virtual reality meditation to virtual reality imagery. RESULTS: Anxiety scores decreased in all groups, with a larger reduction among the virtual reality meditation group (difference=10.8) compared to the web-based meditation or virtual reality images groups (difference=5.8 and 5.0, respectively). After controlling for baseline values, there were no significant group differences in changes in anxiety scores or cortisol levels. In comparing virtual reality meditation and audio meditation, the effect size for anxiety was moderate (Cohen d=0.58) while the effect size for cortisol was small (Cohen d=0.08). CONCLUSIONS: Preliminary results suggest that virtual reality meditation has a moderate benefit for anxiety but not physiologic stress. Future research is needed to confirm these results in a larger sample and to investigate whether the effects are sustained or increase with repeated use of virtual reality mediation. Virtual reality meditation appears feasible to deliver among homeless youth and merits further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT04004520; https://clinicaltrials.gov/ct2/show/NCT04004520.

The Family System and Depressive Symptoms during the College Years: Triangulation, Parental Differential Treatment, and Sibling Warmth as Predictors.

Guided by Bowen theory, we investigated the relationships between parent-child triangulation, parental differential treatment (PDT), sibling warmth, and individual depressive symptoms in a sample of 77 sibling dyads, aged 18-25 years, recruited through undergraduate classes at a U.S. public University. Results of the actor-partner interdependence models suggested that being triangulated into parental conflict was positively related to both siblings' perception of PDT; however, as one sibling felt triangulated, the other perceived reduced levels of PDT. For both siblings, the perception of higher levels of PDT was related to decreased sibling warmth and higher sibling warmth was associated with fewer depressive symptoms. The implications of these findings for research and the treatment of depression in the college-aged population are discussed.

Therapist Differentiation and Couple Clients' Perceptions of Therapeutic Alliance.

Therapeutic alliance has been acknowledged as one of the catalysts for change within a therapeutic relationship. The contributions of therapists' characteristics to alliance are not often studied. From a Bowen System's Theory perspective, the therapist's level of differentiation would be highly relevant to the development of a therapeutic alliance. The hypothesis for this study was that therapists who are able to take a more differentiated stance in therapy will build a stronger therapeutic alliance. To test this hypothesis, multilevel modeling procedures were performed, using data from nine therapists and 93 couple cases collected at a large, Midwestern university. Therapist differentiation of self was found to be weakly associated with the clients' perception of therapeutic alliance across the early sessions of therapy, but not in the expected direction. Although the results were unexpected, this study provides an example of the potential of examining therapist characteristics from within one model of therapy, that can be applied across various clients and various models of therapy.

Relational Ethics, Depressive Symptoms, and Relationship Satisfaction in Couples in Therapy.

The purpose of this study was to examine depressive symptoms and relationship satisfaction as problems related to relational ethics in one's family of origin and current partner relationships in a sample of 68 other-sex couples seeking therapy at a large university clinic. We used the Actor Partner Interdependence Model to analyze dyadic data collected prior to beginning therapy. Specifically, we found significant actor effects between relational ethics in one's family of origin and depressive symptoms, as well as between depressive symptoms and low relationship satisfaction for both male and female partners. We also found significant partner effects for relational ethics in current partner relationship, depressive symptoms, and low relationship satisfaction. Clinical application of contextual therapy theory is discussed.