Resilience-Informed Community Violence Prevention and Community Organizing Strategies for Implementation: Protocol for a Hybrid Type 1 Implementation-Effectiveness Trial.

BACKGROUND: Community violence is a persistent and challenging public health problem. Community violence not only physically affects individuals, but also its effects reverberate to the well-being of families and entire communities. Being exposed to and experiencing violence are adverse community experiences that affect the well-being and health trajectories of both children and adults. In the United States, community violence has historically been addressed through a lens of law enforcement and policing; the impact of this approach on communities has been detrimental and often ignores the strengths and experiences of community members. As such, community-centered approaches to address violence are needed, yet the process to design, implement, and evaluate these approaches is complex. Alternatives to policing responses are increasingly being implemented. However, evidence and implementation guidance for community-level public health approaches remain limited. This study protocol seeks to address community violence through a resilience framework-Adverse Community Experiences and Resilience (ACE|R)-being implemented in a major US city and leveraging a strategy of community organizing to advance community violence prevention. OBJECTIVE: The objective of this research is to understand the impact of community-level violence prevention interventions. Furthermore, we aim to describe the strategies of implementation and identify barriers to and facilitators of the approach. METHODS: This study uses a hybrid type 1 effectiveness-implementation design. Part 1 of the study will assess the effectiveness of the ACE|R framework plus community organizing by measuring impacts on violence- and health-related outcomes. To do so, we plan to collect quantitative data on homicides, fatal and nonfatal shootings, hospital visits due to nonaccidental injuries, calls for service, and other violence-related data. In Part 2 of the study, to assess the implementation of ACE|R plus community organizing, we will collect process data on community engagement events, deliver community trainings on community leadership and organizing, and conduct focus groups with key partners about violence and violence prevention programs in Milwaukee. RESULTS: This project received funding on September 1, 2020. Prospective study data collection began in the fall of 2021 and will continue through the end of 2023. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2024. CONCLUSIONS: Community violence is a public health problem in need of community-centered solutions. Interventions that center community and leverage community organizing show promise in decreasing violence and increasing the well-being of community members. Methods to identify the impact of community-level interventions continue to evolve. Analysis of outcomes beyond violence-specific outcomes, including norms and community beliefs, may help better inform the short-term and proximal impacts of these community-driven approaches. Furthermore, hybrid implementation-effectiveness trials allow for the inevitable contextualization required to disseminate community interventions where communities drive the adaptations and decision-making. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50444.

Multidisciplinary Strategies for Preventing Opioid Misuse and Escalation by Targeting Mental Health Symptoms and Conditions.

We aim to review the association between childhood-onset mental health conditions and increased risk for early substance use including opioid misuse and opioid use disorders (OUD). The association between mental health conditions and opioid misuse suggests youth with mental health conditions may benefit from opioid prevention efforts that concurrently address mental health. To aid in the identification of youth with mental health conditions who could benefit from interventions, we will review opportunities and challenges associated with screening for mental health symptoms or substance use in settings where youth at high risk for mental health conditions present. We will also review how research projects within the National Institutes of Health's Helping to End Addiction Long-term (HEAL) Prevention Cooperative are addressing mental health within opioid misuse and OUD prevention interventions for youth.

Introduction to Helping to End Addiction Long-Term Prevention Cooperative: Overview and Strategies.

This supplemental issue describes the individual studies and collaborative efforts of the Helping to End Addiction Long-term Prevention Cooperative's (HPC's) innovative approaches to rapidly develop evidence-based prevention programs for widespread dissemination. This introduction succinctly reviews (1) the context that demands the rapid development of efficacious prevention programs and their scale-ups, (2) the unique objectives of the individual HPC research projects, and (3) collective efforts to harmonize research across studies to advance the prevention of opioid misuse and gain insight into opioid misuse etiology to inform improvements in preventive interventions. At the conclusion of HPC studies, we anticipate the availability of multiple evidence-based programs to prevent opioid misuse and use disorder for persons who experience particular sources of risk and for delivery in settings where prevention has traditionally been lacking. By harmonizing and coordinating efforts across 10 distinct outcomes studies of prevention programs and making data available for analysis by non-HPC researchers, the HPC's efficacy and etiology evidence will far surpass the additive contributions of 10 individual research projects.

Power analysis for idiographic (within-subject) clinical trials: Implications for treatments of rare conditions and precision medicine.

Power analysis informs a priori planning of behavioral and medical research, including for randomized clinical trials that are nomothetic (i.e., studies designed to infer results to the general population based on interindividual variabilities). Far fewer investigations and resources are available for power analysis of clinical trials that follow an idiographic approach, which emphasizes intraindividual variabilities between baseline (control) phase versus one or more treatment phases. We tested the impact on statistical power to detect treatment outcomes of four idiographic trial design factors that are under researchers' control, assuming a multiple baseline design: sample size, number of observations per participant, proportion of observations in the baseline phase, and competing statistical models (i.e., hierarchical modeling versus piecewise regression). We also tested the impact of four factors that are largely outside of researchers' control: population size, proportion of intraindividual variability due to residual error, treatment effect size, and form of outcomes during the treatment phase (phase jump versus gradual change). Monte Carlo simulations using all combinations of the factors were sampled with replacement from finite populations of 200, 1750, and 3500 participants. Analyses characterized the unique relative impact of each factor individually and all two-factor combinations, holding all others constant. Each factor impacted power, with the greatest impact being from larger treatment effect sizes, followed respectively by more observations per participant, larger samples, less residual variance, and the unexpected improvement in power associated with assigning closer to 50% of observations to the baseline phase. This study's techniques and R package better enable a priori rigorous design of idiographic clinical trials for rare diseases, precision medicine, and other small-sample studies.

Feasibility of combining biosensor and ecological momentary assessment to measure stress experiences among economically disadvantaged adolescents.

Adolescent stress is complex and impairing. Novel measures are needed to understand stress variability within individuals over time from a physiological as well as a subjective perspective. To test the feasibility of combining ecological momentary assessment (EMA) and wearable biosensors to assess adolescent stress, using an idiographic approach with experience sampling methods. A small sample (n = 23) of predominantly African American, economically disadvantaged adolescents were asked to complete EMA surveys four times per day and wear an armband measuring Heart rate (HR) and skin response for a 2-week period. Descriptive analyses examined number of hours of armband wear, percentage of viable data, and percentage of surveys completed by gender and race. Associations between biosensor data and EMA reports within and across individuals were also examined using hierarchical linear regression. EMA survey completion was good (81%) as was adherence to biosensor protocols, although technological difficulties interfered with collection of HR variability for youth with darker skin tones. Youth reported stressful events in 12.79% of EMA surveys, although 43% reported no negative mood experiences. Convergent validity was supported for detecting between-person (EMA) and within-person (EMA and biosensors) variability in stress across time, although associations across youth were highly variable. Results suggest value for biobehavioral methods in understanding day-to-day stress in adolescents but highlight variability in stress experiences as well as technological limitations, especially for youth of colour.

Methodological Strategies for Prospective Harmonization of Studies: Application to 10 Distinct Outcomes Studies of Preventive Interventions Targeting Opioid Misuse.

The Helping to End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is rapidly developing 10 distinct evidence-based interventions for implementation in a variety of settings to prevent opioid misuse and opioid use disorder. One HPC objective is to compare intervention impacts on opioid misuse initiation, escalation, severity, and disorder and identify whether any HPC interventions are more effective than others for types of individuals. It provides a rare opportunity to prospectively harmonize measures across distinct outcomes studies. This paper describes the needs, opportunities, strategies, and processes that were used to harmonize HPC data. They are illustrated with a strategy to measure opioid use that spans the spectrum of opioid use experiences (termed involvement) and is composed of common "anchor items" ranging from initiation to symptoms of opioid use disorder. The limitations and opportunities anticipated from this approach to data harmonization are reviewed. Lastly, implications for future research cooperatives and the broader HEAL data ecosystem are discussed.

Substance Use Screening and Prevention for Adolescents in Pediatric Primary Care: A Randomized Clinical Trial using the Family Check-Up.

This study evaluated acceptability, engagement in prevention, and efficacy of a primary care screening-and-referral-to-prevention program to reduce substance use in early adolescence. Screening tools were the Youth Risk Index and Transmissible Liability Index and prevention consisted of the Family Check-Up (FCU). Three hundred sixty-one 10- to 13-year-olds from low resource neighborhoods (85.9% African American; 52.4% female) screened "at risk" during primary care visits and were randomized to the FCU (n = 123) or usual care (n = 238). Screening was acceptable to parents and youths: nearly 95% of each rated it as important, about 90% of each were happy with or did not mind it, and only 2.4% of parents did not want their child to be screened at their next check-up. Of parents who had a chance to receive the FCU (or waitlist-control), 87.5% followed through with researchers while 93.5% who were offered FCU engaged in it. FCU efficacy primarily involved interactions such that youth with greater risk at baseline experienced larger benefits. At 12-month follow-up, FCU was associated with 11% reduced risk of initiating a new substance per substance that had been initiated before baseline; greater reductions in tolerance of deviance among those with higher tolerance of deviance at baseline; and a main effect of reduced anxiety, but no effect for conduct problems. Pediatric well-child check-up screening can identify high-risk youth before, or in the initial stages of, problematic SU; engage families in a preventive intervention; and reduce rates of substance use and related risk factors.

Racial Discrimination Experienced by Black Parents: Enduring Mental Health Consequences for Adolescent Youth.

OBJECTIVE: Despite evidence linking experiences of racial discrimination by Black parents and problem behaviors in youth, little is known about the mechanisms that explain this link. To elucidate these developmental pathways, a serial mediation model was tested, in which Black parents' experiences of racial discrimination were hypothesized to predict increased parental depression and parent-child conflict in early adolescence, which in turn would be associated with youth depression, anxiety, and conduct problems in early to mid-adolescence. METHOD: Participants were 252 Black parent-child dyads. Youth (56% female) were on average 11.98 years old at study entry (wave 1). Parents and youth completed questionnaires during a home-based assessment at wave 1 and were assessed again 1 and 2 years later (waves 2 and 3). RESULTS: Black parents' experiences of racial discrimination at wave 1 were linked to higher levels of parent-child conflict at wave 2 (0.20; 95% CI [0.05, 0.33]), which in turn predicted greater youth-reported depression at wave 3 (0.30; 95% CI [0.15, 0.47]). There was a significant indirect effect of racial discrimination on youth-reported depression via parent-child conflict (indirect effect: 0.06, 95% CI [0.02, 0.10]). Findings were replicated across multiple outcomes (ie, depression, anxiety, conduct problems) and multiple informants (ie, youth report, parent report). There was no evidence to support a serial mediation model via parental depression and then parent-child conflict. CONCLUSION: This study identified a developmental pathway from Black parents' experiences of racial discrimination to adolescent problem behaviors via parent-child conflict. Findings may inform interventions aimed at promoting resilience in parents and youth faced with pervasive racism. CLINICAL TRIAL REGISTRATION INFORMATION: Substance Use Screening and Prevention for Adolescents in Pediatric Primary Care (SKY); https://clinicaltrials.gov/; NCT03074877.

Neuropsychiatric features of Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is a genetic disorder characterized by hypotonia and poor feeding in infancy which progresses to hyperphagia in early-mid childhood, as well as developmental delays, a spectrum of behavioral and psychiatric concerns, endocrinopathies, orthopedic issues, and less commonly, seizures, sleep apnea, and narcolepsy with or without cataplexy. This study used data in the Global PWS Registry (N = 893) to explore the onset and severity over time of the neuropsychiatric features reported in individuals with PWS and explored its associations with sleep disorders, seizures, and psychiatric symptoms. Results demonstrate that seizures are more common in the deletion subtype and that narcolepsy and cataplexy are more common in individuals who have sleep-related seizures. Finally, this work shows that anxiety and compulsive behaviors are persistent features of PWS that may arise early in childhood, and that anxiety is associated with higher frequency of other comorbid psychiatric diagnoses. In conclusion, this study is one of the largest to date characterizing sleep disorders and neuropsychiatric characteristics of individuals with PWS and reports on the novel association between sleep disorders and seizures. This study is also one of the first to offer details on the nature of the progression of these features in individuals with PWS.

Co-occurrence of Psychopathology Problems in At-Risk Adolescents.

No known studies have investigated co-occurrence of psychopathology problems in adolescents with biologic and/or environmental susceptibility, including prenatal drug exposure. This study identified comorbidity patterns of psychopathology problems by utilizing data from urban, primarily African American, youth, majority of whom were at heightened risk for exposure to drugs in utero. The roles of Research Domain Criteria (RDoC)-informed behavioral constructs of the Negative Valence (irritability) and Social Process Systems (social disinhibition) as antecedents of the comorbidity patterns were further examined. Lastly, the predictive validity of the identified patterns was evaluated in relation to emerging adulthood outcomes. Participants were 358 urban adolescents, primarily African Americans, drawn from a 21-year prospective birth-cohort study of the effects of prenatal drug exposure. Psychopathology problems were assessed at age 15. Irritability and social disinhibition were self-reported at age 12. Emerging adulthood outcomes were measured at age 21. Latent class modeling indicated four patterns: Normative (57%), substance-use (SU; 24%), mental-health-problems-without-substance-use (MH; 11%), and substance-use-and-other-mental-health-problems (SUMH; 7%). Higher irritability increased the odds of developing the MH pattern, whereas higher social disinhibition increased the odds of developing the SU pattern. The odds of manifesting the SUMH pattern were higher for children with higher irritability. For children with higher social disinhibition, the odds of manifesting the SUMH pattern were higher at a trend level. Adolescent comorbidity patterns were differentially associated with problematic tobacco and marijuana use and clinically relevant mental health problems in emerging adulthood, and completion of high school education. Peri-pubertal identification of individual differences in irritability and social disinhibition may mitigate the emergence of adolescent psychopathology, which could influence emerging adulthood adjustment in this at-risk population.

Addressing Barriers to Primary Care Screening and Referral to Prevention for Youth Risky Health Behaviors: Evidence Regarding Potential Cost-Savings and Provider Concerns.

Despite growing evidence and support for co-locating behavioral services in primary care to prevent risky health behaviors, implementation of these services has been limited due to a lack of reimbursement for services and negative perceptions among providers. We investigated potential to overcome these barriers based on new developments in healthcare funding and screening and referral to prevention (SRP) in primary care based on the Consolidated Framework for Implementation Research (CFIR), which could guide future SRP implementation strategies. To investigate the economic need for healthcare-based SRP, we quantified hospital charges to healthcare payors for services arising from adolescent risky behaviors (e.g., substance use, risky sex). Annual North Carolina (NC) hospital charges for these services exceeded $327 M (2019 dollars), suggesting high potential for cost savings if SRP can curb hospital services associated with risky behaviors. To investigate provider barriers and facilitators, we surveyed 151 NC pediatricians and 230 NC family therapists about their attitudes regarding a recently developed well-child visit SRP with family-based prevention. Both sets of professionals reported widespread need for and interest in the SRP but cited barriers of lack of reimbursement, training, and referrals to/from each other. Physicians, but not family therapists, reported concerns with poor patient or parent compliance. Many barriers could be resolved by co-locating family therapists in pediatric clinics to conduct well-child SRP. Our results support further research to develop business models for payor-funded SRP and CFIR-guided research to develop implementation strategies for primary care SRP to prevent adolescent risky health behaviors.

Adolescent and Young Women's Daily Reports of Emotional Context and Episodes of Dating Violence.

PURPOSE: To investigate same day, previous day, and next day associations between trust, closeness, commitment, jealousy and provision of instrumental support with dating violence victimization and perpetration. METHOD: A convenience sample of young women, 16-19 years, in a heterosexual dating relationship with at least one act (past month) of physical or psychological victimization or perpetration, were recruited from urban public locations. Participants answered questions daily via text continuously for four months on dating violence and partner-specific emotions. Daily surveys asked about trust, closeness, commitment for their partner, jealousy, perceptions of partner's jealousy and provision of instrumental support to and from partner, and dating violence victimization and perpetration. Multilevel modeling examined within-relationship associations over time. RESULTS: Mean (sd) age for the full sample was 18.1 (1.1) years. Same-day emotional context (trust, closeness, commitment, jealousy and provision of instrumental support) was more strongly associated with victimization and perpetration compared to previous day emotions. Strongest same-day positive associations were with partner's perpetration, both partner's jealousy, and females' instrumental support. Partner's jealousy and increased trust were best predictors of next day victimization. Closeness, commitment and trust went down on the day of violence. Perpetration was positively associated with next day commitment. Victimization was positively associated with next day trust. CONCLUSIONS: This event-level analysis demonstrates the role and timing that emotional aspects of adolescent relationships - including positive feelings - have surrounding episodes of dating violence. This granular understanding of the emotional context of dating violence has the potential to facilitate development of effective, developmentally appropriate interventions.

Personal preferences for Personalised Trials among patients with chronic diseases: an empirical Bayesian analysis of a conjoint survey.

OBJECTIVE: To describe individual patient preferences for Personalised Trials and to identify factors and conditions associated with patient preferences. DESIGN: Each participant was presented with 18 conjoint questions via an online survey. Each question provided two choices of Personalised Trials that were defined by up to eight attributes, including treatment types, clinician involvement, study logistics and trial burden on a patient. SETTING: Online survey of adults with at least two common chronic conditions in the USA. PARTICIPANTS: A nationally representative sample of 501 individuals were recruited from the Chronic Illness Panel by Harris Poll Online. Participants were recruited from several sources, including emails, social media and telephone recruitment of the target population. MAIN OUTCOME MEASURES: The choice of Personalised Trial design that the participant preferred with each conjoint question. RESULTS: There was large variability in participants' preferences for the design of Personalised Trials. On average, they preferred certain attributes, such as a short time commitment and no cost. Notably, a population-level analysis correctly predicted 62% of the conjoint responses. An empirical Bayesian analysis of the conjoint data, which supported the estimation of individual-level preferences, improved the accuracy to 86%. Based on estimates of individual-level preferences, patients with chronic pain preferred a long study duration (p≤0.001). Asthma patients were less averse to participation burden in terms of data-collection frequency than patients with other conditions (p=0.002). Patients with hypertension were more cost-sensitive (p<0.001). CONCLUSION: These analyses provide a framework for elucidating individual-level preferences when implementing novel patient-centred interventions. The data showed that patient preference in Personalised Trials is highly variable, suggesting that individual differences must be accounted for when marketing Personalised Trials. These results have implications for advancing precise interventions in Personalised Trials by indicating when rigorous scientific principles, such as frequent monitoring, is feasible in a substantial subset of patients.

Characterizing psychiatric symptoms and neurocognitive functioning among substance-naïve early adolescents: Associations with sleep problems.

AIM: Evidence consistently links psychiatric symptoms, reduced neurocognitive functioning (NCF) and sleep problems to the initiation of a wide range of risk behaviours. Less is known, however, about the associations between sleep problems with psychiatric symptoms and NCF among early adolescents yet to engage in substance use. METHODS: The present study examined baseline data from an ongoing prospective study of 529 youth aged 10-12 years who completed a battery of instruments measuring symptom counts for four psychiatric disorders, performance on six tests of NCF and five types of sleep behaviour on week days. We used latent class analysis to classify the 473 substance-naïve youth into subtypes characterized by probabilistic patterns of psychiatric symptoms and poorer NCF. RESULTS: Four subtypes emerged: normative (24% of the sample); nonspecific mental health symptoms (27%); lower neurocognitive function (24%) and comorbid psychiatric symptoms and lower neurocognitive function (25%). In a multivariable latent regression model, three or more sleep arousals per night, sleep phase of two or more hours and sleep latency of 20 minutes or more were significantly associated with the two classes having higher symptom counts. Lack of family support was significantly associated with the two classes having lower neurocognitive function and comorbid psychiatric symptoms. CONCLUSIONS: The youth subtypes in this study provide an important baseline characterization to subsequently understand how these neuropsychiatric relationships may change when substance use and other risk behaviours develop during adolescence. Implications for preventing and treating sleep problems associated with psychiatric comorbidity and neurocognitive dysfunctions are discussed.

Associations between Child Maltreatment, Harsh Parenting, and Sleep with Adolescent Mental Health.

Youth who suffer from psychiatric disorders are at high risk for negative outcomes, including aggression and substance abuse. Although many youth with psychiatric disorders have endured harsh parenting and/or child maltreatment (CM), differential associations between these experiential factors have yet to be fully explored. Sleep problems have also been implicated in psychiatric disorders and are consistently associated with CM. The overlap and unique contributions of CM and sleep problems to the mental health of youth remains unclear; longitudinal studies from late childhood into adolescence, when psychiatric illnesses frequently onset, are rare. The current longitudinal study examined associations of CM, harsh parenting, and sleep problems with symptoms of four psychiatric disorders: Conduct Disorder, Attention Deficit Hyperactivity Disorder, Anxiety, and Depression. Early adolescent youth with no history of substance use (N = 529) were sampled from a working class, medium-sized city in northern Kentucky, and an extensive battery of tests were administered to youth and a parent. CM was more strongly and consistently related to psychiatric disorder symptoms at baseline than was harsh parenting. Reports of harsh parenting were more strongly associated with externalizing symptoms than internalizing symptoms. Sleep problems were also positively associated with psychiatric disorder symptoms at baseline, but did not exacerbate the effects of CM or harsh parenting on symptom counts. Longitudinally, harsh parenting was more predictive of change in psychiatric symptoms two to three years later than was CM. The potential significance of childhood adversity and sleep problems for prevention of later mental health problems are discussed.

Residential Transience Among Adults: Prevalence, Characteristics, and Association with Mental Illness and Mental Health Service Use.

This study examined the association between frequent residential mobility (i.e., residential transience) and mental illness, mental health service use, and unmet need for services. Data are from the 2010 to 2014 National Surveys on Drug Use and Health (n = ~ 229,600). Logistic regression models examined the relationship between proximal (past year) and distal (past 2-5 years) residential transience and past year any mental illness (AMI), serious mental illness (SMI), mental health service use among adults with mental illness, and unmet need for services. Adults with transience had greater odds of AMI and SMI than those without transience. Proximal and distal transience were unrelated to past year mental health service use among adults with mental illness, but the odds of unmet need for services were greater among adults with transience compared with those without, suggesting a level of unmet service need among those with transience.

Association With Deviant Peers Across Adolescence: Subtypes, Developmental Patterns, and Long-Term Outcomes.

Indices of deviant peer group involvement are inconsistent and confound type, frequency, and severity of deviant peer behaviors. These measurement approaches thus obfuscate potential meaningful differences in deviant peer involvement in terms of subtypes, developmental patterns, and long-term outcomes. The current study employed latent class analysis to derive subtypes of deviant peer involvement and examined relations to substance use disorder in adulthood, a common outcome of deviant peer involvement. Youth (76% Caucasian) completed assessments across four time points: ages 10-12 years (Time 1; N = 775, 71% male), 12-14 years (Time 2; n = 649, 72% male), 16 years (Time 3; n = 613, 73% male), and 22 years (Time 4; n = 425, 71% male). At Times 1 to 3, participants completed an interview assessing deviant peer involvement. At Time 4, participants completed a structured interview assessing substance use disorder. Classes of youth with different profiles of deviant peer associations were derived at Times 1, 2, and 3. Classes varied by type (conduct problems vs. substance use) and severity of deviant peer behavior. Youth reported higher levels of involvement with deviant peers across adolescence, suggesting that some of these deviant peer behaviors may be normative. Earlier involvement with deviant peers and involvement with groups defined by severe conduct problems and substance use were related to the greatest risk for substance use disorder at Time 4. Type and severity of peer deviant behavior differentially relate to long-term risk for substance use disorder and should be included in screening and assessment for risk across adolescence.

Randomized controlled trial of emotionally focused couple therapy compared to treatment as usual for depression: Outcomes and mechanisms of change.

This randomized controlled trial examined the effectiveness of Emotionally Focused Therapy (EFT) for depression and relationship satisfaction versus usual care (i.e., couple therapy other than EFT), and explored mechanisms of change. Mixed model trajectory analyses of 16 couples indicated EFT was associated with greater improvement in relationship satisfaction among men and women. Men receiving EFT reported greater improvements in depressive symptoms compared to usual care. Unified structural equation modeling revealed changes in relationship satisfaction preceded changes in depressive symptoms in one cluster of partners, while changes in depression preceded changes in relationship satisfaction in a second cluster. Two other clusters reported simultaneous changes in satisfaction and depression. This study provides encouraging results on the effectiveness of EFT for depression, and insight into mechanisms of change.

Residential Transience and Substance Use Disorder Are Independently Associated with Suicidal Thoughts, Plans, and Attempts in a Nationally Representative Sample of U.S. Adults.

This study tests the association between past-year residential transience (RT), substance use disorder (SUD), major depressive episode (MDE), and suicidal outcomes in a nationally representative sample of noninstitutionalized, civilian, community-dwelling adults who participated in the 2008-2013 National Surveys on Drug Use and Health. RT, SUD, and MDE were each significantly associated with suicidal thoughts, plans, and attempts in models adjusted for each other and sociodemographic covariates. Because RT is independently associated with each suicidal outcome, even when there is no co-occurring SUD or MDE, assessment of RT should occur when screening for suicide.