National trends and correlates of treatment resistance in major depressive episode and associated suicidal ideation and behaviors among adults in the United States.

OBJECTIVE: To examine recent 12-year trends in prevalence of suicidal ideation and behaviors (SIBs) among US adults experiencing a past-year treatment-resistant depression (TRD). METHODS: Using data from the National Survey of Drug Use and Health, we estimated the annual percentage of individuals aged ≥18 with TRD who reported past-year SIBs, and estimated linear trends adjusting for potentially confounding factors from 2009 to 2020. RESULTS: Of estimated 237.5 million US adults, 7.1 % met diagnostic criteria for a past-year major depressive episode (MDE) between 2009 and 2020. Of these, 9.7 % met criteria for TRD. The proportion reporting past-year suicidal ideation in TRD ranged from 39.5 % (95 % confidence interval [CI], 32.1-47.3 %) in 2009-2010 to 43.4 % (95 % CI, 36.7-503 %) in 2019-2020, with an average annual percent change (AAPC) of 1.3 % (95 % CI, -0.7 % to 3.3 %). The prevalence of past-year suicide attempts in TRD was 7.3 % across the study period (AAPC, 0.1 %; 95 % CI, -4.3 % to 4.7 %). Past-year SIBs were significantly associated with an increased likelihood of meeting criteria for TRD among adults with MDE (adjusted odds ratio [AOR], 1.53; 95 % CI, 1.35-1.75 for suicidal ideation; AOR, 2.17; 95 % CI, 1.79-2.62 for suicide attempts). No significant differences were observed between 2019 and 2020, reflecting the COVID-19 pandemic. CONCLUSION: Among individuals with TRD, proportions of SIBs are high. These findings underscore an urgent need for suicide prevention efforts in this high-risk population, including preventive services across diverse settings and accessibility to evidence-based pharmacological and non-pharmacological interventions.

Association of mental health related quality of life and other factors with treatment seeking for substance use disorders: A comparison of SUDs rooted in legal, partially legal, and illegal substances.

The association of subjective mental health-related quality of life (MHRQOL) and treatment use among people experiencing common substance use disorders (SUDs) is not known. Furthermore, the association of a given substance's legal status with treatment use has not been studied. This work aims determine the association of MHRQOL with SUD treatment use, and how substance legal status modulates this relationship. Our analysis used nationally-representative data from the NESARC-III database of those experiencing past-year SUDs (n = 5,808) to compare rates of treatment use and its correlates among three groups: those with illicit substance use disorders (ISUDs); those with partially legal substance use disorders, i.e., cannabis use disorder (CUD); and those with fully legal substance use disorders, i.e., alcohol use disorder (AUD). Survey-weighted multiple regression analysis was used to assess the association of MHRQOL with likelihood of treatment use among these three groups, both unadjusted and adjusted for sociodemographic, behavioral, and diagnostic factors. Adults with past-year ISUDs were significantly more likely to use treatment than those with CUD and AUD. Among those with ISUDs, MHRQOL had no significant association with likelihood of treatment use. Those with past-year CUD saw significant negative association of MHRQOL with treatment use in unadjusted analysis, but not after controlling for diagnostic and other behavioral health factors. Those with past-year AUD had significant negative association of MHRQOL with treatment use in both unadjusted and adjusted analysis. If legalization and decriminalization continue, there may be a greater need for effective public education and harm reduction services to address this changing SUD landscape.

Efficacy and safety of ketamine-assisted electroconvulsive therapy in major depressive episode: a systematic review and network meta-analysis.

OBJECTIVE: To meta-analyze clinical efficacy and safety of ketamine compared with other anesthetic agents in the course of electroconvulsive therapy (ECT) in major depressive episode (MDE). METHODS: PubMed/MEDLINE, Cochrane Library, Embase, GoogleScholar, and US and European trial registries were searched from inception through May 23, 2023, with no language limits. We included RCTs with (1) a diagnosis of MDE; (2) ECT intervention with ketamine and/or other anesthetic agents; and (3) measures included: depressive symptoms, cognitive performance, remission or response rates, and serious adverse events. Network meta-analysis (NMA) was performed to compare ketamine and 7 other anesthetic agents. Hedges' g standardized mean differences (SMDs) were used for continuous measures, and relative risks (RRs) were used for other binary outcomes using random-effects models. RESULTS: Twenty-two studies were included in the systematic review. A total of 2322 patients from 17 RCTs were included in the NMA. The overall pooled SMD of ketamine, as compared with propofol as a reference group, was -2.21 (95% confidence interval [CI], -3.79 to -0.64) in depressive symptoms, indicating that ketamine had better antidepressant efficacy than propofol. In a sensitivity analysis, however, ketamine-treated patients had a worse outcome in cognitive performance than propofol-treated patients (SMD, -0.18; 95% CI, -0.28 to -0.09). No other statistically significant differences were found. CONCLUSIONS: Ketamine-assisted ECT is tolerable and may be efficacious in improving depressive symptoms, but a relative adverse impact on cognition may be an important clinical consideration. Anesthetic agents should be considered based on patient profiles and/or preferences to improve effectiveness and safety of ECT use.

Emergency Department Use Among Recently Homeless Adults in a Nationally Representative Sample.

Introduction: In this study we examined the association of homelessness and emergency department (ED) use, considering social, medical, and mental health factors associated with both homelessness and ED use. We hypothesized that social disadvantage alone could account for most of the association between ED use and homelessness. Methods: We used nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Emergency department use within the prior year was categorized into no use (27,674; 76.61%); moderate use (1-4 visits: 7,972; 22.1%); and high use (5 or more visits: 475; 1.32%). We used bivariate analyses followed by multivariable-adjusted logistic regression analyses to identify demographic, social, medical, and mental health characteristics associated with ED use. Results: Among 36,121 respondents, unadjusted logistic regression showed prior-year homelessness was strongly associated with moderate and high prior-year ED use (odds ratio [OR] 2.31 and 7.34, respectively, P < 0.001). After adjusting for sociodemographic factors, the associations of homelessness with moderate/high ED use diminished (adjusted OR [AOR] 1.27 and 1.62, respectively, both P < 0.05). Adjusting for medical/mental health variables, alone, similarly diminished the association between homelessness and moderate/high ED use (AOR 1.26, P < .05 and 2.07, P < 0.001, respectively). In a final stepwise model including social and health variables, homelessness was no longer significantly associated with moderate or high ED use in the prior year. Conclusion: After adjustment for social disadvantage and health problems, we found no statistically significant association between homelessness and ED use. The implications of our findings suggest that ED service delivery must address both health issues and social factors.

Characterization of quality of life among individuals with current treated, untreated, and past alcohol use disorder.

Background: Understanding health-related quality of life (HRQOL) among those who seek treatment for their alcohol use disorder (AUD) and those not seeking AUD treatment is critical to decreasing morbidity and mortality, yet HRQOL in these groups has been little characterized.Objectives: Characterize HRQOL among those who meet diagnostic criteria for AUD, both receiving and not receiving treatment.Methods: This analysis used the NESARC-III database (n = 36,309; female = 56.3%), a nationally representative survey of US adults, to compare four groups: those treated for current AUD; those untreated for current AUD; those with past AUD only; and those who never met criteria for AUD. Multiple regression analysis was used to account for differences in sociodemographic and other behavioral factors across these groups. HRQOL was operationalized using annual quality-adjusted life years (QALYs).Results: Patients treated for past-year AUD had a deficit of 0.07 QALYs/year compared to those who never met criteria for AUD (P < .001). They retained a still clinically meaningful 0.03 QALYs/year deficit after controlling for concomitant psychiatric disorders and other behavioral health factors (P < .001). Those with past-year untreated AUD or past AUD had a near-zero difference in QALYs compared with those who never met criteria for AUD.Conclusion: These findings suggest that previously-reported differences in HRQOL associated with AUD may be due to the problems of the relatively small sub-group who seek treatment. Clinicians seeking to treat those with currently untreated AUD may do better to focus on the latent potential health effects of AUD instead of current HRQOL concerns.

Abbreviation: AUD: alcohol use disorder; HRQOL- health-related quality of life; NESARC-III: National Epidemiologic Survey on Alcohol and Related Conditions Wave III; SF-12: 12-Item Short Form Survey; SF-6D: Short-Form Six-Dimension; QALYs: Quality adjusted life years; AUDADIS-5: Alcohol Use Disorder and Associated Disabilities Interview Schedule-5; NIAAA: National Institute on Alcohol Abuse and Alcoholism; MCS: mental component summary; PCS: physical component summary; EuroQOL-5D: EuroQOL 5-Dimension; SUD: substance use disorder.

Monotonic Association of Increasing Past-Year Substance Use Disorder across a Four-Level Trauma Post-Traumatic Stress Disorder (PTSD) Hierarchy in a Nationwide Sample.

OBJECTIVE: There is limited information on the differences in the association of substance use disorders (SUD) with four clinically relevant hierarchical groups based on trauma exposure and its consequences (1-no trauma; 2-trauma but no PTSD; 3-remitted PTSD; and 4-current PTSD). METHODS: Among adults enrolled in a large nationally representative survey, the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC III), we compared differences in SUD prevalence between each of the hierarchical trauma group and the prior group adjusting for potentially confounding factors. RESULTS: Unadjusted results show that each increase in the hierarchy was associated with a greater likelihood of SUD diagnoses, even after adjusting for potentially confounding variables. However, after adjusting for covariates, comparison of adults with past to those with current PTSD showed persistence of SUD indicators. CONCLUSION: SUD prevalence increased substantially with trauma exposure even without PTSD and monotonically increased further with past and current PTSD, respectively, illustrating the differential effect of the clinical consequences of trauma.

Rising Rates of Suicidal Behaviors and Large Unmet Treatment Needs Among US Adults With a Major Depressive Episode, 2009 to 2020.

OBJECTIVE: To examine recent 12-year trends in the incidence of suicidal ideation (SI) and suicide attempts (SAs) and receipt of mental health treatment among individuals experiencing a past-year major depressive episode (MDE). PATIENTS AND METHODS: Using data from the National Survey of Drug Use and Health, we estimated the annual percentage of individuals with MDE who reported past-year SI or SAs and their use of mental health services from 2009 to 2020 and calculated odds ratios (ORs) for longitudinal change adjusting for potentially confounding factors. RESULTS: During our study period, the weighted unadjusted proportion of patients with a past-year MDE who reported SI increased from 26.2% (668,690 of 2,550,641) to 32.5% (1,068,504 of 3,285,986; OR, 1.38; 95% CI, 1.25 to 1.51) and remained significant in the multivariable-adjusted analysis (P<.001). The greatest increase in SI was seen among Hispanic patients, young adults, and individuals with alcohol use disorder. Similar trends were seen for past-year SAs, increasing from 2.7% (69,548 of 2,550,641) to 3.3% (108,135 of 3,285,986; OR, 1.29; 95% CI, 1.04 to 1.61), especially among Black individuals, patients with incomes greater than $75,000, and those with substance use disorders. In multivariable-adjusted analyses, the temporal trend of increasing SI and SAs remained significant (P<.001 and P=0.04, respectively). Among individuals with past-year SI or SAs, there was no notable change in the mental health service use, and over 50% of individuals with MDE and SI (2,472,401 of 4,861,298) reported unmet treatment needs. No notable differences were observed between 2019 and 2020, reflecting the coronavirus disease 2019 pandemic. CONCLUSION: Among individuals with MDE, rates of SI and SAs have increased, especially among racial minorities and individuals with substance use disorders, without a corresponding change in mental health service use.

Association of Recent and Past Suicide Attempts With Health-Related Quality of Life.

Background: Suicide prevention is a major public health priority. The effectiveness of suicide prevention initiatives is typically assessed by reductions in incidents of suicidal behavior. However, the association of suicide attempts with changes in measures of overall health-related quality of life (HRQOL) has been understudied.Methods: Nationally representative data from 36,309 adults from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) were used to compare 3 groups: individuals with any suicide attempt in the past 3 years, individuals with a suicide attempt prior to the past 3 years, and those with no prior attempts. Using the 12-item Short Form (SF-12) items, standard measures of mental component score (MCS) and physical component score (PCS) of HRQOL and of quality-adjusted life-years (QALYs) were constructed and compared across these groups. Multivariable regression analyses adjusted scores for sociodemographic, diagnostic, and behavioral covariates.Results: Overall, 1.0% (n = 355) reported an attempt in the last 3 years, 4.3% (n = 1,569) reported an attempt prior to the past 3 years, and 94.7% (n = 34,385) had no prior attempt. In unadjusted analysis, individuals with recent attempts reported much lower MCS scores compared to individuals with no prior attempts (-13.5 points; 95% confidence interval [CI], -15.4 to -11.6) as well as those with past attempts (-7.7 points; 95% CI, -8.5 to -7.0). QALYs were also much lower (-0.13; 95% CI, -0.14 to -0.11 for those with recent attempts and -0.09; 95% CI, -0.10 to -0.08 for those with past attempts, respectively). Adjustment for correlated factors, especially psychiatric disorders and substance use disorders, accounted for 75%-86% of the association of recent and past suicide attempts with MCS-HRQOL and 89%-91% of QALYs; ie, these factors were largely incorporated in these measures of HRQOL.Conclusions: Individuals with relatively recent suicide attempts report significantly lower MCS-HRQOL and QALYs compared to both individuals with no prior attempts and individuals with more remote attempts. Psychiatric and substance use comorbidities account for most but not all of the group differences in these measures and thus provide a brief approach to assessing suicide prevention initiatives encompassing multiple aspects of well-being and providing a basis for future cost-benefit analysis.

Increasing Use of Cannabis for Medical Purposes Among U.S. Residents, 2013-2020.

INTRODUCTION: Cannabis use for medical purposes is legalized across 39 states and the District of Columbia in the U.S. The objective of this study was to evaluate temporal trends and correlates of cannabis use for medical purposes in the U.S. METHODS: Data from the 2013-2020 National Survey on Drug Use and Health were used. Since 2013, medical cannabis use has been assessed using a dichotomous question asking whether any medical cannabis use was recommended by a doctor among those who used cannabis in the past 12 months. A modified Poisson model was used to estimate the average annual percentage change in medical cannabis use from 2013 to 2020. The analyses were repeated for key sociodemographic and clinical subgroups. Data were analyzed from September to November 2022. RESULTS: The prevalence of U.S. residents using cannabis for medical purposes increased significantly from 1.2% in 2013-2014 to 2.5% in 2019-2020, with an average annual percentage change of 12.9% (95% CI=10.4, 15.5), and many of sociodemographic and clinical subgroups showed similar significant increases in cannabis use for medical purposes. In the multivariable-adjusted model, living in a state that legalized medical cannabis remained significantly associated with medical cannabis use (AOR=4.10; 95% CI=3.68, 4.56). CONCLUSIONS: The study documents a continued nationwide increase in the use of cannabis for diverse medical purposes between 2013 and 2020, two decades after the first state passed legalizing legislation.

Mental health problems of black and white children in a nationally representative epidemiologic survey.

Black children face more numerous socio-economic disadvantages than White children, but whether they have more adverse mental health problems remains understudied. Using nationally-representative data from the 2018-2019 National Survey of Children's Health, we examined differences in mental health problems between non-Hispanic Black (n = 2,890) and White (n = 30,015) children aged 6-17. Multivariate analyses were used to determine whether differences in mental health conditions could be accounted for by other factors. We found Black children were significantly less likely than White children to have clinically-identified internalizing conditions (especially anxiety) and more likely to be identified with conduct problems. Black children were also substantially more likely to have greater exposure to adverse childhood experiences (ACEs), to be uninsured, experience poverty, and less likely to receive needed mental health services. After adjusting for these potential confounders, Black children remained half as likely to have clinically-recognized internalizing conditions, but were no longer more likely to have clinically-identified conduct problems. Differences in ACEs alone fully accounted for the racial difference in conduct problems. These results point to the potential impact of assessment bias by clinicians and underscore the potential benefit of routine screening for depression/anxiety in racial/ethnic minority children, especially in light of rising suicide rates among Black youth.

Multimorbidity and Correlates of Comorbid Depression and Generalized Anxiety Disorder in a Nationally Representative US Sample.

ABSTRACT: Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently occur together, but sociodemographic, behavioral, and diagnostic correlates of this comorbidity have not been comprehensively studied. Data from the nationally representative US sample surveyed in the National Epidemiologic Survey on Alcohol and Related Conditions-III ( N = 36,309) were used to define three groups, individuals with a) both past-year GAD and MDD ( n = 909, 16.9%), b) GAD only ( n = 999, 18.6%), and c) MDD only ( n = 3471, 64.5%). The comorbid group was compared with each single-diagnosis group on sociodemographic, behavioral, and diagnostic characteristics based on effect sizes (risk ratios and Cohen's d ) rather than p values because of the large sample sizes. Multivariable-adjusted logistic regression analyses were used to identify factors independently associated with the comorbid group. Bivariate analysis showed that the comorbid group had more parental and childhood adversities, additional psychiatric disorders, and poorer mental health quality of life than both single-disorder groups. Multivariable-adjusted logistic regression of the comorbid group showed that on two of five factors, additional psychiatric diagnoses were significantly more frequent than in the GAD-only group, and that on three of six factors, additional psychiatric diagnoses were significantly more frequent than in the MDD-only group. There is a significantly higher burden of social adjustment problems, comorbid psychiatric disorders, and poorer mental health-related quality of life among individuals with comorbid GAD-MDD than those with single disorders. The adversities associated with this non-SUD psychiatric comorbidity are comparable to those associated with the more extensively studied comorbidity of psychiatric and substance use disorders and deserve further research and treatment.

Gender differences in outcomes of early intervention services for first episode psychosis.

AIMS: There is growing interest in early intervention in psychotic disorders. However, gender differences in the outcomes of such treatment have not been studied in a randomized clinical trial. METHODS: Patients diagnosed with schizophrenia spectrum disorders with less than 6 months antipsychotic exposure entered a cluster randomized trial of early intervention services compared to usual care in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study. Masked evaluators assessed the Quality of Life Scale (QLS) and the Positive and Negative Syndrome Scale (PANSS) every 6 months. Our secondary analyses examined gender differences in baseline characteristics, 2-year gender outcomes, and intervention responses. RESULTS: Altogether 404 individuals aged 15-40 entered the study: 111 (27.4%) women and 293 (72.5%) men. At baseline, women were significantly more likely to have been married (p = .007) and to be living independently (p = .012) than men. Women were also more likely to be diagnosed with schizoaffective disorder, bipolar type (p = .006) and scored higher on the depression subscale of the PANSS (p = .0004) but not the CDSS. Women were less likely to use or abuse cannabis (p = .0004), though no less likely to abuse alcohol. Controlling for these differences, there were no significant gender differences in the QLS or PANSS outcomes. CONCLUSION: Baseline gender differences in comorbid substance use and prevalence of mood symptoms in women with first episode psychosis are consistent with previous studies. The absence of significant gender differences in outcomes with early intervention has not been previously reported in a multi-site randomized US clinical trial.

Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers.

OBJECTIVE: Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap. METHODS: Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378). RESULTS: Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia. CONCLUSIONS: VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.

Comparison of Black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use.

BACKGROUND: While there is increasing recognition of disparities in healthcare for Black Americans, there have been no comparisons in a nationally representative U.S. sample of Black and White adults with clinical diagnoses of schizophrenia. METHODS: Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we compared Black (n = 240, 36.2%) and White (n = 423, 63.8%) adults who report having been told by a physician that they have schizophrenia. Due to the large sample size, effect sizes (risk ratios and Cohen's d), rather than p-values, were used to identify the magnitude of differences in sociodemographic and clinical characteristics, including experiences of discrimination and service use. Multivariate analyses were used to identify independent factors. RESULTS: Black individuals with diagnoses of schizophrenia reported multiple sociodemographic disadvantages, including lower rates of employment, educational attainment, income, marriage, and social support, with little difference in incarceration, violent behavior, and quality of life. They reported much higher scores on a general lifetime discrimination scale (Cohen's d = 0.75) and subscales representing job discrimination (d = 0.85), health system discrimination (d = 0.70), and public race-based abuse (d = 0.55) along with higher rates of past year alcohol and drug use disorders, but lower rates of co-morbid psychiatric disorders. Multivariable-adjusted regression analyses highlighted the independent association of Black race with measures of discrimination and religious service attendance; less likelihood of receiving psychiatric treatment (p = 0.02) but no difference in substance use treatment. CONCLUSION: Black adults with schizophrenia report numerous social disadvantages, especially discrimination, but religious service attendance may be an important social asset.

Racial and ethnic differences in suicidal behavior and mental health service use among US adults, 2009-2020.

BACKGROUND: While suicide rates have recently declined for White individuals, rates among Black and Hispanic individuals have increased. Yet, little is known about racial/ethnic differences in precursors to suicide, including suicidal ideation (SI) and suicide attempts (SA). METHODS: Data from 2009-2020 National Survey of Drug Use and Health (NSDUH) consisted of non-institutionalized US civilians aged ⩾18 (n = 426 008). We compared proportions of White, Black, and Hispanics among adults reporting no past-year suicidal thoughts/behavior, SI, and SA. Multivariable-adjusted analyses were used to evaluate the independence of observed racial/ethnic differences in past-year SI, SA, and mental health service use. RESULTS: In the entire sample, 20 791 (4.9%) reported past-year SI only and 3661 (0.9%) reported a SA. Compared to White individuals, Black and Hispanic individuals were significantly less likely to report past-year SI [OR 0.73 (95% CI 0.69-0.77); OR 0.75 (95% CI 0.71-0.79), respectively], but more likely to report a past-year SA [OR 1.45 (95% CI 1.28-1.64); OR 1.19 (95% CI 1.04-1.37), respectively] even after multivariable adjustment. Black and Hispanic individuals were significantly less likely to use mental health services, but the lack of significant interactions between race/ethnicity and SI/SA in association with service use suggests differences in service use do not account for differences in SI or SA. CONCLUSIONS: Black and Hispanic individuals are significantly less likely than White individuals to report SI but more likely to report SAs, suggesting differences in suicidal behavior across race/ethnicity that may be impacted by socio-culturally acceptable expressions of distress and structural racism in the healthcare system.

Rates and correlates of dual diagnosis among adults with psychiatric and substance use disorders in a nationally representative U.S sample.

Treatment needs of adults diagnosed with both psychiatric and substance use disorders (i.e., dual diagnosis) have not received detailed characterization in a nationally representative US sample. Data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III were used to compare socio-behavioral, diagnostic, and service use characteristics of dually diagnosed adults to those with psychiatric disorders or SUDs alone. Adults with dual diagnosis were estimated to constitute 25.8% of those with any psychiatric disorder; 36.5% of those with any SUD and 17.8% of the 75.8 million adults with either disorder. Among those with psychiatric disorders, the independent correlates of dual diagnosis reflected substantial social or psychopathological disadvantages (e.g., violent behavior, poor mental health-related quality of life [HRQOL], police trouble, homelessness, and incarceration). Similarly, among those with SUD all independent correlates of dual diagnosis also reflected social or psychopathological disadvantages including poor mental HRQOL, witnessing trauma in childhood, childhood sex abuse, drug use diagnoses, suicide attempt, medical problems, having more than one SUD diagnosis, child neglect, repeated adult traumas, and less social support. Provision of medical, psychiatric, addiction and especially diverse social services in an integrated and accessible setting appear necessary and deserve further study.

Women's Use of Substance Use Disorder Treatment Services: Rates, Correlates, and Comparisons to Men.

In spite of evidence of increasing prevalence of substance use disorders (SUDs) among women, there is little information on gender differences in SUD treatment use. Nationally representative survey data were used to compare specialized SUD treatment among women and men with past-year DSM-5 SUD diagnoses (N = 5,789, 42.8% women). An estimated 10.7% of women and 9.9% of men (p = 0.45) received SUD treatment. Those who received treatment among both men and women had more problems than others. Five variables were independently associated with receipt of past-year treatment in both women and men and while five others were independently associated with receipt of treatment for only one gender. Interaction analysis, however, revealed no statistically significant gender differences in any correlate of treatment receipt. Although men were more likely to have SUDs than women, there were no significant differences by gender in rates or correlates of service use.

Outcomes During and After Early Intervention Services for First-Episode Psychosis: Results Over 5 Years From the RAISE-ETP Site-Randomized Trial.

To examine long-term effects of early intervention services (EIS) for first-episode psychosis, we compared Heinrichs-Carpenter Quality of Life (QLS) and Positive and Negative Syndrome Scale (PANSS) scores and inpatient hospitalization days over 5 years with data from the site-randomized RAISE-ETP trial that compared the EIS NAVIGATE (17 sites; 223 participants) and community care (CC) (17 sites; 181 participants). Inclusion criteria were: age 15-40 years; DSM-IV diagnoses of schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified; first psychotic episode; antipsychotic medication taken for ≤6 months. NAVIGATE-randomized participants could receive NAVIGATE from their study entry date until NAVIGATE ended when the last-enrolled NAVIGATE participant completed 2 years of treatment. Assessments occurred every 6 months. 61% of participants had assessments conducted ≥2 years; 31% at 5 years. Median follow-up length was CC 30 months and NAVIGATE 38 months. Primary analyses assumed data were not-missing-at-random (NMAR); sensitivity analyses assumed data were missing-at-random (MAR). MAR analyses found no significant treatment-by-time interactions for QLS or PANSS. NMAR analyses revealed that NAVIGATE was associated with a 13.14 (95%CI:6.92,19.37) unit QLS and 7.73 (95%CI:2.98,12.47) unit PANSS better improvement and 2.53 (95%CI:0.59,4.47) fewer inpatient days than CC (all comparisons significant). QLS and PANSS effect sizes were 0.856 and 0.70. NAVIGATE opportunity length (mean 33.8 (SD = 5.1) months) was not associated (P = .72) with QLS outcome; duration of untreated psychosis did not moderate (P = .32) differential QLS outcome. While conclusions are limited by the low rate of five-year follow-up, the data support long-term benefit of NAVIGATE compared to community care.

Why are women more likely to attempt suicide than men? Analysis of lifetime suicide attempts among US adults in a nationally representative sample.

OBJECTIVE: While it is well-known that women are more likely to attempt suicide than men, little is known about risk and protective factors underlying this difference. METHODS: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III), we compared women and men with and without self-reported lifetime suicide attempts to identify sociodemographic, clinical, and behavioral characteristics that were associated with suicide attempts for each gender. We then examined the interaction of gender and risk factors to identify specific factors that have a significantly different association with the risk of suicide attempts by gender. Multivariate analyses identified factors that were independently associated with a significant interaction of gender and risk of suicide attempt and the extent to which these interactions accounted for the greater risk of suicide attempts among women. RESULTS: In unadjusted analysis, women had 1.78 greater odds of self-reported lifetime suicide attempts than men (95% confidence interval (CI), 1.61-1.96). While men and women shared similar risk and protective factors for suicide attempts, several factors were associated with significantly different risks for women than men. In multivariate analysis, these factors only partially accounted for the gender difference in lifetime risk of suicide attempt (adjusted odds ratio, 1.53; 95% CI, 1.12-2.08). CONCLUSIONS: Several risk factors for suicide attempts appear to have significantly different magnitude of association among women and men; however, these differences only partially account for gender difference in risk for suicide attempts, suggesting that other factors, not measured in this study, are at play.

Admissions to substance use treatment facilities for cannabis use disorder, 2000-2017: Does legalization matter?

BACKGROUND AND OBJECTIVES: A growing number of US states have legalized marijuana use in the past decade. We examined if marijuana legalization is associated with increased marijuana-related admissions to substance use treatment facilities between 2000 and 2017. METHODS: Data from the Treatment Episode Data Set-Admissions were used to examine the relationship between marijuana-related admissions among adults aged ≥18 by year and legalization status (i.e., fully legalized, medical use only [partially legalized], and illegal) (N = 35,457,854). Using interaction analyses, we further examined whether certain patient characteristics were associated with residence in states that legalized marijuana use as compared to those in which marijuana remained illegal. RESULTS: Overall, the proportion of marijuana-related admissions in states with legalization decreased by 2.3% from 31.7% in 2000-2005 to 29.4% in 2012-2017 (odds ratio [OR], 0.90; 95% confidence intervals [CI], 0.89-0.90) with little difference from states where marijuana use remained illegal, in which marijuana use as any reason for admissions decreased by 0.3% from 39.8% in 2000-2005 to 39.5% in 2012-2017 (OR, 0.99; 95% CI, 0.98-0.99). We did not find any striking patient characteristics (e.g., referral by the police) associated with admissions in states that legalized compared to those that had not. DISCUSSION AND CONCLUSIONS: While earlier studies suggested that marijuana legalization is associated with increased levels of use, emergency department visits, and traffic fatalities, our findings suggest that marijuana legalization did not increase marijuana-related treatment use in the United States. SCIENTIFIC SIGNIFICANCE: This is the first study to examine the association of marijuana legalization with marijuana-related treatment use.