Foster Care and Health in Medicaid-Enrolled Children Experiencing Parental Opioid Use Disorder.

Importance: The burden of the US opioid crisis has fallen heavily on children, a vulnerable population increasingly exposed to parental opioid use disorder (POUD) in utero or during childhood. A paucity of studies have investigated foster care involvement among those experiencing parental opioid use during childhood and the associated health and health care outcomes. Objective: To examine the health and health care outcomes of children experiencing POUD with and without foster care involvement. Design, Setting, and Participants: This population-based cohort study used nationwide Medicaid claims data from January 1, 2014, to December 31, 2020. Participants included Medicaid-enrolled children experiencing parental opioid use-related disorder during ages 4 to 18 years. Data were analyzed between January 2023 and February 2024. Exposure: Person-years with (exposed) and without (nonexposed) foster care involvement, identified using Medicaid eligibility, procedure, and diagnostic codes. Main Outcomes and Measures: The main outcomes included physical and mental health conditions, developmental disorders, substance use, and health care utilization. The Pearson χ2 test, the t test, and linear regression were used to compare outcomes in person-years with (exposed) and without (nonexposed) foster care involvement. An event study design was used to examine health care utilization patterns before and after foster care involvement. Results: In a longitudinal sample of 8 939 666 person-years from 1 985 180 Medicaid-enrolled children, 49% of children were females and 51% were males. Their mean (SD) age was 10 (4.2) years. The prevalence of foster care involvement was 3% (276 456 person-years), increasing from 1.5% in 2014 to 4.7% in 2020. Compared with those without foster care involvement (8 663 210 person-years), foster care involvement was associated with a higher prevalence of developmental delays (12% vs 7%), depression (10% vs 4%), trauma and stress (35% vs 7%), and substance use-related disorders (4% vs 1%; P < .001 for all). Foster children had higher rates of health care utilization across a wide array of preventive services, including well-child visits (64% vs 44%) and immunizations (41% vs 31%; P < .001 for all). Health care utilization increased sharply in the first year entering foster care but decreased as children exited care. Conclusions and Relevance: In this cohort study of Medicaid-enrolled children experiencing parental opioid use-related disorder, foster care involvement increased significantly between 2014 and 2020. Involvement was associated with increased rates of adverse health outcomes and health care utilization. These findings underscore the importance of policies that support children and families affected by opioid use disorder, as well as the systems that serve them.

Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment.

Importance: The proportion of mental disorders and burden causally attributable to childhood maltreatment is unknown. Objective: To determine the contribution of child maltreatment to mental health conditions in Australia, accounting for genetic and environmental confounding. Design, Setting, and Participants: This meta-analysis involved an epidemiological assessment accounting for genetic and environmental confounding between maltreatment and mental health and 3 cross-sectional national surveys: the Australian Child Maltreatment Study (ACMS) 2023, National Study of Mental Health and Well-being 2020-2022, and Australian Burden of Disease Study 2023. Causal estimates were derived on the association between childhood maltreatment and mental health conditions from a meta-analysis of quasi-experimental studies. This was combined with the prevalence of maltreatment from the ACMS to calculate the population attributable fraction (PAF). The PAF was applied to the number and burden of mental health conditions in Australia, sourced from 2 population-based, nationally representative surveys of Australians aged 16 to 85 years, to generate the number and associated burden of mental disorders attributable to child maltreatment. Exposure: Physical abuse, sexual abuse, emotional abuse, or neglect prior to age 18 years. Main Outcomes and Measures: Proportion and number of cases, years of life lost, years lived with disability, and disability-adjusted life-years of mental health conditions (anxiety, depression, harmful alcohol and drug use, self-harm, and suicide attempt) attributable to childhood maltreatment. Results: Meta-analytic estimates were generated from 34 studies and 54 646 participants and applied to prevalence estimates of childhood maltreatment generated from 8503 Australians. Childhood maltreatment accounted for a substantial proportion of mental health conditions, ranging from 21% (95% CI, 13%-28%) for depression to 41% (95% CI, 27%-54%) of suicide attempts. More than 1.8 million cases of depressive, anxiety, and substance use disorders could be prevented if childhood maltreatment was eradicated. Maltreatment accounted for 66 143 years of life lost (95% CI, 43 313-87 314), primarily through suicide, and 184 636 disability-adjusted life-years (95% CI, 109 321-252 887). Conclusions and Relevance: This study provides the first estimates of the causal contribution of child maltreatment to mental health in Australia. Results highlight the urgency of preventing child maltreatment to reduce the population prevalence and burden of mental disorders.

Population Neuroscience: Understanding Concepts of Generalizability and Transportability and Their Application to Improving the Public's Health.

In population neuroscience, samples are not often selected with equal or known probability from an underlying population of interest; in other words, samples are not often formally representative of a specified underlying population. This chapter provides an overview of an epidemiological approach to considering the implications of selective participation on the value of our results for population health. We discuss definitions of generalizability and transportability, given the growing recognition that generalizability and transportability are central for interpreting data that are aiming to be population-based. We provide evidence that differences in the prevalence of effect measure modifiers between a study sample and a target population will lead to a lack of generalizability and transportability. We provide an example of an association between a poly-genetic risk score and depression, showing how an internally valid association can differ based on the prevalence of effect measure modifiers. We show that when estimating associations, inferences from a study sample to a population can depend on clearly defining a target population. Given that representative sampling from explicitly defined target populations may not be feasible or realistic in many situations, especially given the sample sizes needed for statistical power for many exposures of interest (and especially when interactions are being tested), researchers should be well versed in tools available to enhance the interpretability of samples regarding target populations.

Adverse childhood experiences among black sexually minoritized men and Black transgender women in Chicago.

BACKGROUND: Adverse childhood experiences (ACE) are important predictors of mental health outcomes in adulthood. However, commonly used ACE measures such as the Behavioural Risk Factor Surveillance System (BRFSS) have not been validated among Black sexually minoritized men (SMM) nor transgender women (TW), whom are known to have higher rates of ACE and poorer mental health outcomes. Assessing the psychometric properties of the measure is important for health equity research, as measurements that are not valid for some populations will render uninterpretable results. METHODS: Data are drawn from the Neighborhoods and Networks (N2) study, a longitudinal cohort of Black SMM and TW living in Southern Chicago. We conducted confirmatory factor analysis, correlation analysis and a two-parameter Item Response Theory (IRT) on the BRFSS ACE measure, an 11-item measure with 8 domains of ACE. RESULTS: One hundred forty seven participants (85% cisgender male) completed the BRFSS ACE measurement in the N2 study with age ranges from 16-34. The cohort were from a low socioeconomic background: about 40% of the cohort were housing insecure and made than $10,000 or less annually. They also have a high number of ACEs; 34% had endorsed 4 or more ACE domains. The three-factor structure fit the BRFSS ACE measure best; the measurement consisted of three subscales: of "Household Dysfunction", "Emotional / Physical", and "Sexual Abuse" (CFI = 0.975, TLI = 0.967, and RMSEA = 0.051). When the 8 domains of ACE were summed to one score, the total score was is correlated with depressive symptoms and anxiety scores, establishing concurrent validity. Item Response Theory model indicated that the "parental separation" domain had a low discrimination (slope) parameter, suggesting that this domain does not distinguish well between those with and without high ACE. CONCLUSIONS: The BRFFS ACE measure had adequate reliability, a well-replicated structure and some moderate evidence of concurrent validity among Black SMM and TW. The parental separation domain does not discriminate between those with high and low ACE experiences in this population. With changing population demographics and trends in marriage, further examination of this item beyond the current study is warranted to improve health equity research for all.

Bringing home the benefits: Do pro-family employee benefits mitigate the risk of depression from competing workplace and domestic labor roles?

Despite significant historical progress toward gender parity in employment status in the US, women remain more likely to provide domestic labor, creating role competition which may increase depression symptoms. Pro-family employee benefits may minimize the stress of competing roles. We tested whether depressive symptoms were higher among women with vs. without competing roles and whether this effect was greater among women without (vs. with) pro-family benefits. Data included employed women surveyed across 4 waves of the National Longitudinal Survey (2010-2019) (N=9884). Depression symptoms were measured with the Mental Health Inventory (MHI-5). The interaction between competing roles and pro-family employee benefits on depressive symptoms was also compared with non-family-related benefits, using marginal structural models to estimate longitudinal effects in the presence of time-varying confounding. MHI-5 scores were 0.56 points higher (95% CI=0.15, 0.97) among women in competing roles (vs. not). Among women without pro-family benefits, competing roles increased MHI-5 scores by 6.1-points (95% CI=1.14, 11.1). In contrast, there was no association between competing roles and MHI-5 scores among women with access to these benefits (MHI-5 difference=0.44; 95% CI=-0.2, 1.0). Results were similar for non-family-related benefits. Dual workplace and domestic labor role competition increases women's depression symptoms, though broad availability of workplace benefits may attenuate that risk.

Poverty and birth cohort effects of experiencing the 2007-2009 Great Recession during adolescence on major depressive episodes and mental health treatment of young adults in the United States.

PURPOSE: Household economic adversity during adolescence is hypothesized to be a risk factor for poor mental health later in life. To test this hypothesis, we conducted a quasi-experimental analysis of an economic shock, the Great Recession of 2007-2009. We tested if going through adolescence during the Great Recession was associated with increased risk of major depressive episodes (MDE) and mental health treatment in young adulthood with potential moderation by household poverty to explore differences by economic adversity. METHODS: We analyzed data on young adults age 18-29 years from the 2005-2019 National Survey on Drug Use and Health (N = 145,394). We compared participants who were adolescents during the recession to those followed-up prior to the recession. Regression analysis tested effect modification by household poverty status. RESULTS: Adolescent exposure to the Great Recession was associated with higher likelihood of MDE during young adulthood (aOR = 1.30, 95% CI = 1.23, 1.37); there was no relationship with mental health treatment. Effects on MDE were stronger among those in households with higher incomes compared to those living in poverty. CONCLUSION: Findings support the hypothesis that exposure to the Great Recession during adolescence may have increased risk for MDE, but raise questions about whether the mechanism of this association is economic distress.

Assessing Trends in Internalizing Symptoms among Racialized and Minoritized Adolescents: Results from the Monitoring the Future Survey 2005-2020.

Depressive symptoms have rapidly accelerated among recent US adolescent birth cohorts, yet there remains little understanding of trends among racialized and minoritized groups. These groups may experience depressive symptoms due to the deleterious effects of structural racism. Using 2005-2020 Monitoring the Future survey data, we examine all racialized groups using within-group analyses to observe trends in high depressive symptoms across cohorts. Generally, across racialized groups and ages, the odds of high depressive symptoms increased in recent birth cohorts. For example, among 15-16-year-old students racialized as American Indian or Alaska Native and Black-Hispanic/Latine, the 2003-2006 birth cohort had 3.08 (95% CI: 2.00, 4.76) and 6.95 (95% CI: 2.70, 17.88) times higher odds, respectively, of high depressive symptoms compared to the 1987-1990 birth cohorts. Moreover, in a given year 15-16-year-olds generally experienced the highest depressive symptoms compared to 13-14 and 17-18-year-olds, suggesting that age-effects peaked during mid-adolescence. Depressive symptoms increased among US adolescents by birth cohort, within all racialized and minoritized groups assessed. Public health efforts to reduce disparities may consider barriers such as structural racism that may impact the mental health of racialized/minoritized adolescents while increasing access to culturally competent mental health providers and school-based services.

Sex-Specific Depressive Symptom Trajectories Among Adolescents in Los Angeles County, 2013 to 2017.

Objective: After remaining stable for many years, the prevalence of depression among adolescents increased over the past decade, particularly among girls. In this study, we used longitudinal data from a cohort of high school students to characterize sex-specific trajectories of depressive symptoms during this period of increasing prevalence and widening gender gap in adolescent depression. Method: Using data from the Health and Happiness Cohort, a longitudinal 8-wave study of high school students residing in Los Angeles County from 2013 to 2017 (N = 3,393), we conducted a multiple-group, latent class growth analysis by sex to differentiate developmental trajectories in depressive symptoms scores measured by the Center for Epidemiological Studies- Depression (CES-D) scale (range, 0-60). Results: A 4-class solution provided the best model fit for both girls and boys. Trajectories among girls included low stable (35.1%), mild stable (42.8%), moderate decreasing (16.2%), and high arching (5.9%). Trajectories among boys included low stable (49.2%), mild increasing (34.7%), moderate decreasing (12.2%), and high increasing (3.9%). Average scores consistently exceeded or crossed the threshold for probable depression (≥16). Across comparable sex-specific trajectory groups, the average CES-D scores of girls were higher than those of boys, whose average scores increased over time. Conclusion: In a diverse cohort of students in Los Angeles County, depressive symptom trajectories were comparable to prior time periods but with a higher proportion of students in trajectories characterized by probable depression. Trajectories differed by sex, suggesting that future research should consider differential severity and onset of depression between boys and girls.

Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties.

BACKGROUND: The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS: Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS: Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS: Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.

Racial inequities in homicide rates and homicide methods among Black and White women aged 25-44 years in the USA, 1999-2020: a cross-sectional time series study.

BACKGROUND: In the USA, Black women aged 25-44 years are disproportionately murdered compared with their White counterparts. Despite ongoing efforts to reduce racial and structural inequities, the result of these efforts remains unclear, particularly in light of the COVID-19 pandemic. METHODS: This study examined a cross-sectional time series of homicide death rates, by race, from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research system. We included data for women aged 25-44 years between 1999 and 2020 among 30 states in the USA. Homicide death was classified using underlying cause and multiple cause of death codes; mortality rates were calculated per 100 000 based on US Census Bureau population sizes. Homicide methods were classified as firearm, cutting or piercing, and other. Firearm homicides were compared with other homicides with logistic regression including covariates of race, time, and their interaction. We report odds ratios and 95% CIs. FINDINGS: In 2020, the homicide rate among Black women was 11·6 per 100 000, compared with 3 per 100 000 among White women. This inequity has persisted over time and is virtually unchanged since 1999. Homicide inequities vary across US states; in 11 states, racial inequities have increased since 1999. The racial inequity was greatest in Wisconsin, where in 2019-20, Black women aged 25-44 years were 20 times more likely to die by homicide than White women. Homicide by firearm is increasing in frequency; women in the USA had 2·44 (95% CI 2·14-2·78) times the odds of homicide involving firearms in 2019-20 compared with 1999-2003. Firearm homicide deaths are disproportionately concentrated among Black women in every region in the USA. INTERPRETATION: Our findings suggest that there is an urgent need to address homicide inequities among Black and White women in the USA. Enacting federal legislation that reduces gun access is a crucial step. Policy makers must address long-standing structural factors that underpin elevated gun violence by implementing sustainable wealth-building opportunities; developing desegregated, mixed income and affordable housing; and increasing green spaces in communities where Black women largely reside. FUNDING: National Institute of Mental Health of the National Institutes of Health.

National and regional trends in seizures of shrooms (psilocybin) in the United States, 2017-2022.

BACKGROUND: Psilocybin, the principle psychoactive component in "shrooms", is regaining acceptance in therapeutic settings, leading to media coverage of medical benefits associated with use. Possession is also becoming increasingly decriminalized throughout the United States. There is a lack of data on prevalence of shroom use, but trends in law enforcement seizure data can provide one indicator of shroom availability in US communities. We determined whether seizures of shrooms have shifted between 2017 and 2022. METHODS: This study examined national and regional trends in counts and total weight of shroom seizures reported to High Intensity Drug Trafficking Areas in the US between 2017 and 2022 (N=4526). RESULTS: There were 402 seizures in 2017 compared to 1396 in 2022 with the plurality occurring in the Midwest (36.0%), followed by the West (33.5%). Between 2017 Quarter 1 (Q1) and 2022 Quarter 4 (Q4), the number of seizures increased by 368.9% (AQPC=7.0; 95 CI: 5.9-8.1) and there were significant increases in all four regions. In terms of weight, 226.0kg was seized in 2017 vs. 844.0kg in 2022, and the greatest total weight in seizures was in the West (1864.2kg, 42.6%), followed by the South (1831.9kg, 41.8%). Between 2017 Q1 and 2022 Q4, the total weight seized in the US increased by 2749.7% (AQPC=6.2, 95% CI: 0.3-12.4) and there were significant increases in all four regions. CONCLUSIONS: Seizures of shrooms have increased, suggesting that availability may be escalating; thus, increases in prevention efforts and harm reduction education are warranted.

Examining racial and ethnic heat exposure disparities in New York City (NYC) across different spatial and political scales through geographic effect measure modification.

Structural racism in the United States has resulted in neighborhoods with higher proportions of non-Hispanic Black (Black) or Hispanic/Latine residents having more features that intensify, and less that cool, the local-heat environment. This study identifies areas of New York City (NYC) where racial/ethnic heat exposure disparities are concentrated. We analyzed data from the 2013-2017 American Community Survey, U.S Landsat-8 Analysis Ready Data on summer surface temperatures, and NYC Land Cover Dataset at the census tract-level (n = 2098). Four cross-sectional regression modeling strategies were used to estimate the overall City-wide association, and associations across smaller intra-city areas, between tract-level percent of Black and percent Hispanic/Latine residents and summer day surface temperature, adjusting for altitude, shoreline, and nature-cover: overall NYC linear, borough-specific linear, Community District-specific linear, and geographically weighted regression models. All three linear regressions identified associations between neighborhood racial and ethnic composition and summer day surface temperatures. The geographically weighted regression models, which address the issue of spatial autocorrelation, identified specific locations (such as northwest Bronx, central Brooklyn, and uptown Manhattan) within which racial and ethnic disparities for heat exposures are concentrated. Through examining the overall effects and geographic effect measure modification across spatial scales, the results of this study identify specific geographic areas for intervention to mitigate heat exposure disparities experienced by Black and Hispanic/Latine NYC residents.

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships.

PURPOSE: To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States. METHODS: We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317). RESULTS: We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state). CONCLUSIONS: This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

"Breaking the silence" suicide Prevention media campaign in Oregon: Evaluation of impact on help-seeking and suicide mortality.

INTRODUCTION: Research has established that suicide-related media can impact suicide rates both positively and negatively, supporting efforts to engage the media in the service of suicide prevention. The goal of the current study is to evaluate the impact of a suicide prevention media campaign implemented April 7-14, 2019 in Oregon. METHODS: Several indices of help-seeking behavior and suicide risk were employed: suicide-related Google Health API searches, National Suicide Prevention Lifeline (Lifeline) (currently known as the 988 Suicide and Crisis Lifeline) call volume, and state suicide mortality data from April 7, 2016-May 6, 2019. Eight states with similar 2016-2018 average suicide rates were compared with Oregon. Bayesian structural time-series modeling in R was used to test intervention effects. RESULTS: During the 30 days following the start of the campaign, there was a significant increase in Lifeline calls from Oregon area codes (2488 observed vs. 2283 expected calls, p = 0.03). There were no significant changes in suicide mortality or suicide-related Google searches in Oregon. CONCLUSIONS: The campaign appeared to increase help-seeking behavior in the form of Lifeline calls, without any indication of an iatrogenic suicide contagion effect. However, the campaign's potential to reduce suicide mortality was unmet.

Excess Mortality in the United States, 2020-21: County-level Estimates for Population Groups and Associations with Social Vulnerability.

To assess the excess mortality burden of Covid-19 in the United States, we estimated sex, age and race stratified all-cause excess deaths in each county of the US during 2020 and 2021. Using spatial Bayesian models trained on all recorded deaths between 2003-2019, we estimated 463,187 (95% uncertainty interval (UI): 426,139 - 497,526) excess deaths during 2020, and 544,105 (95% UI: 492,202 - 592,959) excess deaths during 2021 nationally, with considerable geographical heterogeneity. Excess mortality rate (EMR) nearly doubled for each 10-year increase in age and was consistently higher among men than women. EMR in the Black population was 1.5 times that of the White population nationally and as high as 3.8 times in some states. Among the 25-54 year population excess mortality was highest in the American Indian/Alaskan Native (AI/AN) population among the four racial groups studied, and in a few states was as high as 6 times that of the White population. Strong association of EMR with county-level social vulnerability was estimated, including positive associations with prevalence of disability (standardized effect: 40.6 excess deaths per 100,000), older population (37.6), poverty (23.6), and unemployment (18.5), whereas population density (-50), higher education (-38.6), and income (-35.4) were protective. Together, these estimates provide a more reliable and comprehensive understanding of the mortality burden of the pandemic in the US thus far. They suggest that Covid-19 amplified social and racial disparities. Short-term measures to protect more vulnerable groups in future Covid-19 waves and systemic corrective steps to address long-term societal inequities are necessary.

Trends in Prevalence of Cannabis Use Disorder Among U.S. Veterans With and Without Psychiatric Disorders Between 2005 and 2019.

OBJECTIVE: Cannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders. Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine whether trends in cannabis use disorder prevalence among VHA patients differ by whether they have psychiatric disorders. METHODS: VHA electronic health records from 2005 to 2019 (N range, 4,332,165-5,657,277) were used to identify overall and age-group-specific (<35, 35-64, and ≥65 years) trends in prevalence of cannabis use disorder diagnoses among patients with depressive, anxiety, posttraumatic stress, bipolar, or psychotic spectrum disorders and to compare these to corresponding trends among patients without any of these disorders. Given transitions in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM). RESULTS: Greater increases in prevalence of cannabis use disorder diagnoses were observed among patients with psychiatric disorders compared to those without (difference in prevalence change, 2005-2014: 1.91%, 95% CI=1.87-1.96; 2016-2019: 0.34%, 95% CI=0.29-0.38). Disproportionate increases in cannabis use disorder prevalence among patients with psychiatric disorders were greatest among those under age 35 between 2005 and 2014, and among those age 65 or older between 2016 and 2019. Among patients with psychiatric disorders, the greatest increases in cannabis use disorder prevalences were observed among those with bipolar and psychotic spectrum disorders. CONCLUSIONS: The findings highlight disproportionately increasing disparities in risk of cannabis use disorder among VHA patients with common psychiatric disorders. Greater public health and clinical efforts are needed to monitor, prevent, and treat cannabis use disorder in this population.

Geographic Variation, Economic Activity, and Labor Market Characteristics in Trajectories of Suicide in the United States, 2008-2020.

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

Drug overdose risk with benzodiazepine treatment in young adults: Comparative analysis in privately and publicly insured individuals.

BACKGROUND AND AIMS: Benzodiazepines (BZDs) carry a risk for drug overdose and are prescribed alone or simultaneously with selective-serotonin reuptake inhibitors (SSRIs) for the treatment of anxiety and depression in young adults. We aimed to measure risks of drug overdose following BZD treatment initiation, and simultaneous BZD and SSRI initiation, compared with SSRI treatment alone in young adults with depression or anxiety. DESIGN, SETTING, PARTICIPANTS: The cohort study used administrative databases covering privately (MarketScan, 1/1/2009-12/31/2018) and publicly (Medicaid, 1/1/2015-12/31/2016) insured young adults (18-29 years) in the United States. Those with depression or anxiety diagnoses newly initiating BZD or SSRI treatment (without BZD or SSRI prescriptions in prior year) were included. Simultaneous "BZD + SSRI" initiation was defined as starting BZD and SSRI treatment on the same day. The cohorts included 604 664 privately insured young adults (BZD = 22%, BZD + SSRI = 10%, SSRI = 68%) and 110 493 publicly insured young adults (BZD = 23%, BZD + SSRI = 5%, SSRI = 72%). MEASUREMENTS: Incident medically treated drug overdose events were identified from emergency department and inpatient encounters (ICD poisoning codes) within 6 months of treatment initiation. Crude and propensity-score adjusted cumulative incidence and hazard ratios (HR) were estimated. Sub-analyses evaluated drug overdose intent. FINDINGS: Adjusted HRs of drug overdose for BZD vs. SSRI treatment was 1.36 (95% confidence interval [CI]:1.23-1.51) in privately and 1.59 (95%CI:1.37-1.83) in publicly insured young adults. The adjusted HRs of drug overdose for BZD + SSRI treatment vs. SSRI treatment were 1.99 (95%CI:1.77-2.25) in privately and 1.98 (95%CI:1.47-2.68) in publicly insured young adults. CONCLUSIONS: Among young adults in the United States, initiating benzodiazepine treatment for anxiety and depression, alone or simultaneously with selective-serotonin reuptake inhibitors (SSRI), appears to have an increased risk of medically treated drug overdose compared with SSRI treatment alone. These associations were observed in publicly and privately insured individuals.