Examining NSDUH's Assessment of Fentanyl Use: A Comparison of Trends in Fentanyl Use and Fentanyl Overdose Deaths from 2015-2020.

OBJECTIVE: The National Survey on Drug Use and Health (NSDUH), as the primary source of epidemiological substance use data in the US, could illuminate trends in fentanyl use behaviors contributing to the opioid overdose crisis. We hypothesized that the trend in NSDUH prevalence of lifetime fentanyl injection would match the direction and magnitude of the trend in synthetic opioid overdose deaths. METHOD: Using logistic regression, we modeled the 2015-2020 trend in synthetic opioid overdose deaths as a proportion of all deaths. We modeled contemporary trends from cross-sectional NSDUH data for (1) lifetime fentanyl injection, (2) past year prescription fentanyl (PF) misuse, (3) prescription tramadol misuse (the other synthetic opioid counted alongside fentanyl in the overdose deaths category), and (4) combined prescription fentanyl or tramadol misuse. Average annual NSDUH weighted sample size was 272,519,038 (51.5% female, 48.5% male). RESULTS: Synthetic opioid overdose deaths increased from 2015-2020 (OR 3.39, meaning the odds of a death being from synthetic opioid overdose in 2020 were 3.39 times the odds of death from that cause in 2015, 95% CI: 3.34, 3.44). None of the substance use trends significantly increased. CONCLUSION: Per NSDUH data, the prevalence of fentanyl misuse did not significantly increase in tandem with synthetic opioid overdose deaths from 2015 to 2020. Scrutiny of NSDUH's approach to assessing fentanyl misuse casts doubt on the utility of NSDUH fentanyl data collection. We acknowledge recent changes to the survey and recommend two further changes to optimize a vital source of data on behaviors related to the opioid overdose crisis.

Problematic social media use and psychological symptoms in adolescents.

PURPOSE: This study examined time trends in significant child and adolescent psychological symptoms and explored the association of frequent and problematic social media use with these symptoms. METHODS: Time trends in psychological symptoms were assessed using data from five waves of the international survey of Health Behavior in School-aged Children (HBSC), conducted between 2001 and 2018 (N = 1,036,869). The associations of frequent and problematic social media use with significant psychological symptoms were assessed by hierarchical multinomial logistic regression using data from 2001-2002 and the 2017-2018 survey waves. The direction of effect between social media use variables and psychological symptoms was explored using Linear Non-Gaussian Acyclic Models (LiNGAM). RESULTS: Prevalence of more severe psychological symptoms increased from 6.7% in 2001-2002 to 10.4% in the 2017-2018 survey waves. The increase was especially large among 15-year old and older girls: from 10.9 to 19.1%. The higher prevalence of more severe psychological symptoms in 2017-2018 compared with 2001-2002 was eliminated after adjusting the model for problematic social media use. LiNGAM analysis supported the direction of effect going from social media use and problematic social media use to psychological symptoms. CONCLUSIONS: The findings suggest that frequent and problematic use of social media contribute to the increasing trend of psychological symptoms in adolescents in recent years.

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.

Reduced drug use as an alternative valid outcome in individuals with stimulant use disorders: Findings from 13 multisite randomized clinical trials.

BACKGROUND AND AIMS: Total abstinence has historically been the goal of treatment for substance use disorders; however, there is a growing recognition of the health benefits associated with reduced use as a harm reduction measure in stimulant use disorders treatment. We aimed to assess the validity of reduced stimulant use as an outcome measure in randomized controlled trials (RCTs) of pharmacological interventions for stimulant use disorder. DESIGN: We conducted a secondary analysis of a pooled dataset of 13 RCTs. SETTING AND PARTICIPANTS: Participants were individuals seeking treatment for cocaine or methamphetamine use disorders (N = 2062) in a wide range of treatment facilities in the United States. MEASUREMENTS: We validated reduced stimulant use against a set of clinical indicators drawn from harmonized measurements, including severity of problems caused by drug use, comorbid depression, global severity of substance use and improvement, severity of drug-seeking behavior, craving and high-risk behaviors, all assessed at the end of the trial, as well as follow-up urine toxicology. A series of mixed effect regression models was conducted to validate reduction in frequency of use against no reduction in use and abstinence. FINDINGS: More participants reduced frequency of primary drug use than achieved abstinence (18.0% vs. 14.2%, respectively). Reduced use was significantly associated with decreases in craving for the primary drug [60.1%, 95% confidence interval (CI) = 54.3%-64.7%], drug seeking behaviors (41.0%, 95% CI = 36.6%-45.7%), depression severity (39.9%, 95% CI = 30.9%-48.3%), as well as multiple measures of global improvement in psychosocial functioning and severity of drug-related problems, albeit less strongly so than abstinence. Moreover, reduced use was associated with sustained clinical benefit at follow-up, as confirmed by negative urine tests (adjusted odds ratio compared with those with no reduction in use: 0.50, 95% CI = 0.35-0.71). CONCLUSION: Reduced frequency of stimulant use appears to be associated with meaningful improvement in various clinical indicators of recovery. Assessment of reduced use, in addition to abstinence, could broaden the scope of outcomes measured in randomized controlled trials of stimulant use disorders and facilitate the development of more diverse treatment approaches.

Trends in Telepsychiatry and In-Person Psychiatric Care for Depression in an Academic Health System, 2017-2022.

OBJECTIVE: The authors aimed to assess differences in appointment completion rates between telepsychiatry and in-person outpatient psychiatric care for patients with depression in an academic health system. METHODS: Electronic health records of encounters for patients (ages ≥10) with a depression diagnosis and at least one scheduled outpatient psychiatric appointment (N=586,266 appointments; November 2017-October 2022) were assessed for appointment volume and completion of telepsychiatry versus in-person sessions. RESULTS: Telepsychiatry became the dominant care modality after the onset of the COVID-19 pandemic, although the number of telepsychiatry and in-person appointments nearly converged by October 2022. Logistic regression showed that telepsychiatry appointments (July 2020-October 2022) were more likely (OR=1.30, 95% CI=1.27-1.34) to be completed than in-person appointments. CONCLUSIONS: Telepsychiatry appointments were less likely to be canceled or missed than in-person appointments, suggesting that telepsychiatry improved efficiency and continuity of care. As in-person operations resume following the pandemic, maintaining telepsychiatry services may optimize hospital-level and patient outcomes.

Association of cigarette excise taxes and clean indoor air laws with change in smoking behavior in the United States: a Markov modeling analysis.

The rates of cigarette smoking in the United States have declined over the past few decades in parallel with increases in cigarette taxes and introduction of more stringent clean indoor air laws. Few longitudinal studies have examined association of taxes and clean indoor air policies with change in smoking nationally. This study examined the association of state and local cigarette taxes and clean indoor laws with change in smoking status of 18,499 adult participants of the longitudinal 2010-2011 Tobacco Use Supplement of the Current Population Survey over a period of 1 year. Every $1 increase in cigarette excise taxes was associated with 36% higher likelihood of stopping smoking among regular smokers. We found no association between clean indoor air laws and smoking cessation nor between taxes and clean indoor air laws with lower risk of smoking initiation. Cigarette taxes appear to be effective anti-smoking policies. Some state and local governments do not take full advantage of this effective policy measure.

An integrative literature review of birth cohort and time period trends in adolescent depression in the United States.

PURPOSE: The aim of this literature review is to examine evidence of time trends and birth cohort effects in depressive disorders and symptoms among US adolescents in peer-reviewed articles from January 2004 to April 2022. METHODS: We conducted an integrative systematic literature review. Three reviewers participated at different stages of article review. Of the 2234 articles identified in three databases (Pubmed, ProQuest Central, Ebscohost), 10 met inclusion criteria (i.e., adolescent aged United States populations, included information about birth cohort and survey year, focused on depressive symptoms/disorders). RESULTS: All 10 articles observed increases in depressive symptoms and disorders in adolescents across recent survey years with increases observed between 1991 and 2020. Of the 3 articles that assessed birth cohort trends, birth cohort trends were less prominent than time period trends. Proposed explanations for increases included social media, economic-related reasons, changes in mental health screening and diagnosis, declining mental health stigma, increased treatment, and, in more recent years, the COVID-19 pandemic. CONCLUSIONS: Multiple cross-sectional surveys and cohort studies documented rising prevalence of depressive symptoms and disorder among adolescents from 1991 to 2020. Mechanisms driving this increase are still unknown. Research to identify these mechanisms is needed to inform depression screening and intervention efforts for adolescents.

Adequacy of Children's Psychopharmacology Services: Variations by Race and Clinical Characteristics.

OBJECTIVE: An expert consensus approach was used to determine the adequacy of children's psychopharmacology and to examine whether adequacy varied by demographic or clinical characteristics. METHODS: Data were from the baseline interview of 601 children, ages 6-12 years, who had visited one of nine outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms study. Children and parents were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia and the Service Assessment for Children and Adolescents to assess the child's psychiatric symptoms and lifetime mental health services use, respectively. An expert consensus approach informed by published treatment guidelines was used to determine the adequacy of children's psychotropic medication treatment. RESULTS: Black children (compared with White children; OR=1.84, 95% CI=1.53-2.23) and those with anxiety disorders (vs. no anxiety disorder; OR=1.55, 95% CI=1.08-2.20) were more likely to receive inadequate pharmacotherapy; those whose caregivers had a bachelor's degree or more education (vs. those who had a high school education, general equivalency diploma, or less than high school education; OR=0.74, 95% CI=0.61-0.89) were less likely to receive inadequate pharmacotherapy. CONCLUSIONS: The consensus rater approach permitted use of published treatment efficacy data and patient characteristics (e.g., age, diagnoses, history of recent hospitalizations, and psychotherapy) to assess adequacy of pharmacotherapy. These results replicate findings of racial disparities reported in previous research using traditional methods to determine treatment adequacy (e.g., with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.

Calibrated meta-analysis to estimate the efficacy of mental health treatments in target populations: an application to paliperidone trials for treatment of schizophrenia.

BACKGROUNDS: Meta-analyses can be a powerful tool but need to calibrate potential unrepresentativeness of the included trials to a target population. Estimating target population average treatment effects (TATE) in meta-analyses is important to understand how treatments perform in well-defined target populations. This study estimated TATE of paliperidone palmitate in patients with schizophrenia using meta-analysis with individual patient trial data and target population data. METHODS: We conducted a meta-analysis with data from four randomized clinical trials and target population data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study. Efficacy was measured using the Positive and Negative Syndrome Scale (PANSS). Weights to equate the trial participants and target population were calculated by comparing baseline characteristics between the trials and CATIE. A calibrated weighted meta-analysis with random effects was performed to estimate the TATE of paliperidone compared to placebo. RESULTS: A total of 1,738 patients were included in the meta-analysis along with 1,458 patients in CATIE. After weighting, the covariate distributions of the trial participants and target population were similar. Compared to placebo, paliperidone palmitate was associated with a significant reduction of the PANSS total score under both unweighted (mean difference 9.07 [4.43, 13.71]) and calibrated weighted (mean difference 6.15 [2.22, 10.08]) meta-analysis. CONCLUSIONS: The effect of paliperidone palmitate compared with placebo is slightly smaller in the target population than that estimated directly from the unweighted meta-analysis. Representativeness of samples of trials included in a meta-analysis to a target population should be assessed and incorporated properly to obtain the most reliable evidence of treatment effects in target populations.

Variation in ADHD Treatment by Mental Health Care Setting Among US College Students from 2019 to 2022.

OBJECTIVE: To assess whether prevalence of treatment for ADHD varies by location of mental healthcare among US college students aged 18 to 25 with professionally diagnosed ADHD. METHOD: Our analysis uses cross-sectional data from the National College Health Assessment (NCHA) and evaluated the relationship between types of care received and location of mental health services received in the past year (dichotomized into "use of any on-campus services" and "use of off-campus services only"). We generated unadjusted and adjusted logistic regression models of each type of treatment. RESULTS: Students who reported receiving mental healthcare on campus were less likely to receive any medication (aOR 0.66, 95% CI [0.60, 0.72]), any therapy (aOR 0.82, 95% CI [0.75, 0.89]), and any medication or therapy for ADHD (aOR 0.63, 95% CI [0.57, 0.70]). CONCLUSION: Future research should evaluate the causes of lower prevalence of ADHD treatment among students receiving mental healthcare from campus-based clinics.

Use of Non-Psychiatric Medications With Potential Depressive Symptom Side Effects and Level of Depressive Symptoms in Major Depressive Disorder.

Objective: To determine whether use of medications with potential depressive symptom side effects is associated with a higher level of depressive symptoms in adults with antidepressant-treated major depressive disorder (MDD).Methods: The study was based on the 2013-2014, 2015-2016, and 2017-2018 National Health and Nutrition Examination Survey (NHANES)-a nationally representative cross-sectional survey of the US general population. In 885 adult participants from these NHANES cycles who reported receiving antidepressants for treatment of International Classification of Diseases, Tenth Revision, Clinical Modification MDD, the association between the number of medications with potential depressive symptom side effects and the level of depressive symptoms was assessed.Results: A majority (66.7%, n = 618) of the participants with antidepressant-treated MDD used at least 1 non-psychiatric medication with potential depressive symptom side effects, and 37.3% (n = 370) used more than 1 such medication. The number of medications with depressive symptom side effects was significantly associated with lower odds of no to minimal depressive symptoms, defined as a Patient Health Questionnaire-9 (PHQ-9) score < 5 (adjusted odds ratio [AOR] = 0.75, 95% confidence interval [CI] = 0.64-0.87, P < .001), and higher odds of moderate to severe symptoms, defined as a PHQ-9 score ≥ 10 (AOR = 1.14, 95% CI = 1.004-1.29, P = .044). No such associations were found for medications without potential depressive symptom side effects.Conclusions: Individuals treated for MDD frequently use non-psychiatric medications for comorbid medical conditions that are associated with an increased risk of depressive symptoms. In evaluating the response to antidepressant medication treatment, side effects of concomitantly used medications should be considered.

The Protective Effect of Clozapine on Suicide: A Population Mortality Study of Statewide Autopsy Records in Maryland.

Objective: Clozapine is the most efficacious antipsychotic medication, but it is underutilized and its mechanism of action is still poorly understood. One aspect of its unique efficacy that requires further study is its effect on suicidality. A randomized controlled trial, the InterSePT study, yielded evidence that clozapine reduces suicidality more than olanzapine, after which it became the only medication indicated for recurrent suicidal behavior in schizophrenia and schizoaffective disorder. We present here the first study of population mortality data to investigate the effect of clozapine on suicide.Methods: We reviewed statewide autopsy records of Maryland's Office of the Chief Medical Examiner, which performs uniquely comprehensive death investigations that include full toxicologic panels with postmortem blood levels of antipsychotics. Our study compared clozapine- and olanzapine-positive decedents across demographic, clinical, and manner-of-death outcomes using contingency table analysis and logistic regression.Results: Of 53,144 decedents from 2003 to 2021, 621 had clozapine or olanzapine detected on autopsy, with the two groups showing no demographic differences. Decedents with clozapine were significantly less likely to have died by suicide than by accident compared to those with olanzapine (odds ratio = 0.47; 95% CI, 0.26-0.84; P = .011).Conclusions: Our study thus adds more naturalistic evidence to the growing literature on the beneficial effect of clozapine on suicidality. Our findings also highlight the utility of statewide autopsy records, an untapped resource for investigating the potential protective effect of psychiatric medications on suicide at a population level.

Drug use, drug use disorders, and treatment services in the Eastern Mediterranean region: a systematic review.

Drug use is an increasing global public health concern. We reviewed the prevalence and patterns of drug use, drug use disorders, and the extent of treatment services in 21 countries and one territory in the Eastern Mediterranean region from 2010 to 2022. Online databases were systematically searched on April 17, 2022, along with other sources for grey literature. The extracted data were analysed and used for synthesis at the country, subregional, and regional levels. The prevalence of drug use is higher in the Eastern Mediterranean region than global estimates, with cannabis, opium, khat, and tramadol among the main drugs used in the region. Data on the prevalence of drug use disorders were scarce and heterogeneous. Treatment facilities for drug use disorders are available in most countries, but opioid agonist treatment exists in only seven countries. There is a need to expand evidence-based and cost-effective care. Limited data exist, especially regarding drug use disorders, treatment coverage, and drug use among women and young people.

Factors Affecting State-Level Enforcement of the Federal Mental Health Parity and Addiction Equity Act: A Cross-Case Analysis of Four States.

CONTEXT: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. METHODS: The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. FINDINGS: Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. CONCLUSIONS: Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement.

Enforcement of the Mental Health Parity and Addiction Equity Act: State Insurance Commissioners' Statutory Capacity.

OBJECTIVE: State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. METHODS: Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. RESULTS: The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. CONCLUSIONS: Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.

Effect of General Practitioner Training in a Collaborative Child Mental Health Care Program on Children's Mental Health Outcomes in a Low-Resource Setting: A Cluster Randomized Trial.

Importance: Integrated care for children is rarely studied, especially in low- and middle-income countries, where generalists often provide mental health care. Objectives: To explore the effect of adding a child and youth component to an existing adult collaborative care program on mental health outcomes and receipt of care. Design, Setting, and Participants: This cluster randomized trial was conducted within an adult collaborative care program in Tehran, Iran. General practitioners (GPs), their 5- to 15-year-old patients, and patients' parents were included. Children and youths coming for routine medical visits who scored greater than the cutoff on the Strengths and Difficulties Questionnaire (SDQ) were followed up for 6 months. The study was conducted from May 2018 to October 2019, and analysis was conducted from March 2020 to August 2021. Interventions: GPs were randomized to either a 2.5-day training on managing common child mental health problems (intervention) or refresher training on identification and referral (control). Main Outcomes and Measures: Primary outcome was change in SDQ total problems score; secondary outcomes included discussion of psychosocial issues by the GPs and receipt of mental health care during the follow-up period. Results: Overall, 49 GPs cared for 389 children who scored greater than the cutoff on the SDQ (216 children in intervention group, 173 in control group). Patients' mean (SD) age was 8.9 (2.9) years (range, 5 to 15 years), and 182 (47%) were female patients. At 6 months, children in the intervention group had greater odds of receiving mental health care during the study (odds ratio [OR], 3.0; 95% CI, 1.1 to 7.7), parents were more likely to report that intervention GPs had discussed parent (OR, 2.1; 95% Cl, 1.1 to 3.8) and child (OR, 2.0; 95% Cl, 0.9 to 4.8) psychosocial issues, and intervention GPs were more likely to say they had provided counseling (OR, 1.8; 95% Cl, 1.02 to 3.3). However, there was no greater improvement in SDQ scores among children seen by intervention vs control GPs. Adjusted for clustering within GP, the variables used for balanced allocation (practice size, practice ownership, and study wave), and the other variables associated with change in SDQ scores over time, there was not a significant time-treatment interaction at either the 3- or 6-month follow-up points (linear combination of coefficients for intervention, 0.57 [95% CI, -1.07 to 2.22] and -0.08 [95%CI, -1.76 to 1.56], respectively). In a subgroup of GPs with practices composed of 50% or more children, children seen by intervention GPs improved to a significantly greater extent (-3.6 points; 95% CI, -6.7 to -0.46 points; effect size d = 0.66; 95% CI, 0.30 to 1.01) compared with those seen by control GPs. Conclusions and Relevance: In this cluster randomized trial, GP training on managing common child mental health problems did not demonstrate greater improvement in child SDQ scores. Child mental health training for GPs in collaborative care can improve children's access to mental health care, but prior experience working with children and their families may be required for GPs to use a brief training in a way that improves child outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03144739.

Medicaid Expansion and Racial-Ethnic Health Care Coverage Disparities Among Low-Income Adults With Substance Use Disorders.

OBJECTIVE: In light of historical racial-ethnic disparities in health care coverage, the authors assessed changes in coverage in nationally representative samples of Black, White, and Hispanic low-income adults with substance use disorders after the 2014 Affordable Care Act Medicaid expansion. METHODS: Data from 12 years of the annual National Survey on Drug Use and Health (2008-2019) identified low-income adults ages 18-64 years with alcohol, cannabis, cocaine, or heroin use disorder (N=749,033). Trends in coverage focused on non-Hispanic Black, non-Hispanic White, and Hispanic individuals. Age- and sex-adjusted difference-in-differences analysis assessed effects of expansion state residence on insurance coverage for the three groups. RESULTS: Before Medicaid expansion (2008-2013), 38.5% of Black, 37.6% of White, and 51.2% of Hispanic low-income adults with substance use disorders were uninsured. After expansion (2014-2019), these proportions significantly declined for Black (24.2%), White (22.0%), and Hispanic (34.5%) groups. Decreases in rates of individuals without insurance and increases in Medicaid coverage tended to be more pronounced for those in expansion states than for those in nonexpansion states. In nonexpansion states, the proportions of those without insurance significantly decreased among Black and White individuals but not among Hispanic individuals. Proportions receiving past-year substance use treatment did not significantly change and remained low postexpansion: Black, 10.7%; White, 14.6%; and Hispanic, 9.0%. CONCLUSIONS: After Medicaid expansion, coverage increased for low-income Black, White, and Hispanic adults with substance use disorders. For all three groups, Medicaid coverage disproportionately increased among those living in expansion states. However, coverage remained far from universal, especially for Hispanic adults with substance use disorders.

Long-Term Effect of Group Support Psychotherapy on Depression and HIV Treatment Outcomes: Secondary Analysis of a Cluster Randomized Trial in Uganda.

OBJECTIVE: We aimed to determine the effect of group support psychotherapy (GSP) compared with group HIV education (GHE) on depression and HIV treatment outcomes 24 months after treatment. We further aimed to investigate the mediating role of depression and antiretroviral therapy (ART) adherence in the relationship between GSP and viral load suppression. METHODS: Thirty HIV clinics across three districts were randomly assigned to deliver either GSP or GHE for depression. Depression and optimal (≥95%) ART adherence was assessed at baseline and 6, 12, 18, and 24 months after treatment. Viral load was drawn from the medical charts at baseline and 12 and 24 months after treatment. Multilevel mixed-effects regression models and generalized structural equation modeling were used to estimate 24-month outcomes and mediation effects. RESULTS: Participants ( N = 1140) were enrolled from HIV clinics offering either GSP ( n = 578 [51%]) or GHE ( n = 562 [49%]). Fewer GSP than GHE participants met the criteria for depression at 24 months after treatment (1% versus 25%; adjusted odds ratio [aOR] = 0.002, 95% confidence interval [CI] = 0.0002-0.018). More GSP than GHE participants reported optimal (≥95%) ART adherence (96% versus 88%; aOR = 20.88, 95% CI = 5.78-75.33) and improved viral suppression (96% versus 88%; aOR = 3.38, 95% CI = 1.02-11.02). The indirect effects of GSP through sequential reduction in depression and improvement in ART adherence at 12 months may partially explain the higher viral suppression rates at 24 months in GSP than GHE groups. CONCLUSION: In settings where the HIV epidemic persists, depression treatment with GSP may be critical for optimal HIV treatment outcomes.Trial Registration: The Pan African Clinical Trials Registry, number PACTR201608001738234.

Estimating the Prevalence of Substance Use Disorders in the US Using the Benchmark Multiplier Method.

Importance: Prevalence estimates of substance use disorders in the US rely on general population surveys. However, major population groups, such as homeless individuals and institutionalized individuals, are not captured by these surveys, and participants may underreport substance use. Objective: To estimate the prevalence of substance use disorders in the US. Design, Setting, and Participants: The benchmark multiplier method was used to estimate the prevalence of alcohol, cannabis, opioid, and stimulant use disorders based on data from the Transformed Medicaid Statistical Information System (T-MSIS) (the benchmark) and the National Survey on Drug Use and Health (NSDUH) (the multiplier) for 2018 and 2019. T-MSIS collects administrative data on Medicaid beneficiaries 12 years and older with full or comprehensive benefits. NSDUH is a nationally representative annual cross-sectional survey of people 12 years and older. Data were analyzed from February to June 2022. Main Outcomes and Measures: Prevalence of substance use disorders was estimated using the benchmark multiplier method based on T-MSIS and NSDUH data. Confidence intervals for the multiplier method estimates were computed using Monte Carlo simulations. Sensitivity of prevalence estimates to variations in multiplier values was assessed. Results: This study included Medicaid beneficiaries 12 years and older accessing treatment services in the past year with diagnoses of alcohol (n = 1 017 308 in 2018; n = 1 041 357 in 2019), cannabis (n = 643 737; n = 644 780), opioid (n = 1 406 455; n = 1 575 219), and stimulant (n = 610 858; n = 657 305) use disorders and NSDUH participants with 12-month DSM-IV alcohol (n = 3390 in 2018; n = 3363 in 2019), cannabis (n = 1426; n = 1604), opioid (n = 448; n = 369), and stimulant (n = 545; n = 559) use disorders. The benchmark multiplier prevalence estimates were higher than NSDUH estimates for every type of substance use disorder in both years and in the combined 2018 to 2019 sample: 20.27% (95% CI, 17.04-24.71) vs 5.34% (95% CI, 5.10-5.58), respectively, for alcohol; 7.57% (95% CI, 5.96-9.93) vs 1.68% (95% CI, 1.59-1.79) for cannabis; 3.46% (95% CI, 2.97-4.12) vs 0.68% (0.60-0.78) for opioid; and 1.91% (95% CI, 1.63-2.30) vs 0.85% (95% CI, 0.75-0.96) for stimulant use disorders. In sensitivity analyses, the differences between the benchmark multiplier method and NSDUH estimates persisted over a wide range of potential multiplier values. Conclusions and Relevance: The findings in this study reflect a higher national prevalence of substance use disorders than that represented by NSDUH estimates, suggesting a greater burden of these conditions in the US.

The role of mood disorders in the progression of and recovery from alcohol and drug use problems: A latent transition analysis.

INTRODUCTION: Longitudinal research assessing whether mood disorders predict substance use behaviors is limited. We extend our prior work evaluating transition patterns with alcohol use to assess patterns with alcohol and drug use problems. METHOD: Using National Epidemiologic Survey on Alcohol and Related Conditions prospective data, waves 1 and 2, we completed latent class analyses to empirically define classes of alcohol and drug problems from DSM disorder criteria. Latent transition analyses were used to assess associations of lifetime mood disorders at baseline with transitions across classes of alcohol and drug problems during follow-up. RESULTS: A three-class model of alcohol and drug problems was identified (No problems, Alcohol Problems Only, and Alcohol and Drug Problems) for males and females. Females with mood disorders were over two times more likely to transition from No Problems, and Alcohol Problems Only at baseline to having both Alcohol and Drug Problems at follow-up relative to those without mood disorders (aOR=2.30, 95 % CI=1.31-4.05, p = 0.004, and aOR=2.64, CI=1.24-5.62, p = 0.011, respectively). Furthermore, females with mood disorders were significantly less likely to recover from baseline Alcohol and Drug Problems to Alcohol Problems Only at follow-up (aOR=0.35, CI=0.12-0.98, p = 0.047) relative to those without mood disorders. There were no significant findings for males. DISCUSSION: Our study provides evidence that mood disorders impact transitions through classes of alcohol and drug problems among females. The findings emphasize the need for ongoing evaluation of substance use among those with mood conditions, and recognition and treatment of mood disorders among those recovering from substance use problems.