Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study.

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Adherence to guideline creation recommendations for suicide prevention in the emergency department: A systematic review.

OBJECTIVES: Suicide rates in the United States rose 35.2% from 1999-2018. As emergency department (ED) providers often have limited training in management of suicidal patients and minimal access to mental health experts, clinical practice guidelines (CPGs) may improve care for these patients. However, clinical practice guidelines that do not adhere to quality standards for development may be harmful both to patients, if they promote practices based on flawed evidence, and to ED providers, if used in malpractice claims. In 2011, the Institute of Medicine created standards to determine the trustworthiness of CPGs. This review assessed the adherence of suicide prevention CPGs, intended for the ED, to these standards. Secondary objectives were to assess the association of adherence both with first author/organization specialty (ED vs non-ED) and with inclusion of recommendations on substance use, a potent risk factor for suicide. METHODS: This is a systematic review of available suicide-prevention CPGs for the ED in both peer-reviewed and gray literature. This review followed the PRISMA standards for reporting systematic reviews. RESULTS: Of 22 included CPGs, the 7 ED-sponsored CPGs had higher adherence to quality standards (3.1 vs 2.4) and included the highest-rated CPG (ICAR2E) identified by this review. Regardless of specialty, nearly all CPGs included some mention of identifying or managing substance use. CONCLUSIONS: Most suicide prevention CPGs intended for the ED are written by non-ED first authors or organizations and have low adherence to quality standards. Future CPGs should be developed with more scientific rigor, include a multidisciplinary writing group, and be created by authors working in the practice environment to which the CPG applies.

Substance use in a sexual context: The association of sex-related substance use motives with substance choice and use behaviors.

BACKGROUND: Substance use before sex is associated with riskier behaviors. Sex-related substance use motives may explain pre-sex substance use. We explored what sex-related motives are associated with alcohol versus drug use, and which motives underlie heavier use. METHODS: A sample of 936 participants (50% male, 80% White) completed an Internet survey about sexuality. Those who drank before sex (n=657) reported on six sex-related drinking motives; those who used drugs before sex (n=271) reported on six (parallel) sex-related drug use motives. The frequency of endorsement of each motive between drinkers and drug users was compared with z-distributions. Logistic regressions assessed whether motives were associated with substance use frequency and intoxication before sex. RESULTS: Substance use to relax and to get a sex partner to use were more commonly endorsed for alcohol than drugs; substance use to improve performance and enhance experience were more commonly endorsed for drugs. Most motives were associated with alcohol frequency and intoxication before sex. None were associated with drug frequency; some were associated with drug intoxication. CONCLUSIONS: Alcohol was generally used to facilitate sex, and drugs to enhance sex. Sex-related drinking motives were associated with drinking before sex; sex-related drug use motives were less predictive.

Physical Health Disparities Across Dimensions of Sexual Orientation, Race/Ethnicity, and Sex: Evidence for Increased Risk Among Bisexual Adults.

Accumulating evidence suggests that sexual minority individuals are at increased risk for physical health conditions compared to heterosexual individuals. However, we know little about physical health disparities affecting bisexual individuals, a population at increased risk for psychiatric and substance use conditions compared to both heterosexual and lesbian/gay populations. Using a large, nationally representative sample, we examined physical health disparities for bisexual individuals. To advance research on sexual minority health disparities, we further: (1) compared prevalence rates of physical health conditions across three dimensions of sexual orientation (i.e., identity, attractions, behavior) and (2) examined whether disparities differed by sex and race/ethnicity. Results indicated that sexual minority individuals were at increased risk for many physical health conditions. Notably, individuals with bisexual identity, attractions, and/or behavior were at increased risk for more physical health conditions than other sexual minority groups. The number and types of physical health disparities affecting bisexually identified individuals and individuals with same- and opposite-sex attractions and/or sexual partners varied across sex and race/ethnicity, with the most consistent disparities emerging for individuals who reported same- and opposite-sex sexual partners. Our findings highlight the substantial physical health disparities affecting sexual minorities and the heightened risk conferred by all facets of bisexuality.

Postoperative follow-up practice of phyllodes tumour in the UK: Results from a national survey.

BACKGROUND: Resected phyllodes tumours (PT) of the breast carry a small but significant risk of recurrence. Nevertheless, there are no national guidelines on the postoperative follow-up of these tumours potentially resulting in a wide variation in practice among breast surgeons in the UK. METHODS: A web-based questionnaire was sent to breast surgeons across the UK to assess individual follow-up practices including availability of local guidelines, methods of follow-up and influence of risk factors. RESULTS: Only 38% of 121 responses indicated the availability of local guidelines on PT follow-up. Modal follow-up duration for borderline and malignant disease was 5 years (53.7% and 79.3% of responses respectively), compared to 1 year for benign disease (43%) although 28% of respondents continue to review benign cases for 5 years. Immediate post-operative discharge and self-directed aftercare for benign and borderline cases remains uncommon practice in the UK. Within hospitals represented by more than one respondent in this survey, only around 30% demonstrated consistent practices pertaining to length and frequency of postoperative PT follow-up. Recurrent disease and margin status influenced the follow-up practice of 60% of respondents in our survey. More than 75% indicated that they combine clinical examination with radiological investigations (mammography and/or ultrasound) to follow up PT postoperatively. CONCLUSION: This survey highlights the wide variation in follow-up practice for resected PT. This may affect the detection of disease relapse or, conversely, result in wasted clinical resources and unnecessary patient distress. Evidence-based national guidelines are necessary to resolve this issue and inform best follow-up practice.

Focus Groups of Parents and Teens Help Develop Messages to Prevent Early Marijuana Use in the Context of Legal Retail Sales.

OBJECTIVES: The changes in Washington State and Colorado marijuana laws call for the development of new brief family-focused adolescent marijuana use preventive interventions that are relevant for and tailored to the context of legalization for retail sale. To that end, focus groups with parents and teens were conducted to find out about their concerns and needs in the context of legalization. METHODS: Six semi-structured focus groups (3 with parents, 3 with teens) were conducted in Washington State in 2013 related to consequences of teen marijuana use and messages that would be effective in helping to prevent teens from using marijuana in the context of legal adult use. A total of 33 teens and 35 parents participated. RESULTS: Three primary themes were common to these parents and teens: the negative consequences of marijuana use during adolescence on mental, physical, and social health; the need for more or better information; and the need for information/messages to come from trusted sources. The themes related to potential prevention messages include the use of fear; stories about real people; focusing on short-term consequences; and teens needing alternative activities (something better to do). CONCLUSIONS: The results suggest that parents and teens need information about the new retail marijuana legalization law. Teens are open to both information and guidance from parents as long as it is calm and respectful. Firsthand accounts of consequences of marijuana use from peers and adults, rather than threats from authority figures, could hold some promise for persuading teens to avoid marijuana use.

Substance Use Disorders and Poverty as Prospective Predictors of Adult First-Time Suicide Ideation or Attempt in the United States.

This study examined whether substance use disorders (SUD) and poverty predicted first-time suicide ideation or attempt in United States national data. Respondents without prior histories of suicide ideation or attempt at Wave 1 of the NESARC (N = 31,568) were analyzed to determine the main and interactive effects of SUD and poverty on first-time suicide ideation or attempt by Wave 2, 3 years later. Adjusted for controls, poverty (AOR = 1.35, CI = 1.05-1.73) and drug use disorders (AOR = 2.10, CI = 1.07-4.14) independently increased risk for first-time suicide ideation or attempt at Wave 2. SUD and poverty did not interact to differentially increase risk for first-time suicide ideation or attempt, prior to or after adjustment for controls. This study reinforces the importance of SUD and poverty in the risk for first-time suicide ideation or attempt. Public health efforts should target messages to drug users and the impoverished that highlight their increased risk for first-time suicide.

Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults: Results from a randomized controlled trial.

BACKGROUND: Homeless young adults are more likely than their never-homeless counterparts to abuse alcohol and engage in risky sexual behaviors, yet no interventions to simultaneously reduce both these behaviors among this vulnerable population have been systematically designed and evaluated. We therefore developed a brief intervention (BI) to reduce both alcohol use and sexual risk behaviors among homeless young adults. The results of a randomized trial testing the BI against an education comparison (EC) are presented. METHOD: Young adults (N=61; age 17-22 years) from an urban, Northeastern crisis shelter were randomly assigned to either the 2-session, individual-level BI or a time-matched, 2-session, individual-level EC. Generalized linear mixed models for repeated measures determined effects of treatment condition on outcomes. RESULTS: The BI significantly increased participant readiness to change alcohol use. However, it did not significantly decrease primary alcohol or HIV sexual risk outcomes, independently or relative to EC (all ps>.05). Participants in the EC reduced times engaged in unprotected sex between baseline and post-intervention to a significantly greater extent (p<.01) than those in the BI condition. Participants in both conditions reported satisfaction with respective interventions. CONCLUSIONS: Findings suggest that the BI was acceptable and successful in getting participants to consider changing their drinking. However, lack of change in alcohol and sexual behavior outcomes indicates the need for further research to determine how to translate readiness to change into actual behavioral change among homeless young adults.

Daily Bidirectional Relationships Between Sleep and Mental Health Symptoms in Youth With Emotional and Behavioral Problems.

OBJECTIVE: The present study examined the daily, bidirectional relationships between sleep and mental health symptoms in youth presenting to mental health treatment. METHODS: Youth aged 6 to 11 (36% female, 44% European American) presenting to outpatient behavioral health treatment (N = 25) were recruited to participate in the study. Children and parents completed daily questionnaires regarding the child's sleep, mood, and behavior for a 14-day period, while youth wore an actigraph watch to objectively measure sleep. RESULTS: Examining between- and within-person variance using multilevel models, results indicate that youth had poor sleep duration and quality and that sleep and mental health symptoms were highly related at the daily level. Between-person effects were found to be most important and significant bidirectional relationships exist. CONCLUSIONS: Identifying and addressing sleep problems in the context of mental health treatment is important, as poor sleep is associated with increased symptomology and may contribute to worsened mental health.

Evaluation of effects of pH and ionic strength on colloidal stability of IgG solutions by PEG-induced liquid-liquid phase separation.

Colloidal stability of IgG antibody solutions is important for pharmaceutical and medicinal applications. Solution pH and ionic strength are two key factors that affect the colloidal stability of protein solutions. In this work, we use a method based on the PEG-induced liquid-liquid phase separation to examine the effects of pH and ionic strength on the colloidal stability of IgG solutions. We found that at high ionic strength (≥0.25M), the colloidal stability of most of our IgGs is insensitive to pH, and at low ionic strength (≤0.15M), all IgG solutions are much more stable at pH 5 than at pH 7. In addition, the PEG-induced depletion force is less efficient in causing phase separation at pH 5 than at pH 7. In contrast to the native inter-protein interaction of IgGs, the effect of depletion force on phase separation of the antibody solutions is insensitive to ionic strength. Our results suggest that the long-range electrostatic inter-protein repulsion at low ionic strength stabilizes the IgG solutions at low pH. At high ionic strength, the short-range electrostatic interactions do not make a significant contribution to the colloidal stability for most IgGs with a few exceptions. The weaker effect of depletion force at lower pH indicates a reduction of protein concentration in the condensed phase. This work advances our basic understanding of the colloidal stability of IgG solutions and also introduces a practical approach to measuring protein colloidal stability under various solution conditions.

Child and Parent Report of Parenting as Predictors of Substance Use and Suspensions from School.

This study examined how child and parent reports of parenting were related to early adolescent substance use and school suspensions. Data were from two time points six months apart on 321 families with an eighth grade student attending one of five schools in the Pacific Northwest. Child- and parent-report measures of family management practices were moderately correlated (r = .29). Child report, but not parent report, of more positive family management practices uniquely predicted a lower likelihood of adolescent substance use. Also, discrepancies between child and parent report of parenting predicted substance use, with child positive report of family management losing its protective association with adolescent substance use when parents had negative reports of their parenting. Parent report, but not child report, of better parenting predicted lower likelihood of suspensions, suggesting that the salience of child and parent report may depend on the type of behavioral outcome.

Parent Training to Reduce Problem Behaviors over the Transition to High School: Tests of Indirect Effects through Improved Emotion Regulation Skills.

Adolescent problem behaviors are costly for individuals and society. Promoting the self-regulatory functioning of youth may help prevent the development of such behaviors. Parent-training and family intervention programs have been shown to improve child and adolescent self-regulation. This study helps fill gaps in knowledge by testing for indirect effects of the Common Sense Parenting® (CSP) program on reduced substance use, conduct problems, and school suspensions through previously identified short-term improvements in parents' reports of their children's emotion regulation skills. Over two cohorts, 321 low income families of 8th graders were enrolled and randomly assigned to either the standard CSP program, an adapted CSP Plus program, or a minimal-contact control condition. Pretest, posttest, 1-year follow-up, and 2-year follow-up survey assessments were completed by parents and students with 94% retention. Intent-to-treat multivariate path analyses were conducted. Neither intervention had statistically significant total effects on the three targeted adolescent outcomes. CSP, but not CSP Plus, had statistically significant indirect effects on reduced substance use and school suspensions at the 1-year follow-up as well as conduct problems and school suspensions at the 2-year follow-up through increased child emotion regulation skills at posttest. Findings provide some support for emotion regulation as one pathway through which the intervention was associated, indirectly, with reduced substance use, conduct problems, and school suspensions among at-risk students over the high school transition.

Regularly Drinking Alcohol Before Sexual Activity in a Nationally Representative Sample: Prevalence, Sociodemographics, and Associations With Psychiatric and Substance Use Disorders.

OBJECTIVES: We addressed regular drinking before sex and its associated risk factors. METHODS: From the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative adult US sample (fielded 2004-2005), we determined the 12-month prevalence of regularly drinking alcohol before sexual activity. Among 17,491 sexually active drinkers, we determined the sociodemographic, psychiatric, and substance use correlates of regularly drinking before sex. RESULTS: Regular presex drinking's 12-month prevalence was 1.8%. Significant bivariate sociodemographic correlates were age, gender, race/ethnicity, education, family income, marital status, and employment status. Generalized anxiety disorder and alcohol dependence were associated with significantly increased odds of being a regular presex drinker after controlling for covariates. CONCLUSIONS: We estimate that 4.3 million American adults are regular presex drinkers. Future research should examine this public health issue at the population level, with particular focus on pathways that link it to psychopathology.

Predictors of participation in parenting workshops for improving adolescent behavioral and mental health: results from the common sense parenting trial.

Engaging and retaining participants are crucial to achieving adequate implementation of parenting interventions designed to prevent problem behaviors among children and adolescents. This study examined predictors of engagement and retention in a group-based family intervention across two versions of the program: a standard version requiring only parent attendance for six sessions and an adapted version with two additional sessions that required attendance by the son or daughter. Families included a parent and an eighth grader who attended one of five high-poverty schools in an urban Pacific Northwest school district. The adapted version of the intervention had a higher rate of engagement than the standard version, a difference that was statistically significant after adjusting for other variables assessed at enrollment in the study. Higher household income and parent education, younger student age, and poorer affective quality in the parent-child relationship predicted greater likelihood of initial attendance. In the adapted version of the intervention, parents of boys were more likely to engage with the program than those of girls. The variables considered did not strongly predict retention, although retention was higher among parents of boys. Retention did not significantly differ between conditions. Asking for child attendance at workshops may have increased engagement in the intervention, while findings for other predictors of attendance point to the need for added efforts to recruit families who have less socioeconomic resources, as well as families who perceive they have less need for services.

A framework for testing and promoting expanded dissemination of promising preventive interventions that are being implemented in community settings.

Many evidence-based preventive interventions have been developed in recent years, but few are widely used. With the current focus on efficacy trials, widespread dissemination and implementation of evidence-based interventions are often afterthoughts. One potential strategy for reversing this trend is to find a promising program with a strong delivery vehicle in place and improve and test the program's efficacy through rigorous evaluation. If the program is supported by evidence, the dissemination vehicle is already in place and potentially can be expanded. This strategy has been used infrequently and has met with limited success to date, in part, because the field lacks a framework for guiding such research. To address this gap, we outline a framework for moving promising preventive interventions that are currently being implemented in community settings through a process of rigorous testing and, if needed, program modification in order to promote expanded dissemination. The framework is guided by RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) (Glasgow et al., Am J Publ Health 89:1322-1327, 1999), which focuses attention on external as well as internal validity in program tests, and is illustrated with examples. Challenges, such as responding to negative and null results, and opportunities inherent in the framework are discussed.

Substance-use disorders and poverty as prospective predictors of first-time homelessness in the United States.

OBJECTIVES: We examined whether substance-use disorders and poverty predicted first-time homelessness over 3 years. METHODS: We analyzed longitudinal data from waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions to determine the main and interactive effects of wave 1 substance use disorders and poverty on first-time homelessness by wave 2, among those who were never homeless at wave 1 (n = 30,558). First-time homelessness was defined as having no regular place to live or having to live with others for 1 month or more as a result of having no place of one's own since wave 1. RESULTS: Alcohol-use disorders (adjusted odds ratio [AOR] = 1.34), drug-use disorders (AOR = 2.51), and poverty (AOR = 1.34) independently increased prospective risk for first-time homelessness, after adjustment for ecological variables. Substance-use disorders and poverty interacted to differentially influence risk for first-time homelessness (P < .05), before, but not after, adjustment for controls. CONCLUSIONS: This study reinforces the importance of both substance-use disorders and poverty in the risk for first-time homelessness, and can serve as a benchmark for future studies. Substance abuse treatment should address financial status and risk of future homelessness.

Comparison of On the Way Home aftercare supports to traditional care following discharge from a residential setting: a pilot randomized controlled trial.

This study compares the On the Way Home (OTWH) aftercare program to traditional aftercare supports on placement and school stability for 82 youth (43 treatment, 39 control) with disabilities discharging from residential care. One-year-post-discharge results revealed that negative event occurrence (i.e., returning to care or discontinuing enrollment in the community school) was three to over five times less likely for OTWH youth compared to youth in the control condition.

Parental Divorce, Maternal-Paternal Alcohol Problems, and Adult Offspring Lifetime Alcohol Dependence.

This study examined the influences of parental divorce and maternal-paternal histories of alcohol problems on adult offspring lifetime alcohol dependence using data from the 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Parental divorce and maternal-paternal alcohol problems interacted to differentially influence the likelihood of offspring lifetime alcohol dependence. Experiencing parental divorce and either maternal or paternal alcohol problems doubled the likelihood of alcohol dependence. Divorce and history of alcohol problems for both parents tripled the likelihood. Offspring of parental divorce may be more vulnerable to developing alcohol dependence, particularly when one or both parents have alcohol problems.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department.

OBJECTIVE: The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED). METHODS: Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results. RESULTS: The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits. CONCLUSIONS: Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms.

BACKGROUND: In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options. METHODS/DESIGN: Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective. DISCUSSION: Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05023317.