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

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

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

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

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

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

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

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

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

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

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

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

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

A population-wide perspective on the reach of substance use disorders: Parental exposure, diagnostic remission, and current disorders.

BACKGROUND AND OBJECTIVES: Parental substance use disorder (SUD) increases the risk for childhood adversities. Lifetime and current SUDs are associated with functional impairment and psychiatric comorbidity. Research shows that these abate with diagnostic remission. However, a hierarchically ordered heuristic profile of adult subpopulations affected by SUDs has not been explored. METHODS: We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; N = 36,309) to compare four subpopulations defined by the following hierarchy: (1) neither parental nor lifetime SUD (un-affected group); (2) parental SUD but no personal SUD; (3) past but not current SUD (diagnostic remission); and (4) current SUD. We conducted bivariate comparisons and multivariable-adjusted logistic regression to identify characteristics independently differentiating each group. RESULTS: Almost half of the US adult population (108.9 million) were at risk from SUDs. Relative to the unaffected group (56.1%), the parental-exposure-only group (13.9%) experienced diverse parental and childhood adversities and increased risk for psychiatric disorders. Compared to the parental-exposure-only group those in the remitted group (14.1%) were more likely to report behavioral problems and lifetime psychiatric multimorbidities. Those with current SUD (15.9%) had a poorer mental health-related quality of life. DISCUSSION AND CONCLUSIONS: This heuristic SUD hierarchy is associated with increasing adversities affecting almost half the US population, although only 15.9% meet the criteria for a current disorder. SCIENTIFIC SIGNIFICANCE: Our findings provide a rigorous population-based estimate of the staggering public health impact of SUDs in the United States and suggest that almost half of the US population is either directly or indirectly affected by SUDs.

"Lives of despair" at risk for "deaths of despair": tracking an under-recognized, vulnerable population.

PURPOSE: The substantial and unexpected increase in "deaths of despair" in the US (e.g., deaths from drug overdose, suicide, and alcohol-related liver diseases) reported by economists Case and Deaton in 2015 raises questions about the number and characteristics of US adults potentially living "lives of despair" with these problems. METHODS: We used data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) to examine population estimates and characteristics of adults with lifetime history of substance use disorder (SUD) and suicide attempt, or either condition alone, as compared to those with neither. RESULTS: An estimated 7.2 million adults had both lifetime SUD and suicide attempt and 78.8 million had either. Those with both faced far more psychosocial adversities, familial adverse experiences and psychiatric disorders compared to those with the other two groups, and reported greater mental health service utilization. Multivariable analysis showed that psychiatric multimorbidity and violence were the strongest correlates of having both conditions as compared to neither while those with either condition fell in between. CONCLUSION: A substantial number of US adults live with a lifetime SUD and suicide attempt with a multiplicity of additional socioeconomic, psychiatric and familial problems. While their utilization of mental health care service exceeds those with either or neither conditions, quality of life remained much poorer, suggesting that mental health treatment alone may not be enough to mitigate their sufferings, and a combination of both social policy support and quality mental health care may be needed.

Lifetime risk and correlates of incarceration in a nationally representative sample of U.S. adults with non-substance-related mental illness.

PURPOSE: High rates of psychiatric disorders in correctional facilities have fueled widespread concern about the "criminalization of mental illness." While the link between incarceration, substance abuse, and antisocial-personality disorder is well established, the relationship between non-substance-related psychiatric disorders and incarceration has not been thoroughly investigated. This study examines the association of mental illness, excluding substance use disorders, with risk for incarceration in US adults. METHODS: Nationally representative data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) were used to compare the proportions of respondents with lifetime incarceration among those with no lifetime history of DSM-5 disorders, or with lifetime history of mental illness, substance use disorders, dual diagnosis, and antisocial personality/conduct disorder. Logistic regression analysis was used to examine the independent association of incarceration with mental illness alone, both in comparison to and net of associations with sociodemographic and behavioral characteristics. RESULTS: Among adults with mental illness alone, 6.7% reported past incarceration, compared to 4.8% with no history of DSM-5 disorders, and 20-40% in other DSM-5 diagnostic groups. Sociodemographic and behavioral risk factors were more strongly associated with incarceration (c-statistics = 0.74 and 0.77, respectively), than mental illness (c-statistic = 0.56). Schizophrenia or other psychoses and borderline personality disorder were independently associated with incarceration, but with effect sizes no greater than eight other sociodemographic or behavioral risk factors. CONCLUSION: A weak association of mental illness alone with incarceration was found, despite high level of public attention to "criminalization of mental illness."

Religious institutions as a link to substance use treatment: Characterizing the potential service population through national survey data.

Background: Relatively few Americans with current alcohol or drug use disorders receive outpatient or residential treatment. Outreach initiatives at local places of religious worship have been proposed as a way of facilitating such service use, but the number and characteristics of adults who may be reached in this way has not been studied. Methods: Data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional survey of U.S. adults were used to estimate the number of and proportion of adults with substance use disorders (SUDs) who attended monthly religious service and did not receive SUD treatment in the past year and used multinomial logistic regression to compare them to three SUD groups who did or did not receive treatment and/or attend religious services. Results: A total of 5,795 respondents representing 35.8 million Americans met criteria for a past-year SUD, of whom 8.3 million (23.1%) attended religious services monthly and did not receive substance use treatment. This more often African-American group had substantially fewer socio-demographic disadvantages (e.g., unemployment), behavioral problem indicators (e.g., police involvement), a higher quality of life score and less likelihood of an illicit drug use diagnosis than those who received treatment and either did or did not attend religious services. Conclusion: Almost one quarter of adults with a SUD attend religious services monthly and do not receive SUD treatment. Although they have fewer adversities than people who receive treatment, outreach to this population may link this substantial group of people to needed services.Highlights/reviewNational survey data suggest 8 of 36 million Americans with substance use diagnoses' (23%) do not receive specialized SUD treatment, but they do attend religious services monthly or more.This group, notably, has less numerous problems, such as unemployment, police involvement, and drug use disorder, and have higher quality of life scores than those who receive treatment for SUD.Outreach and linkage initiatives with religious institutions may facilitate use of services by this population.

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

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

Gender Differences in Diagnostic Remission of Posttraumatic Stress Disorder (PTSD): Proportions and Correlates of Remission in a Nationally Representative U.S. Sample.

This study examines differences in a nationally representative sample, in proportions of men and women with lifetime diagnoses of Posttraumatic Stress Disorder (PTSD) who achieved diagnostic remission and gender-specific correlates. Data from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III included 1,997 adults with a lifetime PTSD diagnosis (70.8% female and 29.2% male). Of these 25.3% of women and 24.3% of men experienced remission (ns). Women who remitted were older than other women, more likely to be retired, and less likely to report disability, past homelessness, suicide attempts, criminal history, violent behavior, or parental histories of drug problems or suicide. Men who remitted were less likely than other men to be separated/divorced, disabled, incarcerated after age 15, and reported fewer violent behaviors. Remission was significantly more strongly associated among women than men with greater age, emergency room visits, trauma and less with schizotypal personality. Although women were twice as likely to be diagnosed with PTSD, there were no significant gender differences in the proportions who experienced remission. Remission was associated with diverse sociodemographic and clinical disadvantages among both men and women but only four were statistically significantly different between genders.

Who Uses Veterans Mental Health Services?: A National Observational Study of Male Veteran and Nonveteran Mental Health Service Users.

ABSTRACT: Mental health (MH) research among veterans receiving services from the Veterans Health Administration (VHA) is extensive and growing and informs many clinical practice guidelines. We used nationally representative survey data to examine the generalizability of this extensive body of research by comparing sociodemographic and clinical characteristics of male veteran veterans health service (VHS) users (n = 491) with veteran non-VHS users (n = 840) and nonveteran (n = 6300) MH service users. VHS users were older, more often reported Black race, and less likely to have private or Medicaid insurance, but had similar prevalence of psychiatric or substance use disorder diagnoses but with a greater prevalence of posttraumatic stress disorder (PTSD). VHS users reported higher rates of medical diagnoses, pain interference, and poorer physical and MH status. These results suggest that VHA MH research may be reasonably generalizable to US mental health service users with caveats regarding age, PTSD diagnosis, pain, and racial distribution.

Longitudinal study of the housing and mental health outcomes of tenants appearing in eviction court.

PURPOSE: Millions of people are evicted from rental properties in the U.S. annually, but little is known about them and their mental health. This study followed a cohort of eviction court participants over time and assessed their housing and mental health outcomes. METHODS: One hundred and twenty-one tenants were recruited from an eviction court in New Haven, Connecticut, and their housing, mental health, and psychosocial status were assessed at baseline, 1, 3, 6, and 9 months following their encounter with the court. Inverse probability weighting was used for missing data. RESULTS: At baseline, 42% of participants had appeared in eviction court before, 28% had experienced eviction, and 44% had been previously homeless. In addition, 39% screened positive for generalized anxiety disorder, 37% for posttraumatic stress disorder, 33% for major depressive disorder, and 17% reported suicidal ideation. At follow-up, participants experienced increased days of housing instability and homelessness over time with some persistent mental health symptoms. Less than one-quarter of participants received any mental health treatment during the 9-month follow-up period. About 54% of participants followed reported that they had to change their residence after their court appearance consistent with court records. Participants who had an eviction-related move experienced greater housing instability over time than participants who did not. CONCLUSION: Together, these findings suggest that there is a sizable subgroup of adults who present to eviction court with persistent housing and mental health issues who do not receive adequate assistance in addressing these issues.

Cross-cultural Comparison of Perceptions and Knowledge About Electroconvulsive Therapy Among Adults Who Screened Positive for Depression in the United States, India, and China.

OBJECTIVE: Despite the established efficacy of electroconvulsive therapy (ECT), negative perceptions and inaccurate knowledge about ECT in the United States and other countries persist. This study examined ECT perceptions and knowledge in the 3 most populous countries in the world. METHODS: We recruited participants who screened positive for depression on the Patient Health Questionnaire 9 (PHQ-9) in the United States (n = 1643), India (n = 1469), and China (n = 328) and compared responses on the ECT-Perception and Knowledge Scale. RESULTS: Although the US sample had significantly higher PHQ-9 scores than the India and China samples, the US sample was less likely to have been offered ECT or to have ever received ECT. Moreover, the US sample scored lower on the ECT Perception and Knowledge subscales than the other samples indicating more negative perceptions and inaccurate knowledge about ECT. Across samples, there were moderate fears about ECT being painful or causing brain damage, and misconceptions about ECT being outdated and adverse effects of induced seizures. Higher PHQ-9 scores were correlated with more negative perceptions. CONCLUSIONS: Greater public education is needed about ECT, particularly in the United States. Misperceptions and lack of knowledge may hinder utilization of ECT in India, China, and the United States.

Sex Differences in Opioid Use Disorder Prevalence and Multimorbidity Nationally in the Veterans Health Administration.

OBJECTIVE: Opioid use disorder (OUD) is a significant problem among US veterans with increasing rates of OUD and overdose, and thus has substantial importance for service delivery within the Veterans Health Administration (VHA). Among individuals with OUD, several sex- specific differences have begun to emerge regarding co-occurring medical, psychiatric and pain-related diagnoses. The rates of such multimorbidities are likely to vary between men and women with OUD and may have important implications for treatment within the VHA but have not yet been studied. Methods: The present study utilized a data set that included all veterans receiving VHA health care during Fiscal Year (FY) 2012 (October 1, 2011 through September 30, 2012), who were diagnosed during the year with opioid dependence or abuse. VHA patients diagnosed with OUD nationwide in FY 2012 were compared by sex on proportions with OUD, and among those with OUD, on sociodemographic characteristics, medical, psychiatric and pain-related diagnoses, as well as on service use, and psychotropic and opioid agonist prescription fills. Results: During FY 2012, 48,408 veterans were diagnosed with OUD, 5.77% of whom were women. Among those veterans with OUD, few sociodemographic differences were observed between sexes. Female veterans had a higher rate of psychiatric diagnoses, notably mood, anxiety and personality disorders, as well as higher rates of pain-related diagnoses, such as headaches and fibromyalgia, while male veterans were more likely to have concurrent, severe medical co-morbidities, including hepatic disease, HIV, cancers, peripheral vascular disease, diabetes and related complications, and renal disease. There were few differences in health service utilization, with women reporting greater receipt of prescriptions for anxiolytic/sedative/hypnotics, stimulants and lithium. Men and women did not differ in receipt of opioid agonist medications or mental health/substance use treatments. Conclusions: There are substantial sex-specific differences in patterns of multimorbidity among veterans with OUD, spanning medical, psychiatric and pain-related diagnoses. These results illustrate the need to view OUD as a multimorbid condition and design interventions to target such multimorbidities. The present study highlights the potential benefits of sex-specific treatment and prevention efforts among female veterans with OUD and related co-occurring disorders.

Psychiatric Multimorbidity in a Specialized Program for Severely Mentally Ill Veterans.

It has been suggested that psychiatric multimorbidity may better characterize severely impaired psychiatric patients than individual severe mental illness (SMI) diagnoses, and that these patients may be better served by centers offering integrated co-located, psychiatric and social services than in conventional clinics providing one-to-one care. We tested the hypothesis that multimorbidity is a critical characteristic of Veterans treated at a co-located multi-service Veteran's Health Administration (VHA) program originally established to treat Veterans living with SMI. Administrative data from the VA Connecticut Health Care System from fiscal year 2012 were used to compare veterans using diverse mental health and social services at the Errera Community Care Center (ECCC), an integrated "one-stop shop" for SMI veterans, and those seen exclusively at standard outpatient mental health clinics. Bivariate and multiple logistic regression analyses were used to compare groups on demographic characteristics, psychiatric and medical diagnoses, service utilization, and psychotropic medication fills. Results: Of the 11,092 veterans included in the study, 2281 (20.6%) had been treated at the ECCC and 8811 (79.4%) had not. Multivariable analysis highlighted the association of treatment in the ECCC and younger age, lower income, homelessness, and especially multimorbidity including both multiple substance use and multiple psychiatric diagnoses. Programs originally designed to address the diverse needs of patients living with SMI and homelessness may be usefully characterized as treating patients with psychiatric multimorbidity, a term of greater clinical relevance. Effectiveness research is needed to evaluate the one-stop shop approach to their treatment.

Correlates of Obtaining Employment among Veterans Receiving Treatment for Severe PTSD in Specialized Intensive Programs.

Severe Post-Traumatic Stress Disorder (PTSD) has been identified as a significant impediment to employment. However, little is known about correlates of employment recovery after a period of not working among veterans with severe PTSD treated in specialized intensive treatment programs. This study examines rates and correlates of transitioning from not being employed at admission to working four months after discharge using national Veterans Health Administration (VHA) program evaluation data on veterans engaged in specialized intensive PTSD treatment (N = 27,339). Results suggest that only 5.68% of the sample made the transition to employment while 10.6% lost employment, 8.9% worked both at admission and following discharge, and 74.9%, did not work either at admission or following discharge. Multinomial regression analysis found that compared to other groups, veterans who became employed were younger, less likely to receive service-connected disability payments, and experienced a significantly greater reduction in PTSD symptoms. Findings from this study highlight that this distinct population has very poor employment outcomes and deserves more attention, and that reducing PTSD symptoms can lead to improved employment outcomes. Efforts to integrate evidence-based vocational rehabilitation practice into residential PTSD treatment targeting PTSD symptoms is encouraged.

Association of Adverse Family Experiences with School Engagement and Performance in US Adolescents: Do Behavioral Health Conditions Mediate the Relationship?

To examine the prevalence of adverse family experiences (AFEs), their association with poor school engagement and performance, and whether behavioral health conditions mediate the association among US adolescents. We conducted a cross-sectional analysis of data from adolescents aged 12-17 years from the 2016-2018 National Survey of Children's Health (n = 41,648 unweighted). We first estimated the prevalence of AFEs, investigated the association of AFEs with school engagement and performance, and whether behavioral health conditions mediate such relationships, using multivariable-adjusted Poisson regression models. A mediation analysis was used and covariates included socio-demographic characteristics and co-morbid medical conditions. A total of 52.9% of US adolescents (nationally representative of 12.9 million adolescents nationwide) reported experiencing at least one form of AFE, the most common of which included parental divorce/separation (33.1%), economic hardship (22.0%) and living with a person with substance misuse problems (11.5%). Adolescents with ≥4 AFEs had poorer outcomes in school engagement and performance (p < 0.001 each) when compared to those with no AFEs. Behavioral health conditions (e.g., anxiety, depression, and conduct problems) partially mediated these relationships (p < 0.01 each). The indirect effect of behavioral health conditions accounted for 20.4% of the total effect in the association between AFEs and school performance (p < 0.001). AFEs are common among US adolescents, and cumulative AFEs are associated with behavioral health conditions, which may in turn reduce school engagement and performance. While reducing AFEs is important in children and adolescents, addressing potentially resultant behavioral health conditions is equally important in improving school engagement and performance.

Alcohol Use Disorder Among Adults Recovered From Substance Use Disorders.

BACKGROUND AND OBJECTIVES: Alcohol use is often overlooked and underestimated among patients recovered from substance dependence. The prevalence and correlates of alcohol use disorder (AUD) among adults recovered from substance use disorders (SUDs) are estimated in this study. METHODS: A nationally representative cross-sectional analysis of the National Epidemiological Survey on Alcohol and Related Conditions Wave-III was used in this study. Survey respondents, aged 18 or older, who recovered from SUDs, based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria (n = 2061 unweighted), were included. A total of three comparison groups were identified using DSM-5 criteria (1) current AUD, (2) former AUD, and (3) never had AUD. The prevalence of these groups was estimated; medical and psychiatric comorbidities and health-related quality of life were compared; and factors associated with having a current AUD when compared with those with former AUD and those who never had AUD were examined, controlling for other covariates. RESULTS: About 5.7% of US adults, nationally representative of 14.2 million, have been reported to have recovered from past SUDs. Of these, 28.9% met criteria for current AUD and 48.4% had former AUD. When compared with those who never had AUD, factors associated with having a current AUD included the following: living in urban areas (P = .019), having a bipolar 1 disorder (P < .001), and a history of lifetime incarceration (P = .004). DISCUSSION AND CONCLUSION: Nearly one-third of adults recovered from SUDs had current AUD, and several behavioral factors were associated with having a current AUD when compared with those who never had AUD. SCIENTIFIC SIGNIFICANCE: Our study highlights the substantial risk of AUD in adults who have successfully recovered from SUDs. (Am J Addict 2020;00:00-00).