Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population

The Mediating Role of Distress Tolerance in the Relationship Between Childhood Maltreatment and Mental Health Outcomes Among University Students

A wealth of empirical literature has documented that the experience of childhood maltreatment is related to an increased risk for the development of psychopathologies in adulthood. Empirical studies examining the factors that could possibly explain this relationship, however, remain sparse. The emerging literature on distress tolerance (DT) suggests that it could possibly act as an explanatory or mediating factor within this relationship. The current study, therefore, examined the mediating role of DT in the relationship between childhood maltreatment and psychopathology (posttraumatic stress disorder, depression, anxiety, and alcohol use) in adulthood in a university student population sample (N = 642). Results showed that childhood maltreatment was positively associated with caseness for all mental health outcomes under investigation. It was also found that individuals with higher levels of DT were less likely to experience adverse mental health outcomes. The results of the mediation analysis indicated that the exposure to childhood maltreatment remained associated with elevated risk for being in the symptomatic group across mental health outcomes, and that DT significantly mediated this relationship. These results provide insight into the relationship between childhood maltreatment and mental ill-health later in life, highlighting the importance of considering DT as a potential risk and resilience factor in this relationship.

Trauma and post-traumatic stress disorder in patients treated for opioid use disorder: findings from a 12-month cohort study

BACKGROUND

Exposure to traumatic events is both a risk factor for substance use and an adverse outcome of substance use disorders. Identifying and managing post-traumatic stress disorder (PTSD) in patients with addiction requires attention.

AIMS

To examine the lifetime prevalence of traumatic events and past-month prevalence of PSTD in patients treated for opioid use disorder, and explore the association between trauma, PTSD and treatment outcomes.

METHOD

Participants (n = 674) receiving methadone treatment in 20 community clinics across Ontario, Canada, were administered the Mini-International Neuropsychiatric Interview to identify self-reported traumatic events and PTSD. Drug use was measured for 12 months by urine drug screens.

RESULTS

Eleven per cent of participants met past-month criteria for PTSD (n = 72), and 48% reported history of traumatic events with no current PTSD (n = 323). Participants with PTSD were more likely to be female (odds ratio 2.13, 95% CI 1.20-3.76) and less likely to be employed (odds ratio 0.31, 95% CI 0.16-0.61) or married (odds ratio 0.51, 95% CI 0.26-0.90) than those with no trauma history. Antidepressants (39 v. 24%) and benzodiazepines (36 v. 18%) were differentially prescribed to patients with and without PTSD. Length of time in treatment and opioid use were not associated with trauma; however, suicidal ideation was more common in PTSD (odds ratio 2.29, 95% CI 1.04-5.01).

CONCLUSIONS

Trauma and PTSD are prevalent among patients with opioid use disorder, and consideration of trauma symptoms and associated characteristics is warranted. Patients with and without comorbid PTSD differ clinically and psychosocially, highlighting the relevance of integrating addiction and mental health services for this population.

What treatment and services are effective for people who are homeless and use drugs? A systematic 'review of reviews'

BACKGROUND

People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic 'review of reviews' to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion.

METHODS AND FINDINGS

We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed.

CONCLUSIONS

People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.

Anxiolytic effect of minocycline in posttraumatic stress disorder model of Syrian hamsters

OBJECTIVE

The objective was to study the anxiolytic effect of minocycline in resident-intruder social conflict in submissive hamsters post resident intrusion model using open field test (OFT) and elevated plus maze (EPM) and serum cortisol levels.

MATERIALS AND METHODS

Fifty-two singly housed male Syrian hamsters were used, post standardization of an animal model. Resident intrusion was done (5 min), in which smaller hamsters were placed in the cage of larger hamster, and the behavior of smaller hamster was noted. Eight submissive hamsters per group (disease control, lorazepam group as a positive control, and the test drug was minocycline) were used, and the drug was administered immediately post resident intrusion, intraperitoneally. Behavioral tests, namely OFT and EPM, were done followed by retro-orbital blood collection for serum cortisol estimation. The level of significance was set at P < 0.05.

RESULTS

The minocycline group showed a statistically significant decrease in serum cortisol levels compared to the disease control group. Among all the variables pertaining to both the behavioral tests, namely EPM and OFT, the results indicated an anxiolytic effect, which was statistically significant compared to the disease control group.

CONCLUSION

As per the biochemical test using serum cortisol levels and behavioral tests in the form of EPM and OFT, the study concluded that the anxiolytic effect of minocycline is at least comparable to the positive control, lorazepam.

Exploring Technology-Based Enhancements to Inpatient and Residential Treatment for Young Adult Women with Co-Occurring Substance Use

Young adults have the highest rates of substance use of any age group. Although men historically have higher rates of substance use disorders (SUDs) than women, research shows this gender gap is narrowing. Young adults with comorbid psychiatric disorders are at increased risk for developing a SUD. Co-occurring psychiatric disorders such as depression, anxiety, eating and post-traumatic stress disorders are more prevalent in women than men with SUDs, yet mental health treatment often does not adequately address substance use in patients receiving care for a comorbid psychiatric disorder. Tailored gender-responsive interventions for women with psychiatric disorders and co-occurring SUD have gained empirical support. Digital interventions tailored to young adult women with co-occurring disorders have the potential to overcome barriers to addressing substance use for young adult women in a psychiatric treatment setting. This study utilized a user-centered design process to better understand how technology could be used to address substance use in young adult women receiving inpatient and residential psychiatric care. Methods: Women (N = 15; age 18-25 years), recruited from five psychiatric treatment programs, engaged in a qualitative interview and completed self-report surveys on technology use and acceptability. Qualitative interviews were coded for salient themes. Results: Results showed that few participants were currently using mental health web-based applications (i.e., "apps"), but most participants expressed an interest in using apps as part of their mental health treatment. Participants identified several important topics salient to women their age including substance use and sexual assault, stigma and shame, difficulties abstaining from substance use while maintaining social relationships with peers, and negative emotions as a trigger for use. Conclusions: These data provide preliminary evidence that a digital intervention may be a feasible way to address co-occurring substance use problems in young adult women receiving care in a psychiatric setting.

A pilot randomized clinical trial of Brief Behavioral Treatment for Insomnia to reduce problematic cannabis use among trauma-exposed young adults

BACKGROUND

Insomnia symptoms may be an important etiological factor for substance use disorders; however, whether improving sleep leads to reductions in problematic substance use among at-risk populations remains unclear.

METHOD

As such, the current pilot study used a randomized controlled design to test the effects of Brief Behavioral Treatment for Insomnia (BBTI) against a waitlist control among a sample of trauma-exposed young adults with elevated insomnia symptoms who regularly use cannabis (N = 56).

RESULTS

Intent-to-treat multilevel modeling analyses indicated that BBTI may be more efficacious than waitlist control in reducing self-reported insomnia symptoms, with large effects three months post-treatment (d = 1.34). Further, our initial evidence suggested that BBTI resulted in reductions in cannabis-related problems with medium to large effects at three months post-treatment (d = 0.75). The current pilot analyses indicated BBTI also reduced cravings to use cannabis to reduce negative emotions in response to trauma cues with a large effect size.

CONCLUSION

This pilot study suggests BBTI may be efficacious not only in improving insomnia symptoms among cannabis users but also in reducing cannabis-related problems and cravings over three months. Future research should replicate these results in a larger, fully powered sample with improved follow-up rates designed to test temporal mediation using multimethod assessments of insomnia symptoms and problematic cannabis use. Overall, BBTI may be a promising intervention for trauma-exposed cannabis users to improve sleep and reduce cannabis-related problems.

The application of harm reduction to methamphetamine use during pregnancy: a call to arms

Compared with opioid use disorder, methamphetamine use is a public health crisis that has limited evidence-based pharmacologic interventions for long-term treatment. The prevalence of methamphetamine use during pregnancy is growing and contributes to adverse maternal and neonatal outcomes. Because of widespread stigma and social complexities associated with methamphetamine use during pregnancy, these patients often experience limited prenatal care, further contributing to poor outcomes. In public health circles, harm reduction describes a framework for conceptualizing substance use by championing health promotion and the safest use of substances, as opposed to the unachievable goal of abstinence. There is limited evidence supporting the application of harm reduction in this population. We call for action and research to investigate how the progressive concept of harm reduction might be applied to mitigate adverse outcomes for obstetrical patients who use methamphetamine.

ADHD symptoms as risk factor for PTSD in inpatients treated for alcohol use disorder

Attention deficit hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD) are more common in alcohol use disorder (AUD) patients than in the general population. Still, there is a lack of knowledge about the relationship between the two conditions in these patients. The main objective of this study was to examine the prevalence of ADHD symptoms, and the relationship between ADHD symptoms and PTSD in AUD inpatients in treatment. Data from 85 AUD patients were collected. The Adult ADHD Self-Report Scale (ASRS) was used to measure ADHD symptoms in all patients. Differences between groups split by PTSD diagnosis and by ASRS clinical cut-off were described, and the relationship between ADHD symptom level and PTSD was tested in a multiple regression model. Almost half the patients scored above ASRS cut-off and 14% had PTSD. Of the patients whose score was above cut-off on the ASRS 23% had PTSD, versus 7% among those below cut-off. Higher ASRS score was associated with PTSD even when age, sex and trauma were adjusted for. This study confirms the high level of ADHD symptoms in AUD patients in treatment. Diagnostic evaluation of PTSD is recommended in patients with ADHD attending inpatient treatment programs for AUD.

A Perspective for Understanding Trauma and the Criminal Juvenile Justice System: Using a Trauma-Informed Lens for Meaningful and Sustained Change

Trauma exposure and posttraumatic stress disorder are common and are associated with a wide range of negative psychiatric and physical outcomes. Furthermore, a large percentage of justice-involved youth have high rates of trauma exposure and trauma-related symptoms. Addressing these issues would improve outcomes at the level of the justice system overall and in the lives of justice-involved youth. Nonetheless, awareness, education, and implementation of trauma-informed approaches in the criminal juvenile justice system are lacking. This article explores current literature that operationalizes trauma-informed practices and approaches in the criminal and juvenile justice systems. Unfortunately, there is no shared understanding or definition of trauma and no predictability in trauma-informed practices and approaches in the criminal juvenile justice system. Despite the presence of written policies, the application and execution of such policies are limited and inconsistent throughout the system. These limitations contribute to ongoing, systemic institutional racism, lack of mental health or substance abuse treatment, limited diversion options, and unnecessary jail and prison sentences, which together amplify financial and humanitarian costs. We argue that in order for the criminal juvenile justice system to become trauma-informed, it should (1) meet basic needs of clients, (2) check and change narratives, and check underlying assumptions, (3) focus on skill building/habilitation, (4) move away from punishment and toward rehabilitation and humanitarian approaches, and (5) heal and support members that work in and for the system. We conclude that there is a need to improve processes for education, training, and coaching in, and consistent application of, trauma-informed practices and approaches within the criminal and juvenile justice systems.

Substance use prevention interventions for children and young people in Sub-Saharan Africa: A systematic review

BACKGROUND

Different techniques and approaches have been used for substance use prevention worldwide. No reviews of prevention interventions in Africa exist; hence this study aimed to systematically review interventions undertaken in Sub-Saharan Africa to prevent substance use in children and young people.

METHODS

MEDLINE, EMBASE, Cochrane Central, CAB, PsycINFO, CINAHL, SCOPUS, ERIC, and Web of Science databases were searched. Studies were included if they evaluated a substance use prevention intervention for children and young people in a Sub-Saharan African Country between 2000 and 2020. A narrative synthesis was used to explore and describe the data.

RESULTS

Eighteen studies, mostly from South Africa, were included. Most (10/18) of the interventions were school-based. Only two of the included studies were considered having a strong quality concerning the risk of bias, and some studies poorly reported the interventions. School-based interventions, although successful in improving knowledge, had little or no effects on substance use. Overall, most studies that reported a statistically significant reduction in substance use-related outcomes were brief interventions, individual-focused, and involved participants who were already exposed to substance use. These were mostly delivered by trained professionals using motivational interviewing or cognitive behavioural therapy or both.

CONCLUSION

School-based programs present an opportunity for substance use prevention efforts in the Sub-Saharan region in Africa. Such programs may benefit from an improved focus on individual students. There is a need for improving the quality of design, implementation, and reporting of substance use interventions within the region.

A gender comparative analysis of post-traumatic stress disorder among a community-based cohort of people who use drugs in Vancouver, Canada

BACKGROUND

While exposure to traumatic events and subsequent post-traumatic stress disorder (PTSD) are common among people who use drugs (PWUD), little is known about gender-based differences associated with PTSD in this population. We explore gender-based differences in factors associated with a probable PTSD diagnosis in a cohort of PWUD from Vancouver, Canada.

METHODS

Data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two community-recruited cohorts of PWUD. Participants were administered the PTSD Checklist for DSM-5. Multivariable logistic regression was used to investigate social-structural factors and substance use patterns and behaviours associated with a probable PTSD diagnosis, stratified by self-identified gender. PTSD symptom clusters and brief descriptions of the worst traumatic event experienced were also reported.

RESULTS

Between December 2016 and December 2018, of 797 eligible participants, 295 (37.0%) identified as women. PTSD was more commonly reported in women compared to men (53.2% vs. 31.5%, p < 0.001). In multivariable analysis involving men, no correlates were associated with PTSD. In multivariable analysis involving women, PTSD was positively associated with exposure to violence (AOR: 3.66; 95%CI: 1.14-11.72), daily stimulant use (AOR: 2.32; 95%CI: 1.32-4.08) and heavy alcohol use (AOR: 3.84; 95%CI: 1.84-8.00), and negatively associated with being in a stable relationship (AOR: 0.46; 95%CI: 0.25-0.84).

CONCLUSIONS

Gender-based differences in PTSD diagnosis among a cohort of PWUD point to the need to develop gender-focused and trauma-informed health and social services to meet the immediate needs of PWUD living with PTSD.

Hydrocortisone administration for reducing post-traumatic stress symptoms: A systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating disorder that is often accompanied by alterations in the hypothalamic-pituitary (HPA) axis. While there is abundant evidence for the efficacy of psychological therapies in reducing post-traumatic stress symptoms, barely anything is known about pharmacological interventions. Given the role of the HPA axis in the pathophysiology of PTSD, the aim of this study was to provide the first meta-analysis of Hydrocortisone as a potential treatment for this condition.

METHOD

A systematic review of randomized-controlled trials (RCTs) was conducted to investigate the efficacy of hydrocortisone in the prevention and curative treatment of post-traumatic stress symptoms. This study was pre-registered with the OSF (doi:10.17605/OSF.IO/GJAZF).

FINDINGS

Eight studies (9 effect sizes) covering 362 participants met our inclusion criteria. We found that Hydrocortisone as compared to placebo significantly reduced PTSD symptoms (d = 0.96, 95% Cl 0.22-1.69 p = 0.011) and PTSD incidence (logRR = 0.85, 95% CI 1.12-1.59, p = 0.023). Subgroup analyses revealed a significant effect of Hydrocortisone when it was administered in a preventative context (d = 1.50; 95%CI 0.30-2.69, p = 0.014), but not when it was administered in a curative context (d = 0.28; 95%CI -0.11 to 0.66, p = 0.161).

CONCLUSION

Hydrocortisone appears to be a promising and efficient low-cost medication for the prevention of PTSD. However, the small number of included studies and their limited methodological quality emphasize the need for further rigorous studies in this field.

Adverse childhood experiences (ACEs) and substance use disorder (SUD): A scoping review

BACKGROUND

The long-term negative effects of adverse childhood experiences (ACEs) and their impact on physical and mental health has been widely studied. However, research about the relationship between ACEs and substance use disorder (SUD) diagnosis in adolescence and adulthood is still scarce. Therefore, this scoping review was conducted to collect the existing research findings to explore the relationship between the experience of ACEs and the diagnosis of SUD later in life.

METHODS

The PsycINFO, Medline, Scopus, Web of Science, and Cochrane Library databases were searched. After identifying the records based on eligibility and exclusion criteria, 12 studies were finally selected for inclusion.

RESULTS

Most of the studies were conducted in the USA with adult male and female participants. All studies were cross-sectional in nature and assessed ACEs retrospectively. The main conclusions of the studies were that there is a higher prevalence of ACEs in the population with SUD than in the general population, and a positive association between ACEs and the development and severity of SUD in adolescence and adulthood.

CONCLUSIONS

It is difficult to make comparisons between studies and to draw solid conclusions because of the lack of standardized criteria for evaluating ACEs and due to the heterogeneity in the substance types examined. More research is needed to fully elucidate the underlying mechanism of the relationship between ACEs and SUD.

Childhood Mistreatment, PTSD, and Substance Use in Latinx: The Role of Discrimination in an Omitted-Variable Bias

BACKGROUND

Childhood mistreatment (CM) has been associated with adult posttraumatic disorder (PTSD) and substance use disorders (SUDs) in the general population. Few studies have examined the role of PTSD in the CM-SUD association among Latinx. This cross-sectional study evaluated a theory-driven conceptual model with a specific focus on the impact of perceived discrimination, which may interfere with these associations.

METHOD

Using a nationally representative sample and structural equation modeling (SEM), the study evaluated the mediation of PTSD in the CM-SUD link, adjusting for or omitting discrimination and other sociodemographic variables that are known predictors of Latinx behavioral health. Multi-subsample analyses were then conducted to review nativity differences (US-born = 924.43% and immigrant = 1630.57%).

RESULTS

The fully specified final model (model 1, covariates adjusted) failed to show a significant mediation of PTSD in the tested link, but a direct detrimental effect group of discrimination, for all Latinx. The mediation was only supported, when treating discrimination and other covariates as omitted variables (model 5), which also showed additional direct and indirect effect of CM on SUD. In subsample analyses, models of US-born and immigrant-Latinx subpopulations were identical but showed nativity differences when omitting covariates.

CONCLUSION

When discrimination and other covariates were fully adjusted, Latinx exposed to trauma were more likely to develop SUD in adulthood, regardless of when traumatic exposure occurred. This unexpected finding challenges theories explaining the CM-SUD connection, suggesting possible model misspecifications of parametric SES; namely, omitting the unique impact of perceived discrimination in Latinx can lead to biased results. From a clinical standpoint, both trauma and discrimination must be addressed when assessing Latinx behavioral health.

Childhood trauma and post-trauma environment affect fear memory and alcohol use differently in male and female mice

BACKGROUND

Childhood trauma is associated with the development of adult mental health and substance use disorders, with females generally being more at risk. Alcohol is commonly used for coping with trauma, and alcohol use disorder (AUD) affects ∼14.4 million adult Americans annually. Research investigating sex differences in the environmental modification of anxiety and alcohol use following childhood trauma will extend our understanding of the etiology of AUD. Here, we sought to model the interacting effects of a single-episode late childhood trauma with post-trauma environment on adult alcohol use using male and female mice.

METHODS

C57Bl6/J mice (d22) exposed to predator odor (TMT) or water were reared in standard environments (SE) or environmental enrichment (EE). Mice were assessed for adolescent anxiety and conditioned fear, and for adult alcohol use in a limited access, response non-contingent, alcohol exposure paradigm.

RESULTS

A single exposure to predator odor was an effective stressor, inducing long-term sex-dependent changes in conditioned fear and alcohol behaviors that interacted with post-trauma environment. Adolescent EE females showed more conditioned freezing to the trauma-associated context. Adult EE mice consumed less total alcohol than SE mice. However, alcohol use across time differed for males and females. Exposure to a childhood stressor increased alcohol use significantly in females, but not males. EE males, but not EE females, drank less than SE counterparts.

CONCLUSIONS

Findings from this model recapitulate greater vulnerability to childhood trauma in females and support sex differences in post-trauma development of conditioned fear and alcohol use that are modified by environment.

Functional Alterations and Cerebral Variations in Humans Exposed to Early Life Stress

Early life stress can be caused by acute or chronic exposure to childhood events, such as emotional, physical, sexual abuse, and neglect. Early stress is associated with subsequent alterations in physical and mental health, which can extend into adolescence, adulthood, and even old age. The effects of early stress exposure include alterations in cognitive, neuropsychological, and behavioral functions, and can even lead to the development of psychiatric disorders and changes in brain anatomy. The present manuscript provides a review of the main findings on these effects reported in the scientific literature in recent decades. Early life stress is associated with the presence of psychiatric disorders, mainly mood disorders such as depression and risk of suicide, as well as with the presence of post-traumatic stress disorder. At the neuropsychological level, the involvement of different mental processes such as executive functions, abstract reasoning, certain memory modalities, and poor school-skill performance has been reported. In addition, we identified reports of alterations of different subdomains of each of these processes. Regarding neuroanatomical effects, the involvement of cortical regions, subcortical nuclei, and the subcortical white matter has been documented. Among the telencephalic regions most affected and studied are the prefrontal cortex, the hippocampus, the amygdala, and the anterior cingulate cortex. Understanding the impact of early life stress on postnatal brain development is very important for the orientation of therapeutic intervention programs and could help in the formulation and implementation of preventive measures as well as in the reorientation of research targets.

Self-reported PTSD is associated with increased use of MDMA in adolescents with substance use disorders

BACKGROUND

Adolescent patients with a substance use disorder (SUD) often fulfil the criteria for a co-occurring post-traumatic stress disorder (PTSD). However, it is not clear if these dual-diagnosed adolescents present with unique levels of substance use and how their substance use relates to PTSD symptom clusters.

OBJECTIVE

To investigate substance use in adolescents with co-occurring PTSD and SUD. Additionally, we explored how the use of specific substances is related to specific PTSD symptom clusters.

METHOD

We recruited n = 121 German adolescent SUD patients, in three groups: no history of traumatic events (TEs) (n = 35), TEs but not PTSD (n = 48), probable PTSD (n = 38). All groups were administered a trauma questionnaire and were asked to report their past-month substance use.

RESULTS

Adolescents with probable PTSD and SUD report a higher frequency of MDMA use than adolescents with no PTSD and no TE (PTSD vs. noTE: U = 510.5, p = .016; PTSD vs. TE: U = 710.0, p = .010). The use of MDMA was more frequent in adolescents with avoidance symptoms (X² (1) = 6.0, p = .014). Participants report using substances at a younger age (PTSD vs. noTE: U = 372.0, p = .001; PTSD vs. TE: U = 653.5, p = .022) and PTSD symptom onset was on average 2.2 years earlier than first MDMA use (t (26) = -2.89, p = .008).

CONCLUSIONS

Adolescent SUD patients with probable PTSD are more likely to use MDMA than SUD patients without PTSD. The use of MDMA was associated with reported avoidance symptoms. The first age of MDMA use is initiated after PTSD onset. It is unclear whether the association of MDMA use with avoidance symptoms is due to efforts to reduce these symptoms or a result of regular MDMA use.

Drug Addiction: Hyperkatifeia/Negative Reinforcement as a Framework for Medications Development

Compulsive drug seeking that is associated with addiction is hypothesized to follow a heuristic framework that involves three stages (binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation) and three domains of dysfunction (incentive salience/pathologic habits, negative emotional states, and executive function, respectively) via changes in the basal ganglia, extended amygdala/habenula, and frontal cortex, respectively. This review focuses on neurochemical/neurocircuitry dysregulations that contribute to hyperkatifeia, defined as a greater intensity of negative emotional/motivational signs and symptoms during withdrawal from drugs of abuse in the withdrawal/negative affect stage of the addiction cycle. Hyperkatifeia provides an additional source of motivation for compulsive drug seeking via negative reinforcement. Negative reinforcement reflects an increase in the probability of a response to remove an aversive stimulus or drug seeking to remove hyperkatifeia that is augmented by genetic/epigenetic vulnerability, environmental trauma, and psychiatric comorbidity. Neurobiological targets for hyperkatifeia in addiction involve neurocircuitry of the extended amygdala and its connections via within-system neuroadaptations in dopamine, enkephalin/endorphin opioid peptide, and γ-aminobutyric acid/glutamate systems and between-system neuroadaptations in prostress corticotropin-releasing factor, norepinephrine, glucocorticoid, dynorphin, hypocretin, and neuroimmune systems and antistress neuropeptide Y, nociceptin, endocannabinoid, and oxytocin systems. Such neurochemical/neurocircuitry dysregulations are hypothesized to mediate a negative hedonic set point that gradually gains allostatic load and shifts from a homeostatic hedonic state to an allostatic hedonic state. Based on preclinical studies and translational studies to date, medications and behavioral therapies that reset brain stress, antistress, and emotional pain systems and return them to homeostasis would be promising new targets for medication development. SIGNIFICANCE STATEMENT: The focus of this review is on neurochemical/neurocircuitry dysregulations that contribute to hyperkatifeia, defined as a greater intensity of negative emotional/motivational signs and symptoms during withdrawal from drugs of abuse in the withdrawal/negative affect stage of the drug addiction cycle and a driving force for negative reinforcement in addiction. Medications and behavioral therapies that reverse hyperkatifeia by resetting brain stress, antistress, and emotional pain systems and returning them to homeostasis would be promising new targets for medication development.

Prevalence and Correlates of Sex Selling and Sex Purchasing among Adults Seeking Treatment for Cocaine Use Disorder

Exchange sex places individuals with cocaine use disorder (CUD) at particularly high risk for deleterious safety and health outcomes. A substance use treatment provider who is aware of a patient's exchange sex behavior is better able to provide appropriate screening, care, and/or referral to risk reduction services. However, little is known about exchange sex, especially purchasing, among treatment-seeking adults with CUD. The current study examined the prevalence and correlates of sex selling and sex purchasing among treatment-seeking men and women with CUD (n = 109; ClinicalTrials.gov #NCT02896712). Separate binary logistic regressions via backward elimination were used to identify best fitting models for sex selling and sex purchasing. Over 41% of participants endorsed exchange sex within the last 30 days; 20.2% reported selling sex and 30.3% reported purchasing sex. Sex selling and sex purchasing rates differed by gender and race. Number of sexual partners (OR = 5.83, 95% CI = 2.07-16.43), concern about contracting HIV/AIDS (OR = 2.01, 95% CI = 1.31-3.44), cumulative interpersonal trauma exposure (OR = 1.82, 95% CI = 1.20-2.77), years using cocaine (OR = 1.11, 95% CI = 1.03-1.20), drug-related problem days (OR = 1.07, 95% CI = 1.00-1.14), and sexual preference (OR = 9.50, 95% CI = .69-130.35) were retained in the final model estimating sex selling (Nagelkerke R² = .56). In the final sex purchasing model (Nagelkerke R² = .46), gender (OR = 36.17, 95% CI = 2.96-441.75), number of sexual partners (OR = 6.28, 95% CI = 2.69-14.66), number of convictions (OR = 1.13, 95% CI = 1.02-1.25), and drug-related problem days (OR = 0.96, 95% CI = .92-1.01) were retained. Predictive models in this study identified distinct sets of variables related to sex selling and purchasing. Findings may be used to improve identification of exchange sex in the substance use treatment setting and referral to targeted interventions to reduce associated risk.

The MET(T)A Protocol: Mindfulness and EMDR Treatment Template for Agencies

Evidence indicating the relationship between trauma and substance use disorders (SUDs), in addition to relapse and treatment retention rates for this population, suggests there is a need for a trauma-focused solution to treat SUDs. Eye movement desensitization and reprocessing (EMDR) therapy has been studied extensively as an effective approach for treating trauma and Posttraumatic Stress Disorder (PTSD). The research evaluating its treatment for other mental health disorders such as SUDs is promising. Merging mindfulness and ethical mindfulness practices with EMDR therapy lends additional evidence-based elements to make the case for this integrative system of treatment to be studied as a trauma-focused primary psychotherapy to treat SUDs. The resulting treatment, the MET(T)A Protocol (Mindfulness and EMDR Treatment Template for Agencies), has been created to address the need for a trauma-focused solution to treat SUDs. Procedures of the MET(T)A Protocol as applied in each of the 8 phases of EMDR therapy are described in detail. Clinical examples are provided to explain the application of the MET(T)A Protocol.

Detection of Suicidality Among Opioid Users on Reddit: Machine Learning-Based Approach

BACKGROUND

In recent years, both suicide and overdose rates have been increasing. Many individuals who struggle with opioid use disorder are prone to suicidal ideation; this may often result in overdose. However, these fatal overdoses are difficult to classify as intentional or unintentional. Intentional overdose is difficult to detect, partially due to the lack of predictors and social stigmas that push individuals away from seeking help. These individuals may instead use web-based means to articulate their concerns.

OBJECTIVE

This study aimed to extract posts of suicidality among opioid users on Reddit using machine learning methods. The performance of the models is derivative of the data purity, and the results will help us to better understand the rationale of these users, providing new insights into individuals who are part of the opioid epidemic.

METHODS

Reddit posts between June 2017 and June 2018 were collected from r/suicidewatch, r/depression, a set of opioid-related subreddits, and a control subreddit set. We first classified suicidal versus nonsuicidal languages and then classified users with opioid usage versus those without opioid usage. Several traditional baselines and neural network (NN) text classifiers were trained using subreddit names as the labels and combinations of semantic inputs. We then attempted to extract out-of-sample data belonging to the intersection of suicide ideation and opioid abuse. Amazon Mechanical Turk was used to provide labels for the out-of-sample data.

RESULTS

Classification results were at least 90% across all models for at least one combination of input; the best classifier was convolutional neural network, which obtained an F1 score of 96.6%. When predicting out-of-sample data for posts containing both suicidal ideation and signs of opioid addiction, NN classifiers produced more false positives and traditional methods produced more false negatives, which is less desirable for predicting suicidal sentiments.

CONCLUSIONS

Opioid abuse is linked to the risk of unintentional overdose and suicide risk. Social media platforms such as Reddit contain metadata that can aid machine learning and provide information at a personal level that cannot be obtained elsewhere. We demonstrate that it is possible to use NNs as a tool to predict an out-of-sample target with a model built from data sets labeled by characteristics we wish to distinguish in the out-of-sample target.

Early Mistreatment Contributes to Social Behavior Disorders in Zebrafish

Adverse experiences during childhood have been the focus of a series of studies due to the psychological damage observed in individuals who suffered abuse during their youth. Studies with model animals that can mimic these observations can significantly contribute to understanding the mechanisms behind this phenomenon. In our experiments, young zebrafish (20 dpf) were exposed to aggressive alcoholized male adults for 30 min for 10 days. At 30 dpf, the animals were tested for shoal formation, and at 60 dpf, locomotion and aggression were evaluated. Animals that suffered oppression from adults showed greater group cohesion and lower attack emission and higher distance from the image in the mirror test. Locomotor parameters were not changed. These results show that the stress caused by aggression exposure in the juvenile phase led to increased fear and avoidance behavior later in life. Moreover, we confirm the importance of the zebrafish as a sensitive tool for studies on the effects of early mistreatment and its consequences to adult behavior.

The neural, behavioral, and epidemiological underpinnings of comorbid alcohol use disorder and post-traumatic stress disorder

Alcohol use disorder (AUD) and (PTSD) frequently co-occur and individuals suffering from this dual diagnosis often exhibit increased symptom severity and poorer treatment outcomes than those with only one of these diseases. Although there have been significant advances in our understanding of the neurobiological mechanisms underlying each of these disorders, the neural underpinnings of the comorbid condition remain poorly understood. This chapter summarizes recent epidemiological findings on comorbid AUD and PTSD, with a focus on vulnerable populations, the temporal relationship between these disorders, and the clinical consequences associated with the dual diagnosis. We then review animal models of the comorbid condition and emerging human and non-human animal research that is beginning to identify maladaptive neural changes common to both disorders, primarily involving functional changes in brain reward and stress networks. We end by proposing a neural framework, based on the emerging field of affective valence encoding, that may better explain the epidemiological and neural findings on AUD and PTSD.

Pathways to post-traumatic stress disorder and alcohol dependence: Trauma, executive functioning, and family history of alcoholism in adolescents and young adults

INTRODUCTION

Family history (FH) of alcohol dependence is likely to increase the risk of trauma exposure, post-traumatic stress disorder (PTSD), and alcohol dependence. FH of alcohol dependence and trauma has been separately shown to adversely affect planning/problem-solving aspects of executive function. However, few studies have examined these risk factors in an integrated model.

METHODS

Using data from trauma-exposed individuals from the Collaborative Study on the Genetics of Alcoholism prospective cohort (N = 1,860), comprising offspring from alcohol-dependent high-risk and comparison families (mean age [SE] = 21.9 [4.2]), we investigated associations of trauma (nonsexual assaultive, nonassaultive, sexual assaultive) with DSM-IV PTSD and alcohol dependence symptom counts, and planning/problem-solving abilities assessed using the Tower of London Test (TOLT). Moderating effects of family history density of alcohol use disorder (FHD) on these associations and sex differences were explored.

RESULTS

Family history density was positively associated with PTSD in female participants who endorsed a sexual assaultive trauma. Exposure to nonsexual assaultive trauma was associated with more excess moves made on the TOLT.

CONCLUSION

Findings from this study demonstrate associations with PTSD and alcohol dependence symptom counts, as well as poor problem-solving ability in trauma-exposed individuals from families densely affected with alcohol dependence, depending on trauma type, FHD, and sex. This suggests that having a FH of alcohol dependence and exposure to trauma during adolescence may be associated with more PTSD and alcohol dependence symptoms, and poor problem-solving abilities in adulthood.

A life-course theory exploration of opioid-related maternal mortality in the United States

BACKGROUND AND AIMS

Between 2007 and 2016, pregnancy-associated mortality resulting from overdose more than doubled in the United States. This study explored the circumstances surrounding maternal opioid-related morbidity and mortality, using the life-course theory as a sensitizing framework to examine how each participant's life-course contributed to her substance use, relapse, recovery or overdose.

DESIGN

A mixed-methods study using semi-structured, in-depth face-to-face interviews and focus groups were conducted.

SETTING

Texas, United States.

PARTICIPANTS

Women who had relapsed into opioid use or experienced a 'near-miss' overdose and family members of women who had died during the maternal period due to opioid overdose were interviewed (n = 99).

MEASUREMENTS

A socio-demographic questionnaire captured participants' ethnicity, age, marital status, medical and mental health history and employment status. The Stressful Life Events Screening Questionnaire-revised (SLESQ-R) assessed life-time exposure to trauma.

FINDINGS

Women reported histories of abuse and loss of a loved one through homicide or suicide. Participants indicated that limited social support, interpersonal conflict with their partner and unaddressed mental illness made recovery more challenging. Additionally, losing their children through the child welfare system was described as punitive and placed them at greater risk for relapse and overdose.

CONCLUSIONS

A life-course theory approach to examining maternal opioid-related morbidity and mortality in Texas, United States reveals the complex needs of women at risk for opioid use relapse and overdose and the significant role of previous traumatic experiences.

Hypothalamic-pituitary-adrenal axis activity in post-traumatic stress disorder and cocaine use disorder

Post-traumatic stress disorder (PTSD) is often comorbid with cocaine use disorder (CUD), but little is known about hypothalamic-pituitary-adrenal (HPA) axis function in PTSD + CUD. Here we review the clinical and pre-clinical literature of PTSD and CUD with the goal of generating hypotheses about HPA axis activity in comorbid PTSD + CUD. Low glucocorticoid (CORT) levels immediately after trauma exposure are associated with PTSD. CORT administered within 12 h of trauma exposure reduces later PTSD symptoms. Weeks-years after trauma, meta-analyses find lower CORT levels in patients with PTSD relative to never-traumatized controls; the same is found in a pre-clinical model of PTSD. In rodents, reduced basal CORT levels are consistently found after chronic cocaine self-administration. Conversely, increased CORT levels are found in CUD patients during the first 2 weeks of cocaine abstinence. There is evidence for CORT hyper-suppression after dexamethasone, high glucocorticoid receptor (GR) number pre-trauma, and increased GR translocation to the nucleus in PTSD. Hyper-suppression of HPA axis activity after dexamethasone suggests that PTSD individuals may have increased anterior pituitary GR. Given evidence for decreased anterior pituitary GR in rats that self-administer cocaine, PTSD + CUD individuals may have normal GR density and low basal CORT levels during late abstinence. Future studies should aim to reconcile the differences in pre-clinical and clinical basal CORT levels during cocaine and assess HPA axis function in both rodent models of CUD that consider stress-susceptibility and in PTSD + CUD individuals. Although additional studies are necessary, individuals with PTSD + CUD may benefit from behavioral and psychopharmacological treatments to normalize HPA axis activity. LAY SUMMARY Post-traumatic stress disorder (PTSD) is often comorbid with cocaine use disorder (CUD), but little is known about the hypothalamic-pituitary-adrenal (HPA) axis function in PTSD + CUD. The current review provides a synthesis of available clinical and pre-clinical data on PTSD and CUD with the goal of generating hypotheses about HPA axis activity in comorbid PTSD + CUD. While this review finds ample evidence supporting aberrant HPA axis activity in both PTSD and CUD, it suggests that more research is needed to understand the unique changes HPA axis activity in PTSD + CUD, as well as the bidirectional relationship between stress-susceptibility and motivation to seek cocaine.

The prevalence of mental health disorders among young adults who use amphetamine-type stimulants, compared to young adults who do not

INTRODUCTION AND AIMS

There is a lack of evidence regarding mental health disorder prevalence in people who use amphetamine-type stimulants (ATS). This study compares prevalence in Australian young adults who used ATS and young adults who had never used, and examines potential predictors.

DESIGN AND METHODS

Population-based sampling was used to recruit young adults who used ATS (n = 224) and young adults who had never used ATS (n = 125). Thirty-day prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), panic disorder (PD), post-traumatic stress disorder (PTSD) and mania/hypomania were assessed using the Composite International Diagnostic Interview Short Scale. Adjusted prevalence ratios (APR) of mental disorders in people who used ATS and the comparison group were examined, and a prediction model was developed for people who used ATS.

RESULTS

We found higher prevalence of PD (APR 4.67, 95% confidence interval [CI] 1.14-19.07, P = 0.032) and PTSD (APR 1.68, 95% CI 1.10-2.55, P = 0.016) in people who used ATS, compared to the comparison group, adjusting for sociodemographic variables. Baseline methamphetamine use was positively associated with MDD (ARR 6.45, 95% CI 1.51-27.59, P = 0.012) and GAD (ARR 2.76, 95% CI 1.52-5.02, P = 0.001). Baseline ecstasy use was negatively associated with GAD (ARR 0.52, 95% CI 0.30-0.92, P = 0.025) and PD (ARR 0.15, 95% CI 0.05-0.48, P = 0.001).

DISCUSSION AND CONCLUSION

PTSD and PD appear to be more common in young adults who use ATS. However, the relationship between ATS use and mental disorders is complex, with divergent patterns of association for ecstasy and methamphetamine use. Mental health screening in people using ATS may improve treatment outcomes.

Childhood Maltreatment and Violent Outcomes: A Systematic Review and Meta-Analysis of Prospective Studies

The risk of violence following childhood maltreatment is uncertain. This meta-analytic review identified prospective studies that have examined this association. We systematically searched three electronic databases (PsycINFO, EMBASE, and MEDLINE) and completed a targeted search on Google Scholar. These were supplemented with scanning reference lists and correspondence with authors. We considered non-English-language and unpublished studies. Studies were included if childhood maltreatment was measured before age 18 years and occurred before violent outcomes. We identified 18 eligible studies with data on 39,271 participants. We conducted meta-analysis to calculate odds ratios (ORs) using random-effects models. Heterogeneity was explored through subgroup analyses and meta-regression. The overall OR of violent outcomes in childhood maltreatment was 1.8 (95% confidence interval [1.4, 2.3]) with substantial heterogeneity (I2 = 92%). Meta-regression suggested that risk of violence following childhood maltreatment was more elevated in samples with higher percentage of females, in higher quality investigations, in studies with case-linkage methods compared to that followed-up participants over time using a prospective cohort design, when general population or matched controls were used rather than selected population controls, and when violent outcomes were ascertained in older individuals. In conclusion, the risk of later violence perpetration was modestly increased in individuals with a history of childhood maltreatment. Preventative strategies and interventions for childhood maltreatment may have an important role in violence reduction. Methodological issues and recommendations for future research are discussed.

The COVID-19 cannabis health study: Results from an epidemiologic assessment of adults who use cannabis for medicinal reasons in the United States

Background: Clinical indications for medicinal cannabis include chronic conditions; thus users (MCUs) are at an increased risk of morbidity and mortality resulting from SARS-CoV-2 infection (COVID-19). The study aimed to provide data on cannabis use and self-reported behavioral changes among MCUs with preexisting chronic conditions in response to the pandemic.Methods: An internet-based questionnaire was administered to adults ≥18 who self-reported medicinal cannabis use within the past year. Data are from respondents between March 21 and April 23, 2020; response rate was 83.3%. Health conditions and cannabis frequency, route, and patterns of use were assessed via the COVID-19 Cannabis Health Questionnaire (Vidot et al. 2020).Results: Participants (N = 1202) were predominantly non-Hispanic white (82.5%) and 52.0% male (mean age 47.2 years). Mental health (76.7%), pain (43.7%), cardiometabolic (32.9%), respiratory (16.8%), and autoimmune (12.2%) conditions were most reported. Those with mental health conditions reported increased medicinal cannabis use by 91% since COVID-19 was declared a pandemic compared to those with no mental health conditions (adjusted odds ratio: 1.91, 95% CI: 1.38-2.65). 6.8% reported suspected COVID-19 symptoms. Two percent (2.1%) have been tested for COVID-19 with only 1 positive test result. Some MCUs (16%) changed their route of cannabis administration, switching to nonsmoking forms.Conclusions: The majority of MCUs reported at least one preexisting chronic health condition. Over half report fear of COVID-19 diagnosis and giving the virus to someone else; yet only some switched from smoking to nonsmoking forms of cannabis. Clinicians may consider asking about cannabis use among their patients, particularly those with chronic health conditions.

Exposure to different early-life stress experiences results in differentially altered DNA methylation in the brain and immune system

The existence of a proportional relationship between the number of early-life stress (ELS) events experienced and the impoverishment of child mental health has been hypothesized. However, different types of ELS experiences may be associated with different neuro-psycho-biological impacts, due to differences in the intrinsic nature of the stress. DNA methylation is one of the molecular mechanisms that have been implicated in the "translation" of ELS exposure into neurobiological and behavioral abnormalities during adulthood. Here, we investigated whether different ELS experiences resulted in differential impacts on global DNA methylation levels in the brain and blood samples from mice and humans. ELS exposure in mice resulted in observable changes in adulthood, with exposure to social isolation inducing more dramatic alterations in global DNA methylation levels in several brain structures compared with exposure to a social threatening environment. Moreover, these two types of stress resulted in differential impacts on the epigenetic programming of different brain regions and cellular populations, namely microglia. In a pilot clinical study, blood global DNA methylation levels and exposure to childhood neglect or abuse were investigated in patients presenting with major depressive disorder or substance use disorder. A significant effect of the mental health diagnosis on global methylation levels was observed, but no effect of either childhood abuse or neglect was detected. These findings demonstrate that different types of ELS have differential impacts on epigenetic programming, through DNA methylation in specific brain regions, and that these differential impacts are associated with the different behavioral outcomes observed after ELS experiences.

Obstetrical and perinatal outcomes of patients with methamphetamine-positive drug screen on labor and delivery

BACKGROUND

The incidence of methamphetamine use in reproductive-age women across the United States is increasing. The existing literature on methamphetamine use in pregnancy has indicated an elevated risk of adverse maternal and neonatal health outcomes.

OBJECTIVE

This study aimed to investigate pregnancy outcomes in patients with recent methamphetamine use compared with patients who received negative test results for methamphetamine at the time of delivery.

STUDY DESIGN

A single-site retrospective cohort study from January to December 2015 was performed. Patients with a documented urine drug screen during the delivery encounter were identified from the electronic medical records. The outcomes of patients with methamphetamine-positive urine drug screens were compared with controls with urine drug screens negative for methamphetamine. Maternal outcomes of interest included placental abruption, hypertensive disorders, premature preterm rupture of membranes, postpartum hemorrhage, and preterm birth. Utilization of prenatal care, social work consults, and child protective services referrals were also recorded. Neonatal outcomes included birthweight, neonatal intensive care unit length of stay, Apgar scores, and perinatal mortality.

RESULTS

The 2 groups had similar demographic characteristics (age, multiparity, ethnicity), with the methamphetamine-positive group more likely to have no or limited prenatal care. Both groups engaged in polysubstance use. A methamphetamine-positive urine drug screen at the time of delivery carries an increased risk of abruption (odds ratio, 5.63; confidence interval, 1.21-26.21) but indicated no increased risk of maternal hypertensive disorders. Additional associated risks include preterm birth (odds ratio, 3.10; confidence interval, 1.44-6.68), lower Apgar scores at 1 and 5 minutes (P=.012 and P=.02, respectively), and increased perinatal mortality (odds ratio, 6.9; confidence interval, 1.01-47.4).

CONCLUSION

Positive urine drug testing for methamphetamines during labor admission confers considerable maternal and perinatal morbidity and mortality including an increased risk of placental abruption, preterm birth, and perinatal demise. Given the limited treatments for methamphetamine addiction, further research is urgently needed.

Exposure to personal and community violence and associated drug use outcomes in African American young adults

BACKGROUND

Exposure to violence (ETV) during one's life has been associated with increased risk for substance abuse. Adolescent ETV is also related to substance abuse into adulthood, and has been shown to have a cumulative effect. This study adds to the understanding of how ETV relates to a range of substance use outcomes by specifying how different types of violence affects substance use behaviors in African American young adults, and examines how this exposure is moderated by other life stressors, and health and social experiences.

METHOD

Factor analysis was conducted to identify unique types of ETV in 638 African American men and women ages 18-25. The resulting factors represent 1) childhood ETV and 2) community ETV as adults. These were regressed upon substance abuse outcomes.

RESULTS

78% of the respondents were exposed to some form of violence during their childhood. Lower childhood ETV were significantly associated with a lower risk of engaging in dangerous substance use behaviors. Adult experiences of community violence had more significant predictors of drug use than childhood ETV. Witnessing gunfire or an assault, witnessing or being a victim of sexual assault, and carrying a weapon were consistent risk factors for dangerous drug behaviors, although specific drug use behaviors differed across genders.

CONCLUSIONS

ETV served as an independent explanatory factor for specific drug use behaviors at different stages of life. Future research is needed to understand how these factors put respondents at risk for drug use behaviors or make them less likely to engage in dangerous use patterns.

Berkson's bias in biobank sampling in a specialised mental health care setting: a comparative cross-sectional study

OBJECTIVES

To determine whether studying aetiological pathways of depression, in particular the well-established determinant of childhood trauma, only in a specialised mental healthcare setting can yield biased estimates of the aetiological association, given that the majority of individuals are treated in primary care settings.

DESIGN AND SETTING

Two databanks were used in this study. The Canadian Community Health Survey (CCHS) on Mental Health and Well-Being 2012 is a national survey about mental health of adult Canadians. It measured common mental disorders and utilisation of services. The Signature mental health biobank includes adults from the Island of Montreal recruited at the emergency department of a major university mental health centre. After consent, participants filled standardised psychosocial questionnaires, gave blood samples, and their clinical diagnosis was recorded. We compared the cohort of depressed individuals from CCHS and Signature in contact with specialised services with those in contact with primary care or not in treatment.

PARTICIPANTS

There were 860 participants with depression in the CCHS and 207 participants with depression in the Signature Bank.

PRIMARY AND SECONDARY OUTCOMES

The Childhood Experiences of Violence Questionnaire was used to measure childhood trauma in both settings. Childhood trauma is associated with depression as with other common mental and physical disorders.

RESULTS

Individuals with depression in the CCHS who reported having been hospitalised for psychiatric treatment or having seen a psychiatrist or those from Signature were found to be more strongly associated with childhood abuse than individuals with depression who were treated in primary care settings or did not seek mental healthcare in the preceding year.

CONCLUSIONS

Berkson's bias limits the generalisability of aetiological associations observed in such university-hospital-based biobanks, but the problem can be remedied by broadening recruitment to primary care settings and the general population.

The association between childhood trauma and treatment outcomes in schizophrenia spectrum disorders

Childhood trauma exposure has been associated with poorer treatment outcomes in schizophrenia. Most studies to date have been conducted in naturalistic settings in which the outcome may have been mediated by factors such as poor adherence and substance abuse. We compared the effects of high vs low childhood trauma exposure on the treatment response over 24 months in 78 patients with first-episode schizophrenia spectrum disorders who received standardised treatment with a long acting injectable antipsychotic. Compared to the low childhood trauma group (n = 37), the high childhood trauma group (n = 41) received higher doses of antipsychotic medication and were less likely to achieve remission. When age, sex and cannabis use were controlled for, patients with high levels of childhood trauma had a slower treatment response for positive and disorganized symptom domains, although differences did not differ significantly at 24 months. While there were no differences in functional outcomes, self-rated quality of life was the domain that most clearly differentiated the high and low childhood trauma groups. High childhood trauma exposure was associated with lower quality of life scores at baseline, a lesser degree of improvement with treatment, and lower quality of life scores at 24 months.

Childhood Trauma Predicts Less Remission from PTSD among Patients with Co-Occurring Alcohol Use Disorder and PTSD

Post-traumatic stress disorder (PTSD) is highly prevalent among patients hospitalized for an alcohol use disorder (AUD). Hospitalization can improve PTSD and AUD outcomes in some but not all patients, but we lack data on the baseline predictors of PTSD non-remission. This study aimed to determine the baseline risk factors for non-remitted PTSD in patients hospitalized for an AUD. Of 298 AUD inpatients recruited in a rehabilitation center (Le Courbat, France), we included 91 AUD inpatients with a co-occurring PTSD and a longitudinal assessment at baseline (T1) and before discharge (T2: 8 weeks later). Patients were assessed for PTSD diagnosis/severity (PCL-5=PTSD Checklist for DSM-5), different types of trauma including childhood trauma (LEC-5=Life Events Checklist for DSM-5/CTQ-SF=Childhood Trauma Questionnaire, Short-Form), and AUD diagnosis/severity (clinical interview/AUDIT=Alcohol Use Disorders Identification Test). Rate of PTSD remission between T1 and T2 was 74.1%. Non-remitted PTSD at T2 was associated with a history of childhood trauma (physical, emotional or sexual abuse, physical negligence), but not with other types of trauma experienced, nor baseline PTSD or AUD severity. Among patients hospitalized for an AUD with co-occurring PTSD, PTSD remission was more strongly related to the existence of childhood trauma than to AUD or PTSD severity at admission. These patients should be systematically screened for childhood trauma in order to tailor evidence-based interventions.

Determinants of new-onset alcohol use disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Although veterans are at increased risk of alcohol use disorder (AUD) relative to civilians, few longitudinal studies have examined both risk and protective factors that influence the development of AUD. This study aimed to identify risk and protective factors that contribute to incident AUD.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a nationally representative, prospective cohort study of U.S. veterans. The sample included 1,770 veterans who did not meet criteria for lifetime AUD at Wave 1 and completed at least one follow-up assessment over a 7-year period. Veterans completed self-report measures to assess for risk and protective factors. A multivariable binary logistic regression analysis was conducted to examine baseline factors associated with incident AUD.

RESULTS

A total of 5.9% of veterans without AUD at Wave 1 developed AUD in the 7-year follow-up period. Adult sexual trauma, greater severity of anxious arousal symptoms of PTSD, lifetime history of drug and nicotine use disorders, and higher alcohol consumption at Wave 1 were independently associated with incident AUD. Lifetime drug use disorder (75.9%) and higher alcohol consumption (22.1%) explained the most variance in incident AUD.

CONCLUSION

Approximately 6% of veterans without AUD at Wave 1 developed AUD over a 7-year period. Lifetime drug use disorder and greater alcohol consumption at baseline, as well as trauma-related characteristics (i.e., adult sexual trauma, anxious arousal symptoms), were associated with increased risk of developing AUD. Future research should examine whether treatment of drug use disorder and PTSD symptoms in at-risk veterans may help mitigate risk of developing AUD in this population.

The Role of Adverse Childhood Experiences on Perinatal Substance Use Behaviour in KwaZulu-Natal Province, South Africa

The role of risky sexual behaviour has been widely investigated across the sub-Saharan African HIV hyperendemic setting, with few studies having focused on the behaviour attributed to the deep-rooted, neurodevelopmentally-driven adverse childhood experiences (ACE) that sustain the endemic. We investigated the role of ACE on perinatal substance use outcomes in KwaZulu-Natal Province, South Africa, with 223 women being interviewed within one-week post-partum at a general hospital. Our secondary outcome was the occurrence of preterm birth delivery, which is understood to be linked to ACE. Study results suggest that the most common perinatal substance use was alcohol (n = 27, 12.11%), followed by tobacco (n = 18, 8.07%), with the prevalence of preterm birth delivery being 8.97% (n = 20, 8.97%). Regression analyses indicated increased ACE being significantly associated with perinatal alcohol (aOR = 1.45, 95% CI 1.22-1.72), tobacco use (aOR = 1.56, 95% CI 1.23-1.97) and preterm birth delivery (aOR = 1.21, 95% CI 1.03-1.43), independent of socio-economic status. When the model was further adjusted by HIV status, suppressed viral load was more significantly associated with lower odds of preterm birth delivery (aOR = 0.06, 95% CI: 0.01-0.24) than an unsuppressed status. Risk-behaviour reduction strategies should address the role of ACE on substance use and viral load, and hence possibly ART adherence, in HIV hyperendemic settings.

Governance of mental healthcare: Fragmented accountability

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

Alexithymia, Emotion-Regulation Strategies, and Traumatic Experiences in Prenatally Cocaine-Exposed Young Adults

BACKGROUND AND OBJECTIVES

Exposure to early-life trauma may lead to maladaptive characteristics such as alexithymia, and thus to poorer emotional regulation. This relationship may also be influenced by exposure to substances prenatally. We hypothesized that increased alexithymia would be seen in those with prenatal cocaine exposure (PCE). Additionally, we hypothesized that early-life trauma would be associated with alexithymia, and that alexithymia would be associated with poor emotional reappraisal and emotional suppression.

METHODS

A moderated mediation model was developed to examine whether the hypothesized indirect relationship between trauma and emotional reappraisal through alexithymia was different in young adults with and without PCE (Total N = 57). Thirty-seven young adults with PCE and 20 with no such exposure, all of whom were members of a longitudinal cohort, were recruited for the study, and data concerning childhood trauma, alexithymia, and emotional regulation were collected. Intercorrelations were performed between the scores on each measure and moderated mediation models were constructed separately with emotional neglect or emotional abuse as the independent variable and emotional reappraisal or emotional suppression as the dependent variable.

RESULTS

PCE status was associated with alexithymia, and alexithymia mediated the relationship between emotional neglect and emotional reappraisal in individuals with PCE but not those without.

DISCUSSION AND CONCLUSIONS

The data suggest that alexithymia is a mechanism underlying poor use of emotional reappraisal in PCE individuals.

SCIENTIFIC SIGNIFICANCE

Individuals with early-life trauma and substance exposure may represent a vulnerable population, and alexithymia may play a key role in the development of emotional regulation skills in this population. (Am J Addict 2020;29:492-499).

Adverse childhood experiences (ACEs) on mental disorders in young adulthood: Latent classes and community violence exposure

Adverse childhood experiences (ACEs) have significant impacts on mental health outcomes. There is a growing interest in expanding the scope of ACEs beyond household environments. To date, few studies examine multidimensional ACEs with community violence. This study aims to (1) identify underlying ACE classes including exposure to community violence, and (2) investigate the associations of ACE classes with mental disorders in adulthood: depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). We employed Latent Class Analysis (LCA) and logistic regression analyses using the data from the National Longitudinal Study of Adolescent and Adult Health (Add Health). The LCA identified four heterogeneous ACE classes: (1) child maltreatment (17.47%), (2) household dysfunction (14.39%), (3) community violence (5.36%), and (4) low adversity (62.79%). Three logistic analyses showed that the "child maltreatment" class was more likely to report a depression (OR = 1.56, CI = 1.26-1.92), anxiety (OR = 1.31, CI = 1.06-1.62), and PTSD (OR = 1.97, CI = 1.35-2.87) in adulthood compared to the "low adversity" class. Also, the "community violence" class was more likely to have PTSD (OR = 2.15, CI = 1.14-4.06) in adulthood, compared to the "low adversity" class. However, the "household dysfunction" class was not significantly different in all three mental disorders from the "low adversity" class. Findings supported the differences in mental disorders in young adulthood by types of exposures to ACEs. The study highlights the importance of considering types of ACEs exposure for promoting mental health of young adults.

Comorbid Conditions in Relation to Controlled Substance Abuse

Dental patients who experience comorbid psychiatric and medical conditions present an elevated risk of medication misuse, abuse, substance use disorders, and overdose. The authors review the role of notable comorbidities in predicting the development of substance use disorder, including medical, psychiatric, and other psychosocial factors that can be assessed in general dental practice. Psychiatric disorders commonly cooccur with substance abuse, and these typically include anxiety disorders, mood disorders (major depression, bipolar), posttraumatic stress, as well as sleep and eating disorders. Medical disorders commonly found to be present with substance use disorders are also reviewed, including common cardiovascular and pulmonary disorders.

Chronic repeated predatory stress induces resistance to quinine adulteration of ethanol in male mice

BACKGROUND

Trauma related psychiatric disorders, such as posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD) are highly comorbid illnesses that separately present an opposing, sex-specific pattern, with increased prevalence of PTSD in females and increased prevalence of AUD diagnoses in males. Likewise, PTSD is a risk factor in the development of AUD, with conflicting data on the impact of sex in the comorbid development of both disorders. Because the likelihood of experiencing more than one traumatic event is high, we aim to utilize chronic repeated predatory stress (CRPS) to query the extent to which sex interacts with CRPS to influence alcohol consumption, or cessation of consumption.

METHODS

Male (n = 16) and female (n = 15) C57BL/6 J mice underwent CRPS or daily handling for two weeks during adolescence (P35-P49) and two weeks during adulthood (P65-P79). Following the conclusion of two rounds of repeated stress, behavior was assessed in the open field. Mice subsequently underwent a two-bottle choice intermittent ethanol access (IEA) assessment (P90-131) with the options of 20 % ethanol or water. After establishing drinking behavior, increasing concentrations of quinine were added to the ethanol to assess the drinking response to adulteration of the alcohol.

RESULTS

CRPS increased fecal corticosterone concentrations and anxiety-like behaviors in the open field in both male and female mice as compared to control mice that had not been exposed to CRPS. Consistent with previous reports, we observed a sex difference in alcohol consumption such that females consumed more ethanol per gram of body mass than males. In addition, CRPS reduced alcohol aversion in male mice such that higher concentrations of quinine were necessary to reduce alcohol intake as compared to control mice. CRPS did not alter alcohol-related behaviors in female mice.

CONCLUSION

Collectively, we demonstrate that repeated CRPS can induce anxiety-like behavior in both sexes but selectively influences the response to ethanol adulteration in males.

Early Life Stress and Pediatric Posttraumatic Stress Disorder

Traumatic stress exposure during critical periods of development may have essential and long-lasting effects on the physical and mental health of individuals. Two thirds of youth are exposed to potentially traumatic experiences by the age of 17, and approximately 5% of adolescents meet lifetime criteria for posttraumatic stress disorder (PTSD). The role of the stress system is the maintenance of homeostasis in the presence of real/perceived and acute/chronic stressors. Early-life stress (ELS) has an impact on neuronal brain networks involved in stress reactions, and could exert a programming effect on glucocorticoid signaling. Studies on pediatric PTSD reveal diverse neuroendocrine responses to adverse events and related long-term neuroendocrine and epigenetic alterations. Neuroendocrine, neuroimaging, and genetic studies in children with PTSD and ELS experiences are crucial in understanding risk and resilience factors, and also the natural history of PTSD.

Childhood adversity, externalizing behavior, and substance use in adolescence: Mediating effects of anterior cingulate cortex activation during inhibitory errors

Childhood adversity can negatively impact development across various domains, including physical and mental health. Adverse childhood experiences have been linked to aggression and substance use; however, developmental pathways to explain these associations are not well characterized. Understanding early precursors to later problem behavior and substance use can inform preventive interventions. The aim of the current study was to examine neurobiological pathways through which childhood adversity may lead to early adolescent problem behavior and substance use in late adolescence by testing two prospective models. Our first model found that early adolescent externalizing behavior mediates the association between childhood adversity and alcohol, cigarette, and marijuana use in late adolescence. Our second model found that activation in the anterior cingulate cortex (ACC) during an inhibitory control task mediates the association between childhood adversity and early adolescent externalizing behavior, with lower ACC activation associated with higher levels of adversity and more externalizing behavior. Together these findings indicate that the path to substance use in late adolescence from childhood adversity may operate through lower functioning in the ACC related to inhibitory control and externalizing behavior. Early life stressors should be considered an integral component in the etiology and prevention of early and problematic substance use.

Accelerated development of cocaine-associated dopamine transients and cocaine use vulnerability following traumatic stress

Post-traumatic stress disorder and cocaine use disorder are highly co-morbid psychiatric conditions. The onset of post-traumatic stress disorder generally occurs prior to the development of cocaine use disorder, and thus it appears that the development of post-traumatic stress disorder drives cocaine use vulnerability. We recently characterized a rat model of post-traumatic stress disorder with segregation of rats as susceptible and resilient based on anxiety-like behavior in the elevated plus maze and context avoidance. We paired this model with in vivo fast scan cyclic voltammetry in freely moving rats to test for differences in dopamine signaling in the nucleus accumbens core at baseline, in response to a single dose of cocaine, and in response to cocaine-paired cues. Further, we examined differences in the acquisition of cocaine self-administration across groups. Results indicate that susceptibility to traumatic stress is associated with alterations in phasic dopamine signaling architecture that increase the rate at which dopamine signals entrain to cocaine-associated cues and increase the magnitude of persistent cue-evoked dopamine signals following training. These changes in phasic dopamine signaling correspond with increases in the rate at which susceptible rats develop excessive cocaine-taking behavior. Together, our studies demonstrate that susceptibility to traumatic stress is associated with a cocaine use-vulnerable phenotype and suggests that differences in phasic dopamine signaling architecture may contribute to the process by which this vulnerability occurs.