The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders

Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders

Introduction

Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD.

Design and setting

An administrative dataset including Veterans Health Administration (VHA) users.

Participants

The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015.

Measurement

Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy.

Findings

A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment.

Conclusions

Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.

History of co-occurring disorders and current mental health status among homeless veterans

Background

Homeless veterans are at high risk for co-occurring disorders (COD), defined as mental illnesses that include at least one alcohol or other drug use disorder and at least one non-drug related mental disorder. However, epidemiological studies examining the prevalence of COD and associated mental health status in this population are limited. The objectives of the study were: (1) to describe a history of diagnosed mental disorders among homeless veterans admitted to a transitional housing program, and (2) to examine the associations of the prior diagnosed COD and other mental disorders with current mental health status.

Methods

Study participants were male homeless veterans admitted to a transitional housing program from July 2015 to September 2017 in a large municipal area in Northeast Ohio, the United States. Cross-sectional, self-reported data from the admission assessment were included and analyzed. History of mental disorder diagnoses were aggregated into five categories for the purpose of this study: no mental disorders, only alcohol or other drug use disorder(s), one non-drug related mental disorder, two or more non-drug related mental disorders, and COD. Current mental status were measured as empowerment, mental component summary score (MCS) and physical component summary score (PCS) of health related quality of life (VR-12), and perceived overall well-being. Sample distribution of the five categories and their associations with current mental status were examined using Generalized Linear Model test.

Results

Of all participants, 76.7% had at least one prior diagnosed mental disorder, including 47.4% with any drug-related disorders. Over one-third (37.2%) reported having COD. Compared to those with no mental disorder history, those with COD scored significantly lower on MCS and empowerment scores; those with any prior diagnosed non-drug related mental disorders also scored significantly lower on MCS. No significant differences, however, were found in current mental health status between those with COD and those with mental disorders but not COD.

Conclusions

COD prevalence among homeless veterans was within the parameter of other literature reports. Veterans with COD compared to veterans with no history of mental disorders tended to have lower MCS and empowerment scores. Veterans with COD had the same mental health status as those with other mental disorders.

Mining 100 million notes to find homelessness and adverse childhood experiences: 2 case studies of rare and severe social determinants of health in electronic health records

Objective

Understanding how to identify the social determinants of health from electronic health records (EHRs) could provide important insights to understand health or disease outcomes. We developed a methodology to capture 2 rare and severe social determinants of health, homelessness and adverse childhood experiences (ACEs), from a large EHR repository.

Materials and Methods

We first constructed lexicons to capture homelessness and ACE phenotypic profiles. We employed word2vec and lexical associations to mine homelessness-related words. Next, using relevance feedback, we refined the 2 profiles with iterative searches over 100 million notes from the Vanderbilt EHR. Seven assessors manually reviewed the top-ranked results of 2544 patient visits relevant for homelessness and 1000 patients relevant for ACE.

Results

word2vec yielded better performance (area under the precision-recall curve [AUPRC] of 0.94) than lexical associations (AUPRC = 0.83) for extracting homelessness-related words. A comparative study of searches for the 2 phenotypes revealed a higher performance achieved for homelessness (AUPRC = 0.95) than ACE (AUPRC = 0.79). A temporal analysis of the homeless population showed that the majority experienced chronic homelessness. Most ACE patients suffered sexual (70%) and/or physical (50.6%) abuse, with the top-ranked abuser keywords being "father" (21.8%) and "mother" (15.4%). Top prevalent associated conditions for homeless patients were lack of housing (62.8%) and tobacco use disorder (61.5%), while for ACE patients it was mental disorders (36.6%-47.6%).

Conclusion

We provide an efficient solution for mining homelessness and ACE information from EHRs, which can facilitate large clinical and genetic studies of these social determinants of health.

A longitudinal study of suicidal ideation among homeless, mentally ill individuals

PURPOSE

Previous cross-sectional studies have indicated that homeless individuals may present with high rates of suicidal ideation, which are strongly associated with completed suicide. We conducted the first known longitudinal study of suicidal ideation in the homeless.

METHODS

We used data collected over 24 months in the Vancouver At Home project (N = 497), comprised two randomized-controlled trials of housing interventions for homeless individuals with mental disorders. Presence of suicidal ideation was determined using the Colorado symptom index.

RESULTS

Suicidal ideation significantly decreased over time [odds ratio (OR) = 0.31 at 24 months, 95 % confidence interval (CI) 0.21-0.46]. Baseline diagnoses of mood (OR = 2.18, 95 % CI 1.48-3.21) and anxiety disorders (OR = 2.05, 95 % CI 1.42-2.97), as well as depressive mood (OR = 2.52, 95 % CI 1.90-3.33), use of any substance (OR = 1.59, 95 % CI 1.09-2.32), and polysubstance use (OR = 1.90, 95 % CI 1.40-2.60) were significantly associated with suicidal ideation in the multivariate model. Baseline diagnosis of a psychotic disorder (protective effect), daily substance use, intravenous drug use, recent arrest, multiple physical illnesses and history of traumatic brain injury were significantly associated with suicidal ideation in the unadjusted model only.

CONCLUSIONS

Interventions targeting depressive symptoms and substance use could help decrease suicide risk in homeless individuals. Mental health services need to be tailored to address the complex needs of socially marginalized individuals.

TRIAL REGISTRATION

Current controlled trials: ISRCTN57595077 (Vancouver At Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing first plus intensive case management versus treatment as usual). Assigned 9 Oct. 2012.

The cost savings of expanding Medicaid eligibility to include currently uninsured homeless adults with substance use disorders

Following the June 2012 Supreme Court ruling that states are no longer mandated to expand their Medicaid programs in 2014 as part of the Affordable Care Act, many states plan to opt out of the expansion, citing affordability as their primary concern. In response to this controversy, the present study evaluated the cost savings of expanding Medicaid coverage to include currently ineligible homeless adults with substance use disorders, a subset of the population that incurs some of the greatest societal costs and is disproportionately impacted by uninsurance. Using a time horizon of 7 years, separate analyses were conducted for state and federal governments, and then a final analysis evaluated the combined costs for the other two models. Results of the study demonstrate that, although the expansion will be associated with a net cost when combining state and federal expenses and savings, states will experience tremendous savings if they choose to participate.

Treatment outcome in substance use disorder patients with and without comorbid posttraumatic stress disorder: A systematic review

We investigated the role of comorbid posttraumatic stress disorder (CO-PTSD) in substance use disorder (DSM-IV/ICD-10 substance abuse or dependence, SUD) treatment. We conducted a systematic review of treatment outcome studies in SUD patients with and without CO-PTSD from 2000 to 2011. The N = 22 studies found differed clearly with regard to methodology and the sufficiency of provided study information, limiting their comparability. Remarkably, no consistent indication of a negative effect of CO-PTSD on the reported SUD treatment outcome was found. In addition to CO-PTSD, we point out possible further effect modifiers which need to be better understood. Finally, we emphasize the requirements for future research such as methodological standardization and a focus on long-term studies.

Medicaid expansion initiative in Massachusetts: enrollment among substance-abusing homeless adults

OBJECTIVES

We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.

METHODS

We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992-2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.

RESULTS

The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.

CONCLUSIONS

Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.

Trauma experience among homeless female veterans: correlates and impact on housing, clinical, and psychosocial outcomes

This study examined lifetime exposure to traumatic events as reported by 581 homeless female veterans enrolled in a Homeless Women Veterans Program across 11 sites to characterize the types of trauma they experienced; their correlation with baseline characteristics; and their association with housing, clinical outcomes, and psychosocial functioning over a 1-year treatment period. Almost all participants endorsed multiple types and episodes of traumatic events. Among the most common were having someone close experience a serious or life-threatening illness (82%) and rape (67%). Exploratory factor analysis revealed 6 potential trauma categories: being robbed, experiencing accident or disasters, illness or death of others, combat, sexual assault, and physical assault. At baseline, trauma from sexual assault was associated with more days homeless (β = .18, p < .001), trauma from accidents or disasters was associated with poorer physical health (β = -.23, p < .001), and trauma from being robbed was related to greater use of drugs (β = .22, p < .001). Trauma reported at baseline, however, was not predictive of 1-year outcomes, suggesting type and frequency of trauma does not negatively affect the housing gains homeless women veterans can achieve through homeless services.

One-year outcomes of telephone case monitoring for patients with substance use disorder

BACKGROUND

Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM).

METHOD

This study randomized 667 intensive SUD outpatients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3 and 12months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, quality of life, and treatment satisfaction. We also evaluated potential interaction effects for distance to VA provider, SUD severity, and presence of co-morbid psychiatric disorder.

RESULTS

Participants randomized to the telephone case monitoring condition substantially engaged with face-to-face continuing care resulting in cross-over contamination. We addressed this issue by using randomization as an instrumental variable to evaluate the impact of telephone case monitoring (contamination adjusted, intent to treat analysis). Instrumental variable analyses indicated significant benefit of telephone case monitoring for drug and alcohol percent days abstinent and psychiatric symptom outcomes at 3-months follow-up, but not at 12-month follow-up. No interaction analyses were significant.

DISCUSSION

Participants receiving telephone case monitoring achieved better short term outcomes in terms of substance use and psychiatric symptoms. The "on treatment" effects suggests the need for future studies to investigate consumer (patient) perspectives on the optimal duration of telephone case monitoring and use of alternative monitoring methods such as text messaging.