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Dewey JM, Bell JS, Konchak JN, Hinami K, Watson DP. "A lot of moving parts": Recovery home challenges linking and housing individuals with criminal legal system involvement. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 166:209473. [PMID: 39106919 DOI: 10.1016/j.josat.2024.209473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/29/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION There are high rates of substance use disorder (SUD) among people released from carceral settings and, upon release, many of these people also face unstable housing situations, posing challenges to connecting with resources to facilitate SUD recovery. Recovery homes provide a temporary sober living environment for those seeking both SUD recovery and transition back to the community after carceral release. However, successful recovery home placement for this population can prove difficult, and there is a need for research to identify ways to overcome them. METHODS The current qualitative study seeks to understand barriers to recovery home access for people leaving carceral settings and identify potential best practices for overcoming these barriers from the perspective of recovery home directors. The study conducted semi-structured interviews at two data collection points with eight recovery home directors from sites participating in a housing linkage and placement intervention pilot. The research team used qualitative software to identify and organize directors' experiences and practices in housing and supporting this population. RESULTS Recovery home directors identified significant barriers to linkage from carceral settings, including difficulties communicating and coordinating placement with potential residents while still incarcerated. Interviews also revealed approaches recovery home directors take to improve recovery home placement, such as sharing information and resources with carceral settings prior to release and helping residents avoid reincarceration by managing relationships with court agents and parole. CONCLUSION Recovery resident directors have considerable insight into the most significant placement challenges faced by recovery homes upon carceral release as well as experience with potential solutions for overcoming them. Directors can be the key to direct seamless support and continuity of care for criminal legal system involved individuals through coordination with jails, prisons, and other community resources. Directors can also play a significant role in the successful completion of probation and parole by helping residents avoid further issues with the legal system. These directors view working cooperatively with residents as an effective approach to ensuring clients adhere to court orders and are successful in recovery and reentry.
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Affiliation(s)
- Jodie M Dewey
- Chestnut Health System's Lighthouse Institute, 221 W. Walton Street, Chicago, IL 60610, United States of America.
| | - Justin S Bell
- Chestnut Health System's Lighthouse Institute, 221 W. Walton Street, Chicago, IL 60610, United States of America
| | | | - Keiki Hinami
- Cook County Health, 1950 W. Polk Street, Chicago, IL 60612, United States of America
| | - Dennis P Watson
- Chestnut Health System's Lighthouse Institute, 221 W. Walton Street, Chicago, IL 60610, United States of America
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O'Leary C, Ralphs R, Stevenson J, Smith A, Harrison J, Kiss Z, Armitage H. The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1396. [PMID: 38645303 PMCID: PMC11032639 DOI: 10.1002/cl2.1396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing. Objectives To understand the effectiveness of different substance use interventions for adults experiencing homelessness. Search Methods The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews. Selection Criteria Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries. Data Collection and Analysis Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings. Main Results We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest. Authors' Conclusions Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.
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Affiliation(s)
| | - Rob Ralphs
- Manchester Metropolitan UniversityManchesterUK
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Ellis JD, Dunn KE, Huhn AS. Harm Reduction for Opioid Use Disorder: Strategies and Outcome Metrics. Am J Psychiatry 2024; 181:372-380. [PMID: 38706335 DOI: 10.1176/appi.ajp.20230918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Tweet: The authors discuss harm reduction strategies and associated outcome metrics in relation to the ongoing opioid crisis.
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Affiliation(s)
- Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
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Álvaro-Alonso EA, Gómez-Álvarez MDC, Segovia-Tapiador B, Del-Pino-Illaconza MI, Valencia J, Ryan P, Aguilar-Ros A, Escobar-Rodríguez I. Persistence in the Methadone Maintenance Program and Its Relationship with the Medication Regimen Complexity Index in Opioid-Dependent Patients. Pharmaceuticals (Basel) 2024; 17:567. [PMID: 38794137 PMCID: PMC11123973 DOI: 10.3390/ph17050567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
It has been shown that the Medication Regimen Complexity Index (MRCI) is a useful and reliable tool for calculating the complexity of the pharmacotherapeutic regimen (CPR). Furthermore, a high MRCI is associated with lower adherence. However, the MRCI of opioid-dependent patients (ODP) has not been studied. The aim of this study is to calculate the Methadone Maintenance Program (MMP) persistence and the MRCI score in a ODP cohort. Second, to analyze its relationship and association with other variables. To accomplish this research, an observational study including adults with a confirmed diagnosis of opiate-dependency according to the DSM-5 in a MMP center was carried out. To define MMP-persistence, a group was created by the researchers who defined five weighted items according to their agreed importance. Our first contribution was to create a new definition of MMP-persistence. This study also identified age, comorbidities, and received methadone maintenance doses as successful predictors for MMP-persistence. We have also shown that the MRCI does not seem to be a useful tool to determine MMP-persistence, probably because there are multiple factors that influence it in addition to the CPR. It is necessary to continue searching for more precise selection and stratification tools for ODP to improve their persistence.
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Affiliation(s)
- Elena Alba Álvaro-Alonso
- Pharmacy Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain;
| | - María del Carmen Gómez-Álvarez
- General Subdirectorate of Pharmaceutical Inspection and Management, Authorization Area for Pharmaceutical Centers, Services and Establishments, Ministry of Health, C/Aduana, 29, 28013 Madrid, Spain;
| | - Beatriz Segovia-Tapiador
- Vallecas Comprehensive Care Center for Drug Addicts, Calle de las Cinco Villas, 5, 28051 Madrid, Spain; (B.S.-T.); (M.I.D.-P.-I.)
| | - María Isabel Del-Pino-Illaconza
- Vallecas Comprehensive Care Center for Drug Addicts, Calle de las Cinco Villas, 5, 28051 Madrid, Spain; (B.S.-T.); (M.I.D.-P.-I.)
| | - Jorge Valencia
- Internal Medicine Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain; (J.V.); (P.R.)
| | - Pablo Ryan
- Internal Medicine Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain; (J.V.); (P.R.)
| | - Antonio Aguilar-Ros
- Instituto Universitario de Estudios de las Adicciones IEA-CEU, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, 28660 Boadilla del Monte, Spain;
| | - Ismael Escobar-Rodríguez
- Pharmacy Department, Infanta Leonor University Hospital, Av. Gran Vía del Este, 80, 28031 Madrid, Spain;
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Hird R, Radhakrishnan R, Tsai J. A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders. Front Psychiatry 2024; 14:1339801. [PMID: 38260790 PMCID: PMC10800888 DOI: 10.3389/fpsyt.2023.1339801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders. Methods We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale. Results Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points. Discussion The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.
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Affiliation(s)
- Rachel Hird
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Rajiv Radhakrishnan
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Jack Tsai
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Department of Veterans Affairs, National Center on Homelessness Among Veterans, Washington, DC, United States
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States
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Weightman AL, Kelson MJ, Thomas I, Mann MK, Searchfield L, Willis S, Hannigan B, Smith RJ, Cordiner R. Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1329. [PMID: 37206622 PMCID: PMC10189499 DOI: 10.1002/cl2.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority. Objectives To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact. Search Methods We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies. Selection Criteria We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation. Data Collection and Analysis We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data. Main Results We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings. Case Management and Housing Outcomes Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches. Case Management and Mental Health Outcomes The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817). Case Management and Other Outcomes Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment. Case Management Components For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services. Characteristics of Persons Experiencing Homelessness No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3. The Broader Context of Delivery of Case Management Programmes Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice. Cost Effectiveness The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed. Authors' Conclusions Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.
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Affiliation(s)
| | - Mark J. Kelson
- Department of Mathematics and Statistics, Faculty of Environment, Science and EconomyUniversity of ExeterExeterUK
| | - Ian Thomas
- Wales Institute of Social and Economic Research and Data (WISERD)Cardiff UniversityCardiffUK
| | - Mala K. Mann
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Lydia Searchfield
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Simone Willis
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Ben Hannigan
- Mental Health Nursing, School of Healthcare SciencesCardiff UniversityCardiffUK
| | | | - Rhiannon Cordiner
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
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DeLaCruz-Jiron EJ, Hahn LM, Donahue AL, Shore JH. Telemental Health for the Homeless Population: Lessons Learned when Leveraging Care. Curr Psychiatry Rep 2023; 25:1-6. [PMID: 36480149 PMCID: PMC9734763 DOI: 10.1007/s11920-022-01400-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to review key lessons when using telehealth within the context of mental health and homelessness. We examine technological and bandwidth issues the homeless population might face when getting telehealth services, discuss clinical process adaption needed for working remotely, and highlight the lessons learned when leveraging mental health services to homeless patients across telehealth platforms. RECENT FINDINGS Homelessness is associated with chronic, mental health disparities and access to mental health services is often less accessible among communities with unstable housing. Telehealth provides "OnDemand" treatment options while removing specific barriers found with in-person health care such as transportation, overwhelmed mental health facilities, i.e., appointment availability, and office hour limitations while reducing costs for both providers and patients. We provide two case examples to demonstrate successful delivery of telemental health services to homeless patients and review lessons learned when leveraging care.
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Affiliation(s)
| | - Lauren M. Hahn
- Access Management Services LLC, 11100 East Bethany Drive, Aurora, CO 80014 USA
| | - Amy L. Donahue
- Access Management Services LLC, 11100 East Bethany Drive, Aurora, CO 80014 USA
| | - Jay H. Shore
- Access Management Services LLC, 11100 East Bethany Drive, Aurora, CO 80014 USA ,Department of Psychiatry and Family Medicine, School of Medicine and Centers for American Indian and Alaska Native Health Colorado School of Public Health, Anschutz Medical Campus, Aurora, USA
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Biondi BE, Vander Wyk B, Schlossberg EF, Shaw A, Springer SA. Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community. Addict Sci Clin Pract 2022; 17:15. [PMID: 35255967 PMCID: PMC8899775 DOI: 10.1186/s13722-022-00299-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/22/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Medication treatment for opioid use disorder (OUD) (MOUD; buprenorphine and methadone) reduces opioid use and overdose. Discontinuation of MOUD can quickly lead to relapse, overdose and death. Few persons who initiate MOUD are retained on treatment, thus it is critical to identify factors associated with retention. METHODS Evaluated data was from an ongoing prospective cohort study of adults aged 18 or older with DSM-5 moderate to severe OUD seeking MOUD in the community and followed for 6 months. Participants were considered retained on MOUD through 6 months if they reported taking MOUD at every study interview without discontinuation. A high dose of MOUD was defined as a methadone dose > 85 mg or buprenorphine dose ≥ 16 mg. Multivariable logistic regression was conducted to assess factors associated with 6-month MOUD retention. RESULTS A total of 118 participants (73% male, 58% white, 36% with HIV) were included. Buprenorphine was initiated by 58% and 42% started methadone. MOUD retention was 49% and 58% among buprenorphine and methadone, respectively, at 6-months. In adjusted models, a high MOUD dose (OR = 4.71, 95% CI 2.05-10.84) and higher pain interference (OR = 1.59, 95% CI 1.15-2.19) was associated with MOUD retention. CONCLUSIONS Adequate dosing of MOUD leads to improved retention on MOUD. Further, persons with high pain interference at baseline had higher odds of retention on MOUD. Both methadone and buprenorphine have analgesic effects, thus those with high pain interference could have dual benefits of MOUD for treating OUD and pain. Interventions should be tailored to improve adequate MOUD dosing to improve retention on MOUD.
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Affiliation(s)
- Breanne E Biondi
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Brent Vander Wyk
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Esther F Schlossberg
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, Yale AIDS Program, New Haven, CT, USA
| | - Albert Shaw
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, Yale AIDS Program, New Haven, CT, USA
| | - Sandra A Springer
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, Yale AIDS Program, New Haven, CT, USA.
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, New Haven, CT, USA.
- Department of Internal Medicine, Section of Infectious Disease, Yale AIDS Program, 135 College Street, Suite 323, New Haven, CT, 06510, USA.
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A cohort study examining the relationship among housing status, patient characteristics, and retention among individuals enrolled in low-barrier-to-treatment-access methadone maintenance treatment. J Subst Abuse Treat 2022; 138:108753. [DOI: 10.1016/j.jsat.2022.108753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/24/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
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Maina G, Fernandes de Sousa L, Mcharo S, Kiburi S. Risk perceptions and recovery threats for clients with a history of methadone maintenance therapy dropout. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2020.1867661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Geoffrey Maina
- College of Nursing, Prince Albert Campus, University of Saskatchewan, Prince Albert, Saskatchewan, Canada
| | | | - Solomon Mcharo
- College of Nursing, Prince Albert Campus, University of Saskatchewan, Prince Albert, Saskatchewan, Canada
| | - Sarah Kiburi
- College of Nursing, Ngara Clinic, Nairobi County, Kenya
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Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, Tsemberis S. Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review. Drug Alcohol Depend 2021; 228:109052. [PMID: 34601279 DOI: 10.1016/j.drugalcdep.2021.109052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First. METHODS A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use. RESULTS A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work. CONCLUSIONS Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.
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Affiliation(s)
- Nick Kerman
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada.
| | - Alexia Polillo
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada; University of Toronto, Department of Psychiatry, 250 College Street, 8th Floor, Toronto, Ontario, M5T 1R8, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, V6Z 2A9, Canada; University of British Columbia, Department of Medicine, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sophia Gran-Ruaz
- University of Ottawa, School of Psychology, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, Ontario, K1N 6N5, Canada
| | - Cathi Savage
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Charlie Felteau
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Sam Tsemberis
- Pathways Housing First Institute, 1328 2nd Street, Santa Monica, CA, 90403, United States
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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13
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The association of opioid use disorder and homelessness nationally in the veterans health administration. Drug Alcohol Depend 2021; 223:108714. [PMID: 33865213 DOI: 10.1016/j.drugalcdep.2021.108714] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Substance use disorder (SUD) is a major risk factor for homelessness, but the specific association of opioid use disorder (OUD) and homelessness in the context of their shared risk factors has not been the focus of prior studies. We used national data from the United States Veterans Health Administration (VHA) to examine the association of OUD and homelessness in the context of shared risk factors. METHODS In this cross-sectional analysis of veterans who received VHA care during Fiscal Year 2012 (N = 5,450,078), we compared the prevalence of OUD and other sociodemographic, and clinical factors among homeless and non-homeless veterans. We estimated the odds ratio for homelessness associated with OUD alone, and after adjusting for other factors through multivariate logistic regression. RESULTS Homeless veterans had substantially higher prevalence of OUD than other VHA patients (7.7 % Vs 0.6 %) and OUD was associated with 13 times higher unadjusted odds of homelessness (Odds Ratio [OR] 13.36, 95 % CI 13.09-13.62), which decreased with adjustment for sociodemographic factors (black race, mean income and age), other SUD, medical, and psychiatric diagnoses (final OR 1.57, 95 % CI 1.53-1.61). Other SUDs (alcohol, cannabis, cocaine, and hallucinogens) showed similar or slightly higher odds of homelessness as OUD in the final model. CONCLUSIONS OUD was strongly associated with homelessness among US veterans although this association was largely but not entirely attenuated by shared sociodemographic and co-morbid risk factors including several other SUDs. Treatment of homeless veterans with OUD should address socio-economic vulnerabilities and other co-morbidities in addition to treatments for OUD.
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14
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Chan B, Gean E, Arkhipova-Jenkins I, Gilbert J, Hilgart J, Fiordalisi C, Hubbard K, Brandt I, Stoeger E, Paynter R, Korthuis PT, Guise JM. Retention Strategies for Medications for Opioid Use Disorder in Adults: A Rapid Evidence Review. J Addict Med 2021; 15:74-84. [PMID: 32956162 PMCID: PMC7864607 DOI: 10.1097/adm.0000000000000739] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/02/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although medications for opioid use disorder (MOUD) save lives, treatment retention remains challenging. Identification of interventions to improve MOUD retention is of interest to policymakers and researchers. On behalf of the Agency for Healthcare Research and Quality, we conducted a rapid evidence review on interventions to improve MOUD retention. METHODS We searched MEDLINE and the Cochrane Library from February 2009 through August 2019 for systematic reviews and randomized trials of care settings, services, logistical support, contingency management, health information technology (IT), extended-release (XR) formulations, and psychosocial interventions that assessed retention at least 3 months. RESULTS Two systematic reviews and 39 primary studies were included; most did not focus on retention as the primary outcome. Initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Contingency management may improve retention using antagonist but not agonist MOUD. Retention with interventions integrating medical, psychiatric, social services, or IT did not differ from in-person treatment-as-usual approaches. Retention was comparable with XR- compared to daily buprenorphine formulations and conflicting with XR-naltrexone monthly injection compared to daily buprenorphine. Most psychosocial interventions did not improve retention. DISCUSSION Consistent but sparse evidence supports criminal justice prerelease MOUD initiation, and contingency management interventions for antagonist MOUD. Integrating MOUD with medical, psychiatric, social services, delivering through IT, or administering via XR-MOUD formulations did not worsen retention. Fewer than half of the studies we identified focused on retention as a primary outcome. Studies used different measures of retention, making it difficult to compare effectiveness. Additional inquiry into the causes of low retention would inform future interventions.Registration: PROSPERO: CRD42019134739.
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Affiliation(s)
- Brian Chan
- Section of Addiction Medicine, Oregon Health and Science University, Portland, OR (BC, PTK); Central City Concern, Portland, OR (BC); Scientific Resource Center of the Agency for Healthcare Research and Quality Evidence-based Practice Centers Program, Portland, OR (EG, IAJ, JG, JH, CF, KH, IB, ES, RP, JMG)
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15
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Abstract
BACKGROUND Although homelessness and opioid use disorder (OUD) are important public health issues, few studies have examined their cooccurrence. OBJECTIVES The aim of this study was to evaluate the correlates of homelessness among patients enrolled in low-barrier-to-treatment-access methadone maintenance treatment (MMT) programs for OUD. METHODS Demographic, diagnosis-related, and treatment-related correlates were assessed by self-report for 164 patients in MMT. Correlates of past-month homelessness were investigated with logistic regression. RESULTS Twenty-four percent of patients reported homelessness in the past month. Bivariate analyses initially identified 7 statistically significant (P<0.05) correlates of homelessness: gender; Latinx ethnicity; symptoms of depression, anxiety, and somatization; self-criticism; and duration of MMT. In the final logistic regression model, which included significant independent variables from the bivariate logistic regressions, patients in MMT who were homeless (vs. domiciled) were more likely to be male (odds ratio 2.54; confidence interval, 1.01-6.36) and report higher symptoms of depression (odds ratio 1.07; confidence interval, 1.01-1.15). CONCLUSIONS Low-barrier-to-treatment-access programs can attract people who are homeless with OUD into MMT. These programs also have an important public health role in addressing both depression and OUD among people who are homeless.
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16
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Le TA, Ha GH, Le MQT, Tran LMH, Pham DTT, Tran NHT, Vu GT, Nguyen LH, Pham HQ, Nguyen CT, Tran TH, Pham KTH, Tran BX, Latkin CA, Ho CSH, Ho RCM. Treatment adherence amongst drug users attending public and private methadone maintenance clinics in a northern province of Vietnam. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:31. [PMID: 32345318 PMCID: PMC7189574 DOI: 10.1186/s13011-020-00271-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/08/2020] [Indexed: 12/04/2022]
Abstract
Background Methadone maintenance treatment (MMT) has been proven to be effective in improving health status and the quality of life of illicit drug users. Due to the quick expand of methadone program, socialization through co-payment service is a critical to the success of it. In Nam Dinh, Vietnam, MMT has been used in public clinics and one private clinic. Such effectiveness of this treatment has been found to depend largely on adherence to treatment. This study aims to explore the compliance rate and its influencing factors among drug users between public and private clinics in Nam Dinh province, Vietnam. Methods A cross-sectional study was conducted on 395 participants from January to September in 2018 in three MMT clinics in Nam Dinh, Vietnam. We applied the convenience sampling technique to recruit respondents. Data on socioeconomics characteristics, MMT adherence (measured by Visual Analogue Scale – VAS) and level of social/family support were collected. Results 43.3% of participants reported complete adherence to the MMT program during the time of research. Significant factors affect MMT adherence among illicit drug users including family income, history of drug rejections, concurrence in drug usage, far distance from MMT clinics, and having only peer. Patients in MMT private clinic had higher complete adherence than that of public MMT (OR = 1.82, 95% CI = 1.13; 2.94). Having contacts with peer drug users associated with a higher rate of incomplete adherence (OR = 2.83, 95% CI = 1.39; 5.73). Conclusions The findings support the establishment of private MMT clinics alongside public ones, while further researches to determine the optimal dose and ways to reduce the impact of peer drug user’s influence are encouraged to be conducted.
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Affiliation(s)
- Tuan Anh Le
- National Institute of Hygiene and Epidemiology, Hanoi, 100000, Vietnam
| | - Giang Hai Ha
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Vietnam
| | - Mai Quynh Thi Le
- National Institute of Hygiene and Epidemiology, Hanoi, 100000, Vietnam
| | | | | | | | - Giang Thu Vu
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh city, 700000, Vietnam
| | - Long Hoang Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh city, 700000, Vietnam
| | - Hai Quang Pham
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Vietnam
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Vietnam.
| | - Tung Hoang Tran
- Institute of Orthopaedic and Trauma Surgery, Vietnam - Germany Hospital, Hanoi, 100000, Vietnam.,Department of Lower Limb Surgery, Vietnam - Germany Hospital, Hanoi, 100000, Vietnam
| | - Kiet Tuan Huy Pham
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam
| | - Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Vietnam.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, National University Hospital, Singapore, 119074, Singapore
| | - Roger C M Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh city, 700000, Vietnam.,Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, 119077, Singapore
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