Global research challenges and opportunities for mental health and substance-use disorders

Retrospective evaluation of novel serum inflammatory biomarkers in first-episode psychiatric disorders: diagnostic potential and immune dysregulation

Background

This study assessed the diagnostic capabilities of eight inflammatory biomarkers in first-episode schizophrenia (SCZ), bipolar disorder (BD), and depression (D), examining their differential expression across these psychiatric disorders. The markers studied include neutrophils/lymphocyte ratio (NLR), aggregate index of systemic inflammation (AISI), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), lymphocytes/high-density lipoprotein (HDL) ratio (LHR), monocytes/HDL ratio (MHR), neutrophils/HDL ratio (NHR), and platelets/HDL ratio (PHR).

Methods

We conducted a retrospective observational study involving 335 individuals with SCZ, 68 with BD, 202 with D, and 282 healthy controls (C) to evaluate hematologic parameters from untreated patients and controls.

Results

Significant differences in biomarker levels were found between patient groups and controls. Logistic regression analysis indicated that NHR and MHR (p < 0.001), as well as LHR and NLR (p < 0.01), were predictive factors for SCZ. MHR was a predictive factor for BD (p < 0.05). NHR (p < 0.01) and MHR (p < 0.001) were predictive factors for distinguishing between D and C. The area under the curve (AUC) value of the NHR + MHR + NLR composite index model for the SCZ group was 0.846 (p < 0.001). In the BD group, the AUC value for the MHR was 0.816 (p < 0.001). The D group's combined AUC value of NHR + MHR was 0.824 (p < 0.001).

Conclusion

This study highlights the diagnostic value of inflammatory biomarkers in distinguishing SCZ, BD, and D based on their differential expression.

A case study of the development of a valid and pragmatic implementation science measure: the Barriers and Facilitators in Implementation of Task-Sharing Mental Health interventions (BeFITS-MH) measure

BACKGROUND

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. We present a real-world case study of rigorous measure development in IS that assesses Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), with the objective of offering lessons-learned and a framework to enhance measurement utility.

METHODS

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

RESULTS

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility clustered across several common categories.

CONCLUSIONS

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Psychoactive substances for the treatment of neuropsychiatric disorders

In the contemporary landscape of psychiatric medicine, critical advancements have been noted in the utilization of psychoactive substances such as hallucinogens, 3,4-methylenedioxymethamphetamine (MDMA), and ketamine for the treatment of severe mental health disorders. This review provides a detailed evaluation of these substances, focusing on their mechanisms of action and the profound clinical outcomes observed in controlled environments. Hallucinogens like lysergic acid diethylamide and psilocybin primarily target the 5-HT2A receptor agonist-2 (5-HT2AR), inducing substantial perceptual and cognitive shifts that facilitate deep psychological introspection and significant therapeutic advances, particularly in patients suffering from depression and anxiety disorders. MDMA, influencing multiple neurotransmitter systems including 5-Hydroxytryptamine (5-HT), dopamine, and norepinephrine, has been demonstrated to effectively alleviate symptoms of post-traumatic stress disorder, enhancing patients' emotional engagement and resilience during psychotherapy. Meanwhile, ketamine, a glutamate receptor antagonist, rapidly alleviates depressive symptoms, offering a lifeline for individuals with treatment-resistant depression through its fast-acting antidepressant properties. The integration of these substances into psychiatric practice has shown promising results, fundamentally changing the therapeutic landscape for patients unresponsive to traditional treatment modalities. However, the potent effects of these agents also necessitate a cautious approach in clinical application, ensuring careful dosage control, monitoring, and risk management to prevent potential abuse and mitigate adverse effects.

Clustering of methamphetamine users based on personality characteristics and self-efficacy in the west of Iran

With the substantial increase in the use of stimulants, especially methamphetamine, in recent years, the present study aimed to cluster methamphetamine users based on personality traits and self-efficacy, and compare their mental health, sleep quality, and the risk of relapse in the identified clusters. This cross-sectional study was conducted through convenience sampling on 501 methamphetamine users in addiction treatment centers in Kermanshah, western Iran. The data were collected using the Schwarzer General Self-Efficacy Scale, Zuckerman-Kuhlman Personality Questionnaire, Goldberg and Hiller General Health Questionnaire (GHQ), Zuckerman-Kuhlman Personality Questionnaire, and Stimulant Relapse Risk Scale (SRRS). A total of 501 methamphetamine users were distinguished into three clusters with frequencies of 111 (22.2%), 298 (59.5%), and 92 (18.4%) members through hierarchical cluster analysis. The participants in the first cluster were characterized by low self-efficacy, high neuroticism, sensation seeking, and aggressiveness, along with low extroversion and activity, low positive health, high negative health, low sleep quality, and high risk of drug relapse. The participants in the second cluster reported moderate levels of self-efficacy, neuroticism, sensation seeking, activity, and aggressiveness, high extroversion, and moderate levels of mental health, sleep quality, and the risk of relapse. Moreover, the participants in the third cluster reported the highest level of self-efficacy, the lowest level of neuroticism, sensation seeking, and aggressiveness, moderate extroversion and high activity, low relapse risk, high sleep quality, as well as high positive and low negative health symptoms. The third cluster was significantly different from the other two clusters in terms of the mentioned factors. The findings of this study suggest that low self-efficacy and the presence of neuroticism, sensation seeking, and high aggressiveness contribute to reduced mental health and sleep quality, as well as an increased risk of relapse in methamphetamine users.

Just-in-time adaptive interventions for adolescent and young adult health and well-being: protocol for a systematic review

INTRODUCTION

Health behaviours such as exercise and diet strongly influence well-being and disease risk, providing the opportunity for interventions tailored to diverse individual contexts. Precise behaviour interventions are critical during adolescence and young adulthood (ages 10-25), a formative period shaping lifelong well-being. We will conduct a systematic review of just-in-time adaptive interventions (JITAIs) for health behaviour and well-being in adolescents and young adults (AYAs). A JITAI is an emerging digital health design that provides precise health support by monitoring and adjusting to individual, specific and evolving contexts in real time. Despite demonstrated potential, no published reviews have explored how JITAIs can dynamically adapt to intersectional health factors of diverse AYAs. We will identify the JITAIs' distal and proximal outcomes and their tailoring mechanisms, and report their effectiveness. We will also explore studies' considerations of health equity. This will form a comprehensive assessment of JITAIs and their role in promoting health behaviours of AYAs. We will integrate evidence to guide the development and implementation of precise, effective and equitable digital health interventions for AYAs.

METHODS AND ANALYSIS

In adherence to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we will conduct a systematic search across multiple databases, including CENTRAL, MEDLINE and WHO Global Index Medicus. We will include peer-reviewed studies on JITAIs targeting health of AYAs in multiple languages. Two independent reviewers will conduct screening and data extraction of study and participant characteristics, JITAI designs, health outcome measures and equity considerations. We will provide a narrative synthesis of findings and, if data allows, conduct a meta-analysis.

ETHICS AND DISSEMINATION

As we will not collect primary data, we do not require ethical approval. We will disseminate the review findings through peer-reviewed journal publication, conferences and stakeholder meetings to inform participatory research.

PROSPERO REGISTRATION NUMBER

CRD42023473117.

Perspectives of people experiencing homelessness with recent non-fatal street drug overdose on the Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx) intervention

INTRODUCTION

In Scotland, a third of all deaths of people experiencing homelessness (PExH) are street-drug-related, and less than half of their multiple physical- and mental health conditions are treated. New, holistic interventions are required to address these health inequalities. PHOENIx (Pharmacist Homeless Outreach Engagement and Non-medical Independent prescribing Rx) is delivered on outreach by National Health Service (NHS) pharmacist independent prescribers in partnership with third sector homelessness charity workers. We describe participant's perspectives of PHOENIx.

METHODS

This study aims to understand experiences of the PHOENIx intervention by participants recruited into the active arm of a pilot randomised controlled trial (RCT). Semi-structured in-person interviews explored participants' evaluation of the intervention. In this study, the four components (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalisation Process Theory (NPT) framework underpinned data collection and analyses.

RESULTS

We identified four themes that were interpreted within the NPT framework that describe participant evaluation of the PHOENIx intervention: differentiating the intervention from usual care (coherence), embedding connection and consistency in practice (cognitive participation), implementation of practical and emotional operational work (collective action), and lack of power and a commitment to long-term support (reflexive monitoring). Participants successfully engaged with the intervention. Facilitators for participant motivation included the relationship-based work created by the PHOENIx team. This included operational work to fulfil both the practical and emotional needs of participants. Barriers included concern regarding power imbalances within the sector, a lack of long-term support and the impact of the intervention concluding.

CONCLUSIONS

Findings identify and describe participants' evaluations of the PHOENIx intervention. NPT is a theoretical framework facilitating understanding of experiences, highlighting both facilitators and barriers to sustained engagement and investment. Our findings inform future developments regarding a subsequent definitive RCT of PHOENIx, despite challenges brought about by challenging micro and macro-economic and political landscapes.

An empirical analysis of structural neuroimaging profiles in a staging model of depression

We examine structural brain characteristics across three diagnostic categories: at risk for serious mental illness; first-presenting episode and recurrent major depressive disorder (MDD). We investigate whether the three diagnostic groups display a stepwise pattern of brain changes in the cortico-limbic regions. Integrated clinical and neuroimaging data from three large Canadian studies were pooled (total n = 622 participants, aged 12-66 years). Four clinical profiles were used in the classification of a clinical staging model: healthy comparison individuals with no history of depression (HC, n = 240), individuals at high risk for serious mental illness due to the presence of subclinical symptoms (SC, n = 80), first-episode depression (FD, n = 82), and participants with recurrent MDD in a current major depressive episode (RD, n = 220). Whole-brain volumetric measurements were extracted with FreeSurfer 7.1 and examined using three different types of analyses. Hippocampal volume decrease and cortico-limbic thinning were the most informative features for the RD vs HC comparisons. FD vs HC revealed that FD participants were characterized by a focal decrease in cortical thickness and global enlargement in amygdala volumes. Greater total amygdala volumes were significantly associated with earlier onset of illness in the FD but not the RD group. We did not confirm the construct validity of a tested clinical staging model, as a differential pattern of brain alterations was identified across the three diagnostic groups that did not parallel a stepwise clinical staging approach. The pathological processes during early stages of the illness may fundamentally differ from those that occur at later stages with clinical progression.

Determinants of substance use among young people attending primary health centers in India

Background

Substance use is a complex condition with multidimensional determinants. The present study aims to find the prevalence and determinants of substance use among young people attending primary healthcare centers in India.

Methods

A multicentric cross-sectional study was conducted across 15 states in India on 1,630 young people (10-24 years) attending primary health centers. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to capture data on substance use. The degree of substance involvement was assessed and multivariate regression analysis was conducted to determine the risk factors of substance use.

Results

The prevalence of substance use was 32.8%, with a median substance initiation age of 18 years. Among the substance users, 75.5% began before completing adolescence. Tobacco (26.4%), alcohol (26.1%) and cannabis (9.5%) were commonly consumed. Sociodemographic determinants included higher age, male gender, urban residence, positive family history, northeastern state residence and lower socioeconomic class. Over 80% of users had moderate or high involvement.

Conclusions

High substance use prevalence among young people in Indian healthcare centers underscores the urgency of targeted intervention. Insights on determinants guide effective prevention strategies for this complex public health issue.

Integration of substance use disorder treatment in traditional mental health facilities: Timeseries and cross-sectional evaluations

BACKGROUND

Despite efforts to increase substance use disorder (SUD) treatment provision in the United States (US), the extent to which traditional mental health (MH) facilities offer SUD treatment remains unclear. In the present study, we analyzed the trend in SUD treatment integration among traditional MH facilities in the US from 2014 to 2020 and identified facility-level factors associated with SUD treatment provision.

METHODS

Data were extracted from the National Mental Health Services Survey (N-MHSS). A timeseries logit trend analysis for the multi-year dataset (2014-2020) was conducted to assess a yearly change in odds of SUD treatment provision. With the 2020 survey data, analyses were conducted to identify the differences between facilities offering SUD treatment and facilities not offering such treatment. Finally, exploratory multivariable logistic regression was conducted to estimate odds of SUD treatment provision by facility variables.

RESULTS

US MH facility SUD treatment provision went from 51.7 % (2014) to 57.9 % (2020). A mean sample of 12,312 US MH facilities over seven years, demonstrated a significant but small yearly increase in SUD treatment provision (OR = 1.04, 95 % CI = 1.03, 1.04). Important facility characteristics related to SUD treatment provision for facilities without a core SUD focus were MH diagnostics offered (OR = 2.03), dual-diagnosis program offered (OR = 3.65), state drug/alcohol license maintained (OR = 6.66), and VA setting (OR = 7.94).

CONCLUSIONS

Despite incremental progress in integrating SUD treatment services into US MH facilities, the SUD treatment gap remains large. Training and service development incentives for identified characteristics could help further reduce the treatment gap.

A Case Study of the Development of a Valid and Pragmatic Implementation Science Measure: The Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH) Measure

Background

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. In this case study, we describe the process of developing an IS measure that aims to assess Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), and the procedures we implemented to enhance its utility.

Methods

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

Results

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility were seen to cluster across several common categories.

Conclusions

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Causal associations between female reproductive behaviors and psychiatric disorders: a lifecourse Mendelian randomization study

BACKGROUND

The timings of reproductive life events have been examined to be associated with various psychiatric disorders. However, studies have not considered the causal pathways from reproductive behaviors to different psychiatric disorders. This study aimed to investigate the nature of the relationships between five reproductive behaviors and twelve psychiatric disorders.

METHODS

Firstly, we calculated genetic correlations between reproductive factors and psychiatric disorders. Then two-sample Mendelian randomization (MR) was conducted to estimate the causal associations among five reproductive behaviors, and these reproductive behaviors on twelve psychiatric disorders, using genome-wide association study (GWAS) summary data from genetic consortia. Multivariable MR was then applied to evaluate the direct effect of reproductive behaviors on these psychiatric disorders whilst accounting for other reproductive factors at different life periods.

RESULTS

Univariable MR analyses provide evidence that age at menarche, age at first sexual intercourse and age at first birth have effects on one (depression), seven (anxiety disorder, ADHD, bipolar disorder, bipolar disorder II, depression, PTSD and schizophrenia) and three psychiatric disorders (ADHD, depression and PTSD) (based on p<7.14×10-4), respectively. However, after performing multivariable MR, only age at first sexual intercourse has direct effects on five psychiatric disorders (Depression, Attention deficit or hyperactivity disorder, Bipolar disorder, Posttraumatic stress disorder and schizophrenia) when accounting for other reproductive behaviors with significant effects in univariable analyses.

CONCLUSION

Our findings suggest that reproductive behaviors predominantly exert their detrimental effects on psychiatric disorders and age at first sexual intercourse has direct effects on psychiatric disorders.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries

BACKGROUND

Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low- and middle-income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services.

OBJECTIVES

To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs.

SEARCH METHODS

We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies.

SELECTION CRITERIA

All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 66 RCTs with 17,626 participants. Sixty-two of these trials contributed to the meta-analysis. Sixty-three studies were conducted in middle-income countries (MICs), and the remaining three studies were conducted in low-income countries (LICs). Twenty-five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty-two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive-behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive-behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=-0.43, 95% confidence interval (CI): -0.61 to -0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use.   Thirty-one trials reported rates of retention in the intervention. Meta-analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition.

AUTHORS' CONCLUSIONS

In LMICs there is low-certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta-analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results.

Sex differences in the associations of non-medical use of prescription drugs with depressive and anxiety symptoms among undergraduates in China

BACKGROUND

Non-medical use of prescription drugs (NMUPD) and their association with depression and anxiety are becoming global concerns. Biological sex may introduce differential exposure to NMUPD or depressive/anxiety symptoms. However, few studies have investigated the potential sex differences in the associations of NMUPD with depressive/anxiety symptoms.

METHODS

Data were drawn from the 2019 School-based Chinese College Students Health Survey. A total of 30,039 undergraduates (mean age: 19.8 [SD: 1.3] years) from sixty universities/colleges in China completed standard questionnaires and were included in the study (response rate: 97.7 %).

RESULTS

In the final adjusted model, non-medical use of opioids (experimenters: β = 1.10, [95 % CI, 0.62 to 1.57]) or sedatives (frequent users: β = 2.98, [95 % CI, 0.70 to 5.26]) was associated with depressive symptoms, while non-medical use of opioids (frequent users: β = 1.37, [95 % CI, 0.32 to 2.42]) or sedatives (frequent users: β = 1.19, [95 % CI, 0.35 to 2.03]) was also associated with anxiety symptoms. Sex-stratified analyses indicated that lifetime opioids misuse was associated with depressive symptoms in both sexes but with anxiety symptoms only in males (β = 0.39, [95 % CI, 0.09 to 0.70]). The association of lifetime sedative misuse with depressive symptoms was greater in males, while the significant association with anxiety symptoms remained only in female (β = 0.52, [95 % CI, 0.14 to 0.91]).

LIMITATIONS

Causal inference cannot be made due to the cross-sectional nature of the data.

CONCLUSIONS

Our study suggests NMUPD is associated with depressive and anxiety symptoms among Chinese undergraduates, and the associations may differ by sex.

Assessing the Efficacy of Mental Health Assessment Training for Accredited Social Health Activists Workers in Rural India: A Pilot Study

Background Mental health issues are a major concern in rural India, but the lack of trained professionals limits access to care. In this pilot study, we evaluated the efficacy of a mental health assessment training program for Accredited Social Health Activists (ASHA) in rural Maharashtra, India. Aim and objective To conduct a pilot study to evaluate the feasibility and potential efficacy of Mental Health Assessment Training by using the Global Mental Health Assessment Tool-Primary Care Marathi Android version (GMHAT/PC-M) on ASHA workers in the Wardha district to identify mental health problems. Methods The study enrolled 12 ASHA workers from two rural health centers in Maharashtra. The workers completed a pretest and then received training in mental health assessment using the GMHAT/PC Marathi Android version. Mental health knowledge and global mental health assessment tool checklist scale scores were assessed on day seven, month one, and month three after training. Results The ASHA workers had a mean age of 42.2 years and a mean experience of 9.6 years. The majority were Hindus (50%), with the remaining workers being Buddhist. Of the 12 workers, only four had prior mental health training. Mental health knowledge and global mental health assessment tool checklist scale score significantly improved from the pretest to day seven (p<0.001), and the scores continued to improve at month one and month three with a 0.001 level of significance. At the end of the study, the mean mental health knowledge score was 15.2 (out of 20), and the mean global mental health assessment tool checklist scale score was 55.5 (out of 60). Conclusion Our pilot study demonstrated the effectiveness of a mental health assessment training program for ASHA workers in rural Maharashtra, India, using the GMHAT/PC Marathi Android version. The training program improved the mental health knowledge and GMHAT checklist scale of the ASHA workers, suggesting that such programs can help bridge the gap in mental health care in rural areas. Further studies with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness of this training program.

Exploring Naturalistic Diffusion of an Evidence-Based Mental Health Intervention across Peer Networks of Youth in Sierra Leone

BACKGROUND

Understanding the mechanisms by which evidence-based interventions (EBIs) for mental health are naturally diffused among youth in low-and middle-income countries-particularly those with histories of violence and civil unrest-can illuminate which intervention elements are most transferrable and inform scale-up decisions that support youth adjustment. This study explored the diffusion of an evidence-based mental health intervention-the Youth Readiness Intervention (YRI)-among peer networks of Sierra Leonean youth (aged 18-30) who participated in a trial of the intervention as integrated into youth entrepreneurship programs.

METHODS

Trained research assistants recruited index participants who had completed the YRI integrated within entrepreneurship training (N = 165) and control index participants (N = 165). Index participants nominated three of their closest peers. Nominated peers were recruited and enrolled in the current study (N = 289). A sub-sample of index participants and peers participated in dyadic interviews (N = 11) and focus group discussions (N = 16). Multivariate regression analysis compared YRI knowledge levels among YRI participants' peers relative to control participants' peers.

RESULTS

Qualitative findings supported the diffusion of several YRI skills and components across peer networks (i.e., progressive muscle relaxation and diaphragmatic breathing). Quantitative findings indicated that YRI knowledge was significantly higher for YRI participants' peers (β = 0.02, p < 0.00) compared to control participants' peers.

CONCLUSION

Findings suggest that diffusion of evidence-based intervention components can occur naturally among peers in post-conflict LMIC settings. Developing tools to promote the diffusion of the most transferrable EBI components across peer networks could help maximize the benefits of mental health interventions for youth adjustment and resilience in post-conflict settings.

Antidepressant prescriptions and therapy intensification in men and women newly diagnosed with depression in the UK

BACKGROUND

Evidence on therapeutic interventions and factors driving treatment intensification (TI) in people with incident depression in UK are scarce.

AIMS

To explore antidepressant prescribing patterns and factors influencing TI.

DESIGN

and setting: Retrospective cohort study of adults with incident depression diagnosed between 2006 and 2017 using UK primary care database.

METHODS

Patterns of antidepressant prescriptions, and factors influencing TI were evaluated by sex.

RESULTS

In 931,302 people with depression (90% initiating antidepressants), mean age was 39 years, 41% were male, 14% had cardiometabolic multimorbidity (CMM), and 54% were diagnosed at &lt; 40 years. Being the most prescribed first-line antidepressant (62%), SSRI prescribing rate increased from 66 per 1000 person-years to 170 per 1000 person-years; 24% (2% dose escalation, 4% adding, 18% switching) of first-line antidepressant initiators intensified with 13 months median time to TI. Compared to 60-70 years, younger adults had significantly higher TI risk (range of hazards ratio, HR: 1.08-1.42). CMM and anxiety were associated with 15-24% and 39-49% significantly higher TI risks respectively. First-line antidepressant and deprivation status influenced TI differently by gender.

CONCLUSIONS

Men and women with depression in UK have different antidepressant prescription patterns in real-world. Age at diagnosis, deprivation status and cardiometabolic multimorbidity are the major sociodemographic and non-psychiatric risk factors for therapeutic changes.

Communalistic use of psychoactive plants as a bridge between traditional healing practices and Western medicine: A new path for the Global Mental Health movement

The Global Mental Health (GMH) movement aims to provide urgently needed treatment to those with mental illness, especially in low- and middle-income countries. Due to the complexity of providing mental health services to people from various cultures, there is much debate among GMH advocates regarding the best way to proceed. While biomedical interventions offer some degree of help, complementary approaches should focus on the social/community aspects. Many cultures conduct traditional rituals involving the communal use of psychoactive plants. We propose that these practices should be respected, protected, and promoted as valuable tools with regard to mental health care at the community level. The traditional use of psychoactive plants promotes community engagement and participation, and they are relatively affordable. Furthermore, the worldviews and meaning-making systems of local population are respected. The medical systems surrounding the use of psychoactive plants can be explained in biomedical terms, and many recently published clinical trials have demonstrated their therapeutic potential. Psychoactive plants and associated rituals offer potential benefits as complementary aspects of mental health services. They should be considered as such by international practitioners and advocates of the GMH movement.

Success4life Youth Empowerment for Promoting Well-being and Boosting Mental Health: Protocol for an Experimental Study

BACKGROUND

There is an increasingly alarming worsening of mental health among the youth. There remain significant unmet needs for developing innovative, evidence-based technology-enhanced, positive psychology interventions (PPIs) all-inclusive in targeting psychological distress and risk factors related to high-risk behavior commonly encountered in adolescents.

OBJECTIVE

We aim to assess the effectiveness of a hybrid (incorporating both synchronous and asynchronous learning) and holistic (targeting social and emotional learning and tackling risk factors unique for this age group) PPI, "success4life youth empowerment," in improving well-being in the youth.

METHODS

Students' well-being will be assessed by the 5-item World Health Organization Well-Being Index, and hope will be assessed by the 6-item Children's Hope Scale at week 0, week 8, and week 10, month 6, and month 12. Any improvement in well-being and hope will be measured, estimating the difference in postintervention (week 8 and week 10) and preintervention (week 0) scores by determining the P value and effect size using appropriate statistical tests.

RESULTS

This study includes 2 phases: pilot phase 1, delivered by the creators of the succcess4life youth empowerment modules and platform, and phase 2, which will consist of the estimation of scalability through the recruitment of trainers. We hope to start student recruitment by 2022 and aim to complete the results for phase 1 pilot testing by 2023.

CONCLUSIONS

We anticipate that a primarily web-based, 10-week holistic PPI can support improvement in the mental wellness of the youth and has the potential for effective scalability.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/38463.

Health insurance expansion and family violence prevention: A conceptual framework

Family violence, including child maltreatment (CM) and intimate partner violence (IPV), plagues far too many American families, particularly those in low-income communities. CM and IPV are intertwined and impose a significant emotional, health and financial burden on children and families and an economic burden on our country. Although these and other forms of violence are influenced by shared risk factors across the socioecological spectrum, prevention efforts typically intervene on a single type of violence at a microsystem level via individual or family intervention. Research is needed to identify policies operating at macrosystem levels that reduce, at scale, multiple forms of violence affecting children. In this paper, we propose a three-step theory of change through which health insurance expansions might reduce rates of CM and IPV, using Medicaid expansion as an exemplar. The proposed framework can inform research examining the link between health insurance and the primary prevention of CM and IPV.

Income Disparity and Mental Wellbeing among Adults in Semi-Urban and Rural Areas in Malaysia: The Mediating Role of Social Capital

Mental illness is rising worldwide and is more prevalent among the older population. Among others, socioeconomic status, particularly income, has a bearing on the prevalence of mental health. However, little is known about the underlying mechanism that explains the association between income and mental health. Hence, this study seeks to examine the mediating effect of social capital on the association between income and mental illness. Cross-sectional data consisting of 6651 respondents aged 55 years and above were used in this study. A validated tool known as the Depression, Anxiety and Stress Scale, 21 items (DASS-21) was applied to examine mental illness, namely depression, anxiety, and stress. The Karlson, Holm, and Breen (KHB) method was employed to assess the intervening role of social capital on the association between income and mental illness. Results showed that those who disagreed in trust within the community had the highest partial mediation percentage. Those who disagreed in reciprocity, however, had the lowest partial mediation percentage, which explained the positive association between the middle 40% (M40) of the income group and depression, anxiety, and stress. Overall, the study suggests the need to increase trust and attachment within society to curb the occurrence of depression and anxiety.

An adaptive design to screen, treat, and retain people with opioid use disorders who use methamphetamine in methadone clinics (STAR-OM): study protocol of a clinical trial

BACKGROUND

Methamphetamine use could jeopardize the current efforts to address opioid use disorder and HIV infection. Evidence-based behavioral interventions (EBI) are effective in reducing methamphetamine use. However, evidence on optimal combinations of EBI is limited. This protocol presents a type-1 effectiveness-implementation hybrid design to evaluate the effectiveness, cost-effectiveness of adaptive methamphetamine use interventions, and their implementation barriers in Vietnam.

METHOD

Design: Participants will be first randomized into two frontline interventions for 12 weeks. They will then be placed or randomized to three adaptive strategies for another 12 weeks. An economic evaluation and an ethnographic evaluation will be conducted alongside the interventions.

PARTICIPANTS

We will recruit 600 participants in 20 methadone clinics.

ELIGIBILITY CRITERIA

(1) age 16+; (2) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores ≥ 10 for methamphetamine use or confirmed methamphetamine use with urine drug screening; (3) willing to provide three pieces of contact information; and (4) having a cell phone.

OUTCOMES

Outcomes are measured at 13, 26, and 49 weeks and throughout the interventions. Primary outcomes include the (1) increase in HIV viral suppression, (2) reduction in HIV risk behaviors, and (3) reduction in methamphetamine use. COVID-19 response: We developed a response plan for interruptions caused by COVID-19 lockdowns to ensure data quality and intervention fidelity.

DISCUSSION

This study will provide important evidence for scale-up of EBIs for methamphetamine use among methadone patients in limited-resource settings. As the EBIs will be delivered by methadone providers, they can be readily implemented if the trial demonstrates effectiveness and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04706624. Registered on 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

Socioeconomic status, individual behaviors and risk for mental disorders: A Mendelian randomization study

BACKGROUND

There is increasing attention on the association of socioeconomic status and individual behaviors (SES/IB) with mental health. However, the impacts of SES/IB on mental disorders are still unclear. To provide evidence for establishing feasible strategies on disease screening and prevention, we implemented Mendelian randomization (MR) design to appraise causality between SES/IB and mental disorders.

METHODS

We conducted a two-sample MR study to assess the causal effects of SES and IB (dietary habits, habitual physical activity, smoking behaviors, drinking behaviors, sleeping behaviors, leisure sedentary behaviors, risky behaviors, and reproductive behaviors) on three mental disorders, including bipolar disorder, major depressive disorder and schizophrenia. A series of filtering steps were taken to select eligible genetic instruments robustly associated with each of the traits. Inverse variance weighted was used for primary analysis, with alternative MR methods including MR-Egger, weighted median, and weighted mode estimate. Complementary methods were further used to detect pleiotropic bias.

RESULTS

After Bonferroni correction and rigorous quality control, we identified that SES (educational attainment), smoking behaviors (smoking initiation, number of cigarettes per day), risky behaviors (adventurousness, number of sexual partners, automobile speeding propensity) and reproductive behavior (age at first birth) were causally associated with at least one of the mental disorders.

CONCLUSIONS

MR study provides robust evidence that SES/IB play broad impacts on mental disorders.

Reaching into the toolbox: Stem cell models to study neuropsychiatric disorders

Recent advances in genetics, molecular biology, and stem cell biology have accelerated our understanding of neuropsychiatric disorders, like autism spectrum disorder (ASD), major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia (SZ). This progress highlights the incredible complexity of both the human brain and mental illnesses from the biochemical to the cellular level. Contributing to the complexity of neuropsychiatric disorders are their polygenic nature, cellular and brain region interconnectivity, and dysregulation of human-specific neurodevelopmental processes. Here, we discuss available tools, including CRISPR-Cas9, and the applications of these tools to develop cell-based two-dimensional (2D) models and 3D brain organoid models that better represent and unravel the intricacies of neuropsychiatric disorder pathophysiology.

Factors associated with patient-reported experiences and outcomes of substance use disorder treatment in Cape Town, South Africa

Background

Interventions are needed to improve the quality of South Africa’s substance use disorder (SUD) treatment system. This study aimed to identify factors associated with patient-reported suboptimal access, quality, and outcomes of SUD treatment to guide the design of targeted quality improvement initiatives.

Method

We analysed clinical record and patient survey data routinely collected by SUD services in the Western Cape Province, South Africa. The sample included 1097 treatment episodes, representing 32% of all episodes in 2019. Using multivariate logistic regression, we modelled socio-demographic, substance use and treatment correlates of patient-reported suboptimal access to, quality and outcomes of SUD treatment.

Results

Overall, 37.9% of patients reported substantial difficulties in accessing treatment, 28.8% reported suboptimal quality treatment, and 31.1% reported suboptimal SUD outcomes. The odds of reporting poor access were elevated for patients identifying as Black/African, in residential treatment, with comorbid mental health problems, and longer histories of substance use. Length of substance use, comorbid mental health problems, and prior SUD treatment were associated with greater likelihood of reporting suboptimal quality treatment. Patients with comorbid mental health problems, polysubstance use, who did not complete treatment, and who perceived treatment to be of poor quality were more likely to report suboptimal outcomes.

Conclusion

This study is among the first to use patient-reported experiences and outcome measures to identify targets for SUD treatment improvement. Findings suggest substantial room to improve South African SUD treatment services, with targeted efforts needed to reduce disparities in outcomes for patients of Black/African descent, for those with comorbid mental health problems, and for patients who have chronic substance use difficulties. Interventions to enhance the relevance, appropriateness, and acceptability of SUD services for these patient sub-groups are needed to improve system performance.

Regulation of the kynurenine/serotonin pathway by berberine and the underlying effect in the hippocampus of the chronic unpredictable mild stress mice

BACKGROUND

Depression is a common mental disorder and is one of the main causes of disability. Berberine (BBR), the major constituent alkaloid originally from the famous Chinese herb Huanglian (Coptis chinensis), has been shown to exert antidepressant-like effects. This study was to investigate the hypothesis that BBR treats depressive-like behavior by shifting the balance of the kynurenine (KYN)/serotonin (5-HT) pathway toward the 5-HT pathway through downregulated indoleamine 2,3-dioxygenase 1 (IDO1), monoamine oxidase A (MAOA) and upregulated dopamine decarboxylase (DDC) in hippocampus.

METHOD

A chronic unpredictable mild stress (CUMS) mice model of depression was established via 21 days unpredictable stimulation. Then the mice were randomly assigned into six groups, namely control, model, fluoxetine [FLU, (10 mg/kg)], BBRL (25 mg/kg), BBRM (50 mg/kg), and BBRH (100 mg/kg) groups. Behavioral assessments were conducted to evaluate the antidepressant effects of BBR. The levels of 5-HT, KYN, tryptophan (TRP), and 5-hydroxyindoleacetic acid (5-HIAA) in hippocampus were estimated using high performance liquid chromatography (HPLC). The mRNA and protein levels of DDC, MAOA and IDO1 in hippocampus were detected by real-time quantitative polymerase chain reaction (qRT-PCR) and western blot (WB), respectively.

RESULT

The results showed that a successful CUMS mice model was established through 21 days of continuous unpredictable stimulation, as indicated by the significant decrease in locomotor activity and increase in immobility time, reduction in body weight and sucrose preference rate etc. Compared with the normal group, the concentrations of KYN/TRP had significantly increased (p^## <0.01) and 5-HT/5-HIAA had decreased (p^#<0.05) at day 21 in the control group, but then improved after drug treatment with FLU and BBR. Compared with the normal group, the mRNA of IDO1 and MAOA were significantly upregulated (p^#<0.05) in the control group, MAOA and IDO1 gene were downregulated by FLU and BBR treatment. Protein expressions of IDO1 and MAOA was significantly increased (p^#<0.05) and DDC downregulated (p^##<0.01). BBR treatment downregulated IDO1 and MAOA, upregulated DDC.

CONCLUSIONS

BBR reversed the abnormalities of the KYN/5-HT pathway in depressed mice and achieved an excellent antidepressant effect. Its direct impact may be observed as changes in biological indicators in mice hippocampus tissue.

Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks

BACKGROUND

Task-sharing is a promising strategy to expand mental healthcare in low-resource settings, especially in low- and middle-income countries (LMICs). Research on how to best implement task-sharing mental health interventions, however, is hampered by an incomplete understanding of the barriers and facilitators to their implementation. This review aims to systematically identify implementation barriers and facilitators in evidence-based task-sharing mental health interventions using an implementation science lens, organizing factors across a novel, integrated implementation science framework.

METHODS

PubMed, PsychINFO, CINAHL, and Embase were used to identify English-language, peer-reviewed studies using search terms for three categories: "mental health," "task-sharing," and "LMIC." Articles were included if they: focused on mental disorders as the main outcome(s); included a task-sharing intervention using or based on an evidence-based practice; were implemented in an LMIC setting; and included assessment or data-supported analysis of barriers and facilitators. An initial conceptual model and coding framework derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework was developed and iteratively refined to create an integrated conceptual framework, the Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH), which specifies 37 constructs across eight domains: (I) client characteristics, (II) provider characteristics, (III) family and community factors, (IV) organizational characteristics, (V) societal factors, (VI) mental health system factors, (VII) intervention characteristics, and (VIII) stigma.

RESULTS

Of the 26,935 articles screened (title and abstract), 192 articles underwent full-text review, yielding 37 articles representing 28 unique intervention studies that met the inclusion criteria. The most prevalent facilitators occur in domains that are more amenable to adaptation (i.e., the intervention and provider characteristics domains), while salient barriers occur in domains that are more challenging to modulate or intervene on-these include constructs in the client characteristics as well as the broader societal and structural levels of influence (i.e., the organizational, mental health system domains). Other notable trends include constructs in the family and community domains occurring as barriers and as facilitators roughly equally, and stigma constructs acting exclusively as barriers.

CONCLUSIONS

Using the BeFITS-MH model we developed based on implementation science frameworks, this systematic review provides a comprehensive identification and organization of barriers and facilitators to evidence-based task-sharing mental health interventions in LMICs. These findings have important implications for ongoing and future implementation of this critically needed intervention strategy, including the promise of leveraging task-sharing intervention characteristics as sites of continued innovation, the importance of but relative lack of engagement with constructs in macro-level domains (e.g., organizational characteristics, stigma), and the need for more delineation of strategies for task-sharing mental health interventions that researchers and implementers can employ to enhance implementation in and across levels.

TRIAL REGISTRATION

PROSPERO CRD42020161357.

Effectiveness of eHealth Technology-Based Interventions in Reducing Substance Misuse Among Older Adults: A Systematic Review

Generally considered an epidemic among young people, substance misuse has been a growing issue among older Americans for the past 40 years. Legal substances, such as alcohol, tobacco, and prescription drugs, including opioids and marijuana, are of primary concern when it comes to aging Baby Boomers. By 2050, 22% of Americans will be aged ≥65 years. Currently, eHealth interventions are receiving attention in treating substance misuse among younger Americans. The current study has two aims: to evaluate the effectiveness of eHealth interventions for older adults treated for substance misuse problems, as well as to investigate behavioral outcomes in reducing substance misuse. A comprehensive search of databases yielded 35,041 articles that examined reductions in substance misuse and problem behaviors as a primary outcome with eHealth interventions delivered to older adults. Once duplicate and irrelevant articles were removed, seven were left to be analyzed. Findings suggest use of technology to assess and intervene with older adults using various substances shows promise and, as a whole, older adults are receptive to online learning, screening and assessment, and interventions. [Journal of Gerontological Nursing, 47(10), 23-29.].

Priorities for addressing substance use disorder in humanitarian settings

Background

Populations affected by humanitarian emergencies are vulnerable to substance (alcohol and other drug) use disorders, yet treatment and prevention services are scarce. Delivering substance use disorder treatment services in humanitarian settings is hampered by limited guidance around the preparation, implementation, and evaluation of substance use disorder treatment programs. This study aims to identify and prioritize key gaps and opportunities for addressing substance use disorder in humanitarian settings.

Methods

UNODC convened a consultation meeting (n = 110) in coordination with UNHCR and WHO and administered an online survey (n = 34) to, thirteen program administrators and policymakers, eleven service providers, nine researchers, and one person with lived experience to explore best practices and challenges to addressing substance use disorder in diverse populations and contexts. Participants presented best practices for addressing substance use disorder, identified and ranked challenges and opportunities for improving the delivery of substance use disorder treatment interventions, and provided recommendations for guidelines that would facilitate the delivery of substance use disorder treatment services in humanitarian emergencies.

Results

Participants agreed on key principles for delivering substance use disorder treatment in humanitarian settings that centered on community engagement and building trust, integrated service delivery models, reducing stigma, considering culture and context in service delivery, and an ethical ‘do no harm’ approach. Specific gaps in knowledge that precluded the delivery of appropriate substance use disorder treatment include limited knowledge of the burden and patterns of substance use in humanitarian settings, the effectiveness of substance use disorder treatment services in humanitarian settings, and strategies for adapting and implementing interventions for a given population and humanitarian context. Participants emphasized the need to strengthen awareness and commitment related to the burden of substance use disorder treatment interventions among communities, practitioners, and policymakers in humanitarian settings.

Conclusions

Results from this consultation process highlight existing gaps in knowledge related to the epidemiology and treatment of substance use disorders in humanitarian emergencies. Epidemiological, intervention, and implementation research as well as operational guidance are needed to fill these gaps and improve access to substance use treatment services in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00407-z.

Association between Sleep Duration, Physical Activity, and Mental Health Disorders: A Secondary Analysis of the National Survey of Children's Health 2017-2018

Background

The purpose of this article was to examine the association of sleep duration and physical activity and their interactions on mental health disorders in American children aged 6-17 years.

Methods

Data were analyzed from the combined 2017-2018 National Survey of Children's health. Ultimately, a total of 36370 children aged 6-17 years were selected as the samples. Weighted logistic regression models were used to estimate odds ratios and 95% confidence intervals.

Results

Insufficient sleep duration was associated with an increased risk for current anxiety, depression, and behavior/conduct problems (odds ratio = 1.449, 1.991, 1.375; 95% confidence interval: 1.313-1.702, 1.648-2.406, 1.162-1.627). Insufficient physical activity was associated with an increased risk for current anxiety (odds ratio = 1.448; 95% confidence interval: 1.230-1.706) and depression (odds ratio = 1.743; 95% confidence interval: 1.304-2.329). In addition, additive interactions between sleep duration and physical activity were observed on current anxiety and depression.

Conclusions

Insufficient sleep duration and insufficient physical activity in children were associated with mental health disorders. There is a synergistic interaction effect between insufficient sleep duration and insufficient physical activity on current anxiety and current depression.

Use of sequence analysis for classifying individual antidepressant trajectories to monitor population mental health

BACKGROUND

Over the past decade, antidepressant prescriptions have increased in European countries and the United States, partly due to an increase in the number of new cases of mental illness. This paper demonstrates an innovative approach to the classification of population level change in mental health status, using administrative data for a large sample of the Scottish population. We aimed to identify groups of individuals with similar patterns of change in pattern of prescribing, validate these groups by comparison with other indicators of mental illness, and characterise the population most at risk of increasing mental ill health.

METHODS

National Health Service (NHS) prescription data were linked to the Scottish Longitudinal Study (SLS), a 5.3% sample of the Scottish population (N = 151,418). Antidepressant prescription status over the previous 6 months was recorded for every month for which data were available (January 2009-December 2014), and sequence dissimilarity was computed by optimal matching. Hierarchical clustering was used to create groups of participants who had similar patterns of change, with multi-level logistic regression used to understand group membership.

RESULTS

Five distinct prescription pattern groups were observed, indicating: no prescriptions (76%), occasional prescriptions (10%), continuation of prior use of prescriptions (8%), a new course of prescriptions started (4%) or ceased taking prescriptions (3%). Young, white, female participants, of low social grade, residing in socially deprived neighbourhoods, living alone, being separated/divorced or out of the labour force, were more likely to be in the group that started a new course of antidepressant prescriptions.

CONCLUSIONS

The use of sequence analysis for classifying individual antidepressant trajectories offers a novel approach for capturing population-level changes in mental health risk. By classifying individuals into groups based on their anti-depressant medication use we can better identify how over time, mental health is associated with individual risk factors and contextual factors at the local level and the macro political and economic scale.

Global Child Mental Health Research: Time for the Children

Although 9 of 10 of the world's children live in low- and middle-income countries (LMICs), and children constitute nearly half of the populations of these countries, far too little research has focused on child mental health in LMICs.¹ The expansion of research in global health and global mental health over the past several decades has not yet been matched by new research in child and adolescent mental health in LMICs.² It is time for that to change. New research should include a focus on social drivers and the mechanisms by which they contribute to mental illnesses.

Prevalence of physical health conditions and health risk behaviours in people with severe mental illness in South Asia: protocol for a cross-sectional study (IMPACT SMI survey)

INTRODUCTION

People with severe mental illness (SMI) die on average 10-20 years earlier than the general population. Most of these deaths are due to physical health conditions. The aim of this cross-sectional study is to determine the prevalence of physical health conditions and their associations with health-risk behaviours, health-related quality of life and various demographic, behavioural, cognitive, psychological and social variables in people with SMI attending specialist mental health facilities in South Asia.

METHODS AND ANALYSIS

We will conduct a survey of patients with SMI attending specialist mental health facilities in Bangladesh, India and Pakistan (n=4500). Diagnosis of SMI will be confirmed using the Mini-international neuropsychiatric interview V.6.0. We will collect information about physical health and related health-risk behaviours (WHO STEPwise approach to Surveillance (STEPS)); severity of common mental disorders (Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder scale (GAD-7)) and health-related quality of life (EQ-5D-5L). We will measure blood pressure, height, weight and waist circumference according to WHO guidelines. We will also measure glycated haemoglobin, lipid profile, thyroid function, liver function, creatinine and haemoglobin. Prevalence rates of physical health conditions and health-risk behaviours will be presented and compared with the WHO STEPS survey findings in the general population. Regression analyses will explore the association between health-risk behaviours, mental and physical health conditions.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committees of the Department of Health Sciences University of York (UK), Centre for Injury Prevention and Rehabilitation (Bangladesh), Health Ministry Screening Committee and Indian Council of Medical Research (India) and National Bioethics Committee (Pakistan). Findings will be disseminated in peer-reviewed articles, in local and international conferences and as reports for policymakers and stakeholders in the countries involved.

TRIAL REGISTRATION NUMBER

ISRCTN88485933; 3 June 2019.

The ethical, social, and cultural dimensions of screening for mental health in children and adolescents of the developing world

Despite their burden and high prevalence, mental health disorders of children and adolescents remain neglected in many parts of the world. In developing countries, where half of the population is younger than 18 years old, one of every five children and adolescents is estimated to suffer from a mental health disorder. It is then essential to detect these conditions through screening in a timely and accurate manner. But such screening is fraught with considerable ethical, social, and cultural challenges. This study systematically identifies, for the first time, these challenges, along with potential solutions to address them. We report on the results of an international multi- and inter-disciplinary three-round Delphi survey completed by 135 mental health experts from 37 countries. We asked these experts to identify and rank the main ethical, social, and cultural challenges of screening for child and adolescent mental health problems in developing nations, and to propose solutions for each challenge. Thirty-nine significant challenges emerged around eight themes, along with 32 potential solutions organized into seven themes. There was a high degree of consensus among the experts, but a few interesting disagreements arose between members of the panel from high-income countries and those from low- and middle-income nations. The panelists overwhelmingly supported mental health screening for children and adolescents. They recommended ensuring local acceptance and support for screening prior to program initiation, along with careful and comprehensive protection of human rights; integrating screening procedures into primary care; designing and implementing culturally appropriate screening tools, programs, and follow-up; securing long-term funding; expanding capacity building; and task-shifting screening to local non-specialists. These recommendations can serve as a guide for policy and decision-making, resource allocation, and international cooperation. They also offer a novel approach to reduce the burden of these disorders by encouraging their timely and context-sensitive prevention and management.

Promotion, prevention and treatment interventions for mental health in low- and middle-income countries through a task-shifting approach

Recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic 'at risk', to experiencing 'mental distress', 'sub-syndromal symptoms' and finally 'mental disorders'. This new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. This concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. The present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective.

Cebranopadol reduces cocaine self-administration in male rats: Dose, treatment and safety consideration

As a novel first-in-class potent analgesic acting as an agonist of multiple opioid receptors, cebranopadol showed high efficacy and good tolerability in a broad range of preclinical models and clinical trials related to pain. In the present study, to evaluate the efficacy and safety of cebranopadol as a potential treatment of cocaine dependence, we tested the effects of cebranopadol with single and repeated doses (25, 50, 75, or 100 μg/kg, oral gavage) using rat models of cocaine fixed-ratio (FR) self-administration (SA), cocaine progressive-ratio (PR) SA, and sucrose pellet SA. In single-dosing treatment paradigm, cebranopadol significantly and dose-dependently reduced cocaine SA under FR and PR schedules and suppressed food intake under FR schedule without causing apparent side effects. In repeated-dosing treatment scheme, i.e. daily administration of 25, 50, 75, or 100 μg/kg cebranopadol for a week, the similar reduction in cocaine intake was detected, while non-negligible complications/side effects were observed at repeated high doses (75 and 100 μg/kg). The observed side effects were similar to the common toxic signs elicited by heroin at high doses, although cebranopadol did not fully substitute heroin's discriminative stimulant effects in our drug discriminative tests. These results demonstrated that the most appropriate oral dose of cebranopadol to balance the efficacy and safety is 50 μg/kg. Collectively, although cebranopadol may serve as a new treatment for cocaine dependence, more consideration, cautiousness, and a clear optimal dose window to dissociate its therapeutic effects from opioid side effects/complications in male and female subjects will be necessary to increase its practical clinical utility.

Assessing the Causal Effects of Human Serum Metabolites on 5 Major Psychiatric Disorders

Psychiatric disorders are the leading cause of disability worldwide while the pathogenesis remains unclear. Genome-wide association studies (GWASs) have made great achievements in detecting disease-related genetic variants. However, functional information on the underlying biological processes is often lacking. Current reports propose the use of metabolic traits as functional intermediate phenotypes (the so-called genetically determined metabotypes or GDMs) to reveal the biological mechanisms of genetics in human diseases. Here we conducted a two-sample Mendelian randomization analysis that uses GDMs to assess the causal effects of 486 human serum metabolites on 5 major psychiatric disorders, which respectively were schizophrenia (SCZ), major depression (MDD), bipolar disorder (BIP), autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD). Using genetic variants as proxies, our study has identified 137 metabolites linked to the risk of psychiatric disorders, including 2-methoxyacetaminophen sulfate, which affects SCZ (P = 1.7 × 10-5) and 1-docosahexaenoylglycerophosphocholine, which affects ADHD (P = 5.6 × 10-5). Fourteen significant metabolic pathways involved in the 5 psychiatric disorders assessed were also detected, such as glycine, serine, and threonine metabolism for SCZ (P = .0238), Aminoacyl-tRNA biosynthesis for both MDD (P = .0144) and ADHD (P = .0029). Our study provided novel insights into integrating metabolomics with genomics in order to understand the mechanisms underlying the pathogenesis of human diseases.

Assessing the Mental Health of Brazilian Students Involved in Risky Behaviors

Adolescence, which is the transition from childhood to adulthood, is marked by emotional sensitivity and inconsistency and may be affected by mental health problems. In order to fill the gap related to the risky behaviors in students in Brazil, our cross-sectional study aimed to analyze the relationship between risky behaviors and indicators of mental health of Brazilian students. We used the data from the National School Health Survey to analyze the relationship between risk behaviors and three symptoms of mental health issues: feeling of being alone, number of close friends, and trouble sleeping due to worries. The sample consisted of 102,072 students in Brazil (48.3% boys and 51.7% girls), aged between 11 to 19 years. The risk behaviors evaluated were substance use, sedentary lifestyle, sexual behavior, and suffering violence and bullying. We have performed a multivariate analysis based on the Poisson regression model, and the measure of effect used was the prevalence ratio (PR) with confidence intervals (CI) of 95%. Our results showed that students with symptoms of mental health issues were involved in risky behaviors, including drug use and unsafe sex. Thus, mental illness outcomes may be associated with risky behaviors, or mental health may be impaired by them. Given these findings, in-school programs focused on improving mental health outcomes should be developed.

Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally

Workforce shortages pose major obstacles to delivering adequate mental health care and scaling up services to address the global treatment gap. Mounting evidence demonstrates the clinical effectiveness of having nonspecialist health workers, such as community health workers, lay health workers, midwives, or nurses, deliver brief psychosocial treatments for common mental disorders in primary care settings. With rapidly increasing access to, and use of, digital technology worldwide, new opportunities are available to leverage these emerging digital technologies to support nonspecialist health workers and increase mental health workforce capacity. This Perspectives article considers the potential that digital technology holds for supporting nonspecialist health workers in delivering evidence-based mental health care. Specifically, from our search of the academic literature, we identified seven promising examples from primary care settings in different low- and middle-income countries (India, Pakistan, Zimbabwe, Peru, China, and Nigeria) where digital platforms are being used to support delivery of mental health care from a variety of nonspecialist providers by offering training, providing digital tools for diagnosis, guiding treatment, facilitating supervision, and integrating services. We summarize these examples and discuss future opportunities to use digital technology for supporting the development of a trained, effective, and sustainable mental health workforce. We also consider the potential to leverage these technologies for integrating mental health care into existing health systems in low-resource settings.

A community-based system dynamics approach for understanding factors affecting mental Health and Health seeking behaviors in Beirut and Beqaa regions of Lebanon

Background

Available evidence on mental health and psychosocial problems in Lebanon is limited. Recent quantitative data suggests a high prevalence among Syrian refugees and their Lebanese host communities, with significant treatment gaps in both populations. This study aims to determine how Lebanese host and Syrian refugee communities perceive mental health, and identify health seeking behaviors and barriers to health access in two contrasting contexts of fragility.

Methods

A comparative qualitative study design was adopted whereby a total of 36 semi-structured interviews with Lebanese host and Syrian refugees’ community members were conducted, followed by a series of four participatory group model building (GMB) sessions. Participants were recruited from two contrasting fragility contexts: Beirut and Beqaa regions. During these sessions, causal loop diagrams were elicited depicting shared understandings of factors prompting the onset of mental health and psychosocial issues; health seeking behaviors, pathways and elements affecting the rate of health improvement and maintenance were also identified.

Results

Community members in both settings had similar perceptions of factors contributing to mental health. Participants named long-term effects of exposure to wars, political and social effects of conflicts, and financial constraints at the household level as precipitating factors prompting the onset of mental health and psychosocial stressors. Gender and integration related challenges between communities were identified as factors that affect condition onset and associated care seeking. Pathways for health seeking were found to be shaped by trust, the advice and support of loved ones, and the need to ensure confidentiality of affected individuals. Recurrent themes in discussion highlighted major barriers to healthcare access including significant delays in health care seeking from the formal health system, widespread social stigma, prohibitive service costs, lack of health coverage, limited awareness of mental health service availability and limited trust in the quality of services available.

Conclusion

Mental health and psychosocial support strategies need to be gender- and integration-sensitive, primarily focused on condition prevention and awareness raising in order to strengthen health-seeking behaviors.

Oral health interventions for people living with mental disorders: protocol for a realist systematic review

BACKGROUND

The increasing number of people who experience mental disorders is a global problem. People with mental disorders have high rates of co-morbidity and significantly poorer oral health outcomes than the general public. However, their oral health remains largely a hidden and neglected issue. A complex range of factors impact the oral health of this group. These include anxiety and dental phobia, dietary habits, including the heavy consumption of sugary drinks, substance misuse of tobacco, alcohol, and/or psychostimulants, the adverse orofacial side effects of anti-psychotic and anti-depression medications, and financial, geographic, and social barriers to accessing oral health care.

METHODS

The aim of this realist systematic review is to (a) identify and synthesise evidence that explores oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce program theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide future oral health interventions for people with mental disorders at both the policy and practice level. Using a five-step process, that incorporates primary data collection from key stakeholders, a beginning theoretical framework will be developed to describe contextual and mechanistic factors and how they might impact on the success or failure of oral health interventions for people with mental disorders. Key database searches will be conducted, with data extraction focused on the factors that might have impacted on intervention implementation and outcomes. Quality appraisal of studies will occur, and the theoretical framework will be populated with extracted data. Stakeholder input will support the development and refinement of a theory on oral health interventions for people with mental disorders.

DISCUSSION

This will be the first review to take a realist approach to explore the broad scope of causal factors that impact on the success or failure of oral health interventions for people with mental disorders. The approach includes extensive stakeholder engagement and will advance realist systematic review methodology. Review outcomes will be important in guiding policy and practice to ensure oral health interventions better meet the needs of people with mental disorders.Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.

Diffusion and spillover effects of an evidence-based mental health intervention among peers and caregivers of high risk youth in Sierra Leone: study protocol

BACKGROUND

Evidence-based mental health interventions have helped address health services gaps, but their reach and societal benefit can be limited in low resource settings. The current study extends an ongoing scale-up study of a cognitive behavioral therapy (CBT)-based intervention, the Youth Readiness Intervention (YRI), among high risk youth in post-conflict Sierra Leone to investigate mechanisms of diffusion and spillover effects of the YRI among peers and caregivers of youth who receive the intervention.

METHODS

We will recruit and enroll YRI index participants and control index participants (ages 18-30). Index participants will complete a standardized ego-network survey to nominate three peers in their social networks and identify their primary cohabitating caregiver. Identified peers and caregivers who consent to participate will complete a quantitative assessment battery on mental health outcomes, emotion regulation, and daily functioning at baseline and 8-month follow-up. Study outcomes also incorporate common indicators for implementation science, including measures of project context, evaluation, and scaleup. Social network analysis will investigate diffusion of YRI components across peer networks. Linear growth modeling will examine mental health spillover effects among caregivers. Incremental health costs and benefits among YRI participants' caregivers and peers will be assessed through cost-effectiveness and return on investment analysis.

DISCUSSION

Assessing implementation research outcomes, including penetration of YRI effects across social networks and cost-effectiveness of the YRI as distinct outcomes, will provide key information about the success of YRI implementation. Lessons learned could inform decisions to increase scale up efforts in Sub-Saharan Africa and other low resource settings.

Literature on peer-based community physical activity programmes for mental health service users: a scoping review

Physical activity is a key determinant of mental health; community programmes aim to increase health and well-being on a community wide scale with emphasis on social interaction. Regular physical activity participation in community settings yields additional social benefits, such as peer support. This scoping review aimed to explore existing literature that has included peer support as a component of community-based physical activity programmes for MHSU. Published literature was examined using electronic databases (SportDiscus, Web of Science, MEDLINE, and PsycINFO), reference lists, and hand searching of journals. Thirteen eligible articles included; adults aged 18 and over, a peer support component, physical activity and/or sport, participants with mental health diagnoses and were community-based. Research published between 2007 and 2019, peer-reviewed and written in English was included. Nine studies found a significant increase in perceived social support, seven studies reported increased mental wellbeing and five studies reported increased physical activity levels. Effectiveness of reviewed programmes were categorised as; overall improvements in physical activity levels, improvements to mental health, exercise related psychosocial benefits, knowledge relating to self-care, and improved social connections. Community-based physical activity programmes produced psychosocial benefits and positive behaviour change for MHSU, warranting greater focus towards implementing effective peer support into community programmes.

Hippocampal tail volume as a predictive biomarker of antidepressant treatment outcomes in patients with major depressive disorder: a CAN-BIND report

Finding a clinically useful neuroimaging biomarker that can predict treatment response in patients with major depressive disorder (MDD) is challenging, in part because of poor reproducibility and generalizability of findings across studies. Previous work has suggested that posterior hippocampal volumes in depressed patients may be associated with antidepressant treatment outcomes. The primary purpose of this investigation was to examine further whether posterior hippocampal volumes predict remission following antidepressant treatment. Magnetic resonance imaging (MRI) scans from 196 patients with MDD and 110 healthy participants were obtained as part of the first study in the Canadian Biomarker Integration Network in Depression program (CAN-BIND 1) in which patients were treated for 16 weeks with open-label medication. Hippocampal volumes were measured using both a manual segmentation protocol and FreeSurfer 6.0. Baseline hippocampal tail (Ht) volumes were significantly smaller in patients with depression compared to healthy participants. Larger baseline Ht volumes were positively associated with remission status at weeks 8 and 16. Participants who achieved early sustained remission had significantly greater Ht volumes compared to those who did not achieve remission by week 16. Ht volume is a prognostic biomarker for antidepressant treatment outcomes in patients with MDD.

Sustainable development for global mental health: a typology and systematic evidence mapping of external actors in low-income and middle-income countries

INTRODUCTION

Mental disorders account for a substantial burden of disease and costs in low-income and middle-income countries (LMICs), but attract few resources. With LMIC governments often under economic pressure, an understanding of the external funding landscape is urgently needed. This study develops a new typology of external actors in global health adapted for the sustainable development goals (SDGs) era and uses it to systematically map available evidence on external actors in global mental health.

METHODS

The new typology was developed in line with conceptualisation in the literature and the SDGs to include 11 types of external actors for health in LMICs. Five databases (EconLit, Embase, Global Health, MEDLINE, PsycINFO) were searched for manuscripts published in peer-reviewed journals in English, French, Italian, Portuguese or Spanish between 1 January 2000 and 31 July 2018 and reporting information on external actors for mental disorders in LMICs. Records were screened by abstract, then full-text against inclusion criteria. Data were extracted and synthesised using narrative analysis.

RESULTS

79 studies were included in the final review. Five were quantitative studies analysing the resource flow of development assistance for mental health globally over the last two decades. The remainder were qualitative studies providing a description of external actors: the majority of them were published in the last decade, focused on Africa, and on public sector (bilateral and multilateral governmental organisations) and third sector organisations (non-governmental organisations). Evidence was particularly scarce for for-profit organisations and individual households.

CONCLUSION

This study reveals opportunities for unlocking additional funding for global mental health in the SDG-era from an ecosystem of external actors, and highlights the need to coordinate efforts and to use sustainable, ethical approaches to disbursements. Further research is needed to understand all external actors and the allocation of their contributions in different settings.

Mental health research in the Arab region: challenges and call for action

Although mental disorders are a leading cause of disability in the Arab region, which includes 5·54% of the global population, Arab countries produce only 1·0% of the global output of peer-reviewed publications in mental health research. Various stakeholders, including Arab mental health researchers, institutional and funding agency officials, and international research collaborators, convened to identify challenges faced by Arab mental health researchers and propose an evidence-informed call for action. Challenges identified include prevalent stigma and low awareness, conflict and war, scarce institutional and funding resources, inadequate publishing opportunities, insufficient training in mental health research, and shortage of reliable and valid assessment tools. The proposed action plan includes ways of addressing stigma and spreading awareness, increasing collaborative efforts, building research infrastructure, strengthening the mental health workforce, and translating research findings into a call to action on societal and governmental levels. The proposed action plan could provide a roadmap for Arab mental health researchers and research institutions, which might ultimately increase research productivity in the Arab region and close the gap between Arab countries and the rest of the world.

South African service users' perceptions of patient-reported outcome and experience measures for adolescent substance use treatment: A qualitative study

INTRODUCTION AND AIMS

Patient-reported outcome measures (PROM) and experience measures (PREM) for substance use disorder (SUD) treatment exist for adults but have unknown relevance for adolescents. This study aimed to explore adolescents' perceptions of effective SUD treatment and possible barriers to completing PROMs and PREMs to guide efforts to adapt the South African Addiction Treatment Services Assessment (SAATSA) for adolescents.

DESIGN AND METHODS

Five focus groups were conducted with 38 adolescent service users recruited from residential and outpatient SUD treatment facilities in South Africa. Group discussions explored perceptions of treatment components necessary for desired SUD treatment outcomes, treatment experiences that support engagement in care, and perceptions of PROM and PREM completion.

RESULTS

Participants viewed treatment elements that enhance motivation for change, coping and emotional regulation; provide recreational alternatives to substance use; and improve family relationships and home environments as critical to positive treatment outcomes. They reflected that provider characteristics and developmentally and culturally appropriate services facilitated engagement in treatment. PROM and PREM completion seemed acceptable, with participants suggesting ways to enhance their appeal.

DISCUSSION AND CONCLUSION

Findings confirm that adult-oriented PROMs and PREMs require adaptation for adolescents. Service user inputs identified ways to expand the content of the SAATSA to better reflect adolescents' treatment priorities. These inputs have also guided changes to item formulation and administration procedures to enhance the SAATSA's acceptability for adolescents. Ensuring the SAATSA addresses treatment outcomes and experiences that matter to adolescents is vital for generating information to guide improvements to adolescent SUD services.

Are Computer-Based Treatment Programs Effective at Reducing Symptoms of Substance Misuse and Mental Health Difficulties Within Adults? A Systematic Review

Objective: Comorbid substance misuse and mental health difficulties are recognized as a leading contributor to disease burden worldwide. Amid cuts to health care services, computer-based interventions may provide support for patients experiencing these difficulties. The aims of this systematic review were to identify and investigate the efficacy of these computer-based interventions at improving substance misuse and mental health outcomes.Methods: A systematic search was conducted of CINAHL Plus, PsycARTICLES, PsycINFO, Medline, Web of Science, and the Cochrane Library. Gray literature was also searched for relevant papers. Data were extracted from 33 papers, which met eligibility criteria by reporting a computer-based intervention designed to treat substance misuse and mental health in adults. Quality assessments were conducted on these papers.Results: Computer-based interventions generally led to an improvement of substance misuse and mental health outcomes within groups and when compared against waitlist control and psychoeducation. Computer-based interventions were effective at improving dual diagnosis outcomes, and improvements to mental health outcomes specifically were maintained for up to nine months. However, the combined effect of computer-based interventions and therapist support was found to be more effective than the effects of computer-based interventions alone.Conclusions: Many papers were limited by high attrition rates commonly attributed to "digital" interventions. Future research should consider systematically recruiting a range of participants, including those potentially affected by the digital divide, and incorporating methods within research to maintain engagement. This review was also limited by the heterogeneity of the papers reported, many of which differed between targeting dual diagnosis and targeting either substance misuse or mental health respectively, with outcomes investigating other difficulties out of curiosity.