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Doernberg M, Gilstad-Hayden K, Yonkers KA, Forray A. Provider-patient relationships and trauma among pregnant patients with opioid-use disorder. Am J Addict 2024. [PMID: 38685767 DOI: 10.1111/ajad.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/03/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The provider-patient relationship is integral to medical practice and health outcomes, particularly among vulnerable patient populations. This study compared the provider-patient relationship among pregnant patients with opioid-use disorder (OUD), who did or did not have a history of moderate to severe trauma. METHODS This was an exploratory data analysis of 119 patients enrolled in the Support Models for Addiction Related Treatment trial. Probable posttraumatic stress disorder (PTSD) was determined by a score ≥ 31 on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The provider-patient relationship was assessed at 26 ± 4 weeks of pregnancy using the Kim Alliance Scale (KAS). Multivariable regression was used to examine the association of KAS with probable PTSD among pregnant people with OUD. RESULTS The mean KAS score for pregnant participants without probable PTSD (N = 88) was 61.4 (SD ± 2.8) and for pregnant participants with probable PTSD (N = 31) was 59.6 (SD ± 3.7). Results demonstrated significant differences in KAS scores between those with and without probable PTSD after adjusting for demographic variables. Adjusted mean total KAS scores and scores on Empowerment and Communication subscales were significantly lower among those with probable PTSD compared to those without (p = .04 and 0.02, respectively) but did not differ significantly on Collaboration and Integration subscales. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Analyses show an association between probable PTSD and provider-patient relationship among pregnant patients with OUD, with those with probable PTSD having a worse alliance with obstetric providers. This novel finding helps characterize the provider-patient relationship among a uniquely vulnerable population and can inform efforts to integrate trauma-informed practices into prenatal care.
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Affiliation(s)
| | | | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Wong AH, Nath B, Shah D, Kumar A, Brinker M, Faustino IV, Boyce M, Dziura JD, Heckmann R, Yonkers KA, Bernstein SL, Adapa K, Taylor RA, Ovchinnikova P, McCall T, Melnick ER. Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol. BMJ Open 2024; 14:e082834. [PMID: 38373857 PMCID: PMC10882402 DOI: 10.1136/bmjopen-2023-082834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER NCT04959279; Pre-results.
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Affiliation(s)
- Ambrose H Wong
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anusha Kumar
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Isaac V Faustino
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Boyce
- Yale New Haven Health System, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rebekah Heckmann
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts System, Worchester, Massachusetts, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karthik Adapa
- Carolina Health Informatics Program, University of North Carolina System, Chapel Hill, North Carolina, USA
| | - Richard Andrew Taylor
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Polina Ovchinnikova
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terika McCall
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Yonkers KA, Altemus M, Gilstad-Hayden K, Kornstein SG, Gueorguieva R. Does Symptom-Onset Treatment With Sertraline Improve Functional Impairment for Individuals With Premenstrual Dysphoric Disorder?: A Randomized Controlled Trial. J Clin Psychopharmacol 2023; 43:320-325. [PMID: 37212651 PMCID: PMC10313784 DOI: 10.1097/jcp.0000000000001700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PURPOSE/BACKGROUND Daily treatment with sertraline improves functional impairment among individuals with premenstrual dysphoric disorder (PMDD). We do not know whether treatment initiated at symptom onset also improves functional impairment. METHODS/PROCEDURES This 3-site, double blind, randomized, clinical trial compared sertraline (25-100 mg) to similar appearing placebo, both administered at symptom onset, for reduction of PMDD symptoms. Ninety participants were allocated to sertraline and 94 participants to placebo. Functional outcomes from the Daily Ratings of the Severity of Problems included (1) reduced productivity or efficiency at work, school, home, or daily routine; (2) interference with hobbies or social activities; and (3) interference with relationships. Items were measured from 1 (no interference) to 6 (extreme interference) and averaged for the final 5 luteal phase days. This secondary analysis examined whether improvement in functional domains was greater for those allocated to sertraline compared with placebo. Second, we used causal mediation analyses to explore whether specific PMDD symptoms mediated functional improvement. RESULTS/FINDINGS Only relationship functioning improved significantly with active treatment between baseline and the end of the second cycle (active group mean [SD] change, -1.39 [1.38]; placebo group mean change, -0.76 [1.20]; β = -0.40; SE, 0.15; P = 0.009). The total effect of treatment on interference was -0.37 (95% confidence interval [CI], -0.66 to -0.09; P = 0.011). Given the nonsignificant direct effect (0.11; 95% CI, -0.07 to 0.29; P = 0.24) and significant indirect effect (-0.48; 95% CI, -0.71 to -0.24; P < 0.001), amelioration of anger/irritability likely mediated reductions in relationship interference. IMPLICATIONS/CONCLUSIONS That anger/irritability mediates impairments in relationship functioning has face validity but should be replicated in other data sets. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00536198 .
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Affiliation(s)
| | - Margaret Altemus
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | | | - Susan G Kornstein
- Department of Psychiatry, Institute for Women's Health, Virginia Commonwealth University, Richmond, VA
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Fabrizio VA, Lindsay CV, Wilcox M, Hong S, Lynn T, Norwitz ER, Yonkers KA, Abrahams VM. The serotonin reuptake inhibitor fluoxetine induces human fetal membrane sterile inflammation through p38 MAPK activation. J Reprod Immunol 2023; 155:103786. [PMID: 36528909 PMCID: PMC9851981 DOI: 10.1016/j.jri.2022.103786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
Serotonin Reuptake Inhibitors (SRIs) are often used as first line therapy for depression and other psychiatric disorders. SRI use during pregnancy is associated with preterm premature rupture of membranes (PPROM) and subsequent preterm birth. The objective of this study was to investigate the mechanism(s) responsible for SRI-associated PPROM. Putative mechanisms underlying PPROM include fetal membrane (FM) inflammation, increased apoptosis, and/or accelerated senescence, the later which may be reversed by statins. Human FM explants from normal term deliveries without labor, infection, or antidepressant use were treated with or without the SRI, fluoxetine (FLX), either alone or in the presence of a p38 MAPK inhibitor or the statins, simvastatin or rosuvastatin. FMs were also collected from women either unexposed or exposed to FLX during pregnancy. FLX significantly increased FM p38 MAPK activity and secretion of inflammatory IL-6. Inhibition of p38 MAPK reduced FM IL-6 secretion in response to FLX. Statins did not reduce the SRI-induced FM IL-6 production. FMs from women exposed to FLX during pregnancy expressed elevated levels of p38 MAPK activity compared to matched unexposed women. FMs exposed to FLX did not exhibit signs of increased apoptosis and/or accelerated senescence. These results indicate that the SRI, FLX, may induce sterile FM inflammation during pregnancy through activation of the p38 MAPK pathway, and in the absence of apoptosis and senescence. These findings may better inform clinicians and patients as they weigh the risks and benefits of SRI antidepressant treatment during pregnancy.
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Affiliation(s)
- Veronica A Fabrizio
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Christina V Lindsay
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Maya Wilcox
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Suyeon Hong
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Tatyana Lynn
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Errol R Norwitz
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA, United States
| | - Kimberly A Yonkers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Departments of Psychiatry and Obstetrics & Gynecology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States.
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Ondersma SJ, Todd L, Jablonski S, Ahuja C, Gilstad-Hayden K, Goyert G, Loree A, Heffner J, Yonkers KA. Online randomised factorial trial of electronic Screening and Brief Intervention for alcohol use in pregnancy: a study protocol. BMJ Open 2022; 12:e062735. [PMID: 35922101 PMCID: PMC9352990 DOI: 10.1136/bmjopen-2022-062735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Approximately 1 in 7 pregnant women in the USA report past-month alcohol use. Strong evidence connects prenatal alcohol exposure with a range of adverse perinatal outcomes, including the spectrum of conditions known as fetal alcohol spectrum disorders. Screening and Brief Intervention (SBI) has been recommended for pregnant women but has proven difficult to implement. This study will test the efficacy of single-session technology-delivered SBI (electronic SBI) for alcohol use in pregnancy, while simultaneously evaluating the possible additional benefit of tailored text messages and/or booster sessions in a 3×2 factorial trial. METHOD AND ANALYSIS This full factorial trial will use online advertising and clinic-based flyers to recruit pregnant women meeting criteria for unhealthy alcohol use, and randomly assign them to one of six conditions crossing three levels of brief intervention (none, single 120-minute session and single session plus two 5-minute boosters) with two levels of tailored text messaging (none vs twice weekly messages). The primary analysis will test for dose-response effects of the brief intervention on alcohol abstinence, defined as no self-report of alcohol use in the 90 days prior to 34 weeks' gestation, and negative results for ethyl glucuronide analysis of fingernail samples. Secondary analyses will examine main and interaction effects of tailored text messaging as well as intervention effects on birth outcomes. ETHICS AND DISSEMINATION Ethical approval was provided by the Michigan State University Biomedical and Health Institutional Review Board (STUDY00005298). Results will be presented at conferences and community forums, in addition to being published in a peer-reviewed journal. Intervention content demonstrating sufficient efficacy and safety will be made publicly available. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04332172).
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Affiliation(s)
- Steven J Ondersma
- Division of Public Health and Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, Flint, Michigan, USA
| | - Lisa Todd
- Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Samantha Jablonski
- Health Care Value-Business Analytics Division, Blue Cross Blue Shield of Michigan, Detroit, Michigan, USA
| | - Chaarushi Ahuja
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | | | - Gregory Goyert
- Division of Maternal Fetal Medicine, Henry Ford Health, Detroit, Michigan, USA
| | - Amy Loree
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Jaimee Heffner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Kimberly A Yonkers
- Departments of Psychiatry and Obstetrics & Gynecology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open 2022; 12:e059876. [PMID: 35545394 PMCID: PMC9096567 DOI: 10.1136/bmjopen-2021-059876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. DESIGN Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. SETTING Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. PARTICIPANTS We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. RESULTS Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. CONCLUSIONS Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Lauren J Crispino
- Department of Emergency Medicine, Virginia Tech Carilion Clinic, Roanoke, Virginia, USA
| | - John B Parker
- Department of Emergency Medicine, Coliseum Health System, Macon, Georgia, USA
| | | | - Leah Robinson
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne DeSanto Iennaco
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Nursing, Orange, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Dartmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Medical School, Worchester, Massachusetts, USA
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Forray A, Mele A, Byatt N, Londono Tobon A, Gilstad-Hayden K, Hunkle K, Hong S, Lipkind H, Fiellin DA, Callaghan K, Yonkers KA. Support Models for Addiction Related Treatment (SMART) for pregnant women: Study protocol of a cluster randomized trial of two treatment models for opioid use disorder in prenatal clinics. PLoS One 2022; 17:e0261751. [PMID: 35025898 PMCID: PMC8758001 DOI: 10.1371/journal.pone.0261751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction The prevalence of opioid use disorder (OUD) in pregnancy increased nearly five-fold over the past decade. Despite this, obstetric providers are less likely to treat pregnant women with medication for OUD than non-obstetric providers (75% vs 91%). A major reason is many obstetricians feel unprepared to prescribe medication for opioid use disorder (MOUD). Education and support may increase prescribing and overall comfort in delivering care for pregnant women with OUD, but optimal models of education and support are yet to be determined. Methods and analysis We describe the rationale and conduct of a matched-pair cluster randomized clinical trial to compare the effectiveness of two models of support for reproductive health clinicians to provide care for pregnant and postpartum women with OUD. The primary outcomes of this trial are patient treatment engagement and retention in OUD treatment. This study compares two support models: 1) a collaborative care approach, based upon the Massachusetts Office-Based-Opioid Treatment Model, that provides practice-level training and support to providers and patients through the use of care managers, versus 2) a telesupport approach based on the Project Extension for Community Healthcare Outcomes, a remote education model that provides mentorship, guided practice, and participation in a learning community, via video conferencing. Discussion This clustered randomized clinical trial aims to test the effectiveness of two approaches to support practitioners who care for pregnant women with an OUD. The results of this trial will help determine the best model to improve the capacity of obstetrical providers to deliver treatment for OUD in prenatal clinics. Trial registration Clinicaltrials.gov trial registration number: NCT0424039.
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Affiliation(s)
- Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
| | - Amanda Mele
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts School of Medicine, Worcester, Massachusetts, United States of America
- Department of Ob/Gyn, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Amalia Londono Tobon
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, United States of America
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Karen Hunkle
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Suyeon Hong
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Heather Lipkind
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Katherine Callaghan
- Department of Ob/Gyn, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Kimberly A. Yonkers
- Department of Psychiatry, University of Massachusetts School of Medicine, Worcester, Massachusetts, United States of America
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Serowik KL, Yonkers KA, Gilstad-Hayden K, Forray A, Zimbrean P, Martino S. Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients. J Gen Intern Med 2021; 36:668-675. [PMID: 33111239 PMCID: PMC7947066 DOI: 10.1007/s11606-020-06319-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene. OBJECTIVE To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection. DESIGN Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057). PARTICIPANTS A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study. MAIN MEASURES Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records. KEY RESULTS Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively). CONCLUSIONS Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.
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Affiliation(s)
- Kristin L Serowik
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA. .,Psychology Service, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA.,Psychology Service, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA
| | - Paula Zimbrean
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA
| | - Steve Martino
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 301, New Haven, CT, 06520, USA.,Psychology Service, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
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9
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Affiliation(s)
- Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester
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10
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Krystal JH, Alvarado J, Ball SA, Fortunati FG, Hu M, Ivy ME, Kapo J, Olson KD, Rohrbaugh RM, Sinha R, Tebes JK, Vender RJ, Yonkers KA, Mayes LC. Mobilizing an institutional supportive response for healthcare workers and other staff in the context of COVID-19: The Yale experience. Gen Hosp Psychiatry 2021; 68:12-18. [PMID: 33254081 PMCID: PMC7680059 DOI: 10.1016/j.genhosppsych.2020.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022]
Abstract
The burden of the COVID-19 pandemic upon healthcare workers necessitates a systematic effort to support their resilience. This article describes the Yale University and Yale New Haven Health System effort to unite several independent initiatives into a coherent integrated model for institutional support for healthcare workers. Here, we highlight both opportunities and challenges faced in attempting to support healthcare workers during this pandemic.
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Affiliation(s)
- John H. Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Department of Neuroscience, Yale School of Medicine, New Haven, CT, United States of America,Department of Psychology, Yale University, New Haven, CT, United States of America,Department of Psychiatry and Behavioral Health, Yale-New Haven Hospital, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America,Corresponding author at: Department of Psychiatry, Yale School of Medicine, 300 George St #901, New Haven, CT 06511, United States of America
| | - Javier Alvarado
- Department of Social Work, Yale-New Haven Hospital, New Haven, CT, United States of America
| | - Samuel A. Ball
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Office of the Dean, Yale School of Medicine, New Haven, CT, United States of America,Silver Hill Hospital, New Canaan, CT, United States of America
| | - Frank G. Fortunati
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Department of Psychiatry and Behavioral Health, Yale-New Haven Hospital, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America
| | - Mary Hu
- Office of the Dean, Yale School of Medicine, New Haven, CT, United States of America
| | - Michael E. Ivy
- Office of the Chief Medical Officer, Yale New Haven Health, New Haven, CT, United States of America
| | - Jennifer Kapo
- Yale Medicine, New Haven, CT, United States of America,Palliative Medicine, Yale School of Medicine and Yale-New Haven Hospital, New Haven, CT, United States of America
| | - Kristine D. Olson
- Office of the Chief Wellness Officer, Yale-New Haven Hospital, New Haven, CT, United States of America,Department of Internal Medicine, Yale School of Medicine, United States of America
| | - Robert M. Rohrbaugh
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America,Office of the Dean, Yale School of Medicine, New Haven, CT, United States of America
| | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Department of Neuroscience, Yale School of Medicine, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America,Child Study Center, Yale School of Medicine, New Haven, CT, United States of America
| | - Jacob K. Tebes
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Department of Internal Medicine, Yale School of Medicine, United States of America,Department of Epidemiology (Chronic Diseases), Yale School of Public Health, New Haven, CT, United States of America
| | - Ronald J. Vender
- Yale Medicine, New Haven, CT, United States of America,Office of the Dean, Yale School of Medicine, New Haven, CT, United States of America,Department of Internal Medicine, Yale School of Medicine, United States of America
| | - Kimberly A. Yonkers
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America,Department of Epidemiology (Chronic Diseases), Yale School of Public Health, New Haven, CT, United States of America,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States of America
| | - Linda C. Mayes
- Department of Psychology, Yale University, New Haven, CT, United States of America,Yale Medicine, New Haven, CT, United States of America,Office of the Dean, Yale School of Medicine, New Haven, CT, United States of America,Child Study Center, Yale School of Medicine, New Haven, CT, United States of America,Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
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11
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Olmstead TA, Martino S, Ondersma SJ, Gilstad-Hayden K, Forray A, Yonkers KA. The short-term impact on economic outcomes of SBIRT interventions implemented in reproductive health care settings. J Subst Abuse Treat 2020; 120:108179. [PMID: 33298305 DOI: 10.1016/j.jsat.2020.108179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 09/02/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To estimate the impact of screening, brief intervention, and referral to treatment (SBIRT) administered in reproductive health care settings on a variety of economic outcomes, including general health care utilization, criminal activity, and motor vehicle crashes. Whether and by how much SBIRT affects economic outcomes are important unanswered questions related to the economic impact of this technique. METHODS We collected data as part of a randomized clinical trial that examined whether SBIRT delivered electronically (e-SBIRT) or by a clinician (SBIRT) is superior to enhanced usual care (EUC) for substance misuse. Participants were a convenience sample of 439 women from two reproductive health care centers who used cigarettes, risky amounts of alcohol, illicit drugs, or misused prescription medication. For each participant, we measured economic outcomes by self-report 6 months pre- and post-intervention. We used difference-in-differences regression models to estimate the impact of e-SBIRT and SBIRT, compared to EUC, on changes in each of the economic outcomes from pre- to post-intervention. RESULTS None of the difference-in-differences estimates weas statistically significant after adjusting for multiple comparisons. CONCLUSION In a population of women receiving routine care in reproductive health care settings, we did not find a significant effect of either e-SBIRT or SBIRT, compared to EUC, on general health care utilization, criminal activity, or motor vehicle outcomes. However, individual trials are typically underpowered to detect effects that are small but important from a public health perspective. These results may be crucial for future systematic reviews and meta-analyses to determine the economic impact of SBIRT programs from a variety of perspectives.
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Affiliation(s)
- Todd A Olmstead
- The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, 2300 Red River Street, Austin, TX, 78701, USA.
| | - Steve Martino
- Yale School of Medicine, Department of Psychiatry, Division of Substance Abuse, 950 Campbell Avenue, West Haven, CT 06516, USA; VA Connecticut Healthcare System, Psychology Service, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Steven J Ondersma
- Wayne State University, Department of Psychiatry & Behavioral Neurosciences and Merrill-Palmer Skillman Institute, 71 East Ferry St., Detroit, MI 48202, USA
| | - Kathryn Gilstad-Hayden
- Yale School of Medicine, Department of Psychiatry, 40 Temple Street, New Haven, CT 06510, USA
| | - Ariadna Forray
- Yale School of Medicine, Department of Psychiatry, 40 Temple Street, New Haven, CT 06510, USA
| | - Kimberly A Yonkers
- Yale University School of Epidemiology and Public Health, Division of Chronic Disease, 60 College Street, New Haven, CT 06520, USA; Yale School of Medicine, Department of Obstetrics, Gynecology, & Reproductive Sciences, 333 Cedar Street, New Haven, CT 06520, USA; Yale School of Medicine, Department of Psychiatry, 40 Temple Street, New Haven, CT 06510, USA
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12
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Lundsberg LS, Cutler AS, Stanwood NL, Yonkers KA, Gariepy AM. Association of Pregnancy Contexts with Depression and Low Social Support in Early Pregnancy. Perspect Sex Reprod Health 2020; 52:161-170. [PMID: 33047499 DOI: 10.1363/psrh.12155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 04/29/2020] [Accepted: 07/11/2020] [Indexed: 06/11/2023]
Abstract
CONTEXT Research into the relationship between pregnancy intention and perinatal depression or low social support is limited. Women's perspectives on pregnancy and their associations with perinatal depression could help in developing targeted efforts for screening and intervention. METHODS In 2014-2015, 161 women seeking pregnancy testing or abortion care at clinics in New Haven, Connecticut, were surveyed. They were asked about pregnancy context (intentions, planning, wantedness, desirability, timing and happiness), and the Edinburgh Depression Screen (EDS) and the Modified Kendler Social Support Index (MKSSI) were used to identify possible antenatal depression and low social support, respectively. Multivariable logistic regression analysis was employed to examine associations between pregnancy context and these outcomes. RESULTS On average, participants were 27 years old and at nine weeks' gestation. One-fifth reported a previous diagnosis of depression or anxiety, and 22% and 33% screened positive for depression (EDS scores of 13 or higher and 10 or higher, respectively); 52% received low social support (MKSSI score of 3.2 or less). Regression analysis found that pregnancies described as unintended, poorly timed or undesired were associated with depression at the higher cutoff (odds ratios, 3.2-4.5); all unfavorable pregnancy measures were associated with depression at the lower cutoff. Ambivalence regarding pregnancy timing, intention, wantedness and desirability was associated with increased odds of depression by either EDS score. Unplanned pregnancies and those about which the woman was ambivalent were associated with low social support. CONCLUSIONS Findings support the need to screen women for depression early in pregnancy and to integrate assessments of pregnancy context into the evaluation of potential risk factors.
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Affiliation(s)
- Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Abigail S Cutler
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Nancy L Stanwood
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Kimberly A Yonkers
- Department of Psychiatry and Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Aileen M Gariepy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
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13
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Olmstead TA, Yonkers KA, Forray A, Zimbrean P, Gilstad-Hayden K, Martino S. Cost and cost-effectiveness of three strategies for implementing motivational interviewing for substance misuse on medical inpatient units. Drug Alcohol Depend 2020; 214:108156. [PMID: 32659637 PMCID: PMC7448551 DOI: 10.1016/j.drugalcdep.2020.108156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study conducted cost and cost-effectiveness analyses of three strategies for implementing motivational interviewing for substance misuse on general medical inpatient units: workshop, apprenticeship, and consult. METHODS The economic analyses were conducted prospectively alongside a type 3 hybrid effectiveness-implementation randomized trial comprising 38 medical providers, 1173 inpatients, and four consultation-liaison motivational interviewing experts. The trial took place in a university affiliated teaching hospital in New Haven, CT, USA. After completing a 1-day workshop on motivational interviewing, providers were randomized to conditions. The primary outcome measure was the number of study-eligible patients who received a motivational interview. The economic analyses included the costs of both start-up and on-going activities in each condition. Incremental cost-effectiveness ratios were used to determine cost effectiveness. Results are presented from the healthcare provider (i.e., hospital) perspective in 2018 US dollars. RESULTS The total cost per patient receiving a motivational interview averaged $804.53, $606.52, and $185.65 for workshop, apprenticeship, and consult, respectively. Workshop and apprenticeship were extended dominated by the combination of consult and doing nothing. Doing nothing is cost effective when the willingness-to-pay for an additional patient receiving a motivational interview is less than $185.65, and consult is cost-effective when the willingness-to-pay for an additional patient receiving a motivational interview is greater than $185.65. CONCLUSIONS Given that typical reimbursements for brief intervention services for substance misuse are $35-$65, none of the three implementation strategies is likely to be economically viable from the healthcare provider perspective.
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Affiliation(s)
- Todd A. Olmstead
- The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, Sid Richardson Hall, Unit 3, Austin, TX 78712, USA,Corresponding Author: Todd Olmstead, The University of Texas at Austin, LBJ School of Public Affairs, Sid Richardson Hall, Unit 3, Austin, TX, 78712, USA, ; 512.471.8456
| | - Kimberly A. Yonkers
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA,Yale School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, 333 Cedar Street, New Haven, CT 06510, USA,Yale School of Epidemiology and Public Health Division of Chronic Disease, 60 College Street, New Haven, CT 06520, USA
| | - Ariadna Forray
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Paula Zimbrean
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Kathryn Gilstad-Hayden
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Steve Martino
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA,VA Connecticut Healthcare System, Psychology Service, 950 Campbell Avenue (116B), West Haven, CT 06516, USA
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14
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Wong AH, Ray JM, Auerbach MA, Venkatesh AK, McVaney C, Burness D, Chmura C, Saxa T, Sevilla M, Flood CT, Patel A, Whitfill T, Dziura JD, Yonkers KA, Ulrich A, Bernstein SL. Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department. BMJ Open 2020; 10:e036982. [PMID: 32606062 PMCID: PMC7328814 DOI: 10.1136/bmjopen-2020-036982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Emergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists. METHODS AND ANALYSIS Our proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Marc A Auerbach
- Department of Pediatrics and Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Danielle Burness
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher Chmura
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Thomas Saxa
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mark Sevilla
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Colin T Flood
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Amitkumar Patel
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Travis Whitfill
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Kimberly A Yonkers
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
- Departments of Psychiatry and Obstetrics & Gynecology, Yale University, New Haven, Connecticut, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
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15
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Joudrey PJ, Oldfield BJ, Yonkers KA, O’Connor PG, Berland G, Edelman EJ. Inpatient adoption of medications for alcohol use disorder: A mixed-methods formative evaluation involving key stakeholders. Drug Alcohol Depend 2020; 213:108090. [PMID: 32559667 PMCID: PMC7375447 DOI: 10.1016/j.drugalcdep.2020.108090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the inpatient setting presents an important opportunity for medications for alcohol use disorder (MAUD) adoption, this infrequently occurs. We aimed to develop a comprehensive understanding of barriers and facilitators of inpatient MAUD adoption. METHODS A convergent mixed-method study conducted from April to September 2018 of non-prescribing (registered nurse, pharmacist, and social work) and prescribing (physician or advanced practice provider hospitalist, general internist, and psychiatrist) professionals at a large urban academic medical center. Survey assessed organizational readiness to adopt MAUD and focus groups guided by the Consolidated Framework for Implementation Research (CFIR) analyzed using directed content analysis. RESULTS Fifty-seven participants completed surveys and one of seven focus groups. Health professionals perceived clinical evidence (mean 4.0, 95 % confidence interval [CI]: 3.9, 4.2) as supportive and patient preferences (mean 3.4, 95 % CI: 3.2, 3.6) and availability of resources (mean 3.1, 95 % CI: 2.8, 3.3) as less supportive of MAUD adoption. Stakeholders identified barriers across CFIR constructs; 1) Intervention characteristics: limited knowledge of MAUD effectiveness and concerns about side effects, 2) Outer setting: perceived patient vulnerability to care interruptions and a lack of external incentives, 3) Inner setting: a lack of organizational prioritization, and 4) Characteristics of individuals: stigma of people with AUD. Facilitators included: 1) Intervention characteristics: adaptation of workflows and 2) Characteristics of individuals: harm reduction as treatment goal. CONCLUSIONS This study identified multiple intersecting barriers and facilitators of inpatient MAUD adoption. Implementation interventions should prioritize strategies that increase health professional knowledge of MAUD and organizational prioritization of treating AUD.
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Affiliation(s)
- Paul J. Joudrey
- VA Connecticut Healthcare System, West Haven Campus, 950 Campbell Ave, West Haven, CT 06516,Department of Internal Medicine, Yale School of Medicine, Yale University 367 Cedar Street, New Haven, CT
| | - Benjamin J. Oldfield
- Department of Internal Medicine, Yale School of Medicine, Yale University 367 Cedar Street, New Haven, CT
| | - Kimberly A. Yonkers
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Ste Suite 6B, New Haven, CT 06510
| | - Patrick G. O’Connor
- Department of Internal Medicine, Yale School of Medicine, Yale University 367 Cedar Street, New Haven, CT
| | - Gretchen Berland
- Department of Internal Medicine, Yale School of Medicine, Yale University 367 Cedar Street, New Haven, CT
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, Yale University 367 Cedar Street, New Haven, CT
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16
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Wong AH, Roppolo LP, Chang BP, Yonkers KA, Wilson MP, Powsner S, Rozel JS. Management of Agitation During the COVID-19 Pandemic. West J Emerg Med 2020; 21:795-800. [PMID: 32726244 PMCID: PMC7390577 DOI: 10.5811/westjem.2020.5.47789] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 01/10/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.
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Affiliation(s)
- Ambrose H. Wong
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Lynn P. Roppolo
- University of Texas Southwestern, Department of Emergency Medicine, Dallas, Texas
| | - Bernard P. Chang
- Columbia University, Irving Medical Center, Department of Emergency Medicine, New York, New York
| | - Kimberly A. Yonkers
- Yale School of Medicine, Department of Psychiatry, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, Connecticut
| | - Michael P. Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Department of Psychiatry, Little Rock, Arkansas
| | - Seth Powsner
- Yale School of Medicine, Department of Psychiatry, Department of Emergency Medicine New Haven, Connecticut
| | - John S. Rozel
- University of Pittsburgh School of Law and School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania
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17
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Yonkers KA, Dailey JI, Gilstad-Hayden K, Ondersma SJ, Forray A, Olmstead TA, Martino S. Abstinence outcomes among women in reproductive health centers administered clinician or electronic brief interventions. J Subst Abuse Treat 2020; 113:107995. [PMID: 32359666 DOI: 10.1016/j.jsat.2020.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
Treatment of substance use in women seeking reproductive healthcare is crucial for the health of both women and their offspring. Although abstinence from all substance use during pregnancy is optimal, it is difficult to achieve. This secondary analysis reports abstinence outcomes from a randomized clinical trial of screening, brief intervention, and referral to treatment (SBIRT) for substance use among women seeking reproductive healthcare services. Women who screened positive for substance use were randomly assigned to either clinician-administered SBIRT, an electronically-administered brief intervention (e-SBIRT), or an enhanced usual care condition. At a 6-month follow-up assessment, compared to enhanced usual care, the clinician-administered SBIRT increased 1-month point prevalence of abstinence from the primary substance by 7.7%, and e-SBIRT increased abstinence by 12.8%. Both brief interventions were more useful than enhanced usual care and could increase substance use abstinence rates among women in reproductive healthcare clinics. The electronic brief intervention is particularly attractive given that it appears as efficacious as, but requires fewer resources than, clinician-delivered brief interventions.
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Affiliation(s)
- Kimberly A Yonkers
- Department of Psychiatry, Yale School of Medicine, 300 George Street, New Haven, CT 06511, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA; Department of Epidemiology and Public Health, Yale School of Medicine, 60 College Street, New Haven, CT 06510, USA.
| | - Jason I Dailey
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale School of Medicine, 300 George Street, New Haven, CT 06511, USA.
| | - Steven J Ondersma
- Wayne State University, Merrill Palmer Skillman Institute, 71 E. Ferry Ave, Detroit, MI 48202, USA.
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, 300 George Street, New Haven, CT 06511, USA.
| | - Todd A Olmstead
- University of Texas at Austin, PO Box Y, Austin, TX 78713, USA.
| | - Steve Martino
- Department of Psychiatry, Yale School of Medicine, 300 George Street, New Haven, CT 06511, USA; VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA.
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18
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Chang G, Ondersma SJ, Blake-Lamb T, Gilstad-Hayden K, Orav EJ, Yonkers KA. Identification of substance use disorders among pregnant women: A comparison of screeners. Drug Alcohol Depend 2019; 205:107651. [PMID: 31683243 DOI: 10.1016/j.drugalcdep.2019.107651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate five self-report, non-proprietary questionnaires in the identification of substance use disorders [including alcohol, cannabis, opioids, and stimulants] among pregnant women. PROCEDURES A total of 1220 pregnant women completed the NIDA Quick Screen, CRAFFT, Substance Use Risk Profile-Pregnancy (SURP-P), Wayne Indirect Drug Use Questionnaire (WIDUS), and the 5 Ps, as well as the MINI diagnostic interview for substance use disorders, which served as the reference standard. Measures of merit calculated for each screener included sensitivity, specificity, accuracy, and area under the receiver operating curve (AUROC). MAIN FINDINGS The participants were socioeconomically diverse, with a mean age of 29 years. Over 15% met diagnostic criteria for a substance use disorder. AUROCS for identifying any substance use disorder (including alcohol) ranged from a high of 0.75 for the CRAFFT (95% CI = 0.72-79) and 0.74 for the SURP-P (95% CI = 0.71-.78) to a low of 0.62 for the NIDA Quick Screen (95% CI = 0.59-.65). Overall accuracy of most tested measures was higher for identification of alcohol use disorders than for other substance use disorders (e.g., AUROCs for the CRAFFT and SURP-P for identifying alcohol use disorders were 0.78 and 0.77, respectively). PRINCIPAL CONCLUSIONS The CRAFFT and SURP-P showed modest ability to identify substance use disorders among pregnant women. Future research is needed to develop an ideal questionnaire set in the complicated societal context which includes increasing rates of use and potential sanction.
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Affiliation(s)
- Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, United States; VA Boston Healthcare System, Boston, MA, 02301, United States.
| | - Steven J Ondersma
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, 48202, United States
| | - Tiffany Blake-Lamb
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, 02114, United States; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, 02115, United States
| | - Kate Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, United States; Department of Medicine (Biostatistics), Harvard Medical School, Boston, MA, 02115, United States
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States; Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT, 06520, United States; Department of Obstetrics, Gynecology and Reproductive Medicine, Yale University School of Medicine, New Haven, CT, 06520, United States
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19
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Affiliation(s)
- Katherine L. Wisner
- Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kimberly A. Yonkers
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut,Psychological Medicine, Yale New Haven Health, New Haven, Connecticut
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20
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Levis B, McMillan D, Sun Y, He C, Rice DB, Krishnan A, Wu Y, Azar M, Sanchez TA, Chiovitti MJ, Bhandari PM, Neupane D, Saadat N, Riehm KE, Imran M, Boruff JT, Cuijpers P, Gilbody S, Ioannidis JPA, Kloda LA, Patten SB, Shrier I, Ziegelstein RC, Comeau L, Mitchell ND, Tonelli M, Vigod SN, Aceti F, Alvarado R, Alvarado-Esquivel C, Bakare MO, Barnes J, Beck CT, Bindt C, Boyce PM, Bunevicius A, Couto TCE, Chaudron LH, Correa H, de Figueiredo FP, Eapen V, Fernandes M, Figueiredo B, Fisher JRW, Garcia-Esteve L, Giardinelli L, Helle N, Howard LM, Khalifa DS, Kohlhoff J, Kusminskas L, Kozinszky Z, Lelli L, Leonardou AA, Lewis BA, Maes M, Meuti V, Nakić Radoš S, Navarro García P, Nishi D, Okitundu Luwa E-Andjafono D, Robertson-Blackmore E, Rochat TJ, Rowe HJ, Siu BWM, Skalkidou A, Stein A, Stewart RC, Su KP, Sundström-Poromaa I, Tadinac M, Tandon SD, Tendais I, Thiagayson P, Töreki A, Torres-Giménez A, Tran TD, Trevillion K, Turner K, Vega-Dienstmaier JM, Wynter K, Yonkers KA, Benedetti A, Thombs BD. Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis. Int J Methods Psychiatr Res 2019; 28:e1803. [PMID: 31568624 PMCID: PMC7027670 DOI: 10.1002/mpr.1803] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/05/2019] [Accepted: 08/16/2019] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum. METHODS Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics. RESULTS Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased. CONCLUSION Different interviews may not classify major depression equivalently.
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Affiliation(s)
- Brooke Levis
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Dean McMillan
- Hull York Medical School and the Department of Health Sciences, University of York, York, UK
| | - Ying Sun
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Chen He
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Danielle B Rice
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Psychology, McGill University, Montréal, Québec, Canada
| | - Ankur Krishnan
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Yin Wu
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Marleine Azar
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Tatiana A Sanchez
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Matthew J Chiovitti
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Parash Mani Bhandari
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Dipika Neupane
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Nazanin Saadat
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Kira E Riehm
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mahrukh Imran
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada
| | - Jill T Boruff
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montréal, Québec, Canada
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, EMGO Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Simon Gilbody
- Hull York Medical School and the Department of Health Sciences, University of York, York, UK
| | - John P A Ioannidis
- Department of Medicine, Department of Health Research and Policy, Department of Biomedical Data Science, Department of Statistics, Stanford University, Stanford, CA, USA
| | - Lorie A Kloda
- Library, Concordia University, Montréal, Québec, Canada
| | - Scott B Patten
- Department of Community Health Sciences, Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, Alberta, Canada.,Cuthbertson & Fischer Chair in Pediatric Mental Health, University of Calgary, Calgary, Alberta, Canada
| | - Ian Shrier
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Roy C Ziegelstein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Liane Comeau
- International Union for Health Promotion and Health Education, École de santé publique de l'Université de Montréal, Montréal, Québec, Canada
| | - Nicholas D Mitchell
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simone N Vigod
- Women's College Hospital and Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Franca Aceti
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Rubén Alvarado
- Escuela de Salud Pública Dr. Salvador Allende, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Cosme Alvarado-Esquivel
- Laboratorio de Investigación Biomédica, Facultad de Medicina y Nutrición, Avenida Universidad, Durango, Mexico
| | - Muideen O Bakare
- Child and Adolescent Unit, Federal Neuropsychiatric Hospital, Enugu, Nigeria.,Childhood Neuropsychiatric Disorders Initiatives, Enugu, Nigeria
| | - Jacqueline Barnes
- Department of Psychological Sciences, Birkbeck, University of London, Bloomsbury London, UK
| | | | - Carola Bindt
- Department of Child and Adolescent Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip M Boyce
- Discipline of Psychiatry, Westmead Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Psychiatry, Westmead Hospital, Sydney, New South Wales, Australia
| | - Adomas Bunevicius
- Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tiago Castro E Couto
- School of Medicine, Universidade Federal De Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Linda H Chaudron
- Departments of Psychiatry, Pediatrics, Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Humberto Correa
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Valsamma Eapen
- School of Psychiatry, University of New South Wales, Kensington, Australia.,Ingham Institute, Liverpool, New South Wales, Australia.,Sydney South West Local Health District, Liverpool, New South Wales, Australia
| | - Michelle Fernandes
- Faculty of Medicine, Department of Paediatrics, University of Southampton and Southampton Children's Hospital, Southampton, UK.,The Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | | | - Jane R W Fisher
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lluïsa Garcia-Esteve
- Perinatal Mental Health Unit CLINIC-BCN, Institut Clínic de Neurociències, Hospital Clínic, Barcelona, Spain.,Vulnerability, Psychopathology and Gender Research Group, Generalitat de Catalunya, Catalonia, Spain.,August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
| | - Lisa Giardinelli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Nadine Helle
- Department of Child and Adolescent Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Louise M Howard
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Dina Sami Khalifa
- Faculty of Health Sciences, Ahfad University for Women, Omdurman, Sudan.,Department of Community Medicine, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,The Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Kohlhoff
- School of Psychiatry, University of New South Wales, Kensington, Australia.,Ingham Institute, Liverpool, New South Wales, Australia.,Karitane, Carramar, New South Wales, Australia
| | | | - Zoltán Kozinszky
- Department of Obstetrics and Gynaecology, Blekinge Hospital, Karlskrona, Sweden
| | - Lorenzo Lelli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Angeliki A Leonardou
- First Department of Psychiatry, Women's Mental Health Clinic, Athens University Medical School, Athens, Greece
| | - Beth A Lewis
- School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Impact Strategic Research Center, Deakin University, Geelong, Victoria, Australia
| | - Valentina Meuti
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Sandra Nakić Radoš
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Purificación Navarro García
- Perinatal Mental Health Unit CLINIC-BCN, Institut Clínic de Neurociències, Hospital Clínic, Barcelona, Spain.,Psychology Service, Regidoria de Polítiques de Gènere, Ajuntament de Terrassa, Terrassa, Spain
| | - Daisuke Nishi
- Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Mental Health Policy, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Daniel Okitundu Luwa E-Andjafono
- Unité de Neuropsychologie, Département de Neurologie, Centre Neuro-psycho-pathologique, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Tamsen J Rochat
- MRC/Developmental Pathways to Health Research Unit, School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa.,Human and Social Development Programme, Human Sciences Research Council, Johannesburg, South Africa
| | - Heather J Rowe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bonnie W M Siu
- Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
| | - Alkistis Skalkidou
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Alan Stein
- Department of Child and Adolescent Psychiatry, University of Oxford, Oxford, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Robert C Stewart
- Department of Mental Health, College of Medicine, University of Malawi, Zomba, Malawi.,Division of Psychiatry, University of Edinburgh, Edinburgh, UK
| | - Kuan-Pin Su
- College of Medicine, China Medical University, Taichung, Taiwan.,Mind-Body Interface Laboratory and Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
| | | | - Meri Tadinac
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia
| | - S Darius Tandon
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Iva Tendais
- School of Psychology, University of Minho, Braga, Portugal
| | - Pavaani Thiagayson
- Institute of Mental Health, Hougang, Singapore.,KK Women's and Children's Hospital, Kallang, Singapore.,National Healthcare Group, Singapore
| | | | - Anna Torres-Giménez
- Perinatal Mental Health Unit CLINIC-BCN, Institut Clínic de Neurociències, Hospital Clínic, Barcelona, Spain.,Vulnerability, Psychopathology and Gender Research Group, Generalitat de Catalunya, Catalonia, Spain.,August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
| | - Thach D Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kylee Trevillion
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Katherine Turner
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | | | - Karen Wynter
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Nursing and Midwifery, Deakin University, Melbourne, Victoria, Australia
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.,School of Epidemiology and Public Health, Yale University, New Haven, Connecticut, USA
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montréal, Québec, Canada.,Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.,Department of Psychology, McGill University, Montréal, Québec, Canada.,Department of Psychiatry, McGill University, Montréal, Québec, Canada.,Department of Medicine, McGill University, Montréal, Québec, Canada.,Department of Educational and Counselling Psychology, McGill University, Montréal, Québec, Canada
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21
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Abstract
OBJECTIVE Unplanned and poorly timed pregnancies are associated with adverse maternal and neonatal outcomes. Further understanding of preconception substance use with unplanned and poorly timed pregnancy is warranted. METHODS Data were analyzed from a prospective study enrolling women early in pregnancy. Preconception tobacco, alcohol, marijuana, opioid, and cocaine use was ascertained. Participants reported whether their current pregnancy was planned and whether it was a good time to be pregnant. Multivariable logistic regression modeling generated risk estimates for preconception substance use, and pregnancy planning and timing, adjusting for confounders. RESULTS Overall, 37.2% reported unplanned pregnancy, 13.0% poorly timed pregnancy, and 39.0% reported either unplanned and/or poorly timed pregnancy. Within 6 months preconception, one-fifth (20.2%) reported nicotine cigarette use. In the month before conception, 71.8% reported alcohol use, 6.5% marijuana, and approximately 1% opioid or cocaine use. Multivariable analysis demonstrated preconception opioid use was associated with increased odds of poorly timed pregnancy (odds ratio [OR] 2.87, 95% confidence interval [CI] 1.03-7.99). Binge drinking the month before conception was associated with increased odds of poorly timed pregnancy and unplanned pregnancy (OR 1.75, 95% CI 1.01-3.05; and OR 1.68, 95% CI 1.01-2.79, respectively). Marijuana use 2 to 3 times in the month preconception was associated with increased risk of unplanned pregnancy, and unplanned and/or poorly timed pregnancy compared with nonuse (OR 1.78, 95% CI 1.03-3.08; and OR 1.79, 95% CI 1.01-3.17, respectively). Preconception tobacco or cocaine use was not associated with unplanned or poorly timed pregnancy following adjustment. CONCLUSIONS We demonstrate increased odds of unplanned or poorly timed pregnancy among women with preconception binge drinking, marijuana use, and opioid use; however, no association is observed with other substances after multivariable adjustment, including tobacco. Further research to evaluate high-level preconception substance use and substance disorders with pregnancy planning and timing is warranted. Focused efforts optimizing preconception health behaviors and reducing risk of unplanned or poorly timed pregnancy are needed.
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Affiliation(s)
- Lisbet S. Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06520
| | - Stephanie Peglow
- Department of Psychiatry & Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA 23507
| | - Neena Qasba
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06520
| | - Kimberly A. Yonkers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06520
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520
| | - Aileen M. Gariepy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06520
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22
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Forray A, Martino S, Gilstad-Hayden K, Kershaw T, Ondersma S, Olmstead T, Yonkers KA. Assessment of an electronic and clinician-delivered brief intervention on cigarette, alcohol and illicit drug use among women in a reproductive healthcare clinic. Addict Behav 2019; 96:156-163. [PMID: 31100713 DOI: 10.1016/j.addbeh.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/04/2019] [Accepted: 05/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Women are at highest risk for development of a substance use disorder during their reproductive years. We recently evaluated the efficacy of an electronic screening, brief intervention and referral to treatment (e-SBIRT) and a clinician-delivered SBIRT (SBIRT) compared with enhanced usual care (EUC) for reducing overall substance use among women recruited from reproductive health clinics. The present study assessed the impact of the SBIRT interventions within three primary substance subgroups: cigarettes, illicit drugs, and alcohol. METHODS This is a secondary analysis from a 3-group randomized trial comparing e-SBIRT and SBIRT to EUC. For the present study, participants (N = 439) were grouped according to their primary substance: cigarettes, alcohol, or illicit drugs. Differences in days per month of primary substance use over time between treatment groups were examined using generalized estimating equations, modelling linear as well as quadratic effects of time. RESULTS Cigarettes were the most frequently reported primary substance (n = 251), followed by illicit drugs (n = 137) and alcohol (n = 51). For primary cigarette use the interaction between the linear effect of time and treatment was significant for SBIRT (β (SE) = -0.067 (0.029), p = .020), but not e-SBIRT, suggesting greater reductions in cigarette use over the first 3 months following treatment with SBIRT compared to EUC. However, the significant interaction of SBIRT with time-squared (β (SE) = 0.009 (0.004), p = .049) showed that reductions in cigarette use attenuated over time, such that after month 3, monthly reductions in cigarette use were similar between groups. Results followed a similar pattern for primary illicit drug use among the e-SBIRT group in which the interaction of e-SBIRT treatment with linear time (β (SE) = -0.181 (0.085), p = .033) and quadratic time (β (SE) = 0.028 (0.012), p = .018) were statistically significant suggesting greater reductions in illicit drug use with e-SBIRT versus EUC, which attenuated with time. Neither SBIRT nor e-SBIRT was associated with a significant reduction in days of alcohol use per month, as compared to EUC. CONCLUSIONS Reproductive-age women appear to respond differently to electronic- and clinician-delivered interventions, depending on their primary substance. SBIRT reduced use of cigarettes, and e-SBIRT reduced illicit drug use. Although neither intervention reduced primary alcohol use, the sample size was small (n = 51), suggesting a need for further testing in a larger sample.
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Affiliation(s)
- Ariadna Forray
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America.
| | - Steve Martino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America
| | - Trace Kershaw
- Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT, United States of America
| | - Steve Ondersma
- Wayne State University, Department of Psychiatry & Behavioral Neurosciences, & Merrill-Palmer Skillman Institute, Detroit, MI, United States of America
| | - Todd Olmstead
- Lyndon B Johnson School of Public Affairs, University of Texas - Austin, Austin, TX, United States of America
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America; Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States of America; Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT, United States of America
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23
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Ondersma SJ, Chang G, Blake-Lamb T, Gilstad-Hayden K, Orav J, Beatty JR, Goyert GL, Yonkers KA. Accuracy of five self-report screening instruments for substance use in pregnancy. Addiction 2019; 114:1683-1693. [PMID: 31216102 PMCID: PMC8407406 DOI: 10.1111/add.14651] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/27/2019] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS The accuracy of current screening instruments for identification of substance use in pregnancy is unclear, particularly given methodological shortcomings in existing research. This diagnostic accuracy study compared five existing instruments for ability to identify illicit drug, opioid and alcohol use, under privacy expectations consistent with applied practice and using a gold standard incorporating toxicological analysis. DESIGN Prospective cross-sectional screening accuracy study. SETTING Three sites encompassing four prenatal care clinics in the United States. PARTICIPANTS Convenience sample of 1220 racially, ethnically and socio-economically diverse pregnant women aged 18 years and over. MEASUREMENTS In Phase I, participants completed the five screening instruments in counterbalanced order. Instruments included the Substance Use Risk Profile-Pregnancy (SURP-P), CRAFFT (acronym for five-item screener with items related to car, relax, alone, forget, friends and trouble), 5Ps (parents, peers, partner, pregnancy, past), Wayne Indirect Drug Use Screener (WIDUS) and the National Institute on Drug Abuse (NIDA) Quick Screen. In Phase II, participants provided a urine sample and completed a calendar recall-based interview regarding substance use. These screeners were tested, using receiver operating characteristic (ROC) analysis and accuracy statistics, against a reference standard consisting of substance use in three classes (illicit drugs, opioids and alcohol), considered positive if use was evident via 30-day calendar recall or urine analysis. FINDINGS Three hundred and fifteen of 1220 participants (26.3%) met reference standard criteria for positivity. The single-item screening questions from the NIDA Quick Screen showed high specificity (0.99) for all substances, but very poor sensitivity (0.10-0.27). The 5Ps showed high sensitivity (0.80-0.88) but low specificity (0.35-0.37). The CRAFFT, SURP-P and 5Ps had the highest area under the curve (AUC) for alcohol (0.67, 0.66 and 0.62, respectively), and the WIDUS had the highest AUC for illicit drugs and opioids (0.70 and 0.69, respectively). Performance of all instruments varied significantly with race, site and economic status. CONCLUSIONS Of five screening instruments for substance use in pregnancy tested (Substance Use Risk Profile-Pregnancy (SURP-P), CRAFFT, 5Ps, Wayne Indirect Drug Use Screener (WIDUS) and the National Institute on Drug Abuse (Quick Screen), none showed both high sensitivity and high specificity, and area under the curve was low for nearly all measures.
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Affiliation(s)
- Steven J. Ondersma
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Tiffany Blake-Lamb
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - John Orav
- Department of Medicine (Biostatistics) and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica R. Beatty
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Gregory L. Goyert
- Department of Obstetrics and Gynecology, Henry Ford Health System, Detroit, MI, USA
| | - Kimberly A. Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,,Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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24
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Olmstead TA, Yonkers KA, Ondersma SJ, Forray A, Gilstad-Hayden K, Martino S. Cost-effectiveness of electronic- and clinician-delivered screening, brief intervention and referral to treatment for women in reproductive health centers. Addiction 2019; 114:1659-1669. [PMID: 31111591 PMCID: PMC6684836 DOI: 10.1111/add.14668] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/01/2018] [Accepted: 05/13/2019] [Indexed: 12/29/2022]
Abstract
AIMS To determine the cost-effectiveness of electronic- and clinician-delivered SBIRT (Screening, Brief Intervention and Referral to Treatment) for reducing primary substance use among women treated in reproductive health centers. DESIGN Cost-effectiveness analysis based on a randomized controlled trial. SETTING New Haven, CT, USA. PARTICIPANTS A convenience sample of 439 women seeking routine care in reproductive health centers who used cigarettes, risky amounts of alcohol, illicit drugs or misused prescription medication. INTERVENTIONS Participants were randomized to enhanced usual care (EUC, n = 151), electronic-delivered SBIRT (e-SBIRT, n = 143) or clinician-delivered SBIRT (SBIRT, n = 145). MEASUREMENTS The primary outcome was days of primary substance abstinence during the 6-month follow-up period. To account for the possibility that patients might substitute a different drug for their primary substance during the 6-month follow-up period, we also considered the number of days of abstinence from all substances. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves determined the relative cost-effectiveness of the three conditions from both the clinic and patient perspectives. FINDINGS From a health-care provider perspective, e-SBIRT is likely (with probability greater than 0.5) to be cost-effective for any willingness-to-pay value for an additional day of primary-substance abstinence and an additional day of all-substance abstinence. From a patient perspective, EUC is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is less than $0.18 and e-SBIRT is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is greater than $0.18. CONCLUSIONS e-SBIRT could be a cost-effective approach, from both health-care provider and patient perspectives, for use in reproductive health centers to help women reduce substance misuse.
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Affiliation(s)
- Todd A. Olmstead
- The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, 2300 Red River Street, Austin, TX 78713, USA
| | - Kimberly A. Yonkers
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA,Yale University School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, 333 Cedar Street, New Haven, CT 06510, USA,Yale University School of Epidemiology and Public Health, Division of Chronic Disease, 60 College Street, New Haven, CT 06520, USA
| | - Steven J. Ondersma
- Wayne State University, Department of Psychiatry & Behavioral Neurosciences & Merrill-Palmer Skillman Institute, 71 E. Ferry Ave., Detroit, MI 48202, USA
| | - Ariadna Forray
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA
| | - Kathryn Gilstad-Hayden
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA
| | - Steve Martino
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA,VA Connecticut Healthcare System, 950 Campbell Avenue (116B), West Haven, CT 06516, USA
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Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019; 221:B5-B28. [PMID: 30928567 DOI: 10.1016/j.ajog.2019.03.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Yonkers KA. Psychiatric Research and Clinical Practice:
The American Psychiatric Association's New Open‐Access Journal. Psychiatr res clin pract 2019; 1:1. [PMID: 36101567 PMCID: PMC9176008 DOI: 10.1176/appi.prcp.20180101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kimberly A. Yonkers
- Department of PsychiatrySchool of Epidemiology and Public HealthDepartment of Obstetrics, Gynecology, and Reproductive SciencesYale School of MedicineNew HavenConn
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Yonkers KA, Sofuoglu M. The Opioid Crisis: Filling in the Picture. Psychiatr res clin pract 2019; 1:2-3. [PMID: 36101565 PMCID: PMC9175864 DOI: 10.1176/appi.prcp.20180014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kimberly A. Yonkers
- Department of PsychiatrySchool of Epidemiology and Public HealthDepartment of Obstetrics, Gynecology, and Reproductive SciencesYale School of MedicineNew HavenCT
| | - Mehmet Sofuoglu
- Department of PsychiatrySchool of Epidemiology and Public HealthYale School of Medicine, and Veterans Affairs Connecticut Healthcare SystemWest HavenCT
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Loree AM, Yonkers KA, Ondersma SJ, Gilstad-Hayden K, Martino S. Comparing satisfaction, alliance and intervention components in electronically delivered and in-person brief interventions for substance use among childbearing-aged women. J Subst Abuse Treat 2019; 99:1-7. [PMID: 30797381 DOI: 10.1016/j.jsat.2019.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/27/2018] [Accepted: 01/08/2019] [Indexed: 11/17/2022]
Abstract
Electronic delivery of Screening, Brief Intervention, and Referral to Treatment (e-SBIRT) may be a low-cost and high-reach method for screening and brief intervention in health care settings. However, its relative acceptability, ability to build a therapeutic alliance, and delivery of key intervention components compared to in-person SBIRT (SBIRT) is unclear. The association of these factors with intervention outcomes is also not known. We compared SBIRT and e-SBIRT on satisfaction, alliance, and receipt of intervention components, and evaluated the extent to which these intervention dimensions were related to later substance use. Data were collected as part of a randomized clinical trial (N = 439) examining SBIRT, e-SBIRT, and enhanced usual care for childbearing-aged women in two reproductive healthcare clinics (see Martino et al. (2018) for main trial findings). Participants receiving SBIRT or e-SBIRT (N = 270) rated satisfaction and alliance following a single-session, brief intervention, based on motivational interviewing that targeted hazardous substance use (tobacco, alcohol, illicit drugs and prescribed medications). Trained raters coded audio-recorded SBIRT sessions for the presence of six major intervention components, and evaluated the occurrence of these components in the e-SBIRT software. Overall, participants in both groups reported strong satisfaction (on average, "considerably" to "extremely" satisfied) and perceived working alliance (on average, "very often" to "always" allied). SBIRT participants provided higher overall alliance ratings, felt more encouraged to make their own decisions, and rated the intervention's likely helpfulness to other women higher. Fewer e-SBIRT participants received intervention components focusing on personalized feedback, developing importance of and confidence in making changes to substance use, and developing a plan to change, compared to SBIRT participants. However, e-SBIRT participants were equally or more likely to receive components seeking to help them understand their use, discussing reasons for use, and summarizing and supporting what the patients elected to do. Notably, satisfaction, alliance, and number of intervention components received were not associated with total days of substance use. Although we found no evidence that the intervention characteristics evaluated in this study were associated with outcomes, acceptability and alliance may have other important implications. Findings suggest areas for improvement with respect to e-SBIRT satisfaction and alliance formation. ClinicalTrials.govregistration number: NCT01539525.
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Affiliation(s)
- Amy M Loree
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George St, Suite 900, New Haven, CT 06511, USA.
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, 300 George St, Suite 900, New Haven, CT 06511, USA.
| | - Steven J Ondersma
- Merrill Palmer Skillman Institute, Department of Psychiatry & Behavioral Neurosciences, Wayne State University, 71 E. Ferry St, Detroit, MI 48201, USA.
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, 300 George St, Suite 900, New Haven, CT 06511, USA.
| | - Steve Martino
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George St, Suite 900, New Haven, CT 06511, USA.
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Martino S, Ondersma SJ, Forray A, Olmstead TA, Gilstad-Hayden K, Howell HB, Kershaw T, Yonkers KA. A randomized controlled trial of screening and brief interventions for substance misuse in reproductive health. Am J Obstet Gynecol 2018; 218:322.e1-322.e12. [PMID: 29247636 DOI: 10.1016/j.ajog.2017.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Screening, brief intervention, and referral to treatment may reduce substance misuse but has received minimal study among women who are treated in reproductive health settings. OBJECTIVE The purpose of this study was to determine whether "screening, brief intervention and referral to treatment" that is delivered either electronically or by clinician are more effective than enhanced usual care in decreasing days of primary substance use. STUDY DESIGN Women from 2 reproductive centers who smoked cigarettes or misused alcohol, illicit drugs, or prescription medication were allocated randomly to "screening, brief intervention and referral to treatment" delivered electronically or by clinician or to enhanced usual care. Assessments were completed at baseline and at 1-, 3-, and 6-months after a baseline has been established. Coprimary outcomes were days/months of primary substance use and postintervention treatment use. A sample size of 660 women was planned; randomization was stratified by primary substance use and pregnancy status. "Screening, brief intervention and referral to treatment" groups were compared with enhanced usual care groups with the use of generalized estimation equations, and effect sizes were calculated with the use of Cohen's d. RESULTS Between September 2011 and January 2015, women were assigned randomly to a group: 143 women (16.8% pregnant) in the electronic-delivered "screening, brief intervention and referral to treatment" group, 145 women (18.6% pregnant) in the clinician-delivered "screening, brief intervention and referral to treatment" group, and 151 women (19.2% pregnant) in the enhanced usual care group; the retention was >84%. Based on the generalized estimating equations model, predicted mean days per month of use at baseline for primary substance were 23.9 days (95% confidence interval, 22.4-25.5) for the electronic-delivered group, 22.8 days (95% confidence interval, 21.4-24.3) for the clinician-delivered group, and 23.5 days (95% confidence interval, 22.2, 24.9) for enhanced usual care, which respectively declined to 20.5 days (95% confidence interval, 19.0-22.2), 19.8 days (95% confidence interval,18.5-21.3), and 21.9 days (95% confidence interval, 20.7-23.1) at 1 month; 16.9 days (95% confidence interval, 15.0-19.0), 16.6 days (95% confidence interval, 14.8-18.6), and 19.5 days (95% confidence interval, 18.1-21.1) at 3 months; and 16.3 days (95% confidence interval, 14.3-18.7), 16.3 days (95% confidence interval, 14.4-18.5), and 17.9 days (95% confidence interval, 16.1-19.9) at 6 months. Estimated declines were greater in the electronic-delivered group (β [standard error]=-0.090[0.034]; P=.008; Cohen's d, 0.19 at 1 month, 0.30 at 3 months, and 0.17 at 6 months) and the clinician-delivered group (β [standard error]=-0.078[0.037]; P=.038; Cohen's d, 0.17 at 1 month, 0.22 at 3 months, and 0.06 at 6 months) compared with enhanced usual care. Treatment use did not differ between groups. CONCLUSION "Screening, brief intervention and referral to treatment" significantly decreased days of primary substance use among women in reproductive healthcare centers; neither resulted in more treatment use than enhanced usual care.
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Affiliation(s)
- Steve Martino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
| | - Steven J Ondersma
- Department of Psychiatry & Behavioral Neurosciences & Merrill-Palmer Skillman Institute, Detroit, MI
| | - Ariadna Forray
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Todd A Olmstead
- Lyndon B. Johnson School of Public Affairs, University of Texas at Austin, Austin, TX
| | | | - Heather B Howell
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Trace Kershaw
- Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT; Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale University School of Medicine, New Haven, CT; Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT
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Abstract
BACKGROUND Postpartum contraception is especially important for women who use alcohol and other substances, given the risk of possible rapid repeat pregnancy and prenatal substance exposure. However, little is known about postpartum contraceptive use among women with substance use histories. OBJECTIVE To characterize postpartum contraceptive initiation, 24-month continuation, and rapid repeat pregnancy among women who used substances during pregnancy. METHODS This is a secondary analysis of 161 pregnant women who enrolled in a randomized clinical trial to treat substance use in pregnancy and completed at least one follow-up assessment. Women were eligible if they were less than 28 weeks gestation and reported alcohol or illicit drug use within the past 30 days. Participants were recruited from two hospital-based OB/GYN clinics between 2006 and 2010, and completed assessments at delivery and 3-, 12-, and 24-months postpartum. RESULTS Past 30-day use of any substance (not including tobacco) was 52.4%, 58.3%, and 59.8% at 3-, 12-, and 24-month follow-up, respectively. Marijuana was the most commonly reported illicit substance (as high as 48.1%). Rates of any contraceptive use were 71.3%, 66.7% and 65.3% at 3-, 12-, and 24-month follow-up, respectively; DepoProvera and condoms were the most common methods. Rapid repeat pregnancy occurred in 28% of participants by 24-month follow-up. Conclusions/Importance: Postpartum contraceptive use among substance using women was at or near 70%, which is comparable to other samples of postpartum women. Innovative efforts are needed to promote effective contraceptive use among postpartum women in general and among those who use substances in particular.
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Affiliation(s)
- Amy M Loree
- a Psychology Service, VA Connecticut Healthcare System , West Haven , Connecticut , USA.,b Department of Psychiatry, Yale School of Medicine , New Haven , Connecticut , USA
| | - Aileen Gariepy
- c Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine , New Haven , Connecticut , USA
| | - Jennifer Prah Ruger
- d Department of Medical Ethics and Health Policy , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Kimberly A Yonkers
- b Department of Psychiatry, Yale School of Medicine , New Haven , Connecticut , USA.,c Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine , New Haven , Connecticut , USA
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Forray A, Gilstad-Hayden K, Suppies C, Bogen D, Sofuoglu M, Yonkers KA. Progesterone for smoking relapse prevention following delivery: A pilot, randomized, double-blind study. Psychoneuroendocrinology 2017; 86:96-103. [PMID: 28926762 PMCID: PMC5659923 DOI: 10.1016/j.psyneuen.2017.09.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/24/2017] [Accepted: 09/06/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Close to half of women who were smokers prior to conception quit smoking in pregnancy, when endogenous progesterone levels are high. However, at least half resume pre-pregnancy smoking levels within weeks after delivery and when progesterone levels drop. The current pilot study tested the feasibility and preliminary efficacy of postpartum progesterone replacement in preventing relapse to smoking in postpartum women with a history of pre-pregnancy smoking. METHODS This was an 8-week, double-blind, parallel, randomized, placebo-controlled pilot trial of 41 women with a history of pre-pregnancy smoking who achieved abstinence by 32 weeks of gestation. Immediately following delivery women were randomized to oral micronized progesterone (200mg twice daily) or placebo via computerized urn randomization program. The main outcome measures were descriptions of study feasibility: recruitment and retention. Secondary outcomes were 7-day point prevalence of abstinence at week 8, time to relapse and smoking cravings. RESULTS The trial was feasible with adequate randomization, 64% (41/64) of eligible women, and trial retention, 78% (32/41) completed the trial. Women taking progesterone were 1.8 times more likely to be abstinent during week 8 and took longer to relapse (10 vs. 4 weeks) compared to the placebo group, although these differences did not reach statistical significance. After adjusting for age and pre-quit smoking level, the number needed to treat was 7. There was a 10% greater decline per week in craving ratings in the progesterone group compared to placebo (β=-0.10, 95% CI: -0.15, -0.04, p<0.01). No serious adverse events occurred during the trial. CONCLUSIONS These preliminary findings support the promise of progesterone treatment in postpartum smokers and could constitute a therapeutic breakthrough.If these preliminary findings can be evaluated and replicated in a larger study with sufficient power, this may constitute an acceptable and safe smoking relapse prevention strategy for use during lactation.
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Affiliation(s)
- Ariadna Forray
- Department of Psychiatry, Yale School of Medicine,40 Temple Street, Suite 6B, New Haven, CT, 06510, United States.
| | - Kathryn Gilstad-Hayden
- Department of Psychiatry, Yale School of Medicine,40 Temple Street, Suite 6B, New Haven, CT, 06510, United States
| | - Cristine Suppies
- Department of Psychiatry, Yale School of Medicine,40 Temple Street, Suite 6B, New Haven, CT, 06510, United States
| | - Debra Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3420 Fifth Avenue, Pittsburgh, PA, 15213, United States
| | - Mehmet Sofuoglu
- Department of Psychiatry, Yale School of Medicine,40 Temple Street, Suite 6B, New Haven, CT, 06510, United States; VA Connecticut Healthcare System, Building 35, 950 Campbell Avenue, West Haven, CT, 06516, United States
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale School of Medicine,40 Temple Street, Suite 6B, New Haven, CT, 06510, United States; Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine,20 York Street, New Haven, CT, 06510, United States
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Holloway AS, Ferguson J, Landale S, Cariola L, Newbury-Birch D, Flynn A, Knight JR, Sherritt L, Harris SK, O’Donnell AJ, Kaner E, Hanratty B, Loree AM, Yonkers KA, Ondersma SJ, Gilstead-Hayden K, Martino S, Adam A, Schwartz RP, Wu LT, Subramaniam G, Sharma G, McNeely J, Berman AH, Kolaas K, Petersén E, Bendtsen P, Hedman E, Linderoth C, Müssener U, Sinadinovic K, Spak F, Gremyr I, Thurang A, Mitchell AM, Finnell D, Savage CL, Mahmoud KF, Riordan BC, Conner TS, Flett JAM, Scarf D, McRee B, Vendetti J, Gallucci KS, Robaina K, Clark BJ, Jones J, Reed KD, Hodapp RM, Douglas I, Burnham EL, Aagaard L, Cook PF, Harris BR, Yu J, Wolff M, Rogers M, Barbosa C, Wedehase BJ, Dunlap LJ, Mitchell SG, Dusek KA, Gryczynski J, Kirk AS, Oros MT, Hosler C, O’Grady KE, Brown BS, Angus C, Sherborne S, Gillespie D, Meier P, Brennan A, de Vargas D, Soares J, Castelblanco D, Doran KM, Wittman I, Shelley D, Rotrosen J, Gelberg L, Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Deng Y, Dziura J, Fiellin LE, O’Connor PG, Bedimo R, Gibert C, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Justice AC, Bryant KJ, Fiellin DA, Giles EL, Coulton S, Deluca P, Drummond C, Howel D, McColl E, McGovern R, Scott S, Stamp E, Sumnall H, Vale L, Alabani V, Atkinson A, Boniface S, Frankham J, Gilvarry E, Hendrie N, Howe N, McGeechan GJ, Ramsey A, Stanley G, Clephane J, Gardiner D, Holmes J, Martin N, Shevills C, Soutar M, Chi FW, Weisner C, Ross TB, Mertens J, Sterling SA, Shorter GW, Heather N, Bray J, Cohen HA, McPherson TL, Adam C, López-Pelayo H, Gual A, Segura-Garcia L, Colom J, Ornelas IJ, Doyle S, Donovan D, Duran B, Torres V, Gaume J, Grazioli V, Fortini C, Paroz S, Bertholet N, Daeppen JB, Satterfield JM, Gregorich S, Alvarado NJ, Muñoz R, Kulieva G, Vijayaraghavan M, Adam A, Cunningham JA, Díaz E, Palacio-Vieira J, Godinho A, Kushir V, O’Brien KHM, Aguinaldo LD, Sellers CM, Spirito A, Chang G, Blake-Lamb T, LaFave LRA, Thies KM, Pepin AL, Sprangers KE, Bradley M, Jorgensen S, Catano NA, Murray AR, Schachter D, Andersen RM, Rey GN, Vahidi M, Rico MW, Baumeister SE, Johansson M, Sinadinovic C, Hermansson U, Andreasson S, O’Grady MA, Kapoor S, Akkari C, Bernal C, Pappacena K, Morley J, Auerbach M, Neighbors CJ, Kwon N, Conigliaro J, Morgenstern J, Magill M, Apodaca TR, Borsari B, Hoadley A, Scott Tonigan J, Moyers T, Fitzgerald NM, Schölin L, Barticevic N, Zuzulich S, Poblete F, Norambuena P, Sacco P, Ting L, Beaulieu M, Wallace PG, Andrews M, Daley K, Shenker D, Gallagher L, Watson R, Weaver T, Bruguera P, Oliveras C, Gavotti C, Barrio P, Braddick F, Miquel L, Suárez M, Bruguera C, Brown RL, Capell JW, Paul Moberg D, Maslowsky J, Saunders LA, McCormack RP, Scheidell J, Gonzalez M, Bauroth S, Liu W, Lindsay DL, Lincoln P, Hagle H, Wallhed Finn S, Hammarberg A, Andréasson S, King SE, Vargo R, Kameg BN, Acquavita SP, Van Loon RA, Smith R, Brehm BJ, Diers T, Kim K, Barker A, Jones AL, Skinner AC, Hinman A, Svikis DS, Thacker CL, Resnicow K, Beatty JR, Janisse J, Puder K, Bakshi AS, Milward JM, Kimergard A, Garnett CV, Crane D, Brown J, West R, Michie S, Rosendahl I, Andersson C, Gajecki M, Blankers M, Donoghue K, Lynch E, Maconochie I, Phillips C, Pockett R, Phillips T, Patton R, Russell I, Strang J, Stewart MT, Quinn AE, Brolin M, Evans B, Horgan CM, Liu J, McCree F, Kanovsky D, Oberlander T, Zhang H, Hamlin B, Saunders R, Barton MB, Scholle SH, Santora P, Bhatt C, Ahmed K, Hodgkin D, Gao W, Merrick EL, Drebing CE, Larson MJ, Sharma M, Petry NM, Saitz R, Weisner CM, Young-Wolff KC, Lu WY, Blosnich JR, Lehavot K, Glass JE, Williams EC, Bensley KM, Chan G, Dombrowski J, Fortney J, Rubinsky AD, Lapham GT, Forray A, Olmstead TA, Gilstad-Hayden K, Kershaw T, Dillon P, Weaver MF, Grekin ER, Ellis JD, McGoron L, McGoron L. Proceedings of the 14th annual conference of INEBRIA. Addict Sci Clin Pract 2017. [PMCID: PMC5606215 DOI: 10.1186/s13722-017-0087-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ko JY, Wolicki S, Barfield WD, Patrick SW, Broussard CS, Yonkers KA, Naimon R, Iskander J. CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome. MMWR Morb Mortal Wkly Rep 2017; 66:242-245. [PMID: 28278146 PMCID: PMC5687191 DOI: 10.15585/mmwr.mm6609a2] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Xu X, Yonkers KA, Ruger JP. Economic evaluation of a behavioral intervention versus brief advice for substance use treatment in pregnant women: results from a randomized controlled trial. BMC Pregnancy Childbirth 2017; 17:83. [PMID: 28270105 PMCID: PMC5341449 DOI: 10.1186/s12884-017-1260-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/28/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Substance use in pregnancy is associated with severe maternal and fetal morbidities and substantial economic costs. However, few studies have evaluated the cost-effectiveness of substance use treatment programs in pregnant women. The purpose of this study was to evaluate the economic impact of a behavioral intervention that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) for treatment of substance use in pregnancy, in comparison with brief advice. METHODS We conducted an economic evaluation alongside a clinical trial by collecting data on resource utilization and performing a cost minimization analysis as MET-CBT and brief advice had similar effects on clinical outcomes (e.g., alcohol and drug use and birth outcomes). Costs were estimated from the health care system's perspective and included intervention costs, hospital facility costs, physician fees, and costs of psychotropic medications from the date of intake assessment until 3-month postpartum. We compared effects of MET-CBT on costs with those of brief advice using Wilcoxon rank sum tests. RESULTS Although the integrated MET-CBT therapy had higher intervention cost than brief advice (median = $1297/participant versus $303/participant, p < 0.01), costs of care during the prenatal period, delivery, and postpartum period, as well as for psychotropic medications, were comparable between the two groups (all p values ≥ 0.55). There was no statistically significant difference in overall cost of care (median total cost = $26,993/participant for MET-CBT versus $27,831/participant for brief advice, p = 0.90). CONCLUSIONS The MET-CBT therapy and brief advice resulted in similar clinical outcomes and overall medical costs. Further research incorporating non-medical costs, targeting women with more severe substance use disorders, and evaluating the impact of MET-CBT on participants' quality of life will provide additional insights. TRIAL REGISTRATION ClinicalTrials.gov NCT00227903 . Registered 27 September 2005.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar Street, LSOG 205B, New Haven, CT 06520 USA
| | | | - Jennifer Prah Ruger
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
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Yonkers KA, Cameron B, Gueorguieva R, Altemus M, Kornstein SG. The Influence of Cyclic Hormonal Contraception on Expression of Premenstrual Syndrome. J Womens Health (Larchmt) 2016; 26:321-328. [PMID: 27854559 DOI: 10.1089/jwh.2016.5941] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Some women who use cyclic hormonal contraception (CHC) suffer from premenstrual symptoms; whether their symptoms differ from women who do not use CHC is not clear. OBJECTIVE To compare women who use or do not use CHC on perimenstrual symptom timing and change severity. STUDY DESIGN We analyzed daily symptom ratings from women who requested participation in (Screened Cohort: 103 used CHC and 387 did not) or were randomized in (Randomized Cohort: 41 used CHC and 211 did not) a clinical trial for premenstrual syndrome. We used effect sizes to compute and compare change scores between cycle phases in four partially overlapping perimenstrual windows defined relative to day 1 of menses [(-6, -1), (-5, 1), (-4, 2), (-3, 3)]. Differences in magnitude of change and timing were estimated using linear mixed-effects models. RESULTS Both cohorts showed a significant two-way interaction between CHC use and symptom change scores (p < 0.01) and a significant main effect of perimenstrual window (p < 0.0001). Overall menstrual cycle symptom change was greater for the nonhormonal contraception versus hormonal contraception group. In the Screened Cohort, change scores were greater in the nonhormonal group specifically for depression (p = 0.04); anger or irritability (p < 0.01); and physical symptoms (p < 0.01). Mean change scores increased as the window shifted forward toward menses for both cohorts with the largest effect size and greatest group difference for (-4, 2) interval. CONCLUSIONS CHC slightly attenuates menstrual cycle symptom change. The (-4, 2) perimenstrual interval shows the largest change compared with postmenses.
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Affiliation(s)
- Kimberly A Yonkers
- 1 Department of Psychiatry, and Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine , New Haven, Connecticut.,2 Yale University School of Medicine , New Haven, Connecticut.,3 School of Epidemiology and Public Health, Yale University School of Medicine , New Haven, Connecticut
| | - Brianna Cameron
- 4 Department of Biostatistics, Yale University School of Public Health , New Haven, Connecticut
| | - Ralitza Gueorguieva
- 4 Department of Biostatistics, Yale University School of Public Health , New Haven, Connecticut
| | - Margaret Altemus
- 5 Department of Psychiatry, Yale University School of Medicine , New Haven, Connecticut
| | - Susan G Kornstein
- 6 Department of Psychiatry, Institute for Women's Health, Virginia Commonwealth University , Richmond, Virginia
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Gariepy AM, Lundsberg LS, Miller D, Stanwood NL, Yonkers KA. Are pregnancy planning and pregnancy timing associated with maternal psychiatric illness, psychological distress and support during pregnancy? J Affect Disord 2016; 205:87-94. [PMID: 27423065 PMCID: PMC5048515 DOI: 10.1016/j.jad.2016.06.058] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 06/26/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pregnancy planning and timing may be associated with psychiatric illness, psychological distress and support during pregnancy. METHODS We performed secondary analyses of a prospective cohort of 2654 pregnant women evaluating the impact of depression on preterm birth. We used multivariable logistic regression to test associations between pregnancy planning ("Was this pregnancy planned? Yes/No") and/or timing ("Do you think this is a good time for you to be pregnant?") with Composite International Diagnostic Interview generated psychiatric diagnoses and measures of psychological distress and support. RESULTS 37% and 13% of participants reported an unplanned or poorly timed pregnancy, respectively. Unplanned pregnancies were associated with a Major Depressive Episode (MDE) (adjusted odds ratio (aOR) 1.69, 95%CI 1.23-2.32) and the Cohen Perceived Stress Scale's (CPSS) highest quartile (aOR 1.74, 95%CI 1.40-2.16). Poorly timed pregnancies were associated with a MDE (aOR 3.47, 95%CI 2.46-4.91) and the CPSS's highest quartile (aOR 5.20, 95%CI 3.93-6.87). Poorly timed pregnancies were also associated with General Anxiety Disorder (GAD; aOR 1.60, 95%CI 1.07-2.40), and the modified Kendler Social Support Inventory's (MKSSI) lowest quartile (aOR 1.64, 95%CI 1.25-2.16). Psychiatric conditions were strongly associated with planned pregnancies that were subsequently deemed poorly timed (MDE=aOR 5.08, 95%CI 2.52-10.25; GAD=aOR 2.28, 95%CI 1.04-5.03); high CPSS=aOR 6.48, 95%CI 3.59-11.69; and low MKSSI=aOR 3.19, 95%CI 1.81-5.62. LIMITATIONS Participant characteristics may limit generalizability of findings. CONCLUSIONS Pregnancy timing was a stronger predictor of maternal psychiatric illness, psychological distress and low social support than pregnancy planning in our cohort.
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Affiliation(s)
- Aileen M Gariepy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Devin Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Nancy L Stanwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
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Abstract
A 2012 committee opinion from the American College of Obstetricians and Gynecologists highlights the considerable increase in opioid addiction in recent years, yet little is known about clinical correlates of prescribed opioids among pregnant women. This study examines clinical and demographic factors associated with the use of opioid analgesics in pregnancy. Data were derived from a prospective cohort study of pregnant women. Participants were administered the Composite International Diagnostic Interview to identify depressive and anxiety disorders and data on medication use were gathered at three assessment points and classified according to the Anatomical Therapeutic Chemical Code (ATC) classification system ATC group N02A. Participants included 2,748 English or Spanish speaking pregnant women. Six percent (n = 165) of women used opioid analgesics at any point in pregnancy. More pregnant women using opioids met diagnostic criteria for major depressive disorder (16 vs. 8 % for non users), generalized anxiety disorder (18 vs. 9 % for non users), post-traumatic stress disorder (11 vs. 4 % for non users) and panic disorder (6 vs. 4 % for non users). Women who reported opioid use were also significantly more likely than non users to report using illicit drugs and almost three times as likely to report smoking cigarettes in the second or third trimester of pregnancy (4 and 23 %, respectively) as compared to non-opioid users (0.5 and 8 %). The use of opioids in pregnancy was associated with higher levels of psychiatric comorbidity and use of other substances as compared to non-opioid users.
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Affiliation(s)
- Megan V Smith
- Department of Psychiatry, Yale School of Medicine, 300 George Street, 9th floor, New Haven, CT, 06511, USA,
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Gariepy AM, Lundsberg LS, Stolar M, Stanwood NL, Yonkers KA. Are pregnancy planning and timing associated with preterm or small for gestational age births? Fertil Steril 2015; 104:1484-92. [PMID: 26364840 PMCID: PMC4663160 DOI: 10.1016/j.fertnstert.2015.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/07/2015] [Accepted: 08/10/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate whether unplanned or poorly timed pregnancies (self-reported at enrollment) are associated with preterm or small for gestational age births. DESIGN Prospective cohort study. SETTING Not applicable. PATIENT(S) Two thousand six hundred fifty-four pregnant women <18 weeks estimated gestational age with a singleton pregnancy. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Preterm and small for gestational age births. RESULT(S) In adjusted analyses, pregnancy planning was not statistically significantly associated with preterm (odds ratio [OR] 1.18; 95% confidence interval [CI], 0.85-1.65) or small for gestational age birth (OR 1.17; 95% CI, 0.69-1.97). Similarly, poorly timed pregnancies were not statistically significantly associated with preterm (OR 0.85; 95% CI, 0.53-1.38) or small for gestational age birth (OR 0.92; 95% CI, 0.65-1.29). Combining pregnancy planning (yes/no) and timing (yes/no) into a 4-level category showed no statistically significant association with preterm birth or small for gestational age. CONCLUSION(S) In a large cohort with antenatally assessed pregnancy planning and timing, outcome data collected from medical record abstraction, and robust analysis adjusting for multiple confounding factors including maternal demographics, medical conditions, and other risk factors, neither pregnancy planning nor pregnancy timing showed a statistically significant association with preterm or small for gestational age infants. This study improves upon previous analyses that lacked adjustment for confounding and used retrospective self-reporting to assess pregnancy planning and timing, and preterm and small for gestational age births. Findings may differ in higher risk populations with higher prevalence of preterm or small for gestational age births.
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Affiliation(s)
- Aileen M Gariepy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, Yale University, New Haven, Connecticut.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, Yale University, New Haven, Connecticut
| | - Marilyn Stolar
- Yale Center for Analytical Sciences, School of Public Health, Yale University, New Haven, Connecticut
| | - Nancy L Stanwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, Yale University, New Haven, Connecticut
| | - Kimberly A Yonkers
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, Yale University, New Haven, Connecticut; Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut
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Yonkers KA, Kornstein SG, Gueorguieva R, Merry B, Van Steenburgh K, Altemus M. Symptom-Onset Dosing of Sertraline for the Treatment of Premenstrual Dysphoric Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2015; 72:1037-44. [PMID: 26351969 PMCID: PMC4811029 DOI: 10.1001/jamapsychiatry.2015.1472] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Serotonin reuptake inhibitors (SRIs) are efficacious treatments for premenstrual dysphoric disorder (PMDD) when given daily or for half of the menstrual cycle during the luteal phase. Preliminary studies suggest that SRI treatment can be shortened to the interval from symptom onset through the beginning of menses. OBJECTIVE To determine the efficacy of symptom-onset dosing with the SRI sertraline hydrochloride for treatment of PMDD. DESIGN, SETTING, AND PARTICIPANTS A double-blind, placebo-controlled, multisite, parallel-group randomized clinical trial conducted September 1, 2007, to February 29, 2012, at 3 university medical centers. In all, 252 women with PMDD started treatment at symptom onset and continued until the first few days of menses for 6 menstrual cycles. Intent-to-treat analyses were performed February 28, 2014, through April 21, 2015. INTERVENTIONS Placebo or sertraline hydrochloride, 50 to 100 mg/d, during the symptomatic interval. MAIN OUTCOMES AND MEASURES Premenstrual Tension Scale (PMTS) score was the primary outcome measure (score range, 0-36; 36 indicates most severe score). Secondary outcome measures included the Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C) (score range, 0-84; 84 indicates most severe score), Daily Record of Severity of Problems (DRSP) (total and subscale scores; higher scores indicate most severe problems), Clinical Global Impression (CGI) scales (score range, 1-7; 7 indicates most severe symptoms and least improvement), and Michelson SSRI (Selective SRI) Withdrawal Symptoms Scale scores (range, 0-51; higher scores indicate more severe withdrawal symptoms). RESULTS Among the participants, 125 with PMDD were randomized to sertraline, and 127 to placebo. At baseline the mean (SD) PMTS scores for sertaline and placebo were 22.3 (4.8) and 21.4 (4.5), respectively, which declined to 11.7 (6.8) and 12.0 (6.9), respectively; group mean difference, 1.88 (95% CI, 0.01-3.75; P = .06). The mean (SD) estimated difference in IDS-C scores between baseline (35.4 [10.7] for sertraline; 32.8 [10.4] for placebo) and the end point (15.3 [10.7] for sertraline; 17.8 [11.0] for placebo) favored the sertraline group by 5.14 (95% CI, 1.97-8.31) points (P = .02). Compared with the placebo group, those assigned to sertraline showed greater improvement on the total DRSP score (estimated mean difference, 1.09 [95% CI, 0.96-1.25] points; P = .02) and Anger/Irritability DRSP subscale score (1.22 [95% CI, 1.05-1.41] points; P < .01) and were more likely to respond to treatment (77 of 115 patients [67.0%] for sertraline and 65 of 124 [52.4%] for placebo; χ21 = 5.23; P = .02). The mean (SD) number of symptomatic days before treatment diminished over time (sertraline, -0.7 [3.4] days; placebo, -1.0 [3.2] days), with no group differences in symptomatic days or the Michelson SSRI Withdrawal Symptoms Scale. CONCLUSIONS AND RELEVANCE Depending on the symptom scale, women with PMDD may or may not benefit from SRI treatment during the interval from the onset of premenstrual symptoms through the first few days of menses. Abrupt treatment cessation was not associated with discontinuation symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00536198.
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Affiliation(s)
- Kimberly A. Yonkers
- Corresponding Author: Kimberly A. Yonkers, MD, Department of Psychiatry, Yale University School of Medicine, 40 Temple St, Ste 6B, New Haven, CT 06510, ()
| | - Susan G. Kornstein
- Department of Psychiatry and Institute for Women’s Health, Virginia Commonwealth University
| | | | - Brian Merry
- Department of Psychiatry, Yale University School of Medicine
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Martino S, Zimbrean P, Forray A, Kaufman J, Desan P, Olmstead TA, Gueorguieva R, Howell H, McCaherty A, Yonkers KA. See One, Do One, Order One: a study protocol for cluster randomized controlled trial testing three strategies for implementing motivational interviewing on medical inpatient units. Implement Sci 2015; 10:138. [PMID: 26420671 PMCID: PMC4589113 DOI: 10.1186/s13012-015-0327-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 11/30/2022] Open
Abstract
Background General medical hospitals provide care for a disproportionate share of patients who abuse or are dependent upon substances. This group is among the most costly to treat and has the poorest medical and addiction recovery outcomes. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance use problems in that patients are accessible, have time for an intervention, and are often admitted for complications related to substance use that renders hospitalization a “teachable moment.” Methods/Design This randomized controlled trial will examine the effectiveness of three different strategies for integrating motivational interviewing (MI) into the practice of providers working within a general medical inpatient hospitalist service: (1) a continuing medical education workshop that provides background and “shows” providers how to conduct MI (See One); (2) an apprenticeship model involving workshop training plus live supervision of bedside practice (Do One); and (3) ordering MI from the psychiatry consultation-liaison (CL) service after learning about it in a workshop (Order One). Thirty providers (physicians, physician assistants, nurses) will be randomized to conditions and then assessed for their provision of MI to 40 study-eligible inpatients. The primary aims of the study are to assess (1) the utilization of MI in each condition; (2) the integrity of MI when providers use it on the medical units; and (3) the relative costs and cost-effectiveness of the three different implementation strategies. Discussion If implementation of Do One and Order One is successful, the field will have two alternative strategies for supporting medical providers’ proficient use of brief behavioral interventions, such as MI, for medical inpatients who use substances problematically. Trial registration Clinical Trials.gov (NCT01825057)
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Affiliation(s)
- Steve Martino
- Psychology Service, VA Connecticut Healthcare System, 950 Campbell Avenue (116B), West Haven, CT, 06516, USA. .,Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Paula Zimbrean
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Ariadna Forray
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Joy Kaufman
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Paul Desan
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Todd A Olmstead
- Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, 2300 Red River St., Stop E2700, Sid Richardson Hall, Unit 3, Austin, TX, 78712, USA. .,Seton/UT Clinical Research Institute, 1400 North IH 35, Austin, TX, 78701, USA.
| | - Ralitza Gueorguieva
- Department of Biostatistics, Yale University School of Medicine, 60 College Street, New Haven, CT, 06510, USA.
| | - Heather Howell
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Ashley McCaherty
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
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Forray A, Gotman N, Kershaw T, Yonkers KA. Perinatal smoking and depression in women with concurrent substance use. Addict Behav 2014; 39:749-56. [PMID: 24447885 DOI: 10.1016/j.addbeh.2013.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 11/21/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this report was to examine the course of smoking among pregnant women with concurrent substance use, and to assess the impact of depression on smoking. METHODS Data were gathered as part of a randomized controlled trial assessing the efficacy of substance abuse treatment in pregnant women. Women (n=176) were recruited before 28 completed weeks of pregnancy, and followed until 3months postpartum. Depression was assessed using the Inventory of Depressive Symptomatology and the MINI Neuropsychiatric Interview. Our outcome was the average number of cigarettes smoked per day. Linear mixed effects regression was used to measure differential changes in smoking. RESULTS 66% of women smoked in the three months before pregnancy, 42% of pre-pregnancy smokers achieved abstinence before delivery and 60% of the baseline cohort smoked postpartum. Smoking did not differ significantly between depressed and non-depressed groups. After delivery both groups increased smoking at similar rates. CONCLUSION Smoking was common among our cohort of pregnant women with a history of substance use. Women were able to discontinue or decrease smoking during pregnancy, but were likely to resume or increase smoking postpartum. Having clinically significant depressive symptoms or a diagnosis of depression did not have an obvious effect on smoking behaviors.
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Hartlage SA, Breaux CA, Yonkers KA. Addressing concerns about the inclusion of premenstrual dysphoric disorder in DSM-5. J Clin Psychiatry 2014; 75:70-6. [PMID: 24345853 DOI: 10.4088/jcp.13cs08368] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Inclusion of premenstrual dysphoric disorder (PMDD) into the main text of the DSM has been a point of controversy for many years. The purpose of this article is to address the main concerns raised by opponents to its inclusion. Concerns are presented and countered in turn. LITERATURE SEARCH To identify the most prevalent arguments against inclusion of PMDD, we searched MEDLINE (1966-2012), PsycINFO (1930-2012), the Internet, and reference lists of identified articles during September 1-17, 2012, using the keywords PMDD, premenstrual syndrome (PMS), DSM, DSM-5, concerns, controversy, women, political power, workforce, courts, and history. The search was restricted to English-language publications. A total of 55 articles were identified and included. The most pressing arguments against inclusion were grouped by similarity and addressed if they were reported 5 or more times. Our review of the sources yielded 38 concerns regarding PMDD; 6 concerns were reported at least 5 times and are addressed in this article. DISCUSSION Evidence culled from historical and legal trends does not support the alleged societal use of PMS to harm women (eg, keeping women out of the workforce or using PMS against women in child custody disputes). Further, current epidemiologic research has answered all of the methodology criticisms of opponents. Studies have confirmed the existence of PMDD worldwide. The involvement of pharmaceutical companies in research has been questioned. However, irrespective of the level of association with industry, current research on PMDD has consistent results: PMDD exists in a minority of women. CONCLUSIONS Historically, the pain and suffering of women have been dismissed, minimized, and negated. Similarly, women with PMDD have often had their experience invalidated. With the preponderance of evidence in its favor, PMDD has been placed in the main text of the DSM-5, opening the door for affected women to receive the attention full diagnostic status provides.
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Affiliation(s)
- S Ann Hartlage
- Department of Psychiatry, Rush University Medical Center, 2150 W Harrison St, Chicago, IL 60612
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Abstract
Women in their reproductive years are at risk of experiencing depressive and anxiety disorders. As such, it is likely that pregnant women will undergo treatment with antidepressants. We review the risk of adverse birth outcomes and neonatal complications subsequent to antidepressant use in pregnancy. An inconsistent literature shows that antidepressant exposure is associated with shortened gestations and diminished fetal growth; these effects are small. Transitory neonatal signs are seen in some neonates after exposure to antidepressants in utero. No specific pattern of malformations has been consistently associated with antidepressants, with the possible exception of paroxetine and cardiac malformations. There is inconclusive evidence of a link between antidepressants in late pregnancy and persistent pulmonary hypertension in the newborn. Extensive study finds that antidepressants cannot be considered major teratogens. It is likely that confounding factors contribute to a number of the adverse effects found to be associated with antidepressant use in pregnancy.
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Rakofsky JJ, Schettler PJ, Kinkead BL, Frank E, Judd LL, Kupfer DJ, Rush AJ, Thase ME, Yonkers KA, Rapaport MH. The prevalence and severity of depressive symptoms along the spectrum of unipolar depressive disorders: a post hoc analysis. J Clin Psychiatry 2013; 74:1084-91. [PMID: 24330894 DOI: 10.4088/jcp.12m08194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 02/25/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To explore which symptoms are common in patients who experience a range of symptom severity that spans minor depression and major depressive disorder (MDD). METHOD A post hoc analysis of subjects entering outpatient, pharmacologic treatment studies for minor depression or MDD who provided baseline data on the Inventory for Depressive Symptomatology-Clinician Rated (IDS-C) was performed in November 2000. The minor depression sample included 161 patients diagnosed according to the National Institute of Mental Health Diagnostic Interview Schedule, while the MDD subjects included 969 subjects diagnosed according to the Structured Clinical Interview for DSM-III-R. Descriptive statistics were calculated for the total IDS-C score and for each item-rating score for both groups. The percentages of patients within the low, medium, and high severity groups of minor depression and MDD endorsing each IDS-C item were calculated and used to identify specific patterns of prevalence across the 6 groups: symptoms with high prevalence in all groups (core symptoms), those with increasing prevalence across groups (continuum symptoms), and those that become prominent only at a certain threshold of illness severity. RESULTS The mean (SD) IDS-C score was 21.18 (5.37) for minor depression patients, while it was 37.14 (7.27) for the MDD patients (P = .0001). Ten items pertaining mostly to mood state and cognition were identified as "core" symptoms of depression based on their high prevalence in all groups. Fourteen items consisting mostly of neurovegetative and somatic symptoms were identified as "continuum" symptoms based on their general pattern of increasing prevalence across the 6 severity groups. Four "threshold" symptoms, including suicidal ideation, psychomotor slowing, gastrointestinal symptoms, and panic/phobic symptoms, were prevalent in only the most severely depressed groups. CONCLUSIONS The presence of core, continuum, and threshold depressive symptoms indicates central features of both minor depression and MDD as well as symptoms that increase or emerge with depressive illness severity. Some of the core symptoms of minor depression and MDD are not included in DSM depressive criteria or traditional assessment rating scales.
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Affiliation(s)
- Jeffrey J Rakofsky
- Mood and Anxiety Disorders Program, Emory University Department of Psychiatry and Behavioral Sciences, 1256 Briarcliff Rd, 3rd Floor North, Atlanta, GA 30306
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Garlow SJ, Kinkead B, Thase ME, Judd LL, Rush AJ, Yonkers KA, Kupfer DJ, Frank E, Schettler PJ, Rapaport MH. Fluoxetine increases suicide ideation less than placebo during treatment of adults with minor depressive disorder. J Psychiatr Res 2013; 47:1199-203. [PMID: 23786912 PMCID: PMC3729337 DOI: 10.1016/j.jpsychires.2013.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 05/17/2013] [Accepted: 05/23/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Some reports suggest an increase in suicide ideations and behaviors in patients treated with antidepressants. This is an analysis of the impact of fluoxetine on suicide ideations in outpatients with minor depressive disorder. METHODS Research subjects were adult outpatients with minor depressive disorder (N = 162), who received fluoxetine or placebo in a prospective, 12-week, double-blind randomized trial. The research participants were evaluated weekly with standard rating scales that included four suicide-related items: item 3 of the Hamilton Rating Scale for Depression (HRSD), item 18 of Inventory of Depressive Symptomatology (IDS-C), and items 15 and 59 of the Hopkins Symptom Checklist (SCL-90). Clinically significant intensification of suicide ideation was defined as an increase of ≥2 points on any of these items. RESULTS Overall 60/162 subjects (37%) had an increase of ≥1 point during treatment and 17/162 (10.5%) of ≥2 points on at least one suicide item, with 12/81 (14.8%) placebo and 5/81 (6.2%) fluoxetine-treated subjects having a ≥2 point gain. Of the study participants with baseline suicide ideation, 9/22 (40.9%) placebo and 3/24 (12.5%) fluoxetine treated had ≥2 point increase (p = 0.04). Survival analysis revealed that subjects on placebo were significantly more likely (p = 0.050) to experience a ≥2 point increase on one or more item, a difference that emerged early and continued throughout the 12-week trial. CONCLUSIONS Compared to placebo, fluoxetine was not associated with a clinically significant increase in suicide ideation among adults with minor depressive disorder during 12 weeks of treatment.
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Affiliation(s)
- Steven J. Garlow
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Becky Kinkead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | | | - Lewis L. Judd
- Department of Psychiatry, University of California, San Diego
| | - A. John Rush
- Duke-National University of Singapore Graduate Medical School
| | | | - David J. Kupfer
- Western Psychiatric Institute and Clinic, University of Pittsburgh
| | - Ellen Frank
- Western Psychiatric Institute and Clinic, University of Pittsburgh
| | - Pamela J. Schettler
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Mark Hyman Rapaport
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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Yonkers KA. The possible effects of depressive symptoms on risk of preterm birth are clouded by lack of control over confounding factors. ACTA ACUST UNITED AC 2013; 18:194-5. [PMID: 23328968 DOI: 10.1136/eb-2012-101136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Yonkers KA, Forray A, Howell HB, Gotman N, Kershaw T, Rounsaville BJ, Carroll KM. Motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice: a randomized trial for treatment of hazardous substance use in pregnancy and after delivery. Gen Hosp Psychiatry 2012; 34:439-49. [PMID: 22795046 PMCID: PMC3428516 DOI: 10.1016/j.genhosppsych.2012.06.002] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 06/05/2012] [Accepted: 06/05/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective was to compare the efficacy of motivational enhancement therapy coupled with cognitive behavioral therapy (MET-CBT) to brief advice for treatment of substance use in pregnancy. METHOD This was a randomized, parallel, controlled trial that was yoked to prenatal care and delivered at hospital outpatient clinics. We enrolled 168 substance-using women who had not yet completed an estimated 28 weeks of pregnancy. Obstetrical clinicians provided brief advice, and study nurses administered manualized MET-CBT. The primary outcome was percentage of days in the prior 28 days in which alcohol and/or drugs were used immediately before and 3 months postdelivery. RESULTS There were no significant differences across groups in terms of self-reported percentage of days in which drugs or alcohol were used prior to and 3 months postdelivery. Biological measures showed similar results. There was a trend (P=.08) for lower risk of preterm birth among those who received MET-CBT. CONCLUSIONS The tested interventions had similar therapeutic effects. Hence, both treatments may be suitable for pregnant substance users, depending on the population, setting and provider availability. Interventions that are intensified after delivery may decrease postpartum "rebound" effects in substance misuse.
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Affiliation(s)
- Kimberly A. Yonkers
- Departments of Psychiatry and, Obstetrics, Gynecology and Reproductive Sciences and the School of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA 06510
| | - Ariadna Forray
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA 06510
| | - Heather B. Howell
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA 06510
| | - Nathan Gotman
- Department of Psychiatry, Yale University School of Medicine New Haven, CT, USA 06510
| | - Trace Kershaw
- School of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA 06510
| | | | - Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA 06510
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Quesada O, Gotman N, Howell HB, Funai EF, Rounsaville BJ, Yonkers KA. Prenatal hazardous substance use and adverse birth outcomes. J Matern Fetal Neonatal Med 2012; 25:1222-7. [PMID: 22489543 DOI: 10.3109/14767058.2011.602143] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Assess the relative effects of a variety of illicit and licit drugs on risk for adverse birth outcomes. METHODS We used data from two large prospective investigations, and a novel analytic method, recursive partitioning class analysis to identify risk factors associated with preterm birth and delivering a small for gestational age infant. RESULTS Compared to cocaine and opiate non-users, cocaine users were 3.53 times as likely (95% CI: 1.65-7.56; p = 0.001) and opiate users 2.86 times as likely (95% CI: 1.11-7.36; p = 0.03) to deliver preterm. The odds of delivering a small for gestational age infant for women who smoked more than two cigarettes daily was 3.74, (95% CI: 2.47-5.65; p<0.0001) compared to women who smoked two or less cigarettes daily and had one previous child. Similarly, less educated, nulliparous women who smoked two or fewer cigarettes daily were 4.12 times as likely (95% CI: 2.04-8.34; p < 0.0001) to have a small for gestational age infant. CONCLUSIONS Among our covariates, prenatal cocaine and opiate use are the predominant risk factors for preterm birth; while tobacco use was the primary risk factor predicting small for gestational age at delivery. Multi-substance use did not substantially increase risk of adverse birth outcomes over these risk factors.
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Affiliation(s)
- Odayme Quesada
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510, USA.
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Epperson CN, Steiner M, Hartlage SA, Eriksson E, Schmidt PJ, Jones I, Yonkers KA. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry 2012; 169:465-75. [PMID: 22764360 PMCID: PMC3462360 DOI: 10.1176/appi.ajp.2012.11081302] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Premenstrual dysphoric disorder, which affects 2%–5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments.
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Davis KJ, Yonkers KA. Making lemonade out of lemons: a case report and literature review of external pressure as an intervention with pregnant and parenting substance-using women. J Clin Psychiatry 2012; 73:51-6. [PMID: 22316576 PMCID: PMC3286840 DOI: 10.4088/jcp.11cr07363] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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