Syphilis testing and treatment outcomes among people experiencing homelessness: a street medicine intervention in South Los Angeles, California.

Commentary

Understanding Associations Between Serious Mental Illness and HIV Among Patients in the VA Health System

Substance Abuse-Related Mortality Among Middle-Aged Male VA Psychiatric Patients

Schizophrenia and Co-Occurring Substance Use Disorder

Relationship Between Diabetes and Mortality Among Persons With Co-occurring Psychotic and Substance Use Disorders

In 2015, the Centers for Disease Control and Prevention (CDC) and the American Academy of Ophthalmology (AAO) released clinical advisories on rising cases of ocular syphilis. We examined the association between eye disease and syphilis infection among primary care and sexually transmitted infection (STI) clinic patients attending an urban lesbian, gay, bisexual, transgender (LGBT) health center. We conducted a retrospective medical record review of all patients who underwent syphilis testing at Howard Brown Health between 1 January 2010 and 31 December 2015. Confirmed eye diagnosis was based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for conjunctivitis, uveitis, keratitis, retinitis, and red eye. Demographic information, syphilis treatment, HIV status, and high-risk behaviors were abstracted. Syphilis diagnosis was defined by available laboratory data (enzyme immunoassay [EIA], rapid plasma reagin [RPR] titer, fluorescent treponemal antibody absorption [FTA-Abs], Treponema pallidum Ab). Multivariable logistic regression with robust variance was used to identify independent associations. During the study period, 71,299 syphilis tests were performed on 30,422 patients. There were 2288 (3.2%) positive syphilis tests. Seventy-seven patients had a confirmed eye diagnosis (0.25%). Patients with eye disease had higher probability of at least one positive syphilis test (33%) compared to those without eye disease (8%) ( p < 0.01). Of patients with eye disease, 77% were men who had sex with men (MSM) and 65% were HIV-positive. Patients with eye disease had 5.97 (95% CI: 3.70, 9.63) higher odds of having syphilis compared to patients without eye disease. When adjusted for age, race, gender/sexual orientation, insurance status, and HIV status, this association between positive syphilis test and eye disease decreased but was still significant (OR 2.00, 95% CI 1.17, 3.41). Patients who present with an eye diagnosis to STI/primary care clinic have a higher probability of positive syphilis tests even after adjusting for other risk factors for syphilis. High-risk patients with eye symptoms should have routine STI testing and in keeping with CDC and AAO recommendations, full ophthalmologic examination.

Early entry into prenatal care and timely syphilis diagnosis and treatment of pregnant women can prevent congenital syphilis (CS). We assessed syphilis testing and treatment for pregnant women and their infants using electronic health records (EHRs). We extracted syphilis testing results from pregnancy episodes documented in EHRs for women seeking care at the Medical University of South Carolina health system during 2021-2022. Chart reviews confirmed syphilis diagnosis, stage, and treatment. We calculated percentages of pregnant women who were (1) screened for syphilis, (2) received abnormal (i.e., reactive) test results, (3) newly diagnosed with syphilis, and (4) adequately treated for syphilis before delivery. We assessed testing and treatment outcomes of infants exposed to maternal syphilis. Among 12,959 pregnant women, 75% (n = 9708) had ≥1 syphilis test during pregnancy; 106 (1.1%) had ≥1 abnormal test. From chart reviews, 54 women (51%) with abnormal test results were newly diagnosed with syphilis. The remaining abnormal test results were false positives (n = 15) or previous diagnoses (n = 37). Forty-four (81%) new diagnoses were treated during pregnancy; 30 (56%) were treated >30 days before delivery. Fifty-six infants born to women with an abnormal syphilis test result were evaluated for CS, of whom 24 (43%) had abnormal test results and 18 (75%) were treated for CS. Although EHRs could reliably assess syphilis testing during pregnancy, chart review and consultation with public health authorities were necessary to confirm adequate treatment and CS follow-up. Triangulating EHRs with other data sources could enhance the understanding of syphilis during pregnancy and inform CS prevention efforts.

This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.

Objectives: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with cooccurring mental and substance use disorders in five states. Methods: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. Results: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. Conclusions: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders. (Psychiatric Services 58:942–948, 2007)

Resident Perspectives 56-5

This study compared the quality of treatment relationships and engagement in peer-based and regular case management. It also assessed the value of positive relationship qualities in predicting motivation for and use of community-based services for persons with severe mental illness. One hundred thirty-seven adults with severe mental illness participated in a 2x2 prospective longitudinal randomized clinical trial with two levels of case management intervention (peer and regular) and two interviews (six and 12 months). Self-report questionnaires assessed treatment relationships, motivation, and service use, and providers rated participants' initial engagement and monthly attendance in treatment. Participants perceived higher positive regard, understanding, and acceptance from peer providers rather than from regular providers at six months only, with initially unengaged clients showing more contacts with case managers in the peer condition and decreasing contacts in the regular condition. Six-month positive regard and understanding positively predicted 12-month treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings. Early in treatment, peer providers may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients and a facility for increasing treatment participation among the most disengaged, leading to greater motivation for further treatment and use of peer-based community services. Findings strongly suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system.

Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which patients with substance use disorders receive guideline-concordant treatment for depression is unknown. The authors investigated the provision of guideline-concordant depression treatment to patients with and without substance use disorders in a large integrated health care system. In a retrospective cohort study of 53,034 patients diagnosed with a depressive disorder in fiscal year 2017 in the U.S. Veterans Health Administration, the authors assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographic and clinical characteristics. Guideline-concordant depression treatment was lower across metrics for patients with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% CI=0.73, 0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69, 0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82, 0.91) of adequate acute-phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73, 0.89) of psychotherapy continuation. Despite the availability of effective treatments for depression, patients with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.

Africa accounts for 56% of maternal syphilis and 62% of congenital syphilis cases globally. The high prevalence of syphilis in this region is particularly concerning in the context of a generalized HIV epidemic, as syphilis infection increases potential for sexual transmission of HIV. The present study qualitatively explores perceptions of syphilis risk, transmission, testing and treatment, and experiences accessing antenatal care from the perspectives of currently pregnant people residing in communities across two Ugandan districts: Wakiso and Hoima. We conducted focus group discussions (k = 10) with pregnant women (n = 82) across six communities. FGDs were audio recorded. Data analysis involved transcription and translation, coding (by two qualitative researchers), and thematic analysis. We promoted trustworthiness through various methodological strategies (e.g. purposive sampling, reflexivity). Many women described barriers to care seeking at government ANC clinics that centered around poor treatment by providers, long wait times for appointments, high out of pocket costs (due to travel and fees) and the expectation that male partners should accompany them to appointments. This led many to seek their antenatal care from traditional birth attendants instead. From these themes we identified several salient barriers to both syphilis testing and treatment, leading us to identify four critical and modifiable targets: [1] structural barriers to care seeking that reflect facility and provider policies that are not necessarily in line with governmental policies; [2] untapped opportunities to leverage alternative care providers (such as traditional birth attendants) to bolster ANC attendance and syphilis treatment uptake [3] improve health literacy around syphilis through education campaigns within the community to increase demand of timely syphilis screening and treatment and [4] sub-optimal patient-provider interactions in government run healthcare facilities. The study provides practical suggestions for enhancing syphilis awareness, engagement in care, and women's experiences in ANC within a resource-limited, high-burden context. Future efforts should concentrate on extending syphilis education beyond clinics, utilizing Village Health Teams (VHTs) as trusted sources, and identifying barriers to improving healthcare quality for women, informing quality improvement programming.

Individuals with bipolar disorder are at significant risk for having a co-occurring substance use disorder-particularly, alcohol and cannabis use disorders. Having a co-occurring substance use disorder is associated with a more pernicious clinical course, lower quality of life, and poorer treatment outcomes. Despite its increased morbidity, there is little research and clinical evidence-based guidelines on the treatment of individuals with co-occurring bipolar and substance use disorders. This review details current knowledge on the prevalence, clinical correlates, and biopsychosocial mechanisms underlying co-occurring bipolar and substance use disorders. The authors present recent research that highlights underlying mechanisms of comorbidity, including aberrant reward processing, stress sensitization, early childhood maltreatment, and gene-environment interactions. Next, the authors review current evidence-based recommendations for the assessment and treatment of co-occurring bipolar and substance use disorder, highlighting areas of needed future clinical research.

This chapter reviews antidepressant treatment considerations and recommendations for patients with co-occurring depression and substance use disorders. Depression and substance use disorders are highly comorbid conditions. Substance use disorders are chronic disorders that result in a cluster of symptoms indicating that an individual continues to use a substance despite significant problems resulting from their use. About 17 million Americans have an alcohol use disorder, and another approximately 7 million individuals have other drug use disorders (not including alcohol) in the United States. The rate of any substance use disorder (including alcohol) in individuals with major depressive disorder is 32% based on a national survey. Evidence suggests that the best outcome for individual with co-occurring conditions is treating both conditions simultaneously. Therefore, practitioners should know the following before prescribing antidepressants for patients with co-occurring substance use disorders: (1) treatment recommendations for patients with co-occurring depression and substance use disorders, (2) potential antidepressant interactions with alcohol and drugs of abuse, and (3) do antidepressants have a risk of misuse? Finally, we will summarize antidepressant treatment recommendations for patients with co-occurring depression and substance use disorders.