Co-occurring Conditions Research Articles

Towards equitable diagnoses for autism and attention-deficit/hyperactivity disorder across sexes and genders.

Sex/gender-related factors contribute to contextual issues influencing the recognition of autism and attention-deficit/hyperactivity disorder (ADHD), and modulate how neurodevelopmental characteristics are manifested. This review summarizes the empirical literature to provide directions for improving clinical diagnostic practices. Timing of autism and/or ADHD diagnosis, particularly in girls/women, is related to the individual's developmental characteristics and co-occurring diagnoses, and expectancy, alongside gender stereotype biases, of referral sources and clinicians. This is further compounded by sex and gender modulations of behavioural presentations. The emerging 'female autism phenotype' concept may serve as a helpful illustration of nuanced autism phenotypes, but should not be viewed as essential features of autism in a particular sex or gender. These nuanced phenotypes that can present across sexes and genders include heightened attention to socially salient stimuli, friendship and social groups, richness in language expression, and more reciprocal behaviours. The nuanced female-predominant ADHD phenotypes are characterized by subtle expressions in hyperactivity-impulsivity (e.g., hyper-verbal behaviours). Optimizing neurodevelopmental diagnoses across sexes and genders also requires an understanding of sex-related and gender-related variations in developmental trajectories, including compensation/masking efforts, and the influences of co-occurring conditions on clinical presentations. Equitable diagnoses across sexes and genders for autism and ADHD require understanding of the nuanced presentations and the Gestalt clinical-developmental profiles, and addressing contextual biases that influence diagnostic practices.

Exploring the Impact of Alcohol and Other Drug Use on HIV Care Among African American Older Adults Living with HIV/AIDS

For people living with HIV, there are multiple barriers to engagement with care. This study qualitatively examines the role of use of alcohol and other drugs (AOD) on the health and management of Human Immunodeficiency Virus (HIV) disease among older African Americans (≥50 years). It draws on interviews conducted with twenty-seven older African Americans living with HIV in the Louisville, Kentucky area. Interviews were transcribed verbatim and then analyzed using constructivist grounded theory analytic techniques. Participants’ understandings of their AOD use fell on a continuum of problematic use to use for self-care. Regardless of where participants fell on this continuum, they faced a) environmental impacts of AOD use and b) current or historic discrimination from the health care system. The analysis focused on gaining a deeper understanding of the intersection of AOD use and engagement in the HIV care continuum. This revealed six major phases, which occurred at various stages of the continuum: (1) Linking AOD use as the cause of HIV diagnosis (2) Having AOD use facilitate denial of HIV, (3) Experiencing problematic use, (4) “Testing the Waters,” (5) Relying on AIDS Service Organizations (ASO) and medical providers and (6) Maintaining health and/or using AOD for self-care. We discuss the ways that stigma along the lines of race, gender, and age intersect with co-occurring conditions such as substance use disorders in complex and multifaceted ways. Recommendations include assessing a patients’ AOD use in relationship to the HIV care continuum to assess patients’ experiences and barriers within systems of care.

Case Management in Primary Care Associated With Service Use by Adults With Dementia and Comorbidities

Population aging has become a challenge to long-term care and health care for the society. Using China as a case study, this paper assesses allocative efficiency of resources in informal care and health care, to explore the effectiveness of the policy, i.e., encouraging informal care as a more cost-effective way to reduce public health care spending. Drawing data from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey, this study examines the impact of informal care on utilization of health care as well as amount of health care expenditures among older people with functional limitations in China. Using random effects model with instrumental variable approach, our findings suggest that informal care significantly reduces the utilization of health care, primarily by reducing the utilization of outpatient care. However, informal care significantly increases the amount of inpatient care expenditures for inpatient care users. We do not observe significant association between informal care and amount of outpatient care expenditures for outpatient care users. This study highlights a pressing need for the Chinese government to support informal caregivers by taking economic values of informal caregiving into consideration, and to improve efficiency in inpatient care by a more integrated resource allocation mechanism

CARING FOR OLDER ADULTS WITH MENTAL HEALTH DISORDERS DURING THE PANDEMIC

Older adults (65 years or older) are prone to various mental health disorders, which require appropriate care. Mental illnesses like depression, dementia and Alzheimer’s disease, among others, increase cognitive deterioration, which leads to dependence on normal activities in life. During pandemics like COVID-19 and Ebola, the mentally ill older adults are highly susceptible to increased morbidity, mortality rates and reduced quality and social life hence require appropriate care. Pandemic occurrence is a concern and worry for the mentally ill older adults since they have an increased vulnerability and are highly dependent on help and care. Moreover, a pandemic like COVID-19 may lead to neurological and mental health complications, which may adversely affect the mentally ill older adults. During the initial stages of the COVID-19 pandemic, older adults were more likely to be infected with the virus and have worse outcomes than their younger counterparts. Similarly, morbidity and mortality rates were highest among older adults who had co-occurring conditions such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease. Older adults were also susceptible to loneliness and social exclusion. The risk factors that were associated with worsening of physical, psychological, and social well-being among these individuals included age, ageism, isolation, loneliness, lack of security, frailty dependency, sexism, stigma, abuse, and cognitive and sensory impairments. The pandemic also had a significant effect on the mental health of older adults.

Co-occurring conditions and racial-ethnic disparities: Medicaid enrolled adults on the autism spectrum.

Evidence suggests that autistic adults have higher odds of developing several co-occurring conditions, but less is known about disparities by race and ethnicity in this population. Using 2008-2012 Medicaid Analytic eXtract (MAX) data, we (i) identify the prevalence of co-occurring conditions among the population of autistic adult Medicaid beneficiaries compared to a matched sample of those without an autism spectrum disorder (ASD) diagnosis, (ii) conduct logistic regression to estimate odds ratios for these health conditions predicted by an autism diagnosis, and (iii) estimate odds of having these health conditions as predicted by racial/ethnic group among the autistic population only. Overall, autistic adults did not have higher prevalence of some major health conditions (cardiovascular conditions, stroke, cancer, cardiovascular disease), but they did have higher odds of others (nutrition conditions, epilepsy, disorders of the central nervous system). Analysis by racial/ethnic group, however, shows that Black, Hispanic, and Asian autistic beneficiaries had higher odds of diabetes, hospitalized cardiovascular diseases, and hypertension, among other conditions. Policymakers should be aware that racial disparities found in the general population persist in the autistic population and should work to implement systems and programs to improve screening and preventive care for minority autistic populations. LAY SUMMARY: Autistic adults may have several co-occurring physical and mental health conditions, which could differ by racial/ethnic group. We find that, compared to the general Medicaid population, autistic adult Medicaid beneficiaries have elevated odds of some health conditions, like epilepsy and nutrition conditions, as well as some psychiatric conditions, such as anxiety and attention disorders. We also find that many of the same health disparities by racial/ethnic group in the general population persist among the autistic adult Medicaid population. For example, Black, Hispanic, and Asian Medicaid autistic beneficiaries have higher odds of diabetes, and Black and Hispanic autistic beneficiaries have higher odds of obesity and nutrition conditions than white autistic beneficiaries.

Anxiety and Depression Mediate the Relationship of Medication-Resistant PTSD to Quality of Life in Service Members

Posttraumatic stress disorder (PTSD) is a significant problem for military service members. For many, PTSD symptoms do not fully remit with available treatments; however, little is known about patients with medication-resistant PTSD. The present research sought to examine the complex relationship of PTSD to patients’ quality of life (QoL) utilizing data previously collected as part of a larger randomized clinical trial of a pharmacological augmentation treatment for individuals with PTSD who did not responded to standard medication treatments. Comorbid psychological conditions, including anxiety and depression, may interfere with treatment response and are known to have debilitating consequences on QoL. Therefore, we sought to examine whether anxiety and depression mediated the relationship of PTSD to QoL across multiple domains. Results indicated depression completely mediated the relation of PTSD to physical, psychological, and social QoL, while anxiety mediated relations to physical and social QoL. This study provides insight into the challenges of individuals who retain PTSD symptoms following treatment as well as the complex relationship of PTSD, co-occurring conditions, and QoL.

Brief Report: The Characterization of Medical Comorbidity Prior to Autism Diagnosis in Children Before Age Two.

In autism spectrum disorder (ASD), medical conditions in infancy could be predictive markers for later ASD diagnosis. In this study, electronic medical records of 579 autistic individuals and 1897 matched controls prior to age 2 were analyzed for potential predictive conditions. Using a novel tool, the relative association of each condition in the autistic group was compared to the control group using logistic regressions across medical records. Generalized convulsive epilepsy, nystagmus, lack of normal physiological development, delayed milestones, and strabismus were more likely in those later diagnosed with ASD while perinatal jaundice was less likely to be associated. Lesser-known conditions, such as strabismus and nystagmus, may point to novel predictive co-occurring condition profiles which could improve screening practices for ASD.

Eruptive Seborrheic Keratoses Are Associated With a Co-Occurring Malignancy in the Majority of Reported Cases: A Systematic Review.

BackgroundEruptive seborrheic keratoses (ESK) is a benign skin condition that has been associated with malignant and nonmalignant diseases. We conducted a systematic review of reported cases of ESK to identify and summarize associated comorbidities.MethodsMEDLINE and Embase were searched from database inception (1946) to July 31, 2020 for original articles describing ESK with or without a co-occurring condition. Subject demographics, as well as details of ESK and associated diagnoses were extracted from 76 articles (70 case reports, 3 case series, 3 case control studies) representing 92 patients.ResultsIn total, 76.1% (n = 70/92) of patients with ESK had a co-occurring malignancy, 4.3% (n = 4/92) presented with a nonmalignant condition, 9.8% (n = 9/92) experienced ESK as an adverse drug reaction, and 9.8% (n = 9/92) did not report any underlying medical condition. ESK preceded a cancer diagnosis in 76.1% (n = 70/92) of patients with a mean latency period of 4.0 months (range: 0.25-9 months). The most common malignancies associated with ESK were cutaneous T-cell lymphoma (n = 10/70, 14.3%) and gastrointestinal adenocarcinoma (n = 9/70, 12.9%). ESK preceded nonmalignant conditions or no disease in 14.1% (n = 13/92) of patients with a mean latency period of 3.1 months (range: 0.75-6 months). Drug-induced ESK occurred in 9.8% (n = 9/92) of patients with a mean latency period of 7.1 weeks after changing medication.ConclusionAlthough the role of ESK as a paraneoplastic cutaneous marker is debated, healthcare providers should consider screening for underlying malignancy in patients presenting with ESK. Larger studies are needed to confirm its role as a marker for disease.

Improvements in Swim Skills in Children with Autism Spectrum Disorder Following a 5-Day Adapted Learn-To-Swim Program (iCan Swim).

Drowning is one of the leading causes of death in children and teenagers. Individuals with autism spectrum disorder (ASD) are at increased risk for drowning. Improvements in swim skills have been observed in children with ASD participating in learn-to-swim programs. However, it is unclear if age, co-occurring conditions, and/or the dose of practice influence swim skills in this population. To this end, a secondary data analysis of iCan Swim program data was conducted to determine the efficacy of the 5-day adapted learn-to-swim program for a cohort of children with ASD ages 3–16 years (n = 86). Participant swim level was evaluated at the start and end of the program. Linear mixed-effects regression was used to examine the effects of Time (start/end), Age, Dose of Swim Practice (i.e., total time–time out of the water), and ADHD status on the overall swim level. Participants significantly increased the swim level from the beginning to the end of the program (B = 0.63, 95% CI = 0.52–0.74), and participants with ASD and co-occurring ADHD had greater swim levels regardless of Time than those without ADHD (B = 0.45, 95% CI = 0.05–0.84). Overall, iCan Swim is effective in improving the swim skills of children and teenagers with ASD.

Autistic Traits and Empathy in Children With Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder and Co-occurring Attention Deficit Hyperactivity Disorder/Autism Spectrum Disorder.

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD) are two of the most represented neurodevelopmental conditions in childhood. The diagnostic shift introduced by the DSM-5, allowing a combined diagnosis of ADHD and ASD, poses different clinical challenges related to diagnostic overshadowing, accuracy of clinical judgment and potential delay in an ASD diagnosis in children presenting with ADHD. Here we tried to disentangle the clinical phenotype and specificity of the two co-occurring conditions in relation to autism traits and empathy, by comparing children with ASD with and without comorbid ADHD with children presenting ADHD only and children with typical development. The child versions of the Autism Quotient (C-AQ) and Empathy Quotient (C-EQ) were administered to a total sample of 198 male children between 6 and 14 years old with age appropriate language skills and normal intelligence. Univariate analysis demonstrated no significant differences in the C-AQ total and subscale scores as well as the C-EQ between children with ASD and children with ASD + ADHD, while children with ADHD alone presented an intermediate phenotype between ASD and TD. Furthermore, a receiver operating characteristic (ROC) analysis was applied to discriminate among the different phenotypes. We found that the C-AQ and C-EQ were accurate at distinguishing with satisfactory reliability between: (a) ASD vs. non- ASD (N-ASD) groups comprising both ADHD and TD children (Area Under the Curve AUC 88% for C-AQ and 81% for C-EQ); (b) ASD and TD (AUC 92% for C-AQ and 95% for C-EQ); (c) ASD and ADHD (AUC 80% for C-AQ and 68% for C-EQ). Our data confirm the reliability of the C-AQ and C-EQ as behavioral markers to differentiate ASD (regardless of comorbid ADHD) from an ADHD condition and TD. Interestingly, in our sample an ADHD condition does not increase the severity of the clinical phenotype in terms of autism traits distribution and empathy, suggesting that the psychological measures detected by the two quantitative instruments are independent of ADHD traits. This evidence will contribute to the translational efforts in developing better tailored treatments and preventive strategies.

Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory.

Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.

'Just keep taking them, keep hoping they'll work': A qualitative study of adhering to medications for multimorbidity.

Compared to single diseases, health psychology reflects many areas of medical research by affording relatively less attention to the experiences of people self-managing multiple co-occurring conditions and, in particular, the experience of managing the associated complex medication regimens. This study aimed to explore the experience of self-managing multimorbidity among older adults, with a focus on medication adherence. A qualitative approach was taken, using individual semi-structured interviews. Sixteen people with complex multimorbidity aged 65 years or older were recruited through general practice to take part in semi-structured interviews. Data were analysed following guidelines for reflexive thematic analysis. Two themes were generated, with each theme comprising three subthemes. Theme one represents the amplified burden arising from multimorbidity that leads to unique challenges for self-management, such as integrating multiple medications into daily life, accumulating new symptoms and treatments, and managing evolving medication regimens. Theme two represents pathways towards relief that reduce this burden and promote medication adherence, such as prioritising certain conditions and treatments, resigning to the need for multiple medications, and identifying and utilising adherence supports. We identified factors relevant to medication adherence for older adults with multimorbidity that go beyond single-disease influences and account for the amplified experience of chronic disease that multimorbidity can produce for some people. While evidence of single-disease influences remains fundamental to tailoring behavioural interventions to individuals, the impact of multimorbidity on medication adherence should be accounted for in research and practice.

Discovering disease\u2013disease associations using electronic health records in The Guideline Advantage (TGA) dataset

Certain diseases have strong comorbidity and co-occurrence with others. Understanding disease–disease associations can potentially increase awareness among healthcare providers of co-occurring conditions and facilitate earlier diagnosis, prevention and treatment of patients. In this study, we utilized the valuable and large The Guideline Advantage (TGA) longitudinal electronic health record dataset from 70 outpatient clinics across the United States to investigate potential disease–disease associations. Specifically, the most prevalent 50 disease diagnoses were manually identified from 165,732 unique patients. To investigate the co-occurrence or dependency associations among the 50 diseases, the categorical disease terms were first mapped into numerical vectors based on disease co-occurrence frequency in individual patients using the Word2Vec approach. Then the novel and interesting disease association clusters were identified using correlation and clustering analyses in the numerical space. Moreover, the distribution of time delay (Δt) between pair-wise strongly associated diseases (correlation coefficients ≥ 0.5) were calculated to show the dependency among the diseases. The results can indicate the risk of disease comorbidity and complications, and facilitate disease prevention and optimal treatment decision-making.

Association of Metabolic Syndrome with Sensorineural Hearing Loss

The prevalence of sensorineural hearing loss has increased along with increases in life expectancy and exposure to noisy environments. Metabolic syndrome (MetS) is a cluster of co-occurring conditions that increase the risk of heart disease, stroke and type 2 diabetes, along with other conditions that affect the blood vessels. Components of MetS include insulin resistance, body weight, lipid concentration, blood pressure, and blood glucose concentration, as well as other features of insulin resistance such as microalbuminuria. MetS has become a major public health problem affecting 20–30% of the global population. This study utilized health examination to investigate whether metabolic syndrome was related to hearing loss. Methods: A total of 94,223 people who underwent health check-ups, including hearing tests, from January 2010 to December 2020 were evaluated. Subjects were divided into two groups, with and without metabolic syndrome. In addition, Scopus, Embase, PubMed, and Cochrane libraries were systematically searched, using keywords such as “hearing loss” and “metabolic syndrome”, for studies that evaluated the relationship between the two. Results: Of the 94,223 subjects, 11,414 (12.1%) had metabolic syndrome and 82,809 did not. The mean ages of subjects in the two groups were 46.1 and 43.9 years, respectively. A comparison of hearing thresholds by age in subjects with and without metabolic syndrome showed that the average pure tone hearing thresholds were significantly higher in subjects with metabolic syndrome than in subjects without it in all age groups. (p < 0.001) Rates of hearing loss in subjects with 0, 1, 2, 3, 4, and 5 of the components of metabolic syndrome were 7.9%, 12.1%, 13.8%, 13.8%, 15.5% and 16.3%, respectively, indicating a significant association between the number of components of metabolic syndrome and the rate of hearing loss (p < 0.0001). The odds ratio of hearing loss was significantly higher in subjects with four components of metabolic syndrome: waist circumference, blood pressure, and triglyceride and fasting blood sugar concentrations (p < 0.0001). Conclusions: The number of components of the metabolic syndrome is positively correlated with the rate of sensorineural hearing loss.

Examining Associations Between Amygdala Volumes and Anxiety Symptoms in Autism Spectrum Disorder

BackgroundAnxiety is one of the most common co-occurring conditions in people with autism spectrum disorder. The amygdala has been identified as being associated with anxiety in populations with and without autism, yet associations in autism were based on relatively small or developmentally constrained samples, leaving questions as to whether these results hold at different developmental ages and in a larger, more robust sample. MethodsStructural neuroimaging and parent report of anxiety symptoms of children ages 5–13 years with (n = 123) and without (n = 171) a diagnosis of autism were collected from the University of Maryland and three sites from the Autism Brain Imaging Data Exchange. Standardized residuals for bilateral amygdala volumes were computed adjusting for site, hemispheric volumes, and covariates (age, sex, Full Scale IQ). ResultsClinically significant anxiety symptoms did not differentiate amygdala volumes between groups (i.e., autism and anxiety, autism without anxiety, without autism or anxiety). No significant association between left or right amygdala volumes and anxiety scores was observed among the sample of individuals with autism. Meta-analytic and Bayes factor estimations provided additional support for the null hypothesis. Age, sex, and autism severity did not moderate associations between anxiety and amygdala volumes. ConclusionsNo relation between amygdala volumes and anxiety symptoms in children with autism was observed in the largest sample to investigate this question. We discuss directions for future research to determine whether additional factors including age or method of assessment may contribute to this lack of association.

Trends and Disparities in Treatment for Co-occurring Major Depression and Substance Use Disorders Among US Adolescents From 2011 to 2019

Major depression and substance use disorders (SUD) commonly co-occur among adolescents, yet little is known about treatment use among adolescents with both conditions. Given the reciprocal influence of these conditions on each other and low prevalence of treatment overall, current information on quantification and trends in treatment of co-occurring depression and SUD is critical toward assessing how the field is performing in reaching youth in need of these services, and among youth with sociodemographic risk factors. To examine temporal trends and sociodemographic disparities in the treatment of co-occurring major depression and SUD among US adolescents. This survey study used publicly available data for adolescents aged 12 to 17 years from the annual cross-sectional surveys of the National Survey on Drug Use and Health from 2011 to 2019 to assess co-occurrence of major depressive episodes (MDE) and SUD through time and prevalence of treatment for either or both of these conditions. Data were analyzed between October 2020 and February 2021. Survey years, adolescent age, gender, race and ethnicity, type of insurance, annual household income, family structure, and residential stability. Presence and treatment of co-occurring 12-month MDE and SUD. In total, 136 262 adolescents participated in the 2011 to 2019 surveys, among whom 69 584 (51.1%) were boys and 66 678 (49.0%) were girls, 46 548 (34.1%) were aged 16 to 17 years, and 18 173 (13.8%) were Black, 28 687 (23.2%) were Hispanic, and 74 512 (53.6%) were White. From 2011 to 2019, the annual prevalence of co-occurring MDE and SUD remained stable, at between 1.4% and 1.7%. Among adolescents with co-occurring MDE and SUD, the prevalence of treatment use for MDE only increased significantly from 28.5% in 2011 to 42.5% in 2019 (odds ratio [OR], 1.07; 95% CI, 1.02-1.11; P = .005), whereas the prevalence of treatment use for SUD only decreased from 4.8% to 1.5% (OR, 0.92; 95% CI, 0.85-0.99; P = .04). Overall, the prevalence of treatment use for both conditions fluctuated between 4.5% and 11.6%, without a significant linear trend over time (OR, 0.95; 95% CI, 0.87-1.03; P = .24). Extensive disparities in treatment use were found among boys for SUD and both conditions, older adolescents for MDE, Hispanic adolescents for co-occurring conditions (adjusted OR, 0.52; 95% CI, 0.27-0.98; P = .04), and Asian, Native Hawaiian, or Pacific Islander adolescents for MDE (adjusted OR, 0.24; 95% CI, 0.10-0.58; P = .002) and co-occurring conditions (adjusted OR, 0.04; 95% CI, 0.01-0.33; P = .003). Moving households 3 or more times in the past 12 months was associated with higher odds that adolescents received treatment for both conditions (adjusted OR, 2.52; 95% CI, 1.26-5.05; P = .009). This survey study found that from 2011 to 2019, less than 12% of adolescents with major depression and SUD received treatment for both conditions from 2011 to 2019. Findings from this study call for expanded service provision for adolescents with co-occurring conditions, improved coordination between service delivery systems, and enhanced policy and funding support for adolescents with unmet treatment needs.

The long-term mental health outcome of adolescent with depression and alcohol abuse comorbidity

Abstract Background Alcohol abuse often co-occurs with adolescent depression and about 1-2% suffer from the dual diagnosis in adolescence. This group is often undertreated or receive inadequate treatment for either of the conditions. Both conditions affect the developing brain and poor long-term outcome might be a potential risk. Yet, long-term follow-up studies are scarce. The aim of this study was to analyse if adolescent depression and alcohol abuse predict poorer mental health in adulthood compared to individuals without either or both conditions. Methods A community-based sample of individuals with adolescent depression in 1991-93 and matched non-depressed peers were followed up using a structured diagnostic interview after 15 years. The participation rate was 65% (depressed n = 227; non-depressed controls n = 155). Information on alcohol abuse in adolescence was collected at baseline with a structured interview. The outcome was mental disorders between the ages 19-31 years; information on depression and alcohol abuse was collected at the follow-up with a structured diagnostic interview. The statistical method used was binary logistic regression. Results Adolescents with depression and alcohol abuse had an excess risk of recurrence of depression (OR 2.12, p &amp;lt; 0.05) and alcohol abuse (OR 6.72, p &amp;lt; 0.01) in adulthood, compared with adolescents with depression only, even when adjusted for confounders. Adolescents with alcohol abuse only had not significantly worse long-term outcome compared with their healthy peers. Conclusions The co-occurrence of depression and alcohol abuse in adolescence is associated with long-lasting health consequences compared to either condition alone. This finding indicates that there is a need to prioritize this group of patients that is at risk of suboptimal treatment, and to further develop effective treatment adjusted to the co-occurring condition. Key messages The co-occurrence of adolescent depression and alcohol abuse has long lasting mental health consequences compared to either condition alone. Improved treatment methods are important for this group of adolescents.

Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems.

IntroductionPragmatic clinical trials (PCTs) can overcome implementation challenges for bringing evidence‐based therapies to people living with pain and co‐occurring conditions, providing actionable information for patients, providers, health systems, and policy makers. All studies, including those conducted within health systems that have a history of advancing equitable care, should make efforts to address justice and equity.MethodsDrawing from collective experience within pragmatic pain clinical trials networks, and synthesizing relevant literature, our multidisciplinary working group examined challenges related to integrating justice and equity into pragmatic pain management research conducted in large, integrated health systems. Our analysis draws from military and veteran health system contexts but offers strategies to consider throughout the lifecycle of pragmatic research more widely.ResultsWe found that PCTs present a unique opportunity to address major influences on health inequities by occupying a space between research, healthcare delivery, and the complexities of everyday life. We highlight key challenges that require attention to support complementary advancement of justice and equity via pragmatic research, offering several strategies that can be pursued.ConclusionsEfforts are needed to engage diverse stakeholders broadly and creatively in PCTs, such as through dedicated health equity working groups and other collaborative relationships with stakeholders, to support robust and inclusive approaches to research design and implementation across study settings. These considerations, while essential to pain management research, offer important opportunities toward achieving more equitable healthcare and health systems to benefit people living with pain and co‐occurring conditions.

Do Online Gambling Products Require Traditional Therapy for Gambling Disorder to Change? Evidence from Focus Group Interviews with Mental Health Professionals Treating Online Gamblers

Online gambling has significantly altered the situational and structural characteristics of gambling products, to the extent that online gamblers might be substantially different from traditional offline gamblers. A growing body of literature has identified the evolving features of online gambling and the individuals who engage in it. However, beyond understanding the individual characteristics of this subgroup, relatively less effort has been made to examine whether existing cognitive-behavioural therapy (CBT) approaches are still entirely relevant for online problem gamblers, or whether changes are needed to adapt according to gambling mode of access. To understand what kind of challenges online gambling poses to mental health professionals dealing with disordered gamblers, four focus groups comprising 28 Spanish participants were carried out. All the treatment providers had ongoing experience with online gamblers undergoing treatment, and included clinical psychologists, mental health social workers, and a medical doctor. The data were examined using thematic analysis. The analysis identified five main themes that characterised online gamblers: (1) being of younger age, (2) lack of conflicts at home and at work/educational centre, rarely presenting violent or aggressive behaviour, (3) gambling disorder only being identified by overdue debt, (4) co-occurring conditions with technology-related abuse rather than other substance-related addictions, and (5) skill-based gambling. The study highlights mental health workers’ perceived insecurities about how to best treat online gamblers, and discusses the specific characteristics that CBT for gambling disorder might need to incorporate to adjust for this particular group of gamblers.

Correlates of obesity in adolescents with and without autism spectrum disorder: The 2017–2018 National Survey of Children's Health

BackgroundThe prevalence of autism spectrum disorder (ASD) and childhood obesity are increasing, and youth with ASD are at an increased risk of obesity compared to typically developing youth. Specific obesity risk factors in adolescents with ASD remain poorly understood. ObjectiveThis study examined correlates of obesity among adolescents with and without ASD using extant 2017–2018 National Survey of Children's Health (NSCH) data. MethodsThis cross-sectional study examined the co-occurrence of obesity among US adolescents with ASD aged 10–17 years compared to those without ASD, adjusting for sociodemographic characteristics, co-occurring conditions, and relevant covariates, using 2017–2018 NSCH data. Multiple logistic regression was used to compare the odds of obesity among children with mild ASD, moderate/severe ASD, and without ASD. ResultsOdds of obesity were higher in adolescents with ASD compared to adolescents without ASD (cOR 1.9, CI 1.3–2.7). In the adjusted model, the odds of obesity were not significantly higher in those with mild or moderate/severe ASD compared to those without ASD. Odds of obesity were higher for all adolescents who were Hispanic or Black, as well as those with lower household income or with one or more co-occurring conditions. ConclusionsThe association between obesity and ASD in this study highlights the need for greater attention to nutrition, physical activity, and co-occurring conditions among adolescents with ASD. Effective interventions to curtail the risks among racial/ethnic minority adolescents and adolescents with lower household income are needed. Further research is needed to examine additional factors associated with obesity in adolescents with ASD, including family, community, organizational, and policy factors.