Mental Health Treatment Settings Research Articles

"I'm not alone": Women's experiences of recovery oriented occupational therapy groups following depression.

Occupational therapy groups have been carried out as interventions in mental health settings across a variety of populations. Limited research explores the lived experience of individuals with depression following participation in recovery oriented occupational therapy groups. To better understand how recovery oriented occupational therapy groups shape participants' personal experience of daily life, including recovery. Five individuals who had previously completed at least one recovery oriented occupational therapy group each participated in two in-depth semi-structured interviews. Analyses of the transcripts were completed using interpretative phenomenological analysis (IPA). Participants' experiences of the recovery oriented occupational therapy groups ranged from positive to negative, with variable impacts on their lived experiences. Two major themes emerged: (a) participants' perception of "normal" and (b) navigation of meaningful participation. Increased understanding of what aspects of recovery oriented occupational therapy groups are meaningful to individuals with depression can help support their personal recovery process.

Bed Tracking Systems: Do They Help Address Challenges in Finding Available Inpatient Beds?

Locating open beds in hospital and residential mental health and substance use disorder treatment settings has been an ongoing challenge in the United States. The inability to find open beds has contributed to long emergency department wait times and missed opportunities to engage patients in treatment. Increasingly, states are creating online bed tracking systems to improve access to timely information about bed availability. This study aimed to document how states are implementing bed tracking systems, their successes and challenges, and lessons learned. A review was conducted of the published and gray literature available between 2008 and 2018, and 13 interviews were conducted with 18 stakeholders in five states (Connecticut, Iowa, Kansas, Massachusetts, and Virginia). The authors identified 17 states with bed tracking systems, of which five make information available to consumers. Most interviewees reported that the bed tracking systems were improving the ability of providers and consumers to more readily locate openings. Challenges identified included that some hospitals will not participate in bed registries, data on bed availability is sometimes not timely enough, bed registries do not provide enough detail on whether the facility is capable of meeting a particular patient's needs, providers have not been coached to use the bed registry system and continue existing practices, and states that provide information to the public have not publicized the registry's existence. Bed tracking systems offer promise, but more needs to be done to understand how to realize their potential and to more widely implement lessons learned.

The development of an innovative, theory-driven, psychoeducational HIV/STI prevention intervention for heterosexually active black adolescents with mental illnesses

ABSTRACTSexually transmitted infections (STIs), including human immunodeficiency virus (HIV), continue to disproportionately affect Black adolescents. Those experiencing the psychological sequelae of mental illnesses are at increased risk. Here, we outline the development of an HIV/STI prevention intervention for heterosexually active Black adolescents with mental illnesses. This research was guided by a psychosocial expansion of the Theory of Planned Behavior, nested within a broader social determinants of health framework. A youth community advisory board provided study oversight. Heterosexually active Black adolescents aged 14–17 were recruited from community-based outpatient mental health providers for focus groups, surveys and two ‘dress rehearsals’ of the intervention protocol (N = 68). The qualitative and quantitative findings indicated that knowledge, attitudes and skills related to consistent condom use, reduced number of sexual partners, routine HIV/STI testing, abstinence and emotion regulation were important areas to target. These elicitation data provided insight into the context of HIV/STI risk for the study population, and were used to develop the intervention content. ‘Project GOLD: We are Kings and Queens’ was designed to be delivered over two days (3 hours per day), with eight, 45-min modules. The activities address behaviors, as well as cognitive, emotional, psychological and social processes associated with HIV/STI risk. Alongside evidence-based HIV/STI prevention strategies (e.g. sexual partner communication skills), the intervention activities are rooted in principles of Cognitive Behavioral Therapy. Dress rehearsal participants were in favor of the intervention and provided feedback on activity length, gender and cultural relevance and strategies to sustain attention; this information was used to finalize the curriculum. In partnership with the community, we developed a theoretically driven, gender and culturally relevant, developmentally and psychologically appropriate HIV/STI prevention program. Our ultimate goal is to standardize sexual health assessment and intervention in outpatient mental health treatment settings to meet sexual health needs in this underserved population.

Multistakeholder Etiological Explanation Agreement and Adolescent/Parent Treatment Engagement

Client–therapist consensus has been hypothesized to be an important element of culturally competent care. However, little is known about the relationship between explanatory model agreement and treatment engagement, particularly for services involving adolescents, where both parent and youth perspectives may need to be considered. This longitudinal study collected youth, parent, and therapist survey data on etiological beliefs as well as therapist-rated treatment engagement related to a culturally diverse sample of 285 outpatient mental health service-using youth (aged 12–18, M = 14.06 at Time 1 interview; 40% female). Youth–therapist and parent–therapist agreement on beliefs about the etiology of the youth’s mental health problems were examined in relationship to later treatment engagement. Although parent–therapist agreement was unrelated to parent engagement, youth–therapist coendorsement of etiological beliefs predicted overall youth treatment engagement. In addition, youth–therapist agreement significantly predicted specific aspects of youth engagement: client–therapist interaction, communication/openness, and client’s perceived usefulness of treatment. Results speak to the importance of agreement between therapist and youth upon key issues related to the youth’s problems in mental health treatment settings and support facilitation of consensus as a component of culturally competent care. Differences between findings for youth and parents suggest that therapeutic relationships may vary for different stakeholders, indicating a need to consider individual perspectives and contributions separately.

Situating adult attention-deficit/hyperactivity disorder in the externalizing spectrum: Etiological, diagnostic, and treatment considerations.

Adult attention-deficit/hyperactivity disorder (ADHD) has a population prevalence of 5%. However, its prevalence is much higher in mental health and substance use treatment settings. It is associated with significant physical and psychiatric morbidity, as well as social, occupational, and legal consequences. Adult ADHD is considered to be a part of the externalizing spectrum with which it shares both homotypic comorbidity and heterotypic continuity across the lifespan. This is attributable to a shared genetic basis, which interacts with environmental risk factors such as nutritional deficiencies and psychosocial adversity to bring about epigenetic changes. This is seen to result in a lag in brain maturation particularly in the areas of the brain related to executive functioning (top-down regulation) such as the prefrontal and cingulate cortices. This delay when coupled with impairments in reward processing, leads to a preference for immediate small rewards and is common to externalizing disorders. Adult ADHD is increasingly understood to not merely be associated with the classically described symptoms of hyperactivity, impulsivity and inattention, but also issues with motivation, emotional recognition and regulation, excessive mind wandering, and behavioral self-regulation. These symptoms are also observed in other disorders which overlap with the externalizing spectrum such as oppositional defiant disorder, conduct disorder, antisocial and borderline personality disorder. It is therefore important to develop both broad-based and specific interventions to be able to target these deficits which can reduce the burden and improve outcomes.

Measuring the Impact of Pastoral Services on Patients in a Private Psychiatric Hospital

This study explores the impact of pastoral care interventions on the mental and emotional health of inpatients at a private psychiatric hospital in Sydney. A total of 99 patients completed study questionnaires over a 3-month period. Feedback for the service was overwhelmingly positive, with the vast majority of patients reporting benefits during and after their meetings, regardless of their religious beliefs. Almost 88% of patients reported a lessening of anxiety after their meetings with pastoral care practitioners, with 85% suggesting that their interactions with the pastoral team had a significant and positive impact on their mental health. These findings were contextualized further with free text responses from respondents. The study results clearly demonstrate the importance of the pastoral services interventions in mental health settings.

Practice-Based Evidence for Effective Music-Making Interventions in Mental Health Settings

Abstract Date Presented 4/20/2018 In this study, an expert panel reached consensus on effective strategies for music-making interventions in mental health settings. Findings resulted in the creation of guidelines that occupational therapy practitioners with no musical training can use to deliver effective, meaningful music-making interventions. Primary Author and Speaker: James Whiton Contributing Authors: Joanna Cosbey

Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study.

BackgroundThe increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data.ObjectiveThe aim of this study was to gain an understanding of patients’ motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit?MethodsWe conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis.ResultsWe identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship.ConclusionsTo integrate wearable data into mental health treatment programs, it is important to understand the patient’s perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

Building Behavioral Health Homes: Clinician and Staff Perspectives on Creating Integrated Care Teams.

Adults with serious mental illness and substance use disorders have elevated risk of mortality and higher healthcare costs compared to the general population. As these disparities have been linked to poor management of co-occurring chronic conditions in primary care, the behavioral health setting may be a preferred setting for routine medical screening and treatment. This qualitative study describes early stages of integrating care teams in emerging medical homes based in mental health and addiction treatment settings. Clinicians and staff from ten agencies engaged in the Behavioral Health Home Learning Collaborative participated in qualitative interviews exploring local definitions of "behavioral health home" and initial barriers and facilitators to integration. Facilitators included clear staff roles, flexible scheduling, and interdisciplinary huddles and staff trainings. Challenges included workforce, limited use of electronic health records, and differing professional cultures. Participants advocated for new workflows and payment structures to accommodate scheduling demands and holistic case management.

Perceived provider stigma as a predictor of mental health service users' internalized stigma and disempowerment

Despite increasing awareness of stigma from mental health service providers as a barrier to recovery, little research has directly examined how it might influence the service users’ self-perceptions and treatment experience. The present study examined the association of service users’ perceived provider stigma with their experience of internalized stigma and disempowerment, two psychosocial constructs known to hinder recovery. Mental health service users (N = 350) completed questionnaires assessing perceived stigma from mental health service providers, including perceptions of negative affective reactions towards individual users and desired social distance towards people with mental illnesses across various life domains, internalized stigma, and disempowerment (i.e., diminished self-efficacy and mastery) in mental health treatment settings. Structural equation modeling showed that both perceived negative affective reactions and perceived social distance were positively associated with disempowerment. Furthermore, these associations were significantly mediated by internalized stigma. These findings illuminate how perceived stigma from providers can “get under the skin” of mental health service users and contribute to their overall sense of disempowerment in mental health settings. They also highlight the need for future stigma reduction interventions to specifically target the attitudes and beliefs held by mental health professionals.

Mammography Among Women With Severe Mental Illness: Exploring Disparities Through a Large Retrospective Cohort Study

This study examined mammogram screening rates among women with severe mental illness by using a socioecological framework. Because it has been shown that people with severe mental illness receive less preventive health care overall, the analysis included psychosocial predictors of mammogram screening rates in a cohort of women with severe mental illness. This retrospective cohort study (N=14,651) used existing statewide data for women ages 48-67 in California with Medicaid insurance who received treatment in the specialty mental health care system. The primary outcome of interest was evidence of breast cancer screening via mammogram. The associations of each predictor of interest with mammogram screening were evaluated by using Poisson models with robust standard errors. Across all demographic and diagnostic categories, rates of breast cancer screening in this cohort of women with severe mental illness fell below the national average. Only 26.3% (3,859/14,651) of women in the cohort received breast cancer screening in the past year. This study replicated previous findings that women with schizophrenia spectrum disorder and those with a comorbid substance use disorder are less likely to receive screening than those with other types of mental illness. In this cohort of women with severe mental illness, evidence of nonpsychiatric health care utilization was strongly associated with breast cancer screening (adjusted risk ratio=3.30, 95% confidence interval=2.61-4.16, p<.001). The findings can inform efforts to improve breast cancer screening among women with severe mental illness, such as targeted outreach to population subsets and colocation of primary care services in mental health treatment settings.

Therapeutic Social Control of People with Serious Mental Illness: An Empirical Verification and Extension of Theory

Mental health services and psychiatric professional values have shifted in the past several decades toward a model of client autonomy and informed consent, at least in principle. However, it is unclear how much has changed in practice, particularly in cases where client behavior poses ethical challenges for clinicians. Drawing on the case of clients’ sexual behavior and contraception use, we examine whether sociological theories of “soft” coercion remain relevant (e.g., therapeutic social control; Horwitz 1982) in contemporary mental health treatment settings. Using structured interview data from 98 men and women with serious mental illness (SMI), we explore client experiences of choice, coercion, and the spaces that lie in between. Patterns in our data confirm Horwitz’s (1982) theory of therapeutic social control but also suggest directions for updating and extending it. Specifically, we identify four strategies used to influence client behavior: coercion, enabling, education, and conciliation. We find that most clients’ experiences reflect elements of ambiguous or limited autonomy, wherein compliance is achieved by invoking therapeutic goals. However, women with SMI disproportionately report experiencing intense persuasion and direct use or threat of force. We argue that it is critical to consider how ostensibly noncoercive and value-free interventions nonetheless reflect the goals and norms of dominant groups.

Embedding exercise interventions as routine mental health care: implementation strategies in residential, inpatient and community settings.

Evaluation of physical activity (PA) programs among populations with severe mental illness (SMI) has predominately focused on efficacy and therapeutic benefits. There is now strong evidence to support the benefits of PA in people with SMI. What remains is a gap in the implementation of pragmatic and sustainable PA interventions in mental-health settings. The current paper provides examples of interventions that have been successfully implemented in Australian settings, identifies key components of successful PA interventions and outlines practical strategies that can assist with widespread implementation of PA interventions in mental-health settings. There is an emergence of PA interventions being imbedded within a variety of mental-health settings. These interventions vary in terms of mode and intensity of service delivery. Yet, all aim to increase PA and reduce sedentary behaviour. Adopting the identified strategies may help facilitate successful implementation and increase access to PA interventions for mental-health service users.

A Prospective Study of Racial and Ethnic Variation in VA Psychotherapy Services for PTSD

To determine whether there are racial or ethnic disparities in receipt of U.S. Department of Veterans Affairs (VA) psychotherapy services for veterans with posttraumatic stress disorder (PTSD), the authors examined the odds of receipt of any psychotherapy and of individual psychotherapy among self-identified racial and ethnic groups for six months after individuals were diagnosed as having PTSD. Data were from a national prospective cohort study of 6,884 veterans with PTSD. Patients with no mental health care in the prior year were surveyed immediately following receipt of a PTSD diagnosis. VA databases were used to determine mental health service use. Analyses controlled for treatment need, access to services, and treatment beliefs. Among veterans with PTSD initially seen in VA mental health treatment settings, Latino veterans were less likely than white veterans to receive any psychotherapy, after the analyses controlled for treatment need, access, and beliefs. Among those initially seen in mental health settings who received some psychotherapy services, Latinos, African Americans, and Asian/Pacific Islanders were less likely than white veterans to receive any individual therapy. These racial-ethnic differences in psychotherapy receipt were due to factors occurring between VA health care networks as well as factors occurring within networks. Drivers of disparities differed across racial and ethnic groups. Inequity in psychotherapy services for some veterans from racial and ethnic minority groups with PTSD were due to factors operating both within and between health care networks.

Factors Supporting the Employment of Young Adult Peer Providers: Perspectives of Peers and Supervisors.

Peer providers are a promising practice for transition-age youth community mental health treatment engagement and support, yet little is known about the experience of being a young adult peer provider or what helps to make an individual in this role successful. Utilizing a capital theory lens, this study uses data from focus groups (two with young adult peer providers and two with their supervisors) to examine facilitators of young adult peer provider success in community mental health treatment settings. Eight factors were identified as critical to young adult peer provider on-the-job success: persistence, job confidence, resilience, job training, skilled communications with colleagues, regular and individualized supervision, support from colleagues, and family support. Findings suggest that young adult peer providers may benefit immensely from an agency level focus on fostering social organizational capital as well as more individualized efforts to increase cultural, social, and psychological capital through training and supervision.

Admission to Psychiatric Residential Treatment Facilities among Youth from Families Investigated for Maltreatment

This study uses large, longitudinal, multisector administrative datasets of families investigated by child welfare services for maltreatment to explore which children are more likely to later enter psychiatric residential treatment facilities. This question is grounded in a pressing interest to understand these costly, highly restrictive mental health treatment settings. We use statewide data from one Southeastern state linked from multiple systems (child welfare services, income maintenance, and Medicaid). We use Cox regression analyses to develop models predicting psychiatric residential treatment facilities entry among children 5–17 years, whose families were investigated for maltreatment between 2003 and 2012 (n = 182,676). Findings show children from these families who enter foster care have a heightened risk for psychiatric residential treatment facilities entry (hazard ratio = 11.63), after controlling for other factors. Study findings build on a body of research underscoring the importance of the overlap of child welfare and mental health systems to child well-being.

Update on Smoking Cessation: E-Cigarettes, Emerging Tobacco Products Trends, and New Technology-Based Interventions.

Tobacco use disorders (TUDs) continue to be overly represented in patients treated in mental health and addiction treatment settings. It is the most common substance use disorder (SUD) and the leading cause of health disparities and increased morbidity/mortality amongst individuals with a psychiatric disorder. There are seven Food and Drug Administration (FDA) approved medications and excellent evidence-based psychosocial treatment interventions to use in TUD treatment. In the past few years, access to and use of other tobacco or nicotine emerging products are on the rise, including the highly publicized electronic cigarette (e-cigarette). There has also been a proliferation of technology-based interventions to support standard TUD treatment, including mobile apps and web-based interventions. These tools are easily accessed 24/7 to support outpatient treatment. This update will review the emerging products and counter-measure intervention technologies, including how clinicians can integrate these tools and other community-based resources into their practice.

On the Challenge of Maladaptive and Impulsive Aggression in the Clinical Treatment Setting.

[Author Affiliation]Daniel F. Connor. Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut.Address correspondence to: Daniel F. Connor, MD, Department of Psychiatry/MC 1410, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-1410, E-mail: dconnor@uchc.eduClinicians working in the mental health setting have long been challenged by children and adolescents with many different types of psychiatric disorders who are often referred for treatment because of frequent, intense, severe, and maladaptive impulsive aggression. This type of clinical presentation occurs commonly in every type of pediatric mental health treatment setting: Outpatient, inpatient, residential, and/or partial hospitalization. Impulsive aggression is often chronic, but waxes and wanes in response to multiple shifting internal and external factors, and may be extremely stressful for parents and other family members. Although normative in the young toddler and preschooler (the terrible twos), with development, the child begins to achieve emotional and behavioral competence and regulation such that by school entry aggression becomes increasingly verbal and not physical. With school entry, aggression is increasingly associated with understandable and recognizable antecedents, goals, and objectives.Maladaptive aggression is defined as behavior with intent to harm another person; is elicited by minimal or routine environmental cues; is less linked to recognizable and understandable social goals; is characterized by its explosive nature, high frequency rate, and severe intensity; and is associated with significant functional impairment for the child and the child's family (Connor 2002). Impulsive aggression is behavior that occurs rapidly without a delay (a short fuse) that would otherwise allow the child to consider an alternative and more adaptive response to frustration or perceived threat (Jensen et al. 2007). Impulsive aggression is driven by low frustration tolerance or fear of threat (Dodge and Coie 1987).Maladaptive and impulsive aggression in psychiatrically referred children and adolescents is common, denotes illness severity not illness specificity (Connor and McLaughlin 2006), and represents a significant public health problem with high societal costs (Foster and Jones 2005). Aggression is a major cause of referral to outpatient and inpatient child and adolescent psychiatry services (Bambauer and Connor 2005) and emergency psychiatric services (Gabel and Shindledecker 1991), predicts longer stays in psychiatric hospitals, and predicts rehospitalization in youth discharged from inpatient settings (Blader 2004). It is associated with child and adolescent psychiatry staff injury (Cunningham et al. 2003), is associated with off-label pediatric antipsychotic use (Olfson et al. 2015), and predicts combined pharmacotherapy (polypharmacy) use independently of diagnosis in referred children (Connor et al. 1997). Youth with moderate to severe impulsive aggression with and without comorbid attention-deficit/hyperactivity disorder (ADHD) are a major challenge for clinicians working in the clinical setting, as few evidence-based treatments are currently available that address these issues.Progress in developing effective treatments for impulsive aggression has been slowed by the multiple ways of clinically identifying and characterizing the aggressive child. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM 5) diagnoses such as oppositional defiant disorder (temper tantrums), conduct disorder (physical aggression), bipolar disorder (aggression and irritability), intermittent explosive disorder (explosive aggression), and/or disruptive mood dysregulation disorder (irritability and temper tantrums) all may have aggression as part of their symptom criteria, yet are nosologically construed as separate and non-overlapping psychiatric diagnoses (American Psychiatric Association 2013). …

Smoking Cessation in Individuals With Serious Mental Illness: A Randomized Controlled Trial of Two Psychosocial Interventions

Objective: Smoking among individuals with serious mental illness is a critical public health problem. Although guidelines recommend bupropion for these smokers, many do not want to use medications for smoking cessation, express ambivalence about identifying a “quit date,” and do not have access to behavioral smoking cessation services integrated with mental health care. Methods: Individuals with serious mental illness who smoked 10 or more cigarettes per day (N = 178) were randomized to either a multifaceted behavioral group intervention or a supportive group intervention, both of which were integrated within outpatient mental health services at three VA medical centers. Participants attended twice-weekly meetings for 12 weeks, provided information on their smoking at each meeting, and completed baseline and post-treatment assessments conducted by an assessor who was blind to condition. Primary outcomes collected at post-treatment included 1-week abstinence, number of cigarettes smoked per day during the last week, and number of quit attempts during the treatment period. Outcomes examined for a subset of participants who attended at least one intervention meeting (n = 152) included smoking abstinence for 1-, 2-, and 4-week blocks during the treatment period. Analyses conducted on those participants who attended three or more intervention meetings (n = 127) included time to 50% reduction in the number of cigarettes smoked and time to first quit attempt. Results: Sixteen participants achieved abstinence (11.8%), smoking quantity was significantly reduced (baseline M = 15.2, SD = 9.8 to post-treatment M = 7.5, SD = 7.7, p <.0001), and most reported making a quit attempt (n = 88, 72.7%). There were no differences by study condition on any abstinence or reduction outcomes. Significant reductions in number of cigarettes smoked generally took place within the first two weeks; however, these reductions did not often translate into abstinence. Conclusions: Many participants reduced their smoking and sampled quitting during the study. Implementing smoking cessation services in mental health treatment settings is feasible and, if delivered in line with best practices, either a behavioral or a supportive approach can be helpful. Future research should examine ways to facilitate the transition from reduction to abstinence. This study was part of a clinical trial registered as NCT #00960375 at www.clinicaltrials.gov.

Racial disparities during admission to an academic psychiatric hospital in a large urban area

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).