Untreated Disorders Research Articles

0347 Sleep health education and a personalized smartphone application improve sleep and productivity and reduce healthcare utilization among employees: Results of a randomized clinical trial

Abstract Introduction Sleep deficiency and undiagnosed or untreated sleep disorders are pervasive among employed adults, yet are often ignored in the context of workplace health promotion. Smartphone applications (apps) are a promising, scalable approach to improving sleep among employees. We evaluated an online sleep education program followed by access to a mobile sleep training program, the dayzz app, that promotes healthy sleep, sleep disorders awareness and intervention. Methods In a sample of daytime employees affiliated with a large healthcare organization, we evaluated the intervention (sleep education at baseline plus access to the personalized app for up to 9 months) in a parallel group, randomized controlled trial. Participants were randomly assigned to either the experimental condition that received the intervention in months 1 through 9 or the control group that was assigned to receive the intervention in month 10. In a prespecified data analysis plan, the experimental and control groups were compared in months 1 through 9; no outcome data was collected thereafter. We collected data on employee sleep, workplace outcomes, and healthcare utilization, monthly throughout the study. Results The final cohort was comprised of 794 participants assigned to the experimental and 561 to the control condition. Those assigned to the experimental condition were more likely to maintain consistent sleep schedules (OR:1.40;95%CI:1.12-1.75) and less likely to experience fatigue and sleepiness (OR:1.30;95%CI:1.08-1.57). At the 9-month follow-up assessment, the experimental group reported significantly longer sleep duration than the control group on work (experimental: 7.20hrs; control: 6.99hrs, p=0.01) and free (experimental: 8.26hrs; control: 8.04hrs, p=0.03) nights. The odds of poor sleep quality at follow-up were lower in the experimental condition (OR:0.79,95%CI:0.63-0.98) as compared to control. Mean total dollars lost due to presenteeism was less among experimental compared to control participants (p=0.0001), corresponding to an average of $274 saved per person per month. Finally, participants in the experimental group were less likely to report mental health visits (p=0.01) and had a lower rate of overall healthcare utilization (p=0.03), compared to the control group. Conclusion Results from this randomized clinical trial demonstrate that a digital workplace sleep wellness program can be beneficial to both employees and employers, by improving employee sleep and fatigue, increasing work productivity, and reducing direct healthcare costs. Support (If Any) This study was funded by dayzz Live Well Ltd.

Postpartum Mood and Anxiety Disorders: A Lexicon of Metaphors.

Undiagnosed and untreated postpartum mental health disorders represent a silent health crisis. The aim of this paper was to develop a lexicon of metaphors women use to describe their postpartum mood and anxiety disorders to assist holistic nurses in recognizing as early as possible these struggling mothers. Mothers may not know the medical terminology to articulate their mental health problems and may turn to using metaphors. The metaphors included in this lexicon were obtained from the author's earlier qualitative studies of metaphors women used to describe their experiences of postpartum depression, postpartum panic disorder, and posttraumatic stress disorder due to traumatic childbirth. In this lexicon these metaphors are organized by these three mental health disorders and includes a table of definitions of each metaphor along with examples of the context of the metaphors represented by quotes from the mothers. Metaphors can be keys that open and unlock doors that stand between holistic nurses and their patients. Being attentive to metaphorical language women use to describe how they are feeling after giving birth can be an innovative approach holistic nurses can use to identify these vulnerable women and provide an opportunity to nurture and empower new mothers.

Why mental health service delivery needs to align alongside mainstream medical services.

There is significant individual human suffering and economic burden because of untreated mental health and substance use disorders. There is high psychiatric morbidity in primary and secondary medical care. At least one-fifth of patients attending primary care services in western countries pertain to mental health and one-third of patients attending general hospitals have a comorbid mental disorder. Patients with mental disorders have lower life expectancy than the general population due to various medical conditions and reduced access to physical healthcare. There is a suicide every 40 seconds and the vast majority of those who die by suicide have a diagnosable mental disorder. Despite this, most countries spend less than 2% of their health budgets on mental health. Effective treatments exist for mental disorders, however underfunding, poor integration of services, lack of trained health care professionals and stigma often prevent access to effective treatments. Stigma is a significant barrier to seeking help and receiving treatment. Geographical separation of mental health services from general hospital settings may be perpetuating the stigma of mental illness among the population. In this article, we review the key reasons why mental health services globally need to align with mainstream healthcare services and the longstanding reasons that necessitate the need to make mental health a public health priority.

Research on Mental Health Education Based on Obstetrics and Gynecology Nursing

To assess and holistically manage mental health sequelae and potential psychiatric comorbidities associated with obstetric and gynecological disorders, optimizing patient care, ensuring efficient use of limited resources, and improving health economic models are critical. Untreated mental health disorders are associated with severe obstetric and psychiatric sequelae and have long-term effects on neonatal and child outcomes. The purpose of this review is to describe the urgent need for mental health education among obstetricians and to present our vision for a set of concise, evidence-based, accessible digital educational materials designed to convey the core concepts of mental health in obstetric care.

Motherhood and Me (Mom-Me): The Development of an Acceptance-Based Group for Women with Postpartum Mood and Anxiety Symptoms.

Untreated postpartum mood and anxiety disorders (PMADs) place women and their families at risk for negative biopsychosocial sequelae. Innovative and tailored treatments are needed to address potential disruptions in maternal functioning. Third-wave cognitive–behavioral approaches, including acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT), hold promise for optimizing functioning given the focus on values-based living, rather than symptom reduction. Purpose: The purpose of this paper is to describe the development of an innovative psychotherapy group for women with symptoms of PMADs. Methods: This seven-session group, Motherhood and Me (Mom-Me), includes selected skills training from ACT, DBT, and Emotion-Centered Problem-Solving Therapy. Results: Mom-Me group sessions are described, and an outline of key information (session goals, content, and homework assignments) is provided to facilitate practical implementation. Conclusion: In line with third-wave approaches, this group was developed to enhance maternal functioning, which, in turn, may help women cope with psychological distress during the transition to motherhood.

Predictors of Mucocutaneous Disorders in HIV-infected Children in Port Harcourt, Southern Nigeria

Background: Unindentified and untreated mucocutaneous disorders can lead to adverse consequences among HIV-infected children. These include physical discomfort, disfigurement , loss of school attendance, social stigma , low self esteem and depression
 Aim: To determine the predictors of mucocutaneous disorders in HIV-infected children receiving care in two tertiary hospitals in Port Harcourt, Southern Nigeria.
 Place and Duration of Study: the study was conducted over a six month period at the Pediatric infectious diseases clinic of the University of Port Harcourt Teaching Hospital (UPTH) and Rivers State University Teaching Hospital (RSUTH) Port Harcourt.
 Materials and Methods: It was a cross sectional study involving 372 HIV-infected children. Study participants were recruited by simple random sampling. Diagnosis of mucocutaneous disorders was based on clinical findings and relevant laboratory investigations.
 Results: The prevalence of mucocutaneous disorders in the study subjects was 30.1% with Pruritic Papular Eruptions as the most occurring lesion. Factors predictive of the occurrence of mucocutaneous disorders in HIV-Infected-subjects included: low socio-economic status (p-value=0.048;AOR=1.81, 95% CI=1.01-3.24), sub-optimal adherence to HAART (p-value=0.008; AOR=2.72,95% CI=1.29-5.73), WHO clinical stages 3 and 4 (p-value=0.043;AOR=2.48,95% CI=1.03-5.97) and non viral suppression (p-value=0.0001; AOR=15.78, 95% CI=8.52-29.25).
 Conclusion: The presence of these factors in a HIV-infected child indicates a need for prompt evaluation for mucocutaneous lesions so as to limit morbidity and mortality from these disorders.

Our Continued Experience With Using Watchpat® (itamar Medical, Ltd.), Home Sleep Testing For The Diagnosis Of Sleep Apnea In Heart Failure And Orthotopic Heart Transplant Patients.

<h3>Introduction</h3> Untreated sleep disorders are well known to significantly increase risk of coronary artery disease (CAD), hypertension (HTN), obesity, diabetes (DM), anxiety and depression. Despite maximal medical therapy, approximately 50% of patients with heart failure (HF) have moderate-to-severe sleep apnea (SA). Moreover, obstructive sleep apnea (OSA) has also been described in cardiac transplant recipients (OHT) as a significant risk factor for late graft dysfunction, thus screening and diagnosis is critical^. Access to in-lab polysomnography (PSG) has been limited throughout the pandemic leading to more reliance on home sleep testing. WatchPAT® Home Sleep Testing (WPHST) has been validated to accurately detect both obstructive as well as central sleep apnea (CSA) in the general population yet there is limited data to date that support its use in advanced HF/OHT patients. <h3>Objective</h3> Herein we describe our prospective utilization of WPHST highlighting differences in sleep apnea patterns in our HF and OHT population. <h3>Methods</h3> This is a single center, prospective, observational analysis, beginning February 22, 2020 through April 7, 2021. 50 consecutive patients that screened positive on the STOP-BANG® sleep apnea screen questionnaire were consented and assigned to WPHST and analyzed for comorbidities, and SA patterns and severity. <h3>Results</h3> Of the 50 patients enrolled, 48 patients (n=38 HF and n=10 OHT) were included in the analysis (1 failed study in each arm). Baseline characteristics were equivalent; mean age of 60 years, BMI 28.6 kg/m2, and 75% were male. A high prevalence of co-morbid conditions included CAD 52%, DM 50% and HTN 98%, (fig 1). Central/Mixed Sleep apnea accounted for 10.4% of the total cohort. Apnea Hypopnea Index (AHI) was significantly greater in the HF patient cohort vs OHT (p=0.02). However, no statistical differences were noted in nocturnal 02 sat (p=0.49). REM% was lower in the OHT compared to the HF cohort (p=0.049). <h3>Conclusion</h3> : In this limited prospective study AHI was significantly higher in the HF cohort compared to OHT. More importantly, WPHST has contributed to greater access to sleep diagnostics for high-risk patient populations throughout the pandemic. Continued work on short- and long-term outcomes is warranted.

Multiple Pre-Treatment miRNAs Levels in Untreated Major Depressive Disorder Patients Predict Early Response to Antidepressants and Interact with Key Pathways.

Major depressive disorder (MDD) is a life-impairing disorder, and early successful treatment is important for a favorable prognosis. However, early response to antidepressants differs widely among individuals, and is difficult to predict pre-treatment. As miRNAs have been reported to play important roles in depression, identification of miRNAs associated with antidepressant treatment responses and their interacting genes and pathways will be beneficial in understanding the predictors and molecular mechanisms of depression treatment. This randomized control trial examined miRNAs correlated with the early therapeutic effect of selective serotonin reuptake inhibitors (SSRIs; paroxetine or sertraline) and mirtazapine monotherapy. Before medication, we comprehensively analyzed the miRNA expression of 92 depressed participants and identified genes and pathways interacting with miRNAs. A total of 228 miRNAs were significantly correlated with depressive symptoms improvements after 2 weeks of SSRIs treatment, with miR-483.5p showing the most robust correlation. These miRNAs are involved in 21 pathways, including TGF-β, glutamatergic synapse, long-term depression, and the mitogen-activated protein kinase (MAPK) signaling pathways. Using these miRNAs enabled us to predict SSRI response at week 2 with a 57% difference. This study shows that pre-treatment levels of miRNAs could be used to predict early responses to antidepressant administration, a knowledge of genes, and an identification of genes and pathways associated with the antidepressant response.

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis.

Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration. Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record. The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n=162), hepatology (n=45), or both (n=41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p=0.03) or depression (1.50, p=0.05) or who were younger (0.97, p=0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p=0.05), prior AUD treatment (9.92, p<0.0001), and a higher PHQ-2 depression score (2.85, p=0.004). We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Counseling Clients With Postpartum Posttraumatic Stress Disorder: A Feminist-Trauma Approach

Prevalence rates, risk factors, and impact of untreated postpartum posttraumatic stress disorder (PTSD) are well documented. Despite evidence suggesting that up to one third of women experience childbirth as traumatic, treatment recommendations remain scant. Given the call for a feminist approach to trauma and postpartum depression, we highlight a feminist-trauma approach to counseling clients with symptoms of postpartum PTSD, based on anti-oppressive feminist-trauma frameworks. A case study conceptualization of a woman experiencing traumatic stress following childbirth is presented to highlight supporting research, rationale, and ethical considerations.

Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers

This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs. This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means. Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years). Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.

History of the World Sleep Day

Background Sleep has also been cherished by society as a basic human need with a crucial importance for human health. People spend around one third of their lives sleeping. Nowadays, it has never been harder to achieve a restful sleep. When sleep is better understand, that will lessen the drawbacks of the different sleep disorders. Healthy sleep is important for maintaining physical and mental health in adult individuals. Sleep deprivation poses a significant risk for the individual and leads to psychological conditions, such as depression and anxiety. Several sleep disorders are known to the science. If breathing during sleep is not regular, a case of obstructive sleep apnea (OSA) may have been diagnosed. The World Sleep Day is traditionally celebrated in March, on the Friday before the Spring vernal equinox of each year. It is a global awareness and internationally recognized event, organized annually since 2008 by the World Sleep Day Committee of the World Sleep Society. Organizers aim to raise awareness of the problems with proper sleep, sleep disorders and aspects connected to it – medical, social, educational and others. Methods Scientific databases – PubMed, SCOPUS and MEDLINE were used to search for the information targeted. The following keywords – World Sleep Day, history, events, prophylaxis, sleep disorders were used. Information from the official websites of the societies involved in celebrating World Sleep Day was included as well. The aim of the following article is to study the history of the event from its foundation till today, aiming to stress out its usefulness. Results and discussion World Sleep Days has been internationally celebrated since 2008 for 15 years now. Since 2016, Bulgaria actively participates in all events organized by the World Sleep Society – Scientific symposiums, prophylactic check-ups for obstructive sleep apnea, elective disciplines in the teaching of students are organized. Importance is put on informing society about the dangers of undiagnosed and untreated sleep disorders, especially sleep apnea. Sleep medicine and Dental Sleep medicine are not recognized as medical specialties in the Republic of Bulgaria. Conclusions Problems of sleep are extremely common in our days. The situation is continuously being worsened due to the hyperconnectivity people experience with the glowing computer and mobile phone screens. It is admirable that specialists in the field and society try to raise awareness and combat the poor sleep quality consequences. Only by doing the abovementioned, alleviation of the undesirable outcomes of irregular sleep can be reached. Legislative measures should be taken in order to certify Sleep medicine and Dental sleep medicine as medical specialties in the Republic of Bulgaria.

History of the World Hearing Day

Background According to recent data from the World Health Organization from 2019, approximately 466 million people are living with a disabling hearing loss, most of them in low- and middle-income countries. Undiagnosed and untreated hearing disorders are proven to be a leading cause for morbidity and cost annually $750 billion. Hearing disorders and hearing loss are believed to higher their prevalence due to the fact that a wide majority of people are exposed to high noises and lack of timely and adequate hearing diagnostics and treatment of ear conditions. Methods Scientific databases – PubMed, SCOPUS and MEDLINE were used to search for the information targeted. The following keywords – World Hearing Day, history, events, prophylaxis, hearing disorders were used. Information from the official websites of the societies involved in celebrating World Hearing Day was included as well. The aim of the following article is to study the history of the event from its foundation till today, aiming to stress out its usefulness. Results and discussion Back in 1995, World Health Assembly passed a resolution WHA48.9, in which attention of the health impact of hearing loss was put – 120 million people worldwide were living with a disabling hearing difficulties. During the World Health Assembly in 2017, with the adoption of the resolution WHA70.13, hearing care and hearing loss were highlighted as a public health issue. Authors claim that most of the causes for hearing loss are preventable. World Hearing Day is an international campaign, organized annually by the Office of Prevention of Blindness and Deafness of the World Health Organization (WHO) on March, 3rd. Organizers claim that World Hearing Day is the largest global awareness event, aiming to bring society’s attention to ear and hearing disorders. It addresses hearing loss. First activities, connected with the World Hearing Day, took place in 2007, after the Beijing Declaration during the 1st International Conference on Prevention and Rehabilitation of Hearing Loss. Conclusions Legislative measures are need to be undertaken to stress even further the importance of proper hearing. In the era of COVID-19 pandemic and its proven consequences on the hearing and vestibular system, urgent measures for timely diagnostics, treatment and rehabilitation are more than ever needed.

A randomized clinical trial of strengths-based case management to link emergency department patients to opioid use disorder treatment

BackgroundDespite the existence of effective pharmacotherapies, rates of opioid use disorder and opioid overdose deaths have continued to increase. Emergency department (ED) visits provide an important opportunity to engage in treatment patients with untreated opioid use disorder (OUD). Case management implemented in other settings is effective in linking those with opioid and other drug use disorders to longer-term treatment, but research has not established its efficacy in the ED. Here we report the results of a trial of Strengths-Based Case Management (SBCM) for people with untreated OUD who are identified during ED visits, with the primary goal of linking them to pharmacologic treatment. MethodsThe study identified patients with untreated OUD during a treatment episode at a large urban ED. The study randomly assigned three hundred participants in 1:1 ratio to receive SBCM or screening, assessment, and referral (SAR) to OUD treatment. Those assigned to SBCM received up to six sessions of SBCM with the primary goal of linkage to treatment. Primary outcomes were initiation of treatment and engagement in pharmacotherapy for OUD. The study defined a “successful outcome” for opioid use as a 3-month urine negative for illicit opioids and no more than 2 days of self-reported opioid misuse in the 4 weeks prior to the 3-month interview. ResultsRates of treatment initiation were not significantly different in the SBCM and SAR groups (57.4% vs. 49.7%, respectively, p > 0.05), nor did engagement in pharmacotherapy differ significantly between groups (p > 0.05). During the 90 days following the index ED visit, SBCM and SAR participants engaged in pharmacotherapy for a mean of 21.8% (SD = 35.1%) versus 17.7% (SD = 31.0%) of days, respectively. Likewise, no significant difference occurred between groups in rates of “successful opioid use outcome” as defined a priori (p > 0.05), although self-reported opioid use over the entire 6-month follow-up period was lower in the SBCM group (10.8 vs. 13.4 days/month, p = 0.042). ConclusionsSBCM-ED did not improve OUD treatment initiation and engagement in this ED study. Although these findings do not necessarily generalize to all EDs, other approaches, such as direct referral or initiation of treatment in the ED, have considerable empirical support, and should be implemented where they are feasible.

Age-related heterogeneity revealed by disruption of white matter structural networks in patients with first-episode untreated major depressive disorder: WM Network In OA-MDD

The clinical treatment and prognosis of major depressive disorder (MDD) are limited by the high degree of disease heterogeneity. It is unclear whether there is a potential network mechanism for age-related heterogeneity. We aimed to uncover the heterogeneity of the white matter (WM) network at different ages of onset and its correlation with different symptom characteristics. 85 first-episode MDD patients and 84 corresponding healthy controls (HCs) were recruited and underwent diffusion tensor imaging scans. Structural network characteristics were analyzed using graph theory methods. We observed an accelerated age-related decline of the WM network in MDD patients compared with HCs. Distinct symptom-related networks were identified in three MDD groups with different onset-age. For early-onset MDD (18–29 years; EOD), higher guilt and loss of interest were correlated with the insula, and inferior parietal lobe which in default mode network and salience network. For mid-term-onset MDD (30–44 years; MOD), higher somatic symptoms were correlated with thalamus which in cortico-striatal-thalamic-cortical circuit. For later-onset MDD (45–60 years; LOD), poor sleep symptoms were correlated with the caudate in the basal ganglia, which suggests the cingulate operculum network in the control of sleep. These results supported a circuit-based heterogeneity associated with the age of onset in MDD. Understanding this circuit-based heterogeneity might help to develop a new target for clinical treatment strategies.

A study on diffusion tensor imaging in patients with untreated first-episode obsessive-compulsive disorder.

The present study provides an overview of studies investigating white matter (WM) integrity in patients with obsessive-compulsive disorder (OCD) using diffusion tensor imaging (DTI). Furthermore, it studies the correlation of fractional anisotropy (FA) in abnormal cerebral WM areas with the course and clinical signs of the disease. The study subjects were divided into two groups, the OCD group (n=38) and the control group (n=40), based on the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) diagnostic criteria for OCD. Patients with untreated first-episode OCD were assigned to the OCD group, while healthy volunteers were assigned to the control group. The study group was evaluated in accordance with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS). Subjects who met the inclusion criteria underwent whole-brain scanning via 3.0 T structural magnetic resonance imaging (sMRI). The WM FA values in different brain areas were compared between the two groups using voxel-based analysis (VBA). Subsequently, the correlations of the patient Y-BOCS score and disorder course with the FA values in significantly improved encephalic areas were analyzed. (I) The FA values of the right precentral gyrus (PreCG.R), left insular lobe, left inferior frontal gyrus and right inferior occipital gyrus (Occipital_Inf_R) WM were significantly lower in the OCD group than in the control group (P<0.05). Elevated FA values were not observed in the OCD group. (II) FA values of PreCG.R, left insular lobe/left inferior frontal gyrus, and Occipital_Inf_R were not found in relation to the total Y-BOCS score (P=0.122; P=0.401; P=0.134), obsessional thoughts score (P=0.299; P=0.760; P=0.062), compulsive activities checklist (P=0.487; P=0.420; P=0.431), and disease course (P=0.604; P=0.380; P=0.182). Multiple microstructural cerebral WM changes were observed in the frontal lobe, occipital lobe, and insula in patients with untreated first-episode OCD, presenting the correlation of these changes with OCD occurrence.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis.

Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment. To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED. This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019. Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements. A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training. In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.

Pharmacologic Treatment for Perinatal Mental Health Disorders.

PROSPERO, CRD42019124057.

Management of chronic insomnia using hypnotics: a friend or a foe?

Epidemiological studies suggest that 10-15% adults meet the present criteria for the diagnosis of insomnia disorder; however, there may be geographical variations. Untreated insomnia disorders have a number of adverse health consequences in addition to economic burden caused by it. Available guidelines mention that CBT-I should be preferred over hypnotics. However, several patients of chronic insomnia are not candidate for CBT-I and for them, hypnotics are the only answer. This paper reviews the literature to answer following questions: What is the current understanding regarding place of hypnotics for in management of insomnia disorder? How many patients misuse or abuse hypnotics, especially benzodiazepines, as commonly believed? Do we have data from human studies regarding low-dose benzodiazepine dependence? What does hypnotics produce-withdrawal insomnia, rebound insomnia or end of dose phenomenon? Are adverse effects of benzodiazepines worse than other psychotropic medications? Is prescription of hypnotics more troublesome than untreated insomnia disorder? Available literature suggests that there is an unreasonable negative bias attached to the use of hypnotics. Only a sub-set of patients who are prescribed hypnotics, meet the criteria for "dependence" in long term. Other patients either discontinue it (as insomnia remits) or change to occasional use (since insomnia may be relapsing remitting disorder), or continue using it in low dose (since insomnia reappears as hypnotics are discontinued, similar to increase in blood sugar after hypoglycemics are discontinued). Meta-analysis shows that adverse effects of hypnotics are comparable to that of other psychotropic medications. Considering the consequences and risks associated with untreated insomnia disorder, even long-term use of hypnotics is justified, however with the careful watch that patients are not increasing the dose. This approach is especially important in geographical areas where trained CBT-I therapists are not available.