Unhealthy Alcohol Use among Adults with Depression or Anxiety: Changes During COVID-19 and Associations with Mental Health Treatment.

OBJECTIVE: Individuals with unhealthy alcohol use and comorbid depression or anxiety may be vulnerable to alcohol use escalation in times of stress such as the COVID-19 pandemic. Among a cohort of individuals with pre-pandemic unhealthy drinking, we compared changes in alcohol use by whether people had a depression or anxiety diagnosis, and examined whether mental health treatment was related to these changes. METHODS: Using electronic health record data from Kaiser Permanente Northern California, we analyzed drinking changes during the pandemic (3/1/2020-6/30/2022) among adults identified in primary care with unhealthy alcohol use (exceeding daily/weekly recommended limits) pre-pandemic (1/1/2019-2/29/2020). Outcomes were mean changes in number of heavy drinking days (prior three months), drinks/week, drinks/day, and drinking days/week. Multivariable linear regression models were fit to: 1) compare outcomes of patients with depression or anxiety diagnoses to those without, and 2) among patients with depression or anxiety, estimate associations between mental health treatment and outcomes. RESULTS: The sample included 62,924 adults with unhealthy alcohol use, of whom 12,281 (19.5%) had depression or anxiety. On average, alcohol use significantly decreased across all measures during the pandemic, but patients with depression or anxiety had greater decreases in drinks/week (adjusted mean difference [aMD] [CI]=-0.34 [-0.55, -0.12]) and drinking days/week (-0.15 [-0.20, -0.10]). No associations were found between mental health treatment and changes in drinking. CONCLUSIONS: Contrary to expectations, patients with unhealthy alcohol use and depression or anxiety decreased alcohol use more than those without depression or anxiety during COVID-19, whether or not they accessed mental health services.

Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic.

BACKGROUND: Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic. METHOD: The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic. RESULTS: Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic. DISCUSSION: Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

Adolescent utilization of eating disorder higher level of care: roles of family-based treatment adherence and demographic factors.

BACKGROUND: Outpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system. METHODS: This retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index. RESULTS: 2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites. CONCLUSIONS: Reported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.

Adolescents with restrictive eating treated by Family-Based Treatment (FBT) teams had better early weight gain but no differences in the use of intensive outpatient, residential, partial hospital programs or inpatient psychiatry care when compared to those treated by teams with a low adherence to the FBT approach. Factors such as sex, race, ethnicity, mood disorders, and suicidality were associated with the use of psychiatric services. These findings are consistent with previously documented systematic disparities in accessing psychiatric services across patient demographics and should be used to inform the development of proposed care models that are more inclusive and accessible to all patients.

A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial.

BACKGROUND: Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy. METHODS: The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months. RESULTS: At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98). CONCLUSION: This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system. TRIAL REGISTRATION: The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).

Risk profiles of adults with heavy alcohol use: Drinking patterns, behavioral and metabolic factors, health problems, and racial and ethnic disparities.

BACKGROUND: Heavy alcohol use is a growing risk factor for chronic disease, yet little is known about its co-occurrence with other risk factors and health problems. This study aimed to identify risk profiles of adults with heavy alcohol use and examined potential disparities by race and ethnicity. METHODS: This cross-sectional study included 211,333 adults with heavy alcohol use (in excess of daily or weekly limits recommended by National Institute on Alcohol Abuse and Alcoholism) between June 1, 2013 and December 31, 2014 in Kaiser Permanente Northern California. Latent class analysis was used to examine how heavy drinking patterns clustered with other behavioral and metabolic risk factors and health problems to form risk profiles. Multinomial logistic regression models were fit to examine associations between race, ethnicity, and risk profiles. RESULTS: A 5-class model was selected as best fitting the data and representing clinically meaningful risk profiles: (1) "heavy daily drinking and lower health risks" (DAILY, 44.3%); (2) "substance use disorder and mental health disorder" (SUD/MH, 2.3%); (3) "heavy weekly drinking and lower health risks" (WEEKLY, 19.6%); (4) "heavy daily drinking and more health risks" (DAILY-R, 18.5%); (5) "heavy weekly drinking and more health risks" (WEEKLY-R, 15.3%). American Indian or Alaska Native (AIAN) and Black patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles than the DAILY profile. AIAN, Black, and Latino/Hispanic patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles rather than the WEEKLY profile. CONCLUSIONS: AIAN, Black, and Latino/Hispanic patients with self-reported heavy drinking were more likely to be in risk profiles with greater alcohol consumption, more health risks, and higher morbidity. Targeted, culturally appropriate interventions for heavy alcohol use that may address other modifiable risk factors are needed to work towards health equity.

Disparities in the receipt of alcohol brief intervention: The intersectionality of sex, age, and race/ethnicity.

BACKGROUND AND AIMS: The increasing trend in alcohol consumption among women, exacerbated by the COVID-19 pandemic, is of growing concern. Screening, brief intervention, and referral to treatment in primary care is an efficacious and cost-effective treatment approach for unhealthy alcohol use. However, disparities exist in delivery of brief interventions by sex, age and race/ethnicity. This study measures brief intervention rates among eligible patients by sex, age and race/ethnicity and their intersectionality, in the context of a program of systematic alcohol screening and brief intervention program in adult primary care in a large, integrated health-care delivery system. DESIGN, SETTING AND PARTICIPANTS: This was a population-based observational study among primary care clinics in an integrated health-care delivery system in Northern California, USA. The participants comprised adult (18+) patients (n = 287 551) screening positive for unhealthy alcohol use between January 2014 and December 2017. MEASUREMENTS: Receipt of brief intervention, patient and provider characteristics from electronic health records. FINDINGS: Multi-level logistic regression showed that women had lower odds of receiving brief intervention than men among all age, racial/ethnic groups and drinking levels. Sex differences were greater among those aged 35-49 years [odds ratio (OR) = 0.67, 95% confidence interval (CI) = 0.64, 0.69]) and 50-65 years (OR = 0.69, 95% CI =0.66, 0.72) than among other age groups. Sex differences in odds of receiving brief intervention were greater for the Latino/Hispanic group for women versus men (OR = 0.69, 95% CI = 0.66, 0.72) and smaller for the Asian/Pacific Islander group (OR = 0.76, 95% CI = 0.72, 0.81). CONCLUSION: In the United States, compared with men, women appear to have lower odds of receiving brief intervention for unhealthy alcohol use across all age groups, particularly during middle age. Black women and Latina/Hispanic women appear to be less likely to receive brief intervention than women in other race/ethnicity groups. Receipt of brief intervention does not appear to differ by drinking levels between men and women.

Associations between alcohol brief intervention in primary care and drinking and health outcomes in adults with hypertension and type 2 diabetes: a population-based observational study.

OBJECTIVES: To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D). DESIGN: A population-based observational study using electronic health records data. SETTING: An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care. PARTICIPANTS: Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017. MAIN OUTCOME MEASURES: We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and 'controlled HbA1c' (HbA1c<8%) at 18-month follow-up. RESULTS: For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined. CONCLUSIONS: Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact.

Young Adult Substance Use and Healthcare Use Associated With Screening, Brief Intervention and Referral to Treatment in Pediatric Primary Care.

PURPOSE: Screening, brief intervention, and referral to treatment (SBIRT) may impact future comorbidity and healthcare utilization among adolescents screening positive for substance use or mood problems. METHODS: In a randomized trial sample, we compared an SBIRT group to usual care for substance use, mental health, medical diagnoses, and healthcare utilization over 7 years postscreening. RESULTS: In logistic regression models adjusting for patient characteristics, the SBIRT group had lower odds of any substance (Odds Ratio[OR] = 0.80, 95% Confidence Interval [CI] = 0.66-.98), alcohol (OR = 0.69, 95% CI = 0.51-0.94), any drug (OR = 0.73, 95% CI = 0.54-0.98), marijuana (OR = 0.70, 95% CI = 0.50-0.98), and tobacco (OR = 0.83, 95% CI = 0.69-1.00) diagnoses, and lower odds of any inpatient hospitalizations (OR = 0.59, 95% CI = 0.41-0.85) compared with usual care. Negative binomial models examining number of visits among adolescents with at least one visit of that type found that those in the SBIRT group had fewer primary care (incidence rate ratio[iRR] = 0.90, p < .05) and psychiatry (iRR = 0.64, p < .01) and more addiction medicine (iRR = 1.52, p < .01) visits over 7 years compared with usual care. In posthoc analyses, we found that among Hispanic patients, those in the SBIRT group had lower odds of any substance, any drug and marijuana use disorder diagnoses compared with usual care, and among Black/African American patients, those in the SBIRT group had lower odds of alcohol use disorder diagnoses compared with usual care. DISCUSSION: Beneficial effects of adolescent SBIRT on substance use and healthcare utilization may persist into young adulthood.

Predicting severe alcohol use disorders in primary care using number of heavy drinking days.

BACKGROUND AND AIMS: Although screening for unhealthy alcohol use is becoming more common, severe alcohol use disorders (AUDs) associated with the most severe medical and socio-economic sequelae still often go unidentified in primary care. To improve identification of severe AUDs and aid clinical decision-making, we aimed to identify a threshold of heavy drinking days (HDDs) associated with severe AUDs. DESIGN, SETTING AND CASES: This cohort study analyzed electronic health record data of 138 765 adults who reported ≥ 1 HDD (4+ drinks/occasion for women and men aged ≥ 65 years, 5+ for men aged 18-64 years) during a 3-month period at a routine alcohol screening in primary care in a large Northern California, USA health-care system from 2014 to 2017. Our sample was 66.5% male, 59.7% white, 11.0% Asian/Pacific Islander, 5.0% black, 17.4% Latino/Hispanic and 7.0% other/unknown race/ethnicity; the mean age was 40.6 years (standard deviation = 15.2). MEASUREMENTS: We compared sensitivity and specificity of different thresholds of the reported number of HDDs during a 3-month period for predicting severe AUD diagnoses in the following year, in the full sample and by sex and age. FINDINGS: The prevalence of severe AUD diagnoses in the year after the screening was 0.6%. The optimal threshold predicting future severe AUD diagnoses in the full sample was ≥ 5 HDDs during a 3-month period [sensitivity = 68.9%, 95% confidence interval (CI) = 65.9, 72.0; specificity = 63.2%, 95% CI = 62.9, 63.4], but varied by sex and age. Women had a lower threshold than men (4 versus 6 HDDs), which decreased as women aged (from 5 HDDs among 18-24 years to 4 HDDs ≥ 25 years), but increased as men aged (from 5 HDDs among 18-24 years to 6 HDDs among 25-64 years, to 7 HDDs ≥ 65 years). CONCLUSIONS: Five or more heavy drinking days in a 3-month period may indicate heightened risk of future severe alcohol use disorder in an adult primary care population. The optimal thresholds are lower for women than for men, and thresholds decrease as women age but increase as men age.

Alcohol brief intervention, specialty treatment and drinking outcomes at 12 months: Results from a systematic alcohol screening and brief intervention initiative in adult primary care.

BACKGROUND: Alcohol screening, brief intervention and referral to treatment (SBIRT) in adult primary care is an evidence-based, public health strategy to address unhealthy alcohol use, but evidence of effectiveness of alcohol brief intervention (ABI) in real-world implementation is lacking. METHODS: We fit marginal structural models with inverse probability weighting to estimate the causal effects of ABI on 12-month drinking outcomes using longitudinal electronic health records data for 312,056 adults with a positive screening result for unhealthy drinking between 2014 and 2017 in a large healthcare system that implemented systematic primary care-based SBIRT. We examined effects of ABI with and without adjusting for receipt of specialty alcohol use disorder (AUD) treatment, and whether effects varied by patient demographic characteristics and alcohol use patterns. RESULTS: Receiving ABI resulted in significantly greater reductions in heavy drinking days (mean difference [95% CI] = -0.26 [-0.45, -0.08]), drinking days per week (-0.04 [-0.07, -0.01]), drinks per drinking day (-0.05 [-0.08, -0.02]) and drinks per week (-0.16 [-0.27, -0.04]). Effects of ABI on 12-month drinking outcomes varied by baseline consumption level, age group and whether patients already had an AUD, with better improvement in those who were drinking at levels exceeding only daily limits, younger, and without an AUD. CONCLUSIONS: Systematic ABI in adult primary care has the potential to reduce drinking among people with unhealthy drinking considerably on both an individual and population level. More research is needed to help optimize ABI, in particular tailoring it to diverse sub-populations, and studying its long-term public health impact.

Substance use disorders among primary care patients screening positive for unhealthy alcohol use.

BACKGROUND: Despite high prevalence of polysubstance use, recent data on concurrent alcohol use in patients with specific substance use disorders (SUDs) are lacking. OBJECTIVE: To examine associations between specific SUDs and alcohol consumption levels. METHODS: Using electronic health record data, we conducted a cross-sectional study of 2,720,231 primary care adults screened for alcohol use between 2014 and 2017 at Kaiser Permanente Northern California. Alcohol consumption levels were categorized as no reported use, low-risk use, and unhealthy use (exceeding daily, weekly, or both recommended drinking limits). Using multinomial logistic regression, and adjusting for sociodemographic and health characteristics, we examined the odds of reporting each alcohol consumption level in patients with a prior-year SUD diagnosis (alcohol, cannabis, cocaine, inhalant, opioid, sedative/anxiolytic, stimulant, other drug, nicotine, any SUD except nicotine) compared to those without. RESULTS: The sample was 52.9% female, 48.1% White; the mean age was 46 years (SD = 18). Patients with SUDs were less likely to report low-risk alcohol use relative to no use compared with patients without SUDs. Patients with alcohol or nicotine use disorder had higher odds of reporting unhealthy alcohol use relative to no use; however, patients with all other SUDs (except cocaine) had lower odds. Among patients who reported any alcohol use (n = 861,427), patients with SUDs (except opioid) had higher odds of exceeding recommended limits than those without. CONCLUSION: The associations of unhealthy alcohol use and SUDs suggest that screening for both alcohol and drug use in primary care presents a crucial opportunity to prevent and treat SUDs early.

Predictors of early and sustained cessation of heavy drinking over 5 years among adult primary care patients.

AIMS: To identify factors asociated with early and sustained cessation of heavy drinking. DESIGN: Retrospective cohort study over 5 years. SETTING: Kaiser Permanente Northern California, United States. PARTICIPANTS: Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31 May 2014. The sample (n = 85 434) was 40.7% female and 33.8% non-white; mean age was 50.3 years (standard deviation = 18.1). MEASUREMENTS: Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1 year and to 5 years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition. FINDINGS: Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.35, 1.44], middle-age (35-64 years: ORs = 1.16-1.19), non-white race/ethnicity (ORs = 1.03-1.57), medical conditions (OR = 1.05, 95% CI = 1.04, 1.06), psychiatric (OR = 1.10, 95% CI = 1.06, 1.15) and drug use disorders (OR = 1.35, 95% CI = 1.17, 1.56) and addiction treatment (OR = 1.19, 95% CI = 1.09, 1.30) were associated with higher odds of early cessation, while older age (≥ 65 years: OR = 0.91, 95% CI = 0.86, 0.96), smoking (OR = 0.81, 95% CI = 0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR = 0.30, 95% CI = 0.29, 0.32) and psychiatric treatment (OR = 0.91, 95% CI = 0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n = 19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR = 1.57, 95% CI = 1.44, 1.71) and addiction treatment post-1 year (OR = 1.41, 95% CI = 1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1 year was associated with lower odds of sustained cessation (OR = 0.62, 95% CI = 0.57, 0.66). CONCLUSIONS: Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.

Parent-focused prevention of adolescent health risk behavior: Study protocol for a multisite cluster-randomized trial implemented in pediatric primary care.

Evidence-based parenting interventions play a crucial role in the sustained reduction of adolescent behavioral health concerns. Guiding Good Choices (GGC) is a 5-session universal anticipatory guidance curriculum for parents of early adolescents that has been shown to reduce substance use, depression symptoms, and delinquent behavior. Although prior research has demonstrated the effectiveness of evidence-based parenting interventions at achieving sustained reductions in adolescent behavioral health concerns, public health impact has been limited by low rates of uptake in community and agency settings. Pediatric primary care is an ideal setting for implementing and scaling parent-focused prevention programs as these settings have a broad reach, and prevention programs implemented within them have the potential to achieve population-level impact. The current investigation, Guiding Good Choices for Health (GGC4H), tests the feasibility and effectiveness of implementing GGC in 3 geographically and socioeconomically diverse large integrated healthcare systems. This pragmatic, cluster randomized clinical trial will compare GGC parenting intervention to usual pediatric primary care practice, and will include approximately 3750 adolescents; n = 1875 GGC intervention and n = 1875 usual care. The study team hypothesizes that adolescents whose parents are randomized into the GGC intervention arm will show reductions in substance use initiation, the study's primary outcomes, and other secondary (e.g., depression symptoms, substance use prevalence) and exploratory outcomes (e.g., health services utilization, anxiety symptoms). The investigative team anticipates that the implementation of GGC within pediatric primary care clinics will successfully fill an unmet need for effective preventive parenting interventions. Trial registration: Clinicaltrials.govNCT04040153.

Patient and provider factors associated with receipt and delivery of brief interventions for unhealthy alcohol use in primary care.

BACKGROUND: Unhealthy alcohol use is a serious and costly public health problem. Alcohol screening and brief interventions are effective in reducing unhealthy alcohol consumption. However, rates of receipt and delivery of brief interventions vary significantly across healthcare settings, and relatively little is known about the associated patient and provider factors. METHODS: This study examines patient and provider factors associated with the receipt of brief interventions for unhealthy alcohol use in an integrated healthcare system, based on documented brief interventions in the electronic health record. Using multilevel logistic regression models, we retrospectively analyzed 287,551 adult primary care patients (and their 2952 providers) who screened positive for unhealthy drinking between 2014 and 2017. RESULTS: We found lower odds of receiving a brief intervention among patients exceeding daily or weekly drinking limits (vs. exceeding both limits), females, older age groups, those with higher medical complexity, and those already diagnosed with alcohol use disorders. Patients with other unhealthy lifestyle activities (e.g., smoking, no/insufficient exercise) were more likely to receive a brief intervention. We also found that female providers and those with longer tenure in the health system were more likely to deliver brief interventions. CONCLUSIONS: These findings point to characteristics that can be targeted to improve universal receipt of brief intervention.

Effectiveness of spironolactone dispensation in reducing weekly alcohol use: a retrospective high-dimensional propensity score-matched cohort study.

There is a need to increase the armamentarium of pharmacotherapies for alcohol use disorder (AUD). Recent research suggests that mineralocorticoid receptor (MR) antagonism via spironolactone may represent a novel pharmacological treatment for AUD. We conducted a pharmacoepidemiologic retrospective cohort study (June 1, 2014 to May 31, 2018) to examine whether spironolactone dispensation (≥90 continuous days), for any indication, is associated with changes in weekly alcohol use about 6 months later. We compared 523 spironolactone-treated adults and 2305 untreated adults, matched on high-dimensional propensity scores created from a set of predefined (sociodemographic and health characteristics, diagnoses, and service utilization) and empirical electronic health record-derived covariates. The sample was 57% female and 27% non-White with a mean age of 59.2 years (SD = 19.3). Treated patients reduced their weekly alcohol use by 3.50 drinks (95% CI = -4.22, -2.79), while untreated patients reduced by 2.74 drinks (95% CI = -3.22, -2.26), yielding a significant difference of 0.76 fewer drinks (95% CI = -1.43, -0.11). Among those who drank >7 drinks/week at baseline, treated patients, compared to untreated patients, reported a greater reduction in weekly alcohol use by 4.18 drinks (95% CI = -5.38, -2.97), while there was no significant difference among those who drank less. There was a significant dose-response relationship between spironolactone dosage and change in drinks/week. Pending additional evidence on its safety and efficacy in individuals with AUD, spironolactone (and MR blockade, at large) may hold promise as a pharmacotherapy for AUD.

Three-Year Outcomes After Brief Treatment of Substance Use and Mood Symptoms.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) for adolescents exhibiting co-occurring substance use and mental health problems may improve outcomes and have long-lasting effects. This study examined the relationship between access to SBIRT and substance use, depression and medical diagnoses, and health services use at 1 and 3 years postscreening for such adolescents. METHODS: The study draws from a cluster-randomized trial comparing SBIRT to usual care (UC) for adolescents endorsing past-year substance use and recent mood symptoms during visits to a general pediatrics clinic between November 1, 2011, and October 31, 2013, in a large, integrated health system (N = 1851); this sample examined the subset of adolescents endorsing both problems (n = 289). Outcomes included depression, substance use and medical diagnoses, and emergency department and outpatient visits 1 and 3 years later. RESULTS: The SBIRT group had lower odds of depression diagnoses at 1 (odds ratio [OR] = 0.31; confidence interval [CI] = 0.11-0.87) and 3 years (OR = 0.51; CI = 0.28-0.94) compared with the UC group. At 3 years, the SBIRT group had lower odds of a substance use diagnosis (OR = 0.46; CI = 0.23-0.92), and fewer emergency department visits (rate ratio = 0.65; CI = 0.44-0.97) than UC group. CONCLUSIONS: The findings suggest that SBIRT may prevent health complications and avert costly services use among adolescents with both mental health and substance use problems. As SBIRT is implemented widely in pediatric primary care, training pediatricians to discuss substance use and mental health problems can translate to positive outcomes for these vulnerable adolescents.

Screening for Gender Identity in Adolescent Well Visits: Is It Feasible and Acceptable?

PURPOSE: This study aimed to pilot systematic gender identity screening during adolescent well checks and examine perceptions of feasibility and acceptability of screening from adolescents, parents/guardians, and clinicians. METHODS: Adolescents aged 12-18 years with a well visit between July 1, 2018, and June 30, 2019 (n = 134,114; 817 pilot and 133,297 usual care) in Kaiser Permanente Northern California (KPNC) pediatric primary care clinics. "What is your gender?" was added to the previsit questionnaire in pilot clinics; all other KPNC clinics provided usual care. Additional anonymous surveys were administered to adolescents and parents/guardians in the pilot clinics and to all KPNC pediatric clinicians. Multivariable logistic regression examined associations between clinics and patients reporting as transgender and gender diverse (TGD). Descriptive statistics summarized patient, parent/guardian, and clinician perceptions of gender identity screening. RESULTS: Adjusting for age and race/ethnicity, adolescents had higher odds of reporting as TGD in pilot clinics than in usual care (odds ratio = 6.91, 95% confidence interval = 3.76-12.74). Two thirds of adolescents, 75.5% of parents/guardians, and 92.5% of clinicians felt it was important to screen for gender identity in primary care. Less than 2% of adolescents found the question confusing, offensive, or uncomfortable, and 2.8% of parents/guardians felt it was offensive. In addition, 36.4% of clinicians and 3.6% of parents/guardians were concerned it would affect visit workflow/time. CONCLUSIONS: Most adolescents, parents/guardians, and pediatric clinicians viewed systematic gender identity screening as both feasible and acceptable. Standardized gender identity screening during adolescent well checks could facilitate and increase identification of TGD adolescents and the delivery of gender-affirming care for adolescents and families in need.

Premature mortality associated with severe mental illness or substance use disorder in an integrated health care system.

OBJECTIVE: Research has reported shortened lifespans (by 15-30 years) for those with severe mental illness (SMI) or substance use disorder (SUD), particularly among public mental health treatment consumers. We assessed SMI- and SUD-associated mortality in the understudied setting of a large, nonprofit integrated health care system. METHOD: This retrospective cohort study examined 2010-2017 health system and death records for 564,592 adult patients. Half had SMI/SUD diagnosis; half were a demographically matched comparison group without SMI, other mental health, or SUD diagnoses. We estimated mortality risks, adjusting for demographic and physical health factors. RESULTS: Having SMI or SUD was associated with higher odds of death (adjusted odds ratio = 1.87) and an average 6.3 years of earlier death relative to comparison individuals. Co-occurring SMI and SUD conferred higher mortality risk from major natural and unnatural causes than did SMI with no SUD. CONCLUSIONS: Some indicators of premature mortality were lower than those reported for U.S. public mental health consumers, but risk level varied widely by diagnosis. While patients' having insurance and broad access to care may lower risk, access to care may be insufficient to overcome the many patient-, provider-, and system-level factors contributing to poor physical health in SMI and SUD.

Associations Between Psychiatric Disorders and Alcohol Consumption Levels in an Adult Primary Care Population.

BACKGROUND: Unhealthy alcohol use frequently co-occurs with psychiatric disorders; however, little is known about the relationship between psychiatric disorders and alcohol consumption levels. Understanding varying levels of unhealthy alcohol use among individuals with a variety of psychiatric disorders in primary care would provide valuable insight for tailoring interventions. METHODS: We conducted a cross-sectional study of 2,720,231 adult primary care patients screened for unhealthy alcohol use between 2014 and 2017 at Kaiser Permanente Northern California, using electronic health record data. Alcohol consumption level was classified as no reported use, low-risk use, and unhealthy use, per National Institute on Alcohol Abuse and Alcoholism guidelines. Unhealthy use was further differentiated into mutually exclusive groups: exceeding only daily limits, exceeding only weekly limits, or exceeding both daily and weekly limits. Multivariable multinomial logistic regression models were fit to examine associations between 8 past-year psychiatric disorders (depression, bipolar disorder, anxiety disorder, obsessive-compulsive disorder, schizophrenia, schizoaffective disorder, anorexia nervosa, and bulimia nervosa) and alcohol consumption levels, adjusting for sociodemographic and health characteristics. RESULTS: In the full sample [53% female, 48% White, mean (SD) age = 46 (18) years], patients with psychiatric disorders (except eating disorders), compared to those without, had lower odds of reporting low-risk and unhealthy alcohol use relative to no use. Among patients who reported any alcohol use (n = 861,427), patients with depression and anxiety disorder, compared to those without, had higher odds of exceeding only weekly limits and both limits; patients with bulimia nervosa were also more likely to exceed both limits. CONCLUSIONS: Findings suggest that patients with anxiety disorder, depression, and bulimia nervosa who drink alcohol are more likely to exceed recommended limits, increasing risk of developing more serious problems. Health systems and clinicians may wish to consider implementing more robust screening, assessment, and intervention approaches to support these vulnerable subgroups in limiting their drinking.