Costs and Effectiveness of Treating Homeless Persons with Cocaine Addiction with Alternative Contingency Management Strategies.

BACKGROUND: Between 1990 and 2006 in Birmingham, Alabama USA, 4 separate randomized controlled studies, called "Homeless 1" through "Homeless 4", treated cocaine substance abuse among chronically homeless adults, largely black men, many with non-psychotic mental health problems. The 4 studies had 9 treatment arms that used various counseling methods plus, in some arms, the provision of housing and work therapy usually with a contingent requirement of urine-test verified abstinence from substances. Participants in the abstinent-contingent arms who lapsed on abstinence were removed from housing and sent to an evening public shelter from which they were daily transported to day treatment until they returned to abstinence. AIMS OF THE STUDY: This paper compares the cost effectiveness of the treatment arms. METHODS: Societal cost per participant (in 2014 dollars) for each arm is defined as direct treatment cost plus cost of jail or hospital plus societal expense of public shelter use by lapsed participants. An untreated Base Case is defined as 5 percent abstinence with 95 percent usage of a public shelter. Incremental Cost Effectiveness Ratios (ICERs) for paired arms are defined as the change in cost per participant divided by the change in abstinence. Bootstrapping estimates confidence intervals. RESULTS: Average cost per participant at the end of 6 months of active treatment in 7 arms with comparable data ranged from USD 10,447 to USD 36,194 with corresponding average weeks abstinent ranging from 6.1 to 15.3 out of a possible 26 weeks. In contrast, the Base Case would cost USD 6,123 for 1.3 weeks of abstinence. Compared to the Base Case, the least expensive "DT2" treatment has an ICER of USD 901 (95% CI = USD 571 to USD 1,681) per additional week of abstinence and the most expensive "CMP4" has an ICER of USD 2,147 (95% CI = USD 1,701 to USD 2,848). Additionally, the Homeless 3 study found that the abstinent contingent housing (ACH3) treatment compared to the Non Abstinent Contingent Housing (NAC3), analogous to "Housing First", achieved better abstinence (12.1 v. 10 weeks) at higher average cost (USD 22,512 v. USD 17,541) yielding an ICER for this comparison of (USD 2,367, 95% CI=USD -10,587 to USD 12,467). Similar results are found at 12 months (6 months after active treatment). DISCUSSION: More intensive methods of counseling improved abstinence but 4 of the 7 treatments were inefficient ("dominated"). Bootstrapping shows that results are sensitive to which individuals were randomly assigned to each arm. A limitation of the analysis is that it does not consider the full societal cost of lost wages, crime costs beyond jail expenses and deterioration of neighborhood quality of life. Additionally, populations treated by Housing First programs may differ from the Birmingham Homeless studies in the severity of addiction or co-occuring psychological problems. IMPLICATIONS FOR TREATMENT: The Homeless studies show that abstinent contingent safe housing with counseling can substantially improve abstinence for homeless cocaine abusers. Incremental costs rise sharply with more intensive counseling; modest programs of counseling may be more cost effective in a stepped treatment strategy.

Cigarette Smokers are Less Likely to Have Undetectable Viral Loads: Results From Four HIV Clinics.

BACKGROUND: The prevalence of smoking among HIV-infected individuals is 2-3 times that of the general population, increasing the risk of smoking-related morbidity and mortality. We examined characteristics associated with smoking behavior among a large cohort of HIV-infected individuals in care in the United States. METHODS: A convenience sample of 2952 HIV-infected patients in the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) was assessed during routine clinic visits and was included. Multinomial logistic regression was used to examine the relationship between smoking status, depression/panic symptoms, alcohol/substance use, and demographic and clinical characteristics. RESULTS: Compared with never-smokers, current smokers were more likely to have moderate to severe depression (odds ratio [OR] 1.37), endorse current substance use (OR 14.09), and less likely to report low-risk alcohol use on the Alcohol Use Disorders Identification Test (AUDIT-C) (OR 0.73). Current smokers were less likely to have an undetectable viral load (OR 0.75), and more likely to have current substance abuse (OR 2.81) and moderate to severe depression (OR 1.50), relative to smokers who had quit smoking. CONCLUSIONS: HIV-infected smokers are less likely to have undetectable viral loads and frequently have psychosocial comorbidities including depression and substance abuse that impact antiretroviral therapy adherence and viral load suppression. To be effective, smoking-cessation interventions need to address the complex underlying concurrent risks in this population.

Comorbidity effects on cocaine dependence treatment and examination of reciprocal relationships between abstinence and depression.

OBJECTIVE: We examined comorbid disorders' prevalence, their impact on abstinence, and the impact of depressive symptoms on abstinence and of abstinence on depressive symptoms. METHOD: A randomized controlled trial's data on outcomes from treating cocaine dependence were used. It compared abstinence-contingent housing and work to contingency management plus behavioral day treatment. Regardless of original trial arm assignment, groups of participants with no additional Axis I disorders (n = 87) and 1 or more additional Axis I disorders (n = 113) were compared for abstinence. Changes in depression symptoms, measured by the Beck Depression Inventory, were analyzed as a function of 4 cohorts of increased consecutive weeks abstinent. An autoregressive cross-lagged path model examined reciprocal relationships between depression and abstinence. RESULTS: Most prevalent additional disorders were depressive disorders, followed by anxiety disorders. Additional disorders did not significantly affect abstinence. Cohorts with more abstinence were linearly related to lower depression symptoms. The cross-lagged model showed that longer abstinence predicted decreases in depressive symptoms at 6 months. However, depressive symptoms did not predict changes in abstinence. CONCLUSIONS: Our study adds to others that have found an effective treatment targeted at specific problems such as substance abuse, social anxiety disorder, and posttraumatic stress disorder that may have the side benefit of reducing depression. Additionally, we find that depression does not interfere with effective substance abuse treatment for cocaine dependency. This may be the 1st formal analysis comparing the ability of cocaine abstinence to predict future depressive symptoms versus depressive symptoms to predict future cocaine abstinence.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.

BACKGROUND: While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. OBJECTIVE: Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. DESIGN: This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). PARTICIPANTS: Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. APPROACH: Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). KEY RESULTS: Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. CONCLUSION: Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

Protective factors against relapse for practicing nurse anesthetists in recovery from anesthetic opiate dependency.

This qualitative inquiry explored factors that protect recovering anesthetic opioid-dependent nurse anesthetists from relapse after their return to anesthesia practice. Practicing nurse anesthetists in recovery from potent opioids were recruited through online advertising and individually interviewed over the telephone. The interview consisted of open-ended questions that aided description of personal experience of individual factors. Content analysis of the interviews revealed an overarching theme of a commitment to the recovery process, which provided the foundational protective element against relapse. Within this context, two major thematic factors emerged: personal factors and external factors. Personal factors came from within the individual and included such features as removing the obsession to use, self-realization, inner strength, and seeing the future. External factors were external to the individual and described as time away from practice, state regulatory agency involvement, and talking with significant others. Although the Twelve-Step process was not a factor per se, it was credited by all participants as the structure on which their recovery was built. This process provided mechanisms for developing the motivation and learning the tools necessary to maintain their sobriety.

Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

OBJECTIVES: The purpose of this study was to better understand substance use behaviors and deleterious health consequences among individuals with HIV. METHODS: We examined a multicenter cohort of HIV-infected patients (n = 3,413) receiving care in 4 US cities (Seattle, Birmingham, San Diego, Boston) between December 2005 and April 2010 in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS). We used generalized estimating equations to model specific substance use outcomes. RESULTS: Overall, 24% of patients reported recent use of marijuana; 9% reported amphetamine use, 9% reported crack-cocaine use, 2% reported opiate use, 3.8% reported injection drug use, and 10.3% reported polydrug use. In adjusted multivariable models, those who reported unprotected anal sex had higher odds of marijuana, amphetamine, injection drug, and polydrug use. An increased number of distinct vaginal sexual partners was associated with polydrug and crack-cocaine use. Nonadherence to antiretroviral therapy was associated with the use of all substances other than marijuana. CONCLUSIONS: The co-occurrence of substance use, unprotected intercourse, and medication nonadherence could attenuate the public health benefits of test, treat, and link to care strategies. Prevention programs are needed that address these coprevalent conditions.

Boosting workplace stair utilization: a study of incremental reinforcement.

PURPOSE: This study was designed to determine whether engagement in stair taking can be increased in a worksite setting through the provision of an employer-sponsored, behavior-based incentive system in which employees (members) accumulate points that can be redeemed for merchandise. METHODS/DESIGN: ChipRewards implemented stair utilization in one employer as a part of a larger health incentive engagement program. Using an AB (baseline-intervention) design, members (N = 216) were observed for 6 months (6.17.10 to 12.14.10 or 129 weekdays after excluding 52 weekend days) before the intervention (baseline) and after 6 months (1.1.11 to 6.30.11 with the same number of weekdays) of implementation. RESULTS: Members were 84% female, 51% Caucasian, 48% African American, 3% Hispanic, and 45 years average age. The number of total stair transactions for all members for all days monitored increased from 5,070 to 38,900, and the average number of stair transactions per day rose from 39 to 301, representing over a 600% increase. The overall cost of incentives for stair utilization was $3,739.30 or $17.55 per member on average. CONCLUSION/IMPLICATIONS: This study supports that stair usage in the workplace is a viable way to increase physical activity. This study adds to existing research that attempted to increase stair utilization through promotion only by adding a behavioral reinforcement strategy. Finally, this study demonstrates that a physical activity among employees at the worksite can be increased with minimal relative cost.

Routine depression screening in an HIV clinic cohort identifies patients with complex psychiatric co-morbidities who show significant response to treatment.

This study described characteristics, psychiatric diagnoses and response to treatment among patients in an outpatient HIV clinic who screened positive for depression. Depressed (25 %) were less likely to have private insurance, less likely to have suppressed HIV viral loads, had more anxiety symptoms, and were more likely to report current substance abuse than not depressed. Among depressed, 81.2 % met diagnostic criteria for a depressive disorder; 78 % for an anxiety disorder; 61 % for a substance use disorder; and 30 % for co-morbid anxiety, depression, and substance use disorders. Depressed received significantly more treatment for depression and less HIV primary care than not depressed patients. PHQ-9 total depression scores decreased by 0.63 from baseline to 6-month follow-up for every additional attended depression treatment visit. HIV clinics can routinely screen and treat depressive symptoms, but should consider accurate psychiatric diagnosis as well as co-occurring mental disorders.

Effects of therapeutic goal management (TGM) on treatment attendance and drug abstinence among men with co-occurring substance use and axis I mental disorders who are homeless: results of the Birmingham EARTH program.

PURPOSE: This study describes the implementation and impact of Therapeutic Goal Management (TGM) in a Substance Abuse and Mental Health Services Administration (SAMHSA)-sponsored demonstration project entitled Enhanced Addiction Recovery through Housing (EARTH). PARTICIPANTS: The sample included 28 male participants followed at six months who completed some treatment. Forty-three percent were Caucasian, and 57% were African American. The average age of participants was 42 years. DESIGN: The relationships between TGM goal achievement, treatment attendance, and drug abstinence outcomes were studied among EARTH program participants who were homeless and met criteria for co-occurring substance use and severe DSM-IV Axis I mental disorders. RESULTS: The results revealed an overall drug abstinence rate of 72.4% over six months and significant positive relationships between TGM goal achievement and drug abstinence (r=0.693) and TGM goal achievement and treatment attendance (r=0.843). CONCLUSIONS: This research demonstrated the relationship and potential positive impact of systematically setting, monitoring, and reinforcing personalized goals in multiple life areas on drug abstinence and treatment attendance outcomes among persons who are homeless with co-occurring substance use and other Axis I disorders in a integrated community service delivery program.

Opioid abuse among nurse anesthetists and anesthesiologists.

Abuse and dependency on potent opioids have long been recognized as problems among nurse anesthetists and anesthesiologists. Research has provided insight into the incidence of abuse, risk factors associated with this type of dependency, identification of an impaired provider, treatment for abuse and dependency, and prevention strategies. Although several factors influence the development of abuse and dependency, access to potent opioids likely has a large role. This access also makes returning to practice while in recovery extremely difficult because the temptation for relapse continually surrounds a recovering anesthesia provider. There is research supporting successful reentry of anesthesia providers into the practice of anesthesia; however, research also reveals high relapse rates among anesthesia providers who return to the practice of anesthesia. This article reviews the literature regarding opioid abuse and dependency among nurse anesthetists and anesthesiologists and offers implications for future research.

Patient reported outcomes in routine care: advancing data capture for HIV cohort research.

INTRODUCTION: Computerized collection of standardized measures of patient reported outcomes (PROs) provides a novel paradigm for data capture at the point of clinical care. Comparisons between data from PROs and Electronic Health Records (EHR) are lacking. We compare EHR and PRO for capture of depression and substance abuse and their relationship to adherence to antiretroviral therapy (ART). METHODS: This retrospective study includes HIV-positive patients at an HIV clinic who completed an initial PRO assessment April 2008-July 2009. The questionnaire includes measures of depression (PHQ-9) and substance abuse (ASSIST). Self-reported ART adherence was modeled using separate logistic regression analyses (EHR vs PRO). RESULTS: The study included 782 participants. EHR vs PRO diagnosis of current substance abuse was 13% (n = 99) vs 6% (n = 45) (P < .0001), and current depression was 41% (n = 317) vs 12% (n = 97) (P < .0001). In the EHR model, neither substance abuse (OR = 1.25; 95% CI = 0.70-2.21) nor depression (OR = 0.93; 95% CI = 0.62-1.40) was significantly associated with poor ART adherence. Conversely, in the PRO model, current substance abuse (OR = 2.78; 95% CI = 1.33-5.81) and current depression (OR = 1.93; 95% CI = 1.12-3.33) were associated with poor ART adherence. DISCUSSIONS: The explanatory characteristics of the PRO model correlated best with factors known to be associated with poor ART adherence (substance abuse; depression). The computerized capture of PROs as a part of routine clinical care may prove to be a complementary and potentially transformative health informatics technology for research and patient care.

Temporal trends in presentation for outpatient HIV medical care 2000-2010: implications for short-term mortality.

BACKGROUND: Many newly diagnosed patients present to outpatient care with advanced HIV infection. More timely HIV diagnosis and initiation of care has the potential to improve individual health outcomes and has public health implications. OBJECTIVE: To assess temporal trends in late presentation for outpatient HIV medial care as measured by CD4 count <200 cells/mm(3) and the implications on short-term (1-year) mortality. DESIGN: We conducted a cohort study nested in a prospective HIV clinical cohort including patients establishing initial outpatient HIV treatment between 2000-2010. Time series regression analysis evaluated temporal trends in late presentation for care measured by the proportion of patients with a CD4 count <200 cells/mm(3) or an opportunistic infection at enrollment, and also evaluated trends in short-term mortality. PARTICIPANTS: Patients establishing initial outpatient HIV treatment between 2000-2010 at an academic HIV clinic. MAIN MEASURES: The proportion of patients with a CD4 count <200 cells/mm(3) or an opportunistic infection at initial presentation and short-term (1-year) mortality following clinic enrollment. KEY RESULTS: Among 1121 patients, 41% had an initial CD4 count <200 cells/mm(3), 25% had an opportunistic infection and 2.4% died within 1-year of their initial visit. Time series regression analysis demonstrated significant reductions in late presentation for HIV care and decreases in short-term mortality with temporal improvement preceding updated CDC HIV testing recommendations. CONCLUSION: We observed a significant decline in the number of patients presenting for outpatient HIV care with advanced disease, particularly in 2006-2010. A significant trend in improved short-term survival among patients establishing HIV care was also observed, likely related to more timely presentation for outpatient care in more recent years.

A qualitative study of the barriers and facilitators to retention-in-care among HIV-positive women in the rural southeastern United States: implications for targeted interventions.

Retention in HIV medical care has been recognized as critical for long-term favorable clinical outcomes among HIV-positive patients. However, relatively little is known about specific factors related to HIV medical care adherence among HIV-positive women in rural areas in the United States, where the epidemic is rapidly growing among minorities and women. The objective of the current study was to assess barriers and facilitators to HIV clinic visit adherence among HIV-positive women in the rural southeastern region of the United States. Forty HIV-positive women were recruited from four outpatient clinics providing services to HIV-positive patients residing in 23 predominately rural counties in Alabama. Four focus groups were conducted ranging from 5 to 16 participants each. Content analysis was used to analyze and interpret the data. Data coding and sorting was conducted using QRS NVivo 8 software. Participants were predominately African American (92.3%) ranging in age from 29 to 69 years (mean = 46.1 years). On average, participants reported living with HIV for 8.8 years. Factors that impacted participants' ability to maintain clinic visit appointments included personal, contextual, and community/environmental factors that included: patient/provider relationships, family support, access to transportation, organizational infrastructure of the health care facility visited and perceived HIV stigma within their communities. The current study highlights the myriad of retention-in-care barriers faced by HIV-positive women living in rural areas in the southeastern United States. Innovative multilevel interventions that address these factors are sorely needed to increase long-term retention-in-care among HIV-positive women residing in rural areas.

High Multiplicity Infection by HIV-1 in Men Who Have Sex with Men.

Elucidating virus-host interactions responsible for HIV-1 transmission is important for advancing HIV-1 prevention strategies. To this end, single genome amplification (SGA) and sequencing of HIV-1 within the context of a model of random virus evolution has made possible for the first time an unambiguous identification of transmitted/founder viruses and a precise estimation of their numbers. Here, we applied this approach to HIV-1 env analyses in a cohort of acutely infected men who have sex with men (MSM) and found that a high proportion (10 of 28; 36%) had been productively infected by more than one virus. In subjects with multivariant transmission, the minimum number of transmitted viruses ranged from 2 to 10 with viral recombination leading to rapid and extensive genetic shuffling among virus lineages. A combined analysis of these results, together with recently published findings based on identical SGA methods in largely heterosexual (HSX) cohorts, revealed a significantly higher frequency of multivariant transmission in MSM than in HSX [19 of 50 subjects (38%) versus 34 of 175 subjects (19%); Fisher's exact p = 0.008]. To further evaluate the SGA strategy for identifying transmitted/founder viruses, we analyzed 239 overlapping 5' and 3' half genome or env-only sequences from plasma viral RNA (vRNA) and blood mononuclear cell DNA in an MSM subject who had a particularly well-documented virus exposure history 3-6 days before symptom onset and 14-17 days before peak plasma viremia (47,600,000 vRNA molecules/ml). All 239 sequences coalesced to a single transmitted/founder virus genome in a time frame consistent with the clinical history, and a molecular clone of this genome encoded replication competent virus in accord with model predictions. Higher multiplicity of HIV-1 infection in MSM compared with HSX is consistent with the demonstrably higher epidemiological risk of virus acquisition in MSM and could indicate a greater challenge for HIV-1 vaccines than previously recognized.

Substance abuse treatment in an urban HIV clinic: who enrolls and what are the benefits?

Substance abuse treatment (SAT) is important for HIV medical care. Characteristics of those who choose SAT and effects of SAT on HIV clinical outcomes are not understood. We compared patients who enrolled and did not enroll in a SAT program offered within an HIV clinic, and evaluated the effect of SAT on CD4 T-cell counts and HIV plasma viral load (VL). Subjects were assessed and invited to enroll in SAT. Enrollees chose to receive psychological and psychiatric treatment, or motivational enhancement and relapse prevention, or residential SAT. We used logistic regressions to determine factors associated with enrollment (age, race, sex, HIV transmission risk factors, CD4 T-cell counts, and VL at assessment). A two-period (assessment and six months after SAT) data analysis was used to analyze the effect of SAT on CD4 T-cell count and log VL controlling for changes in HIV therapy. We find that, compared to Decliners (N=76), Enrollees (N=78) were more likely to be females (29.5% vs. 6.6%, OR=5.32, 95% CI 1.61-17.6), and to report injection drug use (IDU) as the HIV transmission risk factor (23.1% vs. 9.2%, OR=3.92, CI 1.38-11.1). Age (37.2 vs. 38.4), CD4 T-cell count (377.3 vs. 409.2), and log VL (3.21 vs. 2.99) at assessment were similar across the two groups (p>0.05). After six months, Enrollees and Decliners' CD4 T-cell counts increased and log VL decreased. SAT did not affect the change in CD4 T-cell count (p=0.51) or log VL (p=0.73). Similar results were found for patients with CD4 T-cell count < or =350 at assessment. In this small sample of HIV-infected patients with a limited follow-up period, women were more likely to enroll in SAT than men, and SAT reached those who needed it, e.g., IDUs. We did not find an effect of SAT on HIV clinical outcomes.

Wide variation in the multiplicity of HIV-1 infection among injection drug users.

Recent studies indicate that sexual transmission of human immunodeficiency virus type 1 (HIV-1) generally results from productive infection by only one virus, a finding attributable to the mucosal barrier. Surprisingly, a recent study of injection drug users (IDUs) from St. Petersburg, Russia, also found most subjects to be acutely infected by a single virus. Here, we show by single-genome amplification and sequencing in a different IDU cohort that 60% of IDU subjects were infected by more than one virus, including one subject who was acutely infected by at least 16 viruses. Multivariant transmission was more common in IDUs than in heterosexuals (60% versus 19%; odds ratio, 6.14; 95% confidence interval [CI], 1.37 to 31.27; P = 0.008). These findings highlight the diversity in HIV-1 infection risks among different IDU cohorts and the challenges faced by vaccines in protecting against this mode of infection.

Do PTSD symptoms and course predict continued substance use for homeless individuals in contingency management for cocaine dependence?

Homeless individuals (n=187) entering contingency management (CM) for cocaine dependence were assessed for PTSD diagnosis, and a subset of 102 participants reporting traumatic exposure also periodically completed a self-report measure of PTSD symptoms. Patients with PTSD in full remission at 6 months (end of active treatment) and 12 months (end of aftercare) used substances much less frequently during aftercare than those with no PTSD diagnosis. Those whose PTSD diagnosis improved to full remission status during active treatment, and remained in full remission at 12 months, also had superior substance use outcomes. Severity of PTSD symptoms at 6 months, but not baseline or 2 months, was associated with substance use across treatment phases. Substance use during aftercare, however, was better predicted by changes in PTSD symptom severity. Patients whose PTSD symptoms improved more during active treatment fared better during aftercare than those with less improvement. Findings suggest homeless individuals with comorbid PTSD entering CM for cocaine dependence are not necessarily at increased risk for substance use compared to those without the comorbidity. However, course of PTSD does predict substance use, with the potential for CM to be unusually effective for those who respond with substantial, lasting improvements in PTSD.

Routine, self-administered, touch-screen, computer-based suicidal ideation assessment linked to automated response team notification in an HIV primary care setting.

BACKGROUND: Human immunodeficiency virus (HIV) and AIDS continue to be associated with an underrecognized risk for suicidal ideation, attempted suicide, and completed suicide. Suicidal ideation represents an important predictor for subsequent attempted and completed suicide. We sought to implement routine screening of suicidal ideation and associated conditions using computerized patient-reported outcome (PRO) assessments. METHODS: Two geographically distinct academic HIV primary care clinics enrolled patients who attended scheduled visits from December 2005 through February 2009. Touch-screen, computer-based PRO assessments were implemented into routine clinical care. Substance abuse, alcohol consumption, depression, and anxiety were assessed. The 9-item Patient Health Questionnaire assesses the frequency of suicidal ideation in the preceding 2 weeks. A response of "nearly every day" triggered an automated page to predetermined clinic personnel, who completed more detailed self-harm assessments. RESULTS: Overall, 1216 patients (740 from the University of Alabama at Birmingham and 476 from the University of Washington) completed the initial PRO assessment during the study period. Patients were predominantly white (646 [53%]) and male (959 [79%]), with a mean age (+/- standard deviation) of 44 +/- 10 years. Among surveyed patients, 170 (14%) endorsed some level of suicidal ideation, whereas 33 (3%) admitted suicidal ideation nearly every day. In multivariable analysis, suicidal ideation risk was lower with advancing age (odds ratio [OR], 0.74 per 10 years; 95% confidence interval [CI], 0.58-0.96) and was increased with current substance abuse (OR, 1.88; 95% CI, 1.03-3.44) and more-severe depression (OR, 3.91 for moderate depression [95% CI, 2.12-7.22] and 25.55 for severe depression [95% CI, 12.73-51.30]). DISCUSSION: Suicidal ideation was associated with current substance abuse and depression. The use of novel technologies to incorporate routine self-reported screening for suicidal ideation and other health domains allows for timely detection and intervention for this life-threatening condition.

Effects of sustained abstinence among treated substance-abusing homeless persons on housing and employment.

OBJECTIVES: We examined whether cocaine-dependent homeless persons had stable housing and were employed 6, 12, and 18 months after they entered a randomized controlled trial comparing 2 treatments. METHODS: One group (n = 103) received abstinence-contingent housing, vocational training, and work; another group (n = 103) received the same intervention plus cognitive behavioral day treatment. We examined baseline and early treatment variables for association with long-term housing and employment. RESULTS: Although the enhanced-treatment group achieved better abstinence rates, the groups did not differ in long-term housing and employment stability. However, consecutive weeks of abstinence during treatment (and to a lesser extent, older age and male gender) predicted long-term housing and employment stability after adjustment for baseline differences in employment, housing, and treatment. CONCLUSIONS: Our data showed a relationship of abstinence with housing stability. Contrasting these results with the increasingly popular Housing First interventions reveals important gaps in our knowledge to be addressed in future research.