Outness, Discrimination, and Psychological Distress Among LGBTQ+ People Living in the Southern United States.

Purpose: Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people face mental health disparities. These disparities are amplified in the Southern regions of the United States. This study assessed the role of outness, discrimination, and other demographic variables on possible serious mental illness (SMI) among LGBTQ+ Southerners. Methods: This study used data from the 2017 LGBT Institute Southern Survey, a cross-sectional convenience sample of 6502 LGBTQ+ adults living in 14 Southern states. Multivariable logistic regression was performed to examine differences between those with and without possible SMI. Results: Outness was associated with a lower likelihood of possible SMI (odds ratio [OR]: 0.696, 95% confidence interval [CI]: 0.574-0.844, p = 0.001), especially when controlling for discrimination in the past 12 months (OR: 0.693, 95% CI: 0.576-0.834, p ≤ 0.001) and lifetime discrimination (OR: 0.678, 95% CI: 0.554-0.829, p = 0.001). Lifetime discrimination was associated with a higher likelihood of possible SMI (OR: 1.413, 95% CI: 1.034-1.932, p = 0.033), as was discrimination experienced in the past 12 months (OR: 1.626, 95% CI: 1.408-1.877, p ≤ 0.001). Black/African American respondents had the lowest percentage of possible SMI (21.0%) compared with other races, despite having lower or comparable rates of outness. Conclusion: These results indicate a possible promotive effect of outness against possible SMI among LGBTQ+ Southerners, as well as possible promotive group-level factors among Black/African American LGBTQ+ Southerners. Policies and interventions that address discrimination against LGBTQ+ Southerners should be expanded, and future research should address how the relationships between outness, discrimination, and mental health outcomes may vary by subgroup.

Conversion Therapy in the Southern United States: Prevalence and Experiences of the Survivors.

Numerous studies have determined that conversion therapy, a practice meant to change one's sexual orientation to heterosexual or gender identity to cisgender, can be ineffective and severely harmful. However, few studies have documented the prevalence or characteristics of its survivors. This study is a quantitative analysis of the LGBTQ Institute Southern Survey that estimates the prevalence of conversion therapy (specifically SOCE) in the Southern United States and documents its significant association with negative mental health outcomes. Conversion therapy survivors comprised 7.6% of the sample (11.6% after listwise deletion). Respondents who were younger and reported being a gender minority; lesbian, gay, or some other sexual orientation; Hispanic; less educated; and less religious were more likely to have experienced it. Findings support previous studies which report a strong correlation between conversion therapy and poor mental health outcomes. Results regarding the prevalence and demographics of survivors offer new insights for further research.

Preferences for Shigellosis-Related Health Promotion Materials for Gay, Bisexual, and Other Men Who Have Sex With Men: Results From a Qualitative Assessment, Atlanta, GA.

BACKGROUND: Shigellosis, an acute diarrheal disease, is the third most common bacterial infection in the United States. Shigellosis most commonly affects children younger than 5 years; however, clusters and outbreaks of shigellosis have been reported among gay, bisexual, and other men who have sex with men (MSM). Evidence suggests that knowledge of shigellosis among MSM is low, indicating health promotion outreach is needed for this population. METHODS: To inform the development of shigellosis-related health communication materials and strategies, 6 focus groups were conducted in 2017, in Atlanta, GA among 24 self-identified gay and bisexual men. Participants were asked about their preferences and recommendations for health communication materials. RESULTS: Participants indicated they would prefer a range of physical and virtual materials placed in diverse locations where the community would see them. Respondents recommended health messages be simple, quick to read, and concise with limited word counts. Participants also advised the use of diverse images that were inclusive of couples of varying sexual orientations to reduce stigma. Participants advocated for the use of humor and provocative images to increase user engagement. CONCLUSIONS: The results emphasize the potential benefits of conducting formative research when designing health communication materials. Incorporating messaging preferences of MSM in the development of shigellosis-related health communication materials could enhance their relevance for the target population while also avoiding unintended consequences associated with stigmatizing MSM.

Factors Associated With HIV Testing Among Atlanta's Homeless Youth.

Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

Shigellosis Among Gay and Bisexual Men: A Qualitative Assessment to Examine Knowledge, Attitudes, and Practices.

BACKGROUND: Shigellosis is a highly contagious enteric bacterial disease transmitted through the fecal-oral route. It is primarily transmitted through person-to-person contact and via contaminated food and water. Outbreaks of shigellosis among men who have sex with men (MSM) attributed to sexual person-to-person contact have been reported. These outbreaks are of concern because they are often caused by multidrug-resistant strains of Shigella. Little is known about shigellosis-related knowledge, attitudes, and practices among gay, bisexual, and other MSM. METHODS: Six focus groups were conducted among self-identified gay or bisexual men in Atlanta, GA, in Fall 2017. Participants were asked about shigellosis-related knowledge, attitudes, and practices. Focus groups were audio recorded, and the transcribed audio was analyzed using inductive and deductive thematic coding. RESULTS: Among the 24 focus group participants, most perceived that diarrheal illness was caused by contaminated food. Knowledge of shigellosis and Shigella was low, with most never having heard of the disease or bacteria. Participants did not perceive shigellosis to be a serious health concern, especially when compared with HIV; however, they did perceive gay and bisexual men to be at risk of Shigella infection. Participants reported mixed intentions to change sexual behaviors to prevent shigellosis or talk with sexual partners about diarrhea. CONCLUSIONS: Health communication and education efforts could be used to increase knowledge about shigellosis and shift perceptions about the severity of shigellosis among gay, bisexual, and other MSM. Additional work is needed to identify effective ways to promote shigellosis-related prevention behaviors among gay, bisexual, and other MSM.

Assessment of risk behaviors in patients with opioid prescriptions: A study of indiana's inspect data.

BACKGROUND AND OBJECTIVES: Prescription Drug Monitoring Programs (PDMPs) can serve as screening tools and support the clinical decision-making process in patients receiving opioids. The objective of the study was to utilize 2014 INSPECT (Indiana's PDMP) data to identify factors that increase patients' likelihood to engage in opioid-related risk behaviors. METHODS: Based on a literature review, four risk behaviors were identified: Receiving >90 morphine milligram equivalents (MME), having >4 opioid prescribers, obtaining opioids from >4 pharmacies, and concurrent use of opioids and benzodiazepines. Two binary logistic regression analyses (engaging in at least one risk behaviors; engaging in all four risk behaviors) and an ordinal regression analysis (engaging in 0-4 risk behaviors) were conducted to identify factors associated with these opioid-related risk behaviors. RESULTS: Of the 1,538,120 unique opioid patients included in the study, 18.4% engaged in one, 5.3% in two, 1.6% in three, and .4% in all four risk behaviors. Depending on the model, prescribing a second monthly opioid increased patients' odds to engage in risk behaviors by a factor of 10 or more and prescribing two or more benzodiazepines annually increased the odds at least 13-fold. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: About one-fourth of all patients consuming opioids engaged in one or more risk behaviors; higher number of opioid prescriptions and addition of even a small number of benzodiazepine prescriptions dramatically increased these odds. PDMPs can be helpful in identifying opioid users at high-risk for misuse. This information could be used to target efforts to reduce the prescription drug epidemic. (Am J Addict 2017;26:822-829).

A qualitative analysis of prescribers' and dispensers' views on improving prescription drug monitoring programs.

BACKGROUND: Prescription drug abuse is epidemic in the United States (US). To help address the problem, most states operate prescription drug monitoring programs (PDMPs). PDMPs are designed to monitor and help control the distribution of controlled therapeutic medications and to assist prescribers and dispensers in making informed clinical decisions. To this end, PDMPs rely on timely and accurate data submission, as well as review of the data. Consequently, provider acceptance of these systems is essential to maximize their effectiveness. OBJECTIVES: This article explores licensed prescribers' and dispensers' opinions regarding prescription drug monitoring. METHODS: The study surveyed licensed prescribers and dispensers about their experiences and views on drug monitoring, prescribing and dispensing practices, and on prescription drug abuse in general. Two open-ended questions were posed as part of a larger, end-user survey. The analysis culled thematically-coded excerpts to these two questions. RESULTS: Respondents offered a range of comments that unearthed important disagreements among prescribers and dispensers over the administration and ethics pertaining to PDMPs. At the same time, some respondents suggested means to enhance PDMPs functionality. CONCLUSION: Attending to and rectifying providers' views, while considering their improvement suggestions may boost PDMPs effectiveness by maximizing buy-in and utilization. The potential speaks to advancing a tool that intends to help address alarming rates of prescription drug abuse.

Older Gay Men and Their Support Convoys.

OBJECTIVE: We used the convoy model and the network type construct to identify the relationship quality profiles found among older gay men and to examine how they define a satisfactory network. METHOD: We used a network mapping strategy and in-depth qualitative interviews with 20 participants in Atlanta. During the interviews, all network members were discussed, regardless of relationship or map position. RESULTS: For participants, having people in their lives with whom they could fully be "out" as gay men (authenticity) was at the root of a quality network. This allowed them to develop emotional closeness (intimacy), which, in part, provided a foundation of social support. Participants' discussion of network quality, which reflected authenticity, intimacy, and social support, revealed high, moderate, and low quality network types. DISCUSSION: Our findings diversify knowledge of the network type construct, provide a deeper understanding of its qualitative features, and give voice to this often-invisible group, situating meaning within their social-historical context. The findings suggest that the meaning of a quality network is contextual and culturally specific, varying across groups of older adults.

Promoting consistent use of prescription drug monitoring programs (PDMP) in outpatient pharmacies: Removing administrative barriers and increasing awareness of Rx drug abuse.

BACKGROUND: Prescription drug monitoring programs (PDMPs) are proving to be valuable resources in fighting the prescription drug abuse epidemic through improved access to patient drug histories. Ninety-four percent of Indiana pharmacists have heard of Indiana's PDMP (INSPECT), only 71% of them reported using the program in 2012. OBJECTIVE: To identify barriers to PDMP use in outpatient pharmacies and determine the impact these barriers have on utilization. METHODS: A cross-sectional study examined pharmacists' knowledge and use of INSPECT. Bivariate analyses on utilization and perceived barriers were conducted using cross-tabulations and chi-squared tests. Multiple logistic regression examined the relationship between pharmacists' level of concern with prescription drug abuse and reported utilization. RESULTS: Pharmacists were significantly less likely to use INSPECT if they reported at least one barrier and 3 times more likely to use INSPECT if they reported no barrier. Pharmacists were 10 times more likely to use INSPECT and 18 times more likely to use it more consistently if they were extremely concerned about prescription drug abuse in their community as compared to those not at all concerned. CONCLUSION: Strategies to improve utilization of PDMPs should look for innovative ways to limit barriers and build outpatient pharmacists' awareness of prescription drug abuse and misuse within their community.

Integration of prescription drug monitoring programs (PDMP) in pharmacy practice: Improving clinical decision-making and supporting a pharmacist's professional judgment.

BACKGROUND: Pharmacists have shared responsibility to investigate the validity of controlled substance prescriptions (CSPs) that raise concerns, or red flags, and subsequently exercise their right to refuse to dispense a CSP if its validity cannot be verified. Improving access to clinical practice tools, such as prescription drug monitoring programs (PDMPs), may increase availability of a patient's drug history, which is critical to making informed clinical decisions about dispensing CSPs. OBJECTIVES: The purpose of this study was to examine how integration and consistent use of a PDMP in pharmacy practice impacts pharmacists' dispensing practices related to CSPs. METHODS: A cross-sectional study examined pharmacists' knowledge and use of Indiana's (US State) PDMP (INSPECT) and dispensing practices of CSPs. Three outcome measures were analyzed using multiple logistic regression so as to examine the relationship between PDMP use and pharmacists' controlled substance dispensing behaviors. RESULTS: Pharmacists were 6.4 times more likely to change their dispensing practice to dispense fewer CSPs if they reported that INSPECT provides increased access to patient information. Pharmacists who always use INSPECT refused an average of 25 CSPs annually compared to an average of 7 refusals for pharmacists not using INSPECT. Pharmacists using INSEPCT consistently (at every visit) were 3.3 times more likely to refuse to dispense more CSPs than pharmacists who report never using INSPECT. CONCLUSIONS: Integration of PDMPs in pharmacy practice may improve a pharmacist's ability to make informed clinical decisions and exercise sound professional judgment. Providing clinical practice tools to both prescribers and pharmacists is important to preventing drug diversion and prescription drug abuse. Future research should focus on understanding the barriers and challenges to successful integration of PDMPs in pharmacy practice.

State-level marriage equality and the health of same-sex couples.

OBJECTIVES: We assessed the association between the health of people in same-sex relationships and the degree and nature of the legal recognition of same-sex relationships offered in the states in which they resided. METHODS: We conducted secondary data analyses on the 2010 to 2013 Current Population Survey and publicly available data from Freedom to Marry, Inc. We estimated ordered logistic regression models in a 4-level framework to assess the impact of states' legal stances toward same-sex marriage on self-assessed health. RESULTS: Our findings indicated, relative to states with antigay constitutional amendments, that same-sex couples living in states with legally sanctioned marriage reported higher levels of self-assessed health. CONCLUSIONS: Our findings suggested that full legal recognition of same-sex relationships through marriage might be an important legal and policy strategy for improving the health of same-sex couples.

Sexuality and intimacy among people living with serious mental illnesses: Factors contributing to sexual activity.

OBJECTIVE: Limited research has focused on sexuality for those diagnosed with a severe mental illness. We aimed to extend existing work by exploring relationships between mastery (perception of control of one's life and future), sexual self-esteem (perceptions of one's capacity to engage in healthy sexual behavior), sexual attitudes (permissive ideas about sexuality), and perceived importance of relationships/sexuality and number of sexual partners. METHOD: A secondary analysis of survey data from adult participants living with a severe mental illness (N = 401) in the Indiana Mental Health Services and HIV-Risk Study (Perry & Wright, 2006) was conducted. Analysis of covariance (controlling for marital status) compared those with 0 partners, 1 partner, or multiple partners over the past 3 months on the dependent variables of mastery, sexual self-esteem, sexual attitudes, and perceived importance. RESULTS: Participants with more permissive attitudes, greater perceived importance, and higher mastery were more likely to be sexually active with multiple partners. Self-esteem did not differentiate groups. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Given the key role of sexual satisfaction in quality of life and the high rates of sexual risk behavior in this population, it is important that clinicians systematically assess mastery, perceived importance, and attitudes about sexuality when working with consumers diagnosed with a severe mental illness. Individually tailoring existing interventions on the basis of consumers' levels of mastery, related to self-efficacy for implementing changes in life, could improve long-term outcomes for these programs. Future research should examine other constructs that may account for more variance in sexual activity, such as perceptions of risk, intentions for sexual safety, or romantic relationship functioning.

Prescription drug monitoring program inquiry in psychiatric assessment: detection of high rates of opioid prescribing to a dual diagnosis population.

OBJECTIVE: An epidemic of prescription drug abuse is disproportionately impacting the mentally ill. We examined the utility of a state prescription drug monitoring database for assessing recent controlled substance prescribing to patients presenting for dual diagnosis treatment. METHOD: In a community mental health center that provides integrated dual diagnosis care, we queried the Indiana Scheduled Prescription Electronic Collection and Tracking (INSPECT) system for all cases that were open as of August 2, 2011, and had been practitioner-diagnosed (per DSM-IV criteria) by January 2, 2012. INSPECT provided a record of controlled substance dispensations to each patient; diagnostic evaluation was conducted blind from prescription data compilation covering the prior 12 months. Demographic data, insurance status, and DSM-IV diagnoses were compiled from the clinic's electronic medical record. RESULTS: The sample (N = 201) was 51% female, 56% white, and two-thirds uninsured. Over 80% were dually diagnosed with substance use disorders and psychotic, mood, or anxiety disorders. Nicotine and alcohol disorders were identified in most, with about a third diagnosed with cannabis, cocaine, or opioid disorders. A majority of patients (n = 115) had been prescribed opioids in the prior year, with nearly 1 in 5 prescribed an opioid and benzodiazepine simultaneously. Patients were dispensed a mean of 4 opioid prescriptions and 213 opioid pills. More opioid prescriptions correlated with opioid dependence (OR = 1.08; 95% CI, 1.016-1.145), and more prescribers correlated with personality disorder diagnoses (OR = 1.112; 95% CI, 1.001-1.235). Higher rates and riskier patterns of controlled substance prescribing were identified in patients with Medicaid/Medicare insurance compared to uninsured patients. CONCLUSIONS: Prescription drug monitoring is a powerful tool for assessing addictions and high frequencies of patient exposures to prescribed opioids in a dual diagnosis clinic. Improved prevention and treatment strategies for addictions as facilitated by more research and clinical use of prescription drug monitoring in psychiatric care are warranted.

The iatrogenic epidemic of prescription drug abuse: county-level determinants of opioid availability and abuse.

BACKGROUND: Opioid use and abuse in the United States continues to expand at an alarming rate. In this study, we examine the county-level determinants of the availability and abuse of prescription opioids to better understand the socio-ecological context, and in particular the role of the healthcare delivery system, on the prescription drug abuse epidemic. METHODS: We use community-level information, data from Indiana's prescription drug monitoring program in 2011, and geospatial regression methods to identify county-level correlates of the availability and abuse of prescription opioids among Indiana's 92 counties. RESULTS: The findings suggest that access to healthcare generally, and to dentists and pharmacists in particular, increases the availability of prescription opioids in communities, which, in turn, is associated with higher rates of opioid abuse. CONCLUSIONS: The results suggest that the structure of the local healthcare system is a major determinant of community-level access to opioids adding to a growing body of evidence that the problem of prescription opioid abuse is, at least in part, an "iatrogenic epidemic."

Service utilization, expenditures, and success in a well-established system of care for young people with serious emotional disorders.

A major challenge in the implementation of systems of care is creating mechanisms to pay for services that are provided across social services systems and by multiple agencies. Using a managed care approach to coordinate service provision may be one way to effectively bridge the gap across agencies while also providing quality care. The authors explore the benefits of a managed care approach to service delivery within a well established system of care by describing the treatment planning process used by the system of care; describing the type and patterns of services provided to young people; and by describing the process used to bill for services. The authors also examine the impact of client and service characteristics on overall expenditures as well as the effect that patterns of service utilization and expenditures of care have on the likelihood that young people and their families will successfully meet their clinical objectives.

Predicting outcomes among adolescents with disruptive disorders being treated in a system of care program.

BACKGROUND: "Systems of care" are strengths-based approaches to treating adolescents and others with disruptive disorders. However, little is known about why some adolescents improve and others do not. OBJECTIVE: To examine changes in personal strengths and family functioning as predictors of behavioral and social functioning among adolescents with disruptive disorders who participated in a system of care program. DESIGN: Secondary analyses of data from 114 adolescents (12-17 years of age) with disruptive disorders and their caregivers who participated in the Dawn Project Evaluation Study. Caregivers completed in-depth interviews conducted by trained data collectors using standardized questionnaires. Baseline and 12- month data are reported here. RESULTS: Improvement in personal strengths was a significant predictor of improvement in adolescent behavioral and social functioning, controlling for demographics (p < .001). CONCLUSION: In adolescents with disruptive disorders, psychiatric nurses should focus on enhancing adolescents' personal strengths to improve behavioral and social functioning.

Perceived mental illness stigma, intimate relationships and sexual risk behavior in youth with mental illness.

The current study examines the role of mental illness-related stigma on romantic or sexual relationships and sexual behavior among youth with mental illness (MI), including youths' experiences of stigma, the internalization of these experiences, and the behavior associated with managing stigma within romantic and sexual relationships. We conducted in-depth interviews with N=20 youth with mental illness (MI) (55% male, 16-24 years, 75% Latino) from 4 psychiatric outpatient clinics in New York City. We conducted a thematic analysis to investigate shared experiences of MI stigma and its impact on youth's sexual or romantic relationships and associated behaviors. Our analysis revealed four main themes: 1) societal perceptions of those with MI as partners (societal stigma); 2) individual experiences of stigma within relationships (individual level); 3) internalized stigma of self as a partner (social-psychological processes); and 4) managing a stigmatized identity, of which some of the behaviors directly placed them at increased risk for HIV. We found that just under half of the sample (n=9/20) endorsed all themes, including engaging in HIV/STI sexual risk behaviors as a method to manage a stigmatize identity, which suggests that MI stigma and sexual risk may be linked. We discuss differences by gender and diagnosis. Findings provide new information for providers and researchers to address on the role of stigma experiences in the romantic and sexual behavior of youth in psychiatric treatment. Implications for stigma and HIV/STI prevention interventions are discussed.

Perceived Mental Illness Stigma Among Youth in Psychiatric Outpatient Treatment.

This research explores the experiences of mental illness stigma in 24 youth (58.3% male, 13-24 years, 75% Latino) in psychiatric outpatient treatment. Using Link and Phelan's (2001) model of stigmatization, we conducted thematic analysis of the interview texts, examining experiences of stigma at individual and structural levels, in addition to the youths' social-psychological processes. Youth in psychiatric treatment acknowledged that their larger cultural context holds pejorative viewpoints toward those with mental illness and reported experiences of stigma within their families and social networks. Our results also offer insight into the social-psychological processes of stigma, highlighting how labeling may influence their self-concept and the strategies in which youth engage to manage a stigmatized identity. We discuss differences in stigma experiences by gender, age, and diagnosis. Findings provide new information on the stigma experiences of youth in psychiatric treatment and suggest that a multilevel approach to reduce stigma is warranted.

Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol).

OBJECTIVES: Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues. METHODS: A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38-95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol). RESULTS: Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1-17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers. CONCLUSIONS: Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.