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Item Acceptability of an mHealth App for Youth With Substance Use and Mental Health Needs: Iterative, Mixed Methods Design(JMIR Publications, 2021-12-24) Adams, Zachary; Grant, Miyah; Hupp, Samantha; Scott, Taylor; Feagans, Amanda; Phillips, Meredith Lois; Bixler, Kristina; Nallam, Phani Teja; La Putt, Dorothy; Psychiatry, School of MedicineBackground: Treating substance use disorders (SUDs) during adolescence can prevent adult addiction and improve youth outcomes. However, it can be challenging to keep adolescents with SUDs engaged in ongoing services, thus limiting potential benefits. Developmentally appropriate tools are needed to improve treatment engagement during and between sessions for youth with SUDs and mental health disorders. Mobile health apps may augment or replace psychotherapy components; however, few have been developed specifically for youth with SUDs following user-guided design principles, which may limit their appropriateness and utility. Formative research on acceptability to intended end users is needed before the efficacy of such tools can be examined. Objective: This study involves user-centered, iterative development and initial user testing of a web-based app for adolescents with SUDs and mental health concerns. Methods: Adolescents aged 14 to 17 years with past-year involvement in outpatient psychotherapy and behavioral health clinicians with adolescent SUD treatment caseloads were recruited. Across 2 assessment phases, 40 participants (alpha: 10 youths and 10 clinicians; beta: 10 youths and 10 clinicians) viewed an app demonstration and completed semistructured interviews and questionnaires about app content and functionality. Results: Participants expressed positive impressions of the app and its potential utility in augmenting outpatient therapy for youth with SUDs and mental health concerns. Noted strengths included valuable educational content, useful embedded resources, and a variety of activities. Adolescents and clinicians favored the app over conventional (paper-and-pencil) modalities, citing convenience and familiarity. The app was found to be user-friendly and likely to improve treatment engagement. Adolescents suggested the inclusion of privacy settings, and clinicians recommended more detailed instructions and simplified language. Conclusions: The novel app developed here appears to be a promising, acceptable, and highly scalable resource to support adolescents with SUDs and mental health concerns. Future studies should test the efficacy of such apps in enhancing adolescent behavioral health treatment engagement and outcomes.Item Atypical Cortical Activation during Risky Decision-making in Disruptive Behavior Disordered Youth with Histories of Suicidal Ideation(Elsevier, 2020) Dir, Allyson L.; Allebach, Christian L.; Hummer, Tom A.; Adams, Zachary; Aalsma, Matthew C.; Finn, Peter R.; Nurnberger, John I.; Hulvershorn, Leslie A.; Psychiatry, School of MedicineBackground: Suicidality is a leading cause of death among adolescents. In addition to other psychiatric conditions, youths with attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (DBDs) are at heightened risk for suicide. Decision-making deficits are a hallmark symptom of ADHD and DBDs and are also implicated in suicidal behavior. We examined behavioral and neural differences in decision making among youths with ADHD and DBDs with (SI+) and without (SI-) histories of suicidal ideation. Methods: The Balloon Analog Risk Task, a risky decision-making task, was completed by 57 youths with ADHD and DBDs (38% SI+) during functional magnetic resonance imaging. Mean stop wager (mean wager at which youths bank money) was the primary measure of risk taking. We conducted whole-brain and region-of-interest analyses in the anterior cingulate cortex and orbitofrontal cortex (OFC) during choice (win vs. inflate) and outcome (inflate vs. explode) contrasts using parametric modulators accounting for probability of balloon explosion. Results: There were no differences between SI+ and SI- youths in Balloon Analog Risk Task performance. SI+ youths showed decreasing activation in the right medial frontal gyrus when choosing inflate as explosion probability increased compared with SI- youths. During explosions, SI- youths showed increasing activation in the left OFC as explosions became more likely. SI+ showed increasing left medial OFC activity in response to inflations as explosion probability increased. Conclusions: SI+ youths may show heightened sensitivity to immediate reward and decreased sensitivity to potential loss as evidenced by medial frontal gyrus activity. OFC findings suggest that SI+ youths may be drawn to reward even when there is high probability of loss.Item Long-term Prescription Opioid Utilization, Substance Use Disorders, and Opioid Overdoses after Adolescent Trauma(Wolters Kluwer, 2019-03) Bell, Teresa M.; Raymond, Jodi; Vetor, Ashley; Mongalo, Alejandro; Adams, Zachary; Rouse, Thomas; Carroll, Aaron; Surgery, School of MedicineBACKGROUND Injured adolescents have a 56% increased risk of developing a substance use disorder (SUD) within 3 years of their injury. The transition from medical prescription opioid use to nonmedical use in adolescent trauma patients has not been longitudinally studied long-term. The aim of this study is to describe 5-year patterns of opioid use in a cohort of injured adolescents as well as the proportion of patients experiencing overdose and SUD diagnoses. METHODS Our retrospective cohort study consisted of 736 patients 12-18 years old who were admitted for trauma from 2011-2013. We examined up to 5 years of regional health information exchange data containing information on prescription fills as well as diagnoses from inpatient, outpatient, and emergency department encounters. RESULTS At 1 year, over 20% of adolescents filled more than 2 opioid prescriptions after being discharged for their injury; and at 4 years, over 13% had received more than 8 opioid fills. Over the 5 year period, 11% received an opioid antagonist injection, 14% received an SUD diagnosis, and 8% had an overdose diagnosis. Relatively few patients had diagnoses for other mental health conditions including depression (5.5%), post-traumatic stress disorder (PTSD) (2.1%), and chronic pain (3.6%). CONCLUSIONS Opioid usage remains high for multiple years in a subset of the adolescent trauma population. Mental health diagnosis rates were substantially lower in injured adolescents than what has been reported in adults. However, overdose and SUD diagnoses occur in over 1 in 10 adolescents within 5 years of their injury.Item Longitudinal Prospective Study of Emergency Medicine Provider Wellness Across Ten Academic and Community Hospitals During the Initial Surge of the COVID-19 Pandemic(2020-10-15) Kelker, Heather; Yoder, Kyle; Musey, Paul; Harris, Madison; Johnson, Olivia; Sarmiento, Elisa; Vyas, Punit; Henderson, Brooke; Adams, Zachary; Welch, Julie L.; Emergency Medicine, School of MedicineBackground: While the coronavirus (COVID-19) has had far-reaching consequences on society and health care providers, there is a paucity of research exploring emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (APPs) during the initial phase of the COVID-19 pandemic. Methods: A longitudinal, descriptive, prospective cohort survey study of 213 EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher’s Exact, and logistic regression was performed. Results: Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85% to 61% (p<0.001). Impact on basic self-care declined from 66% to 32% (p<0.001). Symptoms of stress, anxiety or fear was initially 83% and reduced to 66% (p=0.009). Reported strain on relationships and feelings of isolation affected >50% of respondents initially without significant change (p=0.05 and p=0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95%CI 1.82-5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10-5.47). Baseline resilience was normal to high. Provider well-being improved over the four-weeks (30% to 14%; p=0.01), but burnout did not significantly change (30% to 22%; p=0.39). Conclusion: This survey of frontline EM providers during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, with many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.Item Mobile devices for the remote acquisition of physiological and behavioral biomarkers in psychiatric clinical research(Elsevier, 2017-02) Adams, Zachary; McClure, Erin A.; Gray, Kevin M.; Danielson, Carla Kmett; Treiber, Frank A.; Ruggiero, Kenneth J.; Psychiatry, School of MedicinePsychiatric disorders are linked to a variety of biological, psychological, and contextual causes and consequences. Laboratory studies have elucidated the importance of several key physiological and behavioral biomarkers in the study of psychiatric disorders, but much less is known about the role of these biomarkers in naturalistic settings. These gaps are largely driven by methodological barriers to assessing biomarker data rapidly, reliably, and frequently outside the clinic or laboratory. Mobile health (mHealth) tools offer new opportunities to study relevant biomarkers in concert with other types of data (e.g., self-reports, global positioning system data). This review provides an overview on the state of this emerging field and describes examples from the literature where mHealth tools have been used to measure a wide array of biomarkers in the context of psychiatric functioning (e.g., psychological stress, anxiety, autism, substance use). We also outline advantages and special considerations for incorporating mHealth tools for remote biomarker measurement into studies of psychiatric illness and treatment and identify several specific opportunities for expanding this promising methodology. Integrating mHealth tools into this area may dramatically improve psychiatric science and facilitate highly personalized clinical care of psychiatric disorders.Item Prospective study of emergency medicine provider wellness across ten academic and community hospitals during the initial surge of the COVID-19 pandemic(Springer, 2021) Kelker, Heather; Yoder, Kyle; Musey, Paul, Jr.; Harris, Madison; Johnson, Olivia; Sarmiento, Elisa; Vyas, Punit; Henderson, Brooke; Adams, Zachary; Welch, Julie; Emergency Medicine, School of MedicineBackground While COVID-19 has had far-reaching consequences on society and health care providers, there is a paucity of research exploring frontline emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (e.g., nurse practitioners and physician assistants; APPs) during the initial phase of the COVID-19 pandemic. Methods A descriptive, prospective, cohort survey study of EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher’s Exact, and logistic regression was performed. Results Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85 to 61% (p < 0.001). Impact on basic self-care declined from 66 to 32% (p < 0.001). Symptoms of stress, anxiety, or fear was initially 83% and reduced to 66% (p = 0.009). Reported strain on relationships and feelings of isolation affected > 50% of respondents initially without significant change (p = 0.05 and p = 0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95% CI 1.82–5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10–5.47). Baseline resilience was normal to high. Provider well-being improved over the four weeks (30 to 14%; p = 0.01), but burnout did not significantly change (30 to 22%; p = 0.39). Conclusion This survey of frontline EM providers, including physicians and APPs, during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, putting many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.Item Provider engagement in Indiana’s opioid use disorder ECHO programme: there is a will but not always a way(BMJ, 2021) Agley, Jon; Henderson, Cris; Adams, Zachary; Hulvershorn, Leslie; Psychiatry, School of MedicineItem Rates of Tobacco Use Disorder, Pharmacologic Treatment, and Associated Mental Health Disorders in a Medicaid Claim Review Among Youth in Indiana, USA(Sage, 2022) McBrayer, Kimberly; Ouyang, Fangqian; Adams, Zachary; Hulvershorn, Leslie; Aalsma, Matthew C.; Pediatrics, School of MedicinePurpose This study delineates a number of Medicaid youth with tobacco use disorder (TUD), prescribing habits for treatment, and associated externalizing disorders. Methods Youth Medicaid claims from 2007-2017 processed in a large Midwestern city were analyzed for a diagnosis of TUD, related pharmacotherapy, and externalizing mental health and substance use disorders. Results Claims connected 6541 patients with 42 890 visits. Mean age was 16.4 with 40% female. 1232 of the 6541 charts contained a TUD diagnosis equating to 1848 visits. A comorbid diagnosis of ADHD, cannabis use, and conduct disorder were more common in males (3.9% vs 1.3% in females; 3.4% vs .8%; and 2.8% vs .8%; P < .05). 808 scripts were provided to 152 of the 1232 youths, with 4.7% of those scripts a nicotine replacement product. Conclusions Pharmacotherapy is underutilized in this Medicaid claims data set. Certain externalizing factors were associated with males with TUD more than females.Item Safety and Efficacy of Exposure-Based Risk Reduction Through Family Therapy for Co-occurring Substance Use Problems and Posttraumatic Stress Disorder Symptoms Among Adolescents(JAMA, 2020-06-01) Kmett Danielson, Carla; Adams, Zachary; McCart, Michael R.; Chapman, Jason E.; Sheidow, Ashli J.; Walker, Jesse; Smalling, Anna; de Arellano, Michael A.; Psychiatry, School of MedicineImportance: No empirically supported treatments have been evaluated to address co-occurring substance use problems (SUP) and posttraumatic stress disorder (PTSD) symptoms among adolescents in an integrative fashion. This lack is partially owing to untested clinical lore suggesting that delivery of exposure-based PTSD treatments to youth with SUP might be iatrogenic. Objective: To determine whether an exposure-based, integrative intervention for adolescents with SUP and PTSD symptoms-risk reduction through family therapy (RRFT)-resulted in improved outcomes relative to a treatment-as-usual (TAU) control condition consisting primarily of trauma-focused cognitive behavioral therapy. Design, setting, and participants: This randomized clinical trial enrolled 124 participants who were recruited from November 1, 2012, through January 30, 2017. Adolescents (aged 13-18 years) who engaged in nontobacco substance use at least once during the past 90 days, experienced at least 1 interpersonal traumatic event, and reported 5 or more PTSD symptoms were enrolled. Blinded assessments were collected at baseline and at 3, 6, 12, and 18 months after baseline. Recruitment and treatment took place in community-based child advocacy centers in the Southeastern United States. Data were analyzed from August 2 through October 4, 2018, and were based on intention to treat. Interventions: Participants were randomized to receive RRFT (n = 61) or TAU (n = 63). Main outcomes and measures: Primary outcomes focused on number of nontobacco substance-using days measured with the timeline follow-back method and PTSD symptom severity using the UCLA (University of California, Los Angeles) PTSD Reaction Index for DSM-IV completed by adolescents and caregivers. Secondary outcomes focused on marijuana, alcohol, and polysubstance use and PTSD criterion standard (re-experiencing, avoidance, and hyperarousal) symptom severity. Results: In all, 124 adolescents (mean [SD] age, 15.4 [1.3] years; 108 female [87.1%]) were randomized. For primary outcomes relative to TAU, RRFT yielded significantly greater reductions in substance-using days from baseline to month 12 (event rate [ER], 0.28; 95% CI, 0.12-0.65) and month 18 (ER, 0.10; 95% CI, 0.04-0.24). Significant reductions in PTSD symptoms were observed within groups for RRFT from baseline to months 3 (β = -9.25; 95% CI, -12.95 to -5.55), 6 (β = -16.63; 95% CI = -20.40 to -12.87), 12 (β = -17.51; 95% CI, -21.62 to -13.40), and 18 (β = -19.02; 95% CI, -23.07 to -14.96) and for TAU from baseline to months 3 (β = -9.62; 95% CI, -13.16 to -6.08), 6 (β = -13.73; 95% CI, -17.43 to -10.03), 12 (β = -15.53; 95% CI, -19.52 to -11.55), and 18 (β = -13.88; 95% CI, -17.69 to -10.09); however, between-group differences were not observed. Conclusions and relevance: In this study, RRFT and TAU demonstrated within-group improvements in SUP and PTSD symptoms, with greater improvement for substance use and PTSD avoidance and hyperarousal symptoms among adolescents randomized to RRFT compared with TAU. No evidence of the worsening of SUP was observed in either condition. These results suggest that this exposure-based treatment is safe, feasibly delivered by community-based clinicians, and offers an effective approach to inform clinical practice.Item The Effect of Impulsivity and Drinking Motives on Alcohol Outcomes in College Students: A 3-year Longitudinal Analysis(Taylor & Francis, 2022) Fisher, Sycarah; Hsu, Wei-Wen; Adams, Zachary; Arsenault, Chelsea; Milich, Richard; Psychiatry, School of MedicineObjective: Substance use is a public health concern and cross-sectional studies have found that impulsivity and drinking motives influence substance use in emerging adults. Despite these findings, longitudinal studies with nuanced measures of impulsivity and drinking motives are needed. Participants: The current study investigated the three-year relationship between impulsivity-related traits, drinking motives, sex, and drinking outcomes in a sample of 509 college students (47.47% male; 81% White). Methods: The effects of impulsivity traits and drinking motives on problematic drinking outcomes were evaluated using linear mixed effects models. Results: The results confirmed the hypothesized relationship between traits of impulsivity, drinking motives, and alcohol outcomes over time. Further, sex significantly interacted with drinking motives longitudinally in its relationship with alcohol use outcomes. Conclusions: These results indicate that intervention efforts may need to be tailored to specific individual attributes to target direct correlates of alcohol use behavior to increase effectiveness.