Audrey Audrey Burnam

Effects of Drug Abuse and Mental Disorders on Use and Type of Antiretroviral Therapy in HIV-infected Persons

AbstractOBJECTIVE: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS: Self-reported ART from first (January 1997–July 1997) to second (August 1997–January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Identification of and guidance for problem drinking by general medical providers: results from a national survey.

Background:Heavy alcohol use is associated with health costs and medical problems. There has been a growing consensus that primary care patients should be screened for alcohol problems. Objectives:We examined rates at which patients were asked about alcohol or drug use and problems, extending research in this area by using a standardized problem drinking instrument with a large national sample, examining community level variables, and assessing the extent to which patients who were identified received follow-up. Subjects:A subsample of 7371 persons from the 1998 Healthcare for Communities survey who reported visiting a general medical provider (GMP) in the past year. Measures:Participants completed questionnaires on demographics, mental and physical health, alcohol, drug use and problems, enrollment in a managed health care plan, whether their medical provider asked about alcohol or drug use, and whether they received advice, counseling, or referral. Results:Being asked about alcohol and drug use was associated with being male, young, highly educated, more health problems, mental health diagnosis, and being classified as a problem drinker. Only 48% of problem drinkers received any follow-up, with most being told to “stop drinking” by their GMP. Conclusions:Few people are queried about alcohol or drug use when they visit a GMP. When problem use is identified, most patients do not receive appropriate follow-up and aftercare. The quality of primary care could improve if GMPs were educated about providing brief advice/counseling and were given information concerning resources in their community to make appropriate referrals for patients.

Pathways to Homelessness Among the Mentally Ill

Abstract  Background: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. Method: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RANDs Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. Results: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a “double dose” of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. Conclusions: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness.

Psychosocial Mediators of Antiretroviral Nonadherence in HIV-positive Adults with Substance Use and Mental Health Problems

This study used data from 1,889 HIV-positive patients on antiretroviral (ARV) medications who participated in the HIV Cost and Services Utilization Study to investigate whether nonadherence to ARV medications among patients with mental health and substance use problems could be explained by difficulty getting and negative attitudes toward ARV medications, poor fit of the regimen with lifestyle, lack of instruction and cues for remembering the regimen from a health care provider, and poor support from others for taking ARV medications. Difficulty getting ARV medications and poor fit with lifestyle were significant mediators of nonadherence for patients with a probable psychiatric disorder. Difficulty getting medication was a mediator for heavy drinkers, and poor fit with lifestyle was a mediator for drug users who drank heavily. Further research is needed to identify and address the barriers to adherence in these populations.

Enumerating Homeless People

Decisions about how inclusive one should be in attempting to sample and/or enumerate homeless populattons are best guided by information regarding what is sacrificed when different sampling choices are made. This article draws upon data from the Course of Homelessness Study to explore how three progressively less inclusive sampling frames affect understandings of the size and characteristics of homeless populations in two Los Angeles sites. Findings suggest that less inclusive sampling frames substantially affect populatton estimates, but do not consistently produce biased estimates of population characteristics. Whether, and the extent to which, such bias is introduced varies by site, by gender, and by the population characteristic in question.

Substance use and high-risk sex among people with HIV: a comparison across exposure groups.

Substance use is associated with increased risk for HIV transmission by HIV-positive people to uninfected partners through sexual contact. The largest risk groups for infection, men who have sex with men (MSM) and injecting drug users (IDUs), have high rates of substance use, but little is known about their substance use post-HIV diagnosis. We compared the prevalence of substance use between these two groups and a third group, heterosexual men and women, and tested for differential association between substance use and sexual behaviors across exposure groups in a national sample of patients in treatment for HIV. Substance use was most prevalent among MSM. Substance use and current dependence were associated with being sexually active among MSM but not IDUs; marijuana, alcohol, and hard drug use were most strongly associated with being sexually active among MSM. Whereas substance use predicted high-risk sex, there were few differences among exposure groups in these associations.

Changes in subjective quality of life among homeless adults who obtain housing: a prospective examination

Background: The aim of this present study is to examine whether overall subjective quality of life and specific domains of quality of life change among homeless adults after they become housed, and if so, what factors predict changes in satisfaction. Methods: The data analysed here were collected through face-to-face interviews with a sample of 485 homeless adults who were interviewed as often as bi-monthly over a 16-month period. Bivariate analyses examined initial differences between three groups: homeless people who did not exit from homelessness; those with an exit from homelessness to dependent housing; and those with an exit to independent housing. Bivariate analyses also examined differences in subjective quality of life before and after an exit from homelessness among the three groups. Multivariate analyses identified predictors of changes in quality of life before and after exit. Results: This study has three main findings. First, homeless people who obtained independent housing had the largest positive and significant improvements in satisfaction with overall quality of life, and in satisfaction with housing, leisure and money. Second, becoming housed was not a predictor of changes in overall quality of life perceived by homeless people, nor in their satisfaction with leisure, clothing, food, and social life. Furthermore, a positive change in housing satisfaction was not associated with all types of exits from homelessness; only a move into independent housing predicted such a change, but a move into dependent housing did not. Finally, of all the covariates included as predictors at baseline, only two variables seemed to consistently predict changes in satisfaction; namely, self-assessed general health and self-assessed self-help skills. Conclusions: This study suggested that becoming independently housed may improve some aspects of quality of life for homeless people, but not others. The results suggest that homeless people prefer to be independently housed relative to remaining homeless or staying in a dependent housing situation, but that independent housing does not necessarily improve other aspects of their lives.

Abuse in the close relationships of people with HIV.

We estimated the proportion of adults receiving HIV care who are involved in abusive close relationships and identified factors associated with abuse perpetration and victimization. A nationally representative sample of 1,421 persons in care for HIV included 51% who reported having a close relationship (a spouse or a primary relationship partner) during a 6-month period. Of those in a close relationship, 26.8%reported the presence of abuse. Forty-eight percent of all abuse was mutual, and abuse perpetration and victimization occurred equally often. Age, substance abuse, and psychiatric disorder, as well as characteristics of relationships (e.g., both partners seropositive) predicted perpetration and/or victimization. After adjusting for these factors, females were not found to differ from gay men in their likelihood of being perpetrators of abuse or victims. However, African Americans were more likely than Whites to be involved in an abusive relationship. Interventions for people with HIV must address the presence of abuse in close relationships, regardless of gender or sexual orientation, but may benefit from targeting people of color.

An empirical comparison of substance and alcohol dependence patterns in the homeless in Madrid (Spain) and Los Angeles (CA, USA).

Background Alcohol and drug use continue to figure heavily in the experience of the contemporary homeless population. The comparison among pattern of use plays a central role in the cross-cultural view of this topic. This article shows the results of comparing the data concerning alcohol and other drug abuse and dependence among the homeless population of Madrid (Spain) and Los Angeles (USA). Methods Data come from two studies carried out independently in each city. Both studies used a comparable methodology which included the same inclusion and diagnostics criteria, representative sampling methods and similar diagnostic structured interviews. In the present study, the data from these two studies are combined in a unique database which allows global and item-to-item comparison between the two studies. Results The results show different sociodemographic profiles for each city. Once controlled for the sociodemographic differences (age, education, current employment status and marital status), the life and 12-month prevalence rates of alcohol and other drug disorders (DSM-III-R) are also different. There are also significant differences in social, emotional and health problems associated with the consumption of alcohol and other drugs. The Madrid and LA samples also present differences in the time patterns of the beginning of the homelessness situation and the onset of alcohol- and drug-related disorders. Conclusions The pattern of results is discussed in the light of the differences in both socioeconomic and cultural among Madrid and Los Angeles which might explain, in turn, differences in the homelessness situation as well as in the alcohol and other drug use patterns.

Usual Care Psychotherapy for Depression in a Large Managed Behavioral Health Organization

Evidence-based psychotherapies to treat depression are available, yet it remains unknown the extent to which these practices are used in routine care for depression. Using survey and administrative data, we sought to describe usual care psychotherapy for depression for adult patients receiving care through a large, managed behavioral health care organization. Data from 420 patients receiving psychotherapy for depression and 159 of their therapists provide evidence that some practitioners are using evidence-based psychotherapy techniques for depression, but also demonstrate the need for improved tools to monitor and improve quality of psychotherapy in usual care.