INTRODUCTION:To examine the relationship between early product substitution and harm reduction (HR) in an ENDS switching trial for adults who smoke. METHODS:We conducted a longitudinal structural equation analysis of 120 treatment participants who received disposable ENDS for 8 weeks and were assessed every 2weeks. The predictor was w2 ENDS sessions/day. The HR latent construct included 4 binary indicators: cigarettes/day (CPD) ≤5 and carbon monoxide (CO) <10ppm at weeks 6 & 8. We tested an indirect path from w2 ENDS use through w2 CPD reduction to HR, and a direct path from w2 ENDS use to HR, both moderated by w0 CPD. RESULTS:Mean age was 45.9 years, and 42.7% smoked ≥20 CPD. ENDS use at w2 significantly increased the odds of HR for all participants (p<0.001), mediated through reductions in w2 CPD. The ENDS direct pathway was moderated by w0 CPD (p<0.001). For the total (direct + indirect) association, greater w2 ENDS use increased chances of HR for individuals with w0 CPD>16, decreased the chances of HR for individuals with w0 CPD<7 and had no impact on those in the w0 CPD 7-15. All predictors combined explained 66% of the variance in HR. CONCLUSIONS:In this study, early ENDS use predicted short-term HR, but only for individuals who smoked more heavily. For those with low smoking intensity, early ENDS use predicted decreased short-term chances of HR and increased dual product use. This is a novel finding limited to a small sample of persons with severe mental illness. IMPLICATIONS:If replicated and extended to later HR outcomes, the finding supports a focus on early ENDS use as an intermediate outcome for phase 2 trials of ENDS products, and adaptive treatment designs aimed at early non responders, with a particular focus on persons who smoke heavily.

INTRODUCTION:People with serious mental illness (SMI) experience health disparities that contribute to reduced life expectancy. Integration of physical and community mental health clinic (CMHC) care is one strategy to improve access to health care that may address health disparities, but the appeal and impact of CMHC-based integrated care has not been widely studied in young adults with SMI, for whom early intervention may be beneficial. METHODS:This qualitative study evaluated perceptions of care among 36 individuals with SMI engaged in integrated care at 3 CMHCs. Researchers conducted focus groups and used open coding analyses of group transcripts to identify themes among younger and middle-aged/older adults with SMI. RESULTS:Similar themes emerged among younger (n = 16; mean age 28.4 ± 3.3 years) and middle-aged/older (n = 20; mean age 50.4 ± 8.7 years) adults. One notable theme was a high level of unmet health needs prior to integrated care due to complex physical health problems and feeling stigmatized by physical health care providers. Themes regarding integrated care included the benefits of colocation, awareness of improved communication among providers, and perceiving integrated primary care providers as respectful and thorough. Participants expressed desire for reduced staff turnover. Desire for increased medical record sharing and communication with specialists emerged solely among the middle-aged/older adults. DISCUSSION:Themes regarding CMHC-based integrated care were mostly positive and similar among younger and middle-aged/older participants with SMI. These results indicate that integrated care could be an acceptable strategy to provide young adults with SMI critical early intervention to address health disparities. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Disparate rates of cardiovascular disease (CVD) contribute to the shortened life expectancy of people with serious mental illness (SMI). CVD and its risk factors, including obesity, hypertension, diabetes and dyslipidemia, often arise in young adulthood, but there is a paucity of research focusing on emerging and young adults. This study describes the health characteristics of emerging (ages 16–24) and young (ages 25–39) adults with SMI upon enrollment into a community mental health (CMH)-based integrated primary and mental health care program (n = 439). Data were collected via structured interviews, biometric assessments and medical record review. Biometric assessments indicated that 54

BACKGROUND:Cannabis use is associated with psychosis development and symptom relapse in persons with schizophrenia spectrum disorders (SCZ). As U.S. states legalize cannabis and products increase in potency, it is crucial to better understand recent cannabis use patterns in SCZ. METHODS:We conducted a scoping review of research on cannabis quantity, frequency, or type in SCZ after January 2016 and present a case series of cannabis use in inpatients with psychosis (2023-2024). RESULTS:Scoping review: Of 672 references, ten studies (2631 participants) were included; none were designed to characterize cannabis quantity, frequency, or type of use over time. Cannabis measurement methodology varied; most studies did not use standardized measures. Frequency and quantity of use at baseline were reported by most studies and these ranged widely. At least a minority of participants with SCZ in each study used cannabis very frequently; quantity of used ranged widely from 0.6 ± 0.6 to 3.4 ± 2.2 joints/day. One small study detailed cannabis product type used for THC by SCZ participants (93% used flower, 80% edibles, 60% concentrates). CASE SERIES:Participants were inpatients (32.0 ± 14.4 years; 83.3% diagnosed with SCZ) who used cannabis 2.7 ± 2.1 days/week. All used cannabis leaf (3.1 ± 2.3 joints/day); half (all heavy users) also used concentrates (33.3%) or edibles (16.7%). CONCLUSION:There is insufficient recent research to confidently characterize cannabis use patterns in clinical populations of persons with SCZ in the era of cannabis legalization. As cannabis legalization expands and product potency increases, further research should characterize cannabis use and its consequences in SCZ.

People with serious mental illness (SMI) are more likely to smoke and less likely to quit than the general population. More effective and accessible cessation treatments are needed to promote health and prevent disease in this disparity population. To this end, we optimized a multicomponent health promotion intervention tailored for people with SMI, Breathe Well, Live Well, and conducted a quasi-experimental program evaluation to assess program feasibility and effectiveness compared with a usual care comparison condition consisting of “The 3 As.” Community mental health center staff trained as health coaches delivered eight telehealth Breathe Well, Live Well sessions over 4 months to individuals. Breathe Well, Live Well content included cognitive behavioral therapy (CBT)-based counseling, pharmacotherapy support, incentivized app use (National Cancer Institute’s quitSTART), and social support person coaching. Participants were 170 integrated mental health and primary care service recipients with SMI who smoked daily; 53 Breathe Well, Live Well and 117 comparison participants were enrolled during February 2020 through July 2022. Effectiveness was measured via biologically verified abstinence; feasibility was measured via Breathe Well, Live Well intervention engagement. Participants of Breathe Well, Live Well were about three times more likely to be abstinent at follow-up compared with comparison participants. Among those still smoking, Breathe Well, Live Well participants were about five times more likely to have decreased their daily cigarette consumption by at least half. Intervention engagement was strong for pharmacotherapy, counseling, and incentivized quitSTART app use, indicating that these components were feasible to deliver by community mental health center staff.

Violence, alcohol use, and schizophrenia spectrum disorders often co-occur, with each factor exacerbating the others. The purpose of this review is to describe the relationship between alcohol use and violent behaviors across different stages of psychosis for individuals with schizophrenia spectrum disorders, and to identify potential opportunities for intervention. Alcohol misuse and alcohol use disorder (AUD) have long been associated with an increased risk of violence among persons with psychosis, with a 2013 meta-analysis of over 100 studies concluding that recent alcohol misuse more than doubled the odds that a person with psychosis would engage in violence. Violent behavior causes major disruptions to the lives of persons with schizophrenia spectrum disorders, such as legal consequences, financial burden, loss of social supports, and worse health outcomes. Research indicates that violent behavior is more common in the early stage of psychosis, while other studies suggests that alcohol use is increasing in midlife. However, the relationship between alcohol use and violence across the different stages of psychosis, including the prodromal period, early psychosis, and chronic stages of psychosis, is unclear. This narrative synthesis review found that rates of violent behavior decrease from 25-33

Understanding whether organizations with Medicare and Medicaid accountable care organization (ACO) contracts offer methadone provides important context about how organizations invested in payment and delivery system reform address the needs of patients with substance use disorders. We used data from the 2021-2022 National Survey of Accountable Care Organizations to assess whether organizations with ACO contracts, which are held accountable for the cost and quality of care for an assigned patient population, offered methadone to patients with opioid use disorder (OUD), and the organizational and contextual characteristics associated with doing so. We found that 28.3% of survey respondents reported that clinicians in their organizations offered methadone via an opioid treatment program. In adjusted analyses, organizations with a Medicaid ACO contract but no Medicare contract were more likely to offer methadone (46.0%, P < 0.05) than organizations with a Medicare-only contract (19.6%) or a Medicare and Medicaid contract (30.3%). Despite incentives to prioritize population health, most ACO-affiliated organizations were not offering individuals with OUD the full range of recommended medications and should work to enhance treatment options for this patient population.

Background Substitution of noncombustible tobacco products for cigarettes could improve respiratory symptoms. We hypothesized that complete cigarette-to-e-cigarette switching would improve respiratory symptoms compared to continued smoking. Methods Longitudinal analysis of data from waves 2-6 (W2-W6; 2014-2021) of the Population Assessment of Tobacco and Health (PATH) Study, an observational cohort study that surveyed 5653 US adults >= 18 years without COPD/chronic bronchitis/emphysema. We compiled 14,947 two-wave (1-2 year) observations with persons who smoked cigarettes at baseline and compared the relation between functionally important respiratory symptoms and switching to exclusive e-cigarette use or quitting tobacco versus continued cigarette use (reference). A 9-point wheezing/nighttime cough index was dichotomized based on index scores of >= 2 or >= 3, previously associated with poorer functional health. Multivariable models assessed how changes in cigarette use predicted worsening/improvement of symptoms. Findings Among those with an index score <2, 3.5% switched to e-cigarettes, and 11.1% quit all tobacco. Functionally important respiratory symptoms worsened (>= 2 at follow-up) in 15.4%, 10.0% and 10.1% of those who continued cigarettes, switched to e-cigarettes, and quit, respectively. Adjusted relative risk (RR) for respiratory symptom worsening was 0.69 (95% confidence interval (CI), 0.52, 0.91) for e-cigarette switching and 0.73 (95% CI, 0.54, 0.97) for quitting. Of persons with index score >= 2, 2.8% switched to e-cigarettes, and 6.7% quit. Respiratory symptoms improved (<2 at follow-up) in 27.7%, 45.8% and 42.1% of those who continued cigarettes, switched to e-cigarettes, and quit, respectively. The RR for improving was 1.31 (95% CI, 1.05, 1.64) for e-cigarette switching and 1.36 (95% CI, 1.15, 1.62) for quitting. The RRs for exclusive e-cigarette use with a cutoff of >= 3 for respiratory symptom worsening and improvement were not significant (0.74 [0.53, 1.05] and 1.20 [0.95, 1.51] respectively) but were significant in an unweighted analysis that included partial data for individuals lost to follow-up (0.74 [0.57, 0.95] and 1.21 [1.06, 1.39] respectively). Interpretation Switching completely from past 30-day use of cigarettes to e-cigarettes had short-term beneficial associations with functionally important respiratory symptoms similar to quitting tobacco completely. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Understanding whether organizations with Medicare and Medicaid accountable care organization (ACO) contracts offer methadone provides important context about how organizations invested in payment and delivery system reform address the needs of patients with substance use disorders. We used data from the 2021-2022 National Survey of Accountable Care Organizations to assess whether organizations with ACO contracts, which are held accountable for the cost and quality of care for an assigned patient population, offered methadone to patients with opioid use disorder (OUD), and the organizational and contextual characteristics associated with doing so. We found that 28.3% of survey respondents reported that clinicians in their organizations offered methadone via an opioid treatment program. In adjusted analyses, organizations with a Medicaid ACO contract but no Medicare contract were more likely to offer methadone (46.0%, P < 0.05) than organizations with a Medicare-only contract (19.6%) or a Medicare and Medicaid contract (30.3%). Despite incentives to prioritize population health, most ACO-affiliated organizations were not offering individuals with OUD the full range of recommended medications and should work to enhance treatment options for this patient population.

Objective: This study examined whether an organization's investment in opioid use disorder services complements or detracts from its capacity to provide alcohol use services. Methods: Using data from the 2022 National Survey of Accountable Care Organizations (N=200 respondents to alcohol-related questions), the authors estimated the percentage of organizations participating in accountable care organization contracts that provided alcohol-related services (brief counseling or medications), either by direct provision or via referral. They tested whether organizations offering buprenorphine for opioid use disorder were more or less likely to offer alcohol-related services. Results: Most respondents (81%) reported that their organization provided brief counseling directly, but less than half (45%) provided medications for alcohol use disorder directly. Respondents providing buprenorphine (62%) had higher rates of alcohol-related service provision. Conclusions: Although medications for alcohol use disorder were provided less frequently than buprenorphine, no evidence suggests that treatment services for opioid use disorder crowded out those for alcohol use disorder.

OBJECTIVE:People with serious mental illness (i.e., disabling psychotic, mood, and other disorders) develop chronic medical diseases early in life. This study aimed to examine the effects of integrating primary care into community mental health centers (CMHCs; reverse integrated care) on service use among young adults with serious mental illness who may benefit from early intervention. METHODS:This retrospective cohort analysis used Medicaid claims of 945 people with serious mental illness (ages 18-40) in CMHC care from 2020 to 2022-315 in reverse integrated care and 630 propensity score matched participants in comparison care (i.e., not reverse integrated care). Logistic regression, adjusted for participant characteristics, enrollment quarter, and past service use, assessed outcomes in the 6 months after enrollment. RESULTS:Participants' mean±SD age was 32.56 ± 7.84 years; 29% had a diagnosis of schizophrenia, 40% had a co-occurring substance use disorder, 33% had a medical emergency department (ED) visit in the 6 months before enrollment, and all were enrolled in CMHC care at baseline. During follow-up, participants in reverse integrated care were more likely to have an outpatient medical visit (65% vs. 58%; adjusted odds ratio [AOR]=1.54, p=0.005) and were less likely to have a medical ED visit (26% vs. 33%; AOR=0.70, p=0.035) than those in comparison care. CONCLUSIONS:Integrating primary care into CMHC services may increase access to outpatient medical care and reduce ED visits for medical reasons among young adults with serious mental illness. Future research should confirm these findings, assess longer-term outcomes, and examine implementation facilitators and barriers.

Introduction Smoking rates among people with serious mental illness (SMI) are higher and quit rates are lower than in the general population. These individuals have higher levels of carcinogens in their bodies, contributing to greater prevalence of chronic disease and early mortality, necessitating implementation of novel harm reduction strategies, including switching to electronic nicotine delivery systems (ENDS). We conducted an RCT of ENDS provision versus assessment only in people with SMI who smoke to assess cancer risk reduction. Methods 240 people with SMI (52 % male; 47 % schizophrenia, 53 % bipolar disorder; 55 % non-white; mean breath CO=26.9 ppm, sd=19.9 ppm) who tried but were currently unwilling to quit smoking were randomly assigned to receive disposable ENDS for 8 weeks or assessments only. Total urine NNAL (a metabolite of a tobacco-specific nitrosamine from smoke) was assessed at baseline, 4, and 8 weeks. Generalized linear mixed models examined the effects of ENDS provision on NNAL. Results Mean NNAL did not differ by group at baseline (estimate=0.22; se=0.22; t = 0.98; p = 0.33). A significant group-by-time interaction (F=3.68, p < 0.026) indicated that NNAL decreased more over time in the ENDS group. The ENDS group had significantly lower NNAL at 4 weeks (estimate=0.54; se=0.23; t = 2.37; p < .02), but the difference attenuated at 8 weeks (estimate=0.42; se=0.23; t = 1.83; p < .07). Conclusions This study demonstrated short-term harm reduction among trial participants who received ENDS. Attenuation of the effect at 8 weeks suggests that ENDS provision alone is insufficient. Development of a program of behavioral support for ENDS substitution may help further reduce harm.

Objective: Characterize the association between Medicare Accountable Care Organizations' (ACOs) behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI). Background: Controlled research supports the efficacy of integrating physical and mental health care for adults with SMI, yet little is known about the organizations integrating care and associations between integration capability and quality. Methods: We surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%) and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. We examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. We fit generalized linear models for each outcome as a function of ACO integration capability, adjusting for ACO and beneficiary characteristics. Results: Study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring-exceeding national quality benchmarks-but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization. Conclusions: ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI.

Although social determinants of health (SDOH) have a significant impact on health outcomes and many are already included among the "Other Conditions That May Be a Focus of Clinical Attention" in the DSM-5, general awareness of these codes and the importance of using them to communicate SDOH has not occurred. This Open Forum proposes that the DSM-5 adopt a biaxial system of assessment to enhance their consideration and reporting. A biaxial approach, the authors argue, when combined with financial incentives, will increase the likelihood of SDOH reporting and potentially improve care.

To inform early intervention, this study describes correlates of substance use among young people with serious mental illness (SMI) enrolled in integrated care in community mental health settings. 227 adults ages 18-35 were assessed for clinical characteristics and substance use. Logistic regressions were used to describe relationships between substance use and participant characteristics. Over a third (38.9%) reported daily cannabis, 15.9% past month other illicit drug, 13.5% frequent/heavy alcohol and 47.4% any of these; 50.2% reported daily tobacco smoking and 23.3% current vaping. Daily cannabis and tobacco were the most common combination. Alcohol, drug, and cannabis with tobacco were associated with higher mental health symptoms but not with emergency room or hospital utilization. Cannabis and other substance use was common and associated with higher symptoms but not with greater hospital utilization, suggesting that early intervention could prevent long-term negative consequences.

Background and Hypothesis Up to 43% of people with schizophrenia have a lifetime cannabis use disorder (CUD). Tetrahydrocannabinol (THC) has been shown to exacerbate psychosis in a dose-dependent manner, but little research has assessed its effects on schizophrenia and co-occurring CUD (SCZ-CUD). In this double-dummy, placebo-controlled trial (total n = 130), we hypothesized that a modest dose of THC would worsen cognitive function but not psychosis.Study Design Effects of single-dose oral THC (15 mg dronabinol) or smoked 3.5% THC cigarettes vs placebo in SCZ-CUD or CUD-only on positive and negative symptoms of schizophrenia (only for SCZ-CUD), cognition, and drug experiences assessed several hours after drug administration. SCZ-only and healthy control participants were also assessed.Study Results Drug liking was higher in THC groups vs placebo. Neither smoked THC nor oral dronabinol predicted positive or negative symptom subscale scores 2 and 5 h, respectively, after drug exposure in SCZ-CUD participants. The oral dronabinol SCZ-CUD group, but not smoked THC SCZ-CUD group, performed worse than placebo on verbal learning (B = -9.89; 95% CI: -16.06, -3.18; P = .004) and attention (B = -0.61; 95% CI: -1.00, -0.23; P = .002). Every 10-point increment in serum THC + THCC ng/ml was associated with increased negative symptoms (0.40 points; 95% CI: 0.15, 0.65; P = .001; subscale ranges 7-49) and trends were observed for worse positive symptoms and performance in verbal learning, delayed recall, and working memory.Conclusions In people with SCZ-CUD, a modest single dose of oral THC was associated with worse cognitive functioning without symptom exacerbation several hours after administration, and a THC dose-response effect was seen for negative symptoms.

OBJECTIVE: Characterize the association between Medicare Accountable Care Organizations' (ACOs) behavioral health integration capability and quality and utilization among adults with serious mental illness (SMI). BACKGROUND: Controlled research supports the efficacy of integrating physical and mental health care for adults with SMI, yet little is known about the organizations integrating care and associations between integration capability and quality. METHODS: We surveyed Medicare ACOs (2017-2018 National Survey of ACOs, response rate 69%) and linked responses to 2016-2017 fee-for-service Medicare claims for beneficiaries with SMI. We examined the cross-sectional association between ACO-reported integration capability (tertiles of a 14-item index) and 7 patient-level quality and utilization outcomes. We fit generalized linear models for each outcome as a function of ACO integration capability, adjusting for ACO and beneficiary characteristics. RESULTS: Study sample included 274,928 beneficiary years (199,910 unique beneficiaries) attributed to 265 Medicare ACOs. ACOs with high behavioral health integration capability (top-tertile) served more dual-eligible beneficiaries (67.8%) than bottom-tertile (63.7%) and middle-tertile ACOs (63.3%). Most beneficiaries received follow-up 30 days after mental health hospitalization and chronic disease monitoring-exceeding national quality benchmarks-but beneficiaries receiving care from top-tertile (vs bottom-tertile) ACOs were modestly less likely to receive follow-up [-2.17 percentage points (pp), P < 0.05], diabetes monitoring (-2.19 pp, P < 0.05), and cardiovascular disease monitoring (-6.07 pp, P < 0.05). Integration capability was not correlated with utilization. CONCLUSIONS: ACOs serving adults with substantial physical and mental health needs were more likely to report comprehensive integration capability but were not yet meeting the primary care needs of many adults with SMI.

Steeper delay discounting (DD) reflects greater impulsivity and has been reported in individuals with schizophrenia (SCZ) and those with substance use disorder, who also tend to report high psychological stress. We sought to compare DD in people with SCZ, cannabis use disorder (CUD), and comorbid SCZ-CUD, and determine its relationship to psychological stress in these groups, to inform treatment improvements. Participants were healthy controls (HC; n=31) and individuals with DSM-IV diagnoses of SCZ (n=21), CUD (n=61), and comorbid SCZ-CUD (n=40). After one week or more of verified abstinence from substances, participants completed the Delay Discounting Questionnaire and the Perceived Stress Scale. DD and perceived stress were greater in all three clinical groups compared to HC, though the clinical groups did not differ. Analyses did not detect a consistent relationship between stress and DD in any group, though females showed greater DD with increased stress when all clinical groups were combined. Findings indicate that, overall, perceived stress cannot account for steeper DD in patients with SCZ, CUD, and SCZ-CUD; thus, interventions for stress would not be expected to impact DD.