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INTRODUCTION: A significant amount of binge drinking among adults escapes public health scrutiny because it occurs among individuals who drink at a moderate average level. This observational study examined the role of a binge pattern of drinking in predicting alcohol problems among moderate drinkers in a U.S. national sample of adults. METHODS: Participants were 1,229 current drinkers aged ≥30 years from 2 waves of the study of Midlife Development in the United States, with a 9-year time lag (2004-2015) (analyzed in 2021‒2022). Negative binomial regression analyses were used to examine the number of alcohol problems, and binary logistic regression analyses were used to examine multiple (≥2) alcohol problems. RESULTS: Independent of the average level of drinking, binge drinking was linked with an almost 3 times increase in the number of concurrent alcohol problems and a 40% increase in the number of alcohol problems prospectively 9 years later. Moderate average level drinkers accounted for most cases of binge drinking and multiple alcohol problems. Among moderate drinkers, binge drinking was linked with a close to 5 times increase in concurrent multiple alcohol problems and a >2 times increase in multiple alcohol problems prospectively 9 years later. CONCLUSIONS: These results substantially broaden an increasing recognition that binge drinking is a public health concern among adults. Moderate average-level drinkers should be included in efforts to reduce alcohol problems in adults. These findings are applicable to primary and secondary prevention of alcohol problems with the potential to advance population health.

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OBJECTIVE: To examine the moderating effect of older adults' history of drinking problems on the relationship between their baseline alcohol consumption and risk of dementia and cognitive impairment, no dementia (CIND) 18 years later. METHOD: A longitudinal Health and Retirement Study cohort (n = 4421) was analyzed to demonstrate how older adults' baseline membership in one of six drinking categories (non-drinker, within-guideline drinker, and outside-guideline drinker groups, divided to reflect absence or presence of a history of drinking problems) predicts dementia and CIND 18 years later. RESULTS: Among participants with no history of drinking problems, 13% of non-drinkers, 5% of within-guideline drinkers, and 9% of outside-guideline drinkers were classified as having dementia 18-years later. Among those with a history of drinking problems, 14% of non-drinkers, 9% of within-guideline drinkers, and 7% of outside-guideline drinkers were classified with dementia. With Non-Drinker, No HDP as reference category, being a baseline within-guideline drinker with no history of drinking problems reduced the likelihood of dementia 18 years later by 45%, independent of baseline demographic and health characteristics; being a baseline within-guideline drinker with a history of drinking problems reduced the likelihood by only 13% (n.s.). Similar patterns obtained for the prediction of CIND. CONCLUSIONS: For older adults, consuming alcohol at levels within validated guidelines for low-risk drinking may offer moderate long-term protection from dementia and CIND, but this effect is diminished by having a history of drinking problems. Efforts to predict and prevent dementia and CIND should focus on older adults' history of drinking problems in addition to how much alcohol they consume.

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AIMS: PTSD, pain, and alcohol and drug use disorders (AUD and DUDs) are prevalent, debilitating, and costly. Clinicians benefit from understanding the co-occurrence among these conditions, especially cocaine and opioid use disorders. This is the first study to examine (1) the odds of having one condition in the presence of one of the other conditions, and (2) the extent to which having PTSD, pain, or an AUD raises the odds of having a DUD in VA primary care patients. METHODS: We used cross-sectional archival data from 1283 primary care patients recruited in VA primary care clinics. Pain was measured by the numeric rating scale. PTSD, AUD, and DUDs (i.e., cannabis, opioid, cocaine, and any drug use disorder) were measured by the Mini International Diagnostic Interview. We conducted logistic regression analyses to examine the odds of having one condition in the presence of other conditions. RESULTS: A total of 14.9 % of patients had PTSD, 52.8 % of patients had moderate or severe pain, 12.8 % had an AUD, and 10.4 % had any DUD. Patients who had one condition (PTSD, pain, AUD, or DUD) were highly likely to have one or more of the other conditions, with or without controlling for demographic variables. CONCLUSIONS: VA Patients who had PTSD, moderate or severe pain, or an AUD were highly likely to have an opioid or cocaine use disorder, and therefore should be screened for DUDs in VA primary care.

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AIMS: Stimulant misuse, overdose, and related deaths have increased dramatically. Identifying and referring individuals with stimulant use disorder to treatment may reduce misuse and overdose. This study validated the 2-item Screen of Drug Use (SoDU; Tiet et al., 2015) to screen for stimulant use disorder (and for cocaine and amphetamine use disorders) in a VA primary care setting, and to establish its concurrent diagnostic validity among diverse subgroups of patients, including age, gender, race/ethnicity, marital status, educational level, and PTSD status. METHODS: Archival data from 1283 VA primary care patients recruited in California were examined. This predominantly male sample matched general VA primary care patient population characteristics. A total of 79 individuals (6.2%) met criteria for a stimulant use disorder. The criterion for having a stimulant use disorder was a DSM-IV cocaine use disorder and/or amphetamine use disorder diagnosis based on the Mini International Diagnostic Interview. RESULTS: For stimulant use disorder, the 2-item SoDU was 93.67% sensitive (95% confidence interval [CI], 85.84%-97.91%), and 89.12% specific (95% CI, 87.22%-90.82%). When tested in diverse subgroups of patients, the sensitivity ranged from 66.67% to 100% and specificity ranged from 76.81% to 94.17%. When a follow-up question was added, the sensitivity was unchanged and the specificity was 99%, with lower false positive rate. CONCLUSIONS: The SoDU, especially with a follow-up question, is an appropriate instrument for routine screening of stimulant use disorder in VA primary care settings. It has good concurrent diagnostic validity for diverse groups of patients.

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OBJECTIVE: As cannabis has been legalized for medicinal and recreational use, rates of cannabis misuse and cannabis use disorder (CUD) have increased. However, only a small percentage of individuals with CUD seek treatment. A practical screening instrument is needed to detect CUD in primary care (PC) to address the needs of individuals with CUD. This study seeks to validate the 2-item Screen of Drug Use (SoDU) to help detect CUD in the PC setting. METHOD: We used archival data from 1283 patients recruited in the Department of Veterans Affairs (VA) PC clinics. A total of 51 individuals (4%) met DSM-IV criteria for CUD (abuse or dependence; with or without other drug use disorders). A diagnosis of CUD based on the Mini International Diagnostic Interview (MINI) was used as the criterion. Concurrent diagnostic properties of the SoDU were examined against the MINI. RESULTS: The SoDU was 100% sensitive (95% confidence interval [CI], 93.00% - 100%), and 87.50% specific (95% CI, 85.53% - 89.23%). When tested in subgroups of patients varying in age, gender, race/ethnicity, marital status, educational level, and PTSD status, the SoDU maintained 100% sensitivity in all subgroups; specificity ranged from 76.26% to 94.34%. CONCLUSIONS: The SoDU is an appropriate instrument to help identify CUD in primary care. It is brief, easy to use, and has good concurrent diagnostic validity for diverse groups of patients.

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AIMS: Opioid related deaths have more than tripled in recent years. Identifying and referring individuals with opioid use disorder (OUD) to treatment is one of the promising approaches to reduce opioid related deaths. However, using urine toxicology to identify opioid misuse is not reliable. This study validates the Screen of Drug Use (SoDU) to screen for OUD in the primary care setting, and establish its concurrent diagnostic validity among diverse subgroups of patients, including age, gender, race/ethnicity, marital status, educational level, and PTSD status. METHODS: We used data from 1283 primary care patients recruited in the VA in CA. This sample matched patient characteristics general VA population with mean age = 62, and 95% men. A total of 10.4% met DSM-5 criteria for any drug use disorder and 2.7% met criteria for OUD (with or without other drug use disorders). An opioid use abuse or dependence diagnosis based on the Mini International Diagnostic Interview was used as the criterion for having a DSM-5 opioid use disorder. RESULTS: The SoDU was 100% sensitive (95% confidence interval [CI], 89.9%-100%), and 86.3% specific (95% CI, 84.3%-88.1%). When tested in subgroups of patients, the SoDU maintained 100% sensitivity in all subgroups. Specificity ranged from 74.5% to 94.2% for diverse subgroups of patients. CONCLUSIONS: The SoDU is an appropriate instrument to screen for opioid use disorder in primary care. It is brief, easy to use, and has good concurrent diagnostic validity for diverse groups of patients.

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BACKGROUND: There is a lack of research on the role of alcohol consumption in cigarette smoking among older adults, and the few studies on alcohol use and smoking with older adults have failed to distinguish between average level and pattern of drinking as predictors of smoking. The main purpose of this study was to examine the independent contributions of average level versus pattern of drinking as predictors of cigarette smoking among older adults. A subsidiary purpose was to examine the link between continued smoking and mortality among older smokers. METHODS: We investigated average level and pattern of drinking as predictors of current smoking among 1,151 older adults at baseline and of continued smoking and mortality among the subset of 276 baseline smokers tracked across 20 years. We used multiple linear and logistic regression analyses and, to test mediation, bias-corrected bootstrap confidence intervals. RESULTS: A high level of average drinking and a pattern of episodic heavy drinking were concurrently associated with smoking at baseline. However, only episodic heavy drinking was prospectively linked to continued smoking among baseline smokers. Continued smoking among baseline smokers increased the odds of 20-year mortality and provided an indirect pathway through which heavy episodic drinking related to mortality. CONCLUSIONS: Smokers who misuse alcohol are a challenging population for smoking cessation efforts. Older adults who concurrently misuse alcohol and smoke cigarettes provide a unique target for public health interventions.

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OBJECTIVE: Drug use is prevalent and costly to society, but individuals with drug use disorders (DUDs) are under-diagnosed and under-treated, particularly in primary care (PC) settings. Drug screening instruments have been developed to identify patients with DUDs and facilitate treatment. The Drug Abuse Screening Test (DAST) is one of the most well-known drug screening instruments. However, similar to many such instruments, it is too long for routine use in busy PC settings. This study developed and validated a briefer and more practical DAST for busy PC settings. METHOD: We recruited 1300 PC patients in two Department of Veterans Affairs (VA) clinics. Participants responded to a structured diagnostic interview. We randomly selected half of the sample to develop and the other half to validate the new instrument. We employed signal detection techniques to select the best DAST items to identify DUDs (based on the MINI) and negative consequences of drug use (measured by the Inventory of Drug Use Consequences). Performance indicators were calculated. RESULTS: The two-item DAST (DAST-2) was 97% sensitive and 91% specific for DUDs in the development sample and 95% sensitive and 89% specific in the validation sample. It was highly sensitive and specific for DUD and negative consequences of drug use in subgroups of patients, including gender, age, race/ethnicity, marital status, educational level, and posttraumatic stress disorder status. CONCLUSIONS: The DAST-2 is an appropriate drug screening instrument for routine use in PC settings in the VA and may be applicable in broader range of PC clinics.

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OBJECTIVE: Research on late-middle-aged and older adults has focused primarily on average level of alcohol consumption, overlooking variability in underlying drinking patterns. The purpose of the present study was to examine the independent contributions of an episodic heavy pattern of drinking versus a high average level of drinking as prospective predictors of drinking problems. METHOD: The sample comprised 1,107 adults ages 55-65 years at baseline. Alcohol consumption was assessed at baseline, and drinking problems were indexed across 20 years. We used prospective negative binomial regression analyses controlling for baseline drinking problems, as well as for demographic and health factors, to predict the number of drinking problems at each of four follow-up waves (1, 4, 10, and 20 years). RESULTS: Across waves where the effects were significant, a high average level of drinking (coefficients of 1.56, 95% CI [1.24, 1.95]; 1.48, 95% CI [1.11, 1.98]; and 1.85, 95% CI [1.23, 2.79] at 1, 10, and 20 years) and an episodic heavy pattern of drinking (coefficients of 1.61, 95% CI [1.30, 1.99]; 1.61, 95% CI [1.28, 2.03]; and 1.43, 95% CI [1.08, 1.90] at 1, 4, and 10 years) each independently increased the number of drinking problems by more than 50%. CONCLUSIONS: Information based only on average consumption underestimates the risk of drinking problems among older adults. Both a high average level of drinking and an episodic heavy pattern of drinking pose prospective risks of later drinking problems among older adults.

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AIMS: The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a screening instrument to detect substance use in primary care (PC). To screen for illicit substances (excluding tobacco and alcohol), the ASSIST consists of 8-57 questions and requires complicated scoring. To improve the efficiency of screening of drug misuse in PC, this study constructed and validated a two-item screen for drug use from the ASSIST. METHODS: Guided by previous reviews, the ASSIST was revised. Patients were recruited in VA primary care clinics (N=1283). Half of the sample was used to develop the ASSIST-Drug; the other half was used to validate it. The Mini International Neuropsychiatric Interview (MINI) and the Inventory of Drug Use Consequences were the criterion measures. RESULTS: A brief, two-item ASSIST-Drug was constructed. Based on the development sample, the ASSIST-Drug was 94.1% sensitive and 89.6% specific for drug use disorders. Based on the validation sample, it was 95.4% sensitive and 87.8% specific. The ASSIST-Drug also had comparable sensitivity and specificity to identify drug use negative consequences, as well as for diverse subgroups of patients in terms of gender, age, race/ethnicity, marital status, educational levels, and post traumatic stress disorder status. CONCLUSIONS: The ASSIST-Drug may be a useful screening tool for PC settings. It is reliable, brief, and easy to remember, administer and score. It is sensitive and specific for drug use disorders and drug use negative consequences, and the predictive properties are consistent across subgroup of patients.

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BACKGROUND: Al-Anon Family Groups, a 12-step mutual-help program for people concerned about another person's drinking, is the most widely used form of help by Concerned Others. OBJECTIVES: This longitudinal study examined newcomers' outcomes of attending Al-Anon. Aims were to better understand early gains from Al-Anon to inform efforts in the professional community to facilitate concerned others' attendance of and engagement in Al-Anon. METHODS: We compared two groups of Al-Anon newcomers who completed surveys at baseline and 6 months later: those who discontinued attendance by the 6-month follow-up (N = 133), and those who were still attending Al-Anon meetings (N = 97); baseline characteristics were controlled in these comparisons. RESULTS: Newcomers who sustained participation in Al-Anon over the first 6 months of attendance were more likely than those who discontinued participation during the same period to report gains in a variety of domains, such as learning how to handle problems due to the drinker, and increased well-being and functioning, including reduced verbal or physical abuse victimization. Newcomers to Al-Anon reported more personal gains than drinker-related gains. The most frequent drinker gain was a better relationship with the Concerned Other; attendees were more likely to report this, as well as daily, in-person contact with the drinker. CONCLUSION: Al-Anon participation may facilitate ongoing interaction between Concerned Others and drinkers, and help Concerned Others function and feel better. Thus, short-term participation may be beneficial. Health-care professionals should consider providing referrals to Al-Anon and monitoring early attendance.

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BACKGROUND: Few longitudinal studies describe the relationship between somatic symptoms and family disagreements. We examined changes over time in somatic symptoms, family disagreements, their interrelationships, and whether these patterns differed between individuals treated for depression (depression group) and individuals from the same community (community group). METHODS: We followed participants in the depression (N = 423) and community (N = 424) groups for 23 years (the community group was matched to the depression group on socioeconomic status, gender, and marital status). All participants were age 18+ and completed surveys at baseline, 1, 4, 10, and 23 year follow-ups. We assessed somatic symptoms and family disagreements at each time point and used latent growth curve modeling to examine change in these constructs over time. RESULTS: Somatic symptoms and family disagreements changed differently over time. Somatic symptoms decreased between baseline and the 10 year follow-up, but increased between the 10 and 23 year follow-ups, whereas family disagreements decreased linearly over time. Somatic symptoms and family disagreements were higher at baseline and declined at a faster rate in the depression compared to the community group. The relationship between changes in somatic symptoms and changes in family disagreements was also stronger in the depression group: a larger decrease in somatic symptoms was associated with a larger decrease in family disagreements. CONCLUSIONS: Longitudinal changes in somatic symptoms and family disagreements differ between depression and community groups. Individuals treated for depression had more somatic symptoms and family disagreements at baseline and improved at a faster rate compared to individuals in the community. Somatic symptoms and family disagreements may be important targets when treating depression, given the strong interrelationship among these factors in individuals with depression.

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BACKGROUND: Though a growing number of US Veterans are being diagnosed with cannabis use disorders, with posttraumatic stress disorder (PTSD) observed as the most frequently co-occurring psychiatric disorder among this population, no research has investigated the impact of PTSD diagnosis on cannabis quit success. OBJECTIVES: The present study sought to determine the impact of PTSD on cannabis use following a self-guided quit attempt. METHODS: Participants included 104, primarily male, cannabis-dependent US Veterans (Mage = 50.90 years, SDage = 9.90). The study design was prospective and included an assessment immediately prior to the quit attempt, and assessments weekly for the first 4 weeks post-quit, and then monthly through 6 months post-quit. RESULTS: Results indicated that PTSD diagnosis was not associated with time to first lapse or relapse. However, individuals with PTSD used more cannabis at baseline and evidenced a slower initial decline in cannabis use immediately following the quit attempt. All findings were significant after accounting for alcohol and tobacco use across the cessation period, as well as co-occurring mood and anxiety disorder diagnoses. CONCLUSION: Findings highlight the potential utility of interventions for individuals with cannabis use disorder and co-occurring PTSD, particularly early in a cessation attempt.

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IMPORTANCE: Illicit drug use is prevalent, and primary care provides an ideal setting in which to screen for drug use disorders (DUDs) and negative consequences of drug use (NCDU). Comprehensive reviews have concluded that existing drug use screening instruments are not appropriate for routine use in primary care. OBJECTIVE: To develop and validate a screening instrument for drug use. DESIGN, SETTING, AND PARTICIPANTS: We revised items drawn from existing screening instruments and conducted signal detection analyses to develop the new instrument. We approached 3173 patients at 2 primary care clinics in a US Department of Veterans Affairs health care system from February 1, 2012, through April 30, 2014. A total of 1300 (41.0%) patients consented to the study, of whom 1283 adults were eligible (mean [SD] age, 62.2 [12.6] years). In the last 12 months, 241 (18.8%) participants reported using illicit drugs or prescription medication for a nonmedical purpose, and 189 (14.7%) reported 1 or more NCDU. A total of 133 (10.4%) patients met DSM-IV criteria for a DUD. The sample was randomly divided first to develop the measure and then to validate it. MAIN OUTCOMES AND MEASURES: The Mini-International Diagnostic Interview was used as the criterion for DUDs, and the Inventory of Drug Use Consequences was used as the criterion for NCDU. RESULTS: The screening instrument has 2 questions. The first is, "How many days in the past 12 months have you used drugs other than alcohol?" Patients meet that criterion with a response of 7 or more days. The second question asks, "How many days in the past 12 months have you used drugs more than you meant to?" A response of 2 or more days meets that criterion. The screening instrument was 100% sensitive and 93.73% specific for DUDs (643 patients); when replicated in the second half of the sample (640 patients), it was 92.31% sensitive and 92.87% specific. The screening instrument was 93.18% sensitive and 96.03% specific for NCDU (643 patients); when replicated in the second half of the sample (640 patients), it was 83.17% sensitive and 96.85% specific. CONCLUSIONS AND RELEVANCE: The 2-item screen of drug use has excellent statistical properties and is a brief screening instrument for DUDs and problems suitable for busy US Department of Veterans Affairs primary care clinics.

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OBJECTIVE: Research on moderate drinking has focused on the average level of drinking. Recently, however, investigators have begun to consider the role of the pattern of drinking, particularly heavy episodic drinking, in mortality. The present study examined the combined roles of average drinking level (moderate vs. high) and drinking pattern (regular vs. heavy episodic) in 20-year total mortality among late-life drinkers. METHOD: The sample comprised 1,121 adults ages 55-65 years. Alcohol consumption was assessed at baseline, and total mortality was indexed across 20 years. We used multiple logistic regression analyses controlling for a broad set of sociodemographic, behavioral, and health status covariates. RESULTS: Among individuals whose high level of drinking placed them at risk, a heavy episodic drinking pattern did not increase mortality odds compared with a regular drinking pattern. Conversely, among individuals who engage in a moderate level of drinking, prior findings showed that a heavy episodic drinking pattern did increase mortality risk compared with a regular drinking pattern. Correspondingly, a high compared with a moderate drinking level increased mortality risk among individuals maintaining a regular drinking pattern, but not among individuals engaging in a heavy episodic drinking pattern, whose pattern of consumption had already placed them at risk. CONCLUSIONS: Findings highlight that low-risk drinking requires that older adults drink low to moderate average levels of alcohol and avoid heavy episodic drinking. Heavy episodic drinking is frequent among late-middle-aged and older adults and needs to be addressed along with average consumption in understanding the health risks of late-life drinkers.

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BACKGROUND: Patient-centered models of assessment have shown considerable promise for increasing patients' readiness for mental health treatment in general, but have not been used to facilitate patients' engagement in substance use disorder (SUD) treatment. We developed a brief patient-centered intervention using assessment and feedback of personality data and examined its acceptability and efficacy to increase early engagement in residential SUD treatment. METHODS: Thirty patients entering a 90-day residential SUD treatment program were randomly assigned to a feedback (n = 17) or control (n = 13; assessment-only) condition. Normal-range personality was assessed with the NEO Personality Inventory-Revised (NEO PI-R). Patients were re-interviewed one month after treatment entry to obtain information on their satisfaction with the intervention, as well as their adjustment to the residential milieu. Electronic medical records were reviewed to obtain information on patients' length of stay in the program and discharge status. Univariate ANOVAs and chi-square tests were conducted to examine group differences on outcomes. RESULTS: Patients' ratings indicated strong satisfaction with the feedback intervention and expectations that it would have a positive impact on their treatment experiences. Among patients who had not previously been treated in the residential program, the feedback intervention was associated with more positive relationships with other residents in treatment and a stronger alliance with the treatment program one month after treatment entry. The feedback intervention was also associated with a longer length of stay in treatment, although this effect did not reach statistical significance. CONCLUSIONS: The findings highlight the clinical utility of providing SUD patients with patient-centered feedback based on the results of personality testing, and provide preliminary support for the acceptability and efficacy of this intervention to facilitate early engagement in residential SUD treatment.

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OBJECTIVE: While family conflict and somatic symptoms are mutually associated, few longitudinal studies have examined multiple (heterogeneous) trajectory subgroups for family conflict and somatic symptoms and their covariation over time. The aim of this study was to identify heterogeneous trajectory subgroups for family conflict and somatic symptoms and their joint trajectories. METHODS: A representative sample of 424 community participants completed surveys at baseline and 1-, 4-, and 10-year follow-ups. Family conflict and somatic symptoms were assessed at each wave. Covariates (age, gender, marital status, education, and medical conditions) were assessed at baseline. Growth mixture modeling (GMM) was used to identify heterogeneous trajectory subgroups for family conflict and somatic symptoms. A parallel process GMM was used to examine joint trajectory subgroup membership between family conflict and somatic symptoms. RESULTS: There were three trajectory subgroups for family conflict: stable low; worsening; and improving, and three somewhat similar trajectory subgroups for somatic symptoms: stable low; stable moderate; and improving. Family conflict and somatic symptom trajectory subgroup memberships were jointly associated. Individuals who had stable low family conflict were most likely to follow a stable low somatic symptom trajectory. Individuals who improved in family conflict were most likely to continue to have stable low somatic symptoms or improve in somatic symptoms. Moreover, individuals who had stable moderate somatic symptoms were most likely to show worsening family conflict. CONCLUSION: This study demonstrates heterogeneous family conflict and somatic symptom trajectories and indicates that these trajectories covary over time.

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This study examined social processes of support, goal direction, provision of role models, and involvement in rewarding activities to explain benefits of participating in Al-Anon, a 12-step mutual-help program for people concerned about another person's substance use. Newcomers to Al-Anon were studied at baseline and 6 months later, at which time they were identified as having either sustained attendance or dropped out. Among both newcomers and established Al-Anon members ("old-timers"), we also used number of Al-Anon meetings attended during follow-up to indicate extent of participation. Social processes significantly mediated newcomers' sustained attendance status versus dropped out and outcomes of Al-Anon in the areas of life context (e.g., better quality of life, better able to handle problems due to the drinker), improved positive symptoms (e.g., higher self-esteem, more hopeful), and decreased negative symptoms (e.g., less abuse, less depressed). Social processes also significantly mediated newcomers' number of meetings attended and outcomes. However, among old-timers, Al-Anon attendance was not associated with outcomes, so the potential mediating role of social processes could not be examined, but social processes were associated with outcomes. Findings add to the growing body of work identifying mechanisms by which 12-step groups are effective, by showing that bonding, goal direction, and access to peers in recovery and rewarding pursuits help to explain associations between sustained Al-Anon participation among newcomers and improvements on key concerns of Al-Anon attendees. Al-Anon is free of charge and widely available, making it a potentially cost-effective public health resource for help alleviating negative consequences of concern about another's addiction.

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OBJECTIVES: To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs). STUDY DESIGN: Retrospective cohort study. METHODS: This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics). RESULTS: Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions. CONCLUSIONS: Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

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