Faculty Bibliography

A Position Paper published in The Lancet Psychiatry in 2020 suggested an agenda for research about the effects of the COVID-19 pandemic on mental health, following which an interdisciplinary Lancet Psychiatry standing commission was established in 2022 to examine the emerging evidence and refine recommendations for more research. In this first Series paper from the standing commission, we focus on changes in the delivery of clinical mental health care during the COVID-19 pandemic. The second paper in the Series focuses on public mental health and policy perspectives, and the third will address neuropsychiatric consequences of infection by SARS-CoV-2. Evidence from high-quality longitudinal studies with pre-pandemic baseline data, controlled intervention trials, or systematic reviews took time to accrue. During the early months of the COVID-19 pandemic, symptoms of anxiety and depression became more prevalent, and many mental health services were compromised by pandemic-related factors; however, whether the COVID-19 pandemic accelerated pre-existing long-term trends of increasing incidence of mental health disorders, especially in children and adolescents, is unclear. Little research has been done in low-income and middle-income countries, or regarding post-COVID-19 condition (also known as long COVID), which emerged as a multisystem condition with mental health implications. Vulnerable populations, including socioeconomically disadvantaged and minoritised groups, faced disproportionate mental health impacts and limited access to care during the COVID-19 pandemic, reflecting systemic, pre-pandemic inequalities. Bold implementation of existing evidence-based mental health support for vulnerable communities, ambitious trials of novel interventions, and systematic pooling of rapidly accumulating evidence about best healh care should be priorities in future pandemics.

The COVID-19 pandemic revealed essential weaknesses in mental health systems and intensified existing inequities, highlighting the need for a comprehensive assessment of policy responses and strategies for future resilience. Guided by four questions relating to system adaptations, approaches to inequities, financing strategies, and evidence gaps, we synthesised evidence from a structured literature search (2020-24), expert consultation, and lived experience. We found that public health systems embedded infodemic management, expanded digital services, and mobilised community workforces, but responses varied in equity and effectiveness. Although gender, age, socioeconomic, and racial disparities worsened during the COVID-19 pandemic, social protection, gender-sensitive policies, school-based services, and culturally adapted interventions showed promise. High-income countries buffered shocks with welfare measures while low-income and middle-income countries faced sharp fiscal constraints. Few studies evaluated cost-effectiveness or equity impacts of psychosocial interventions. Building resilient, equitable mental health systems requires integrated policies spanning communication, digital and community care, gender-responsive and youth-responsive strategies, and sustainable financing, alongside investment in longitudinal and cross-national research.

IMPORTANCE/UNASSIGNED:Approximately 27% of adults in the US and Canada report having ever used cannabis for medical purposes. An estimated 10.5% of the US population reports using cannabidiol (CBD), a chemical compound extracted from cannabis that does not have psychoactive effects, for therapeutic purposes. OBSERVATIONS/UNASSIGNED:Conditions for which cannabinoids have approval from the US Food and Drug Administration include HIV/AIDS-related anorexia, chemotherapy-induced nausea and vomiting, and certain pediatric seizure disorders. A meta-analysis of randomized clinical trials reported a small but significant reduction in nausea and vomiting from various causes (eg, chemotherapy, cancer) when comparing prescribed cannabinoids (eg, dronabinol, nabilone) with placebo or active comparators (eg, alizapride, chlorpromazine; standardized mean difference [SMD], -0.29 [95% CI, -0.39 to -0.18]). A meta-analysis of randomized clinical trials among patients with HIV/AIDS reported that cannabinoids had a moderate effect on increasing body weight compared with placebo (SMD, 0.57 [95% CI, 0.22 to 0.92]). Evidence-based guidelines do not recommend the use of inhaled or high-potency cannabis (≥10% or 10 mg Δ9-tetrahydrocannabinol [Δ9-THC]) for medical purposes. High-potency cannabis compared with low-potency cannabis use is associated with increased risk of psychotic symptoms (12.4% vs 7.1%) and generalized anxiety disorder (19.1% vs 11.6%). A meta-analysis of observational studies reported that 29% of individuals who used cannabis for medical purposes met criteria for cannabis use disorder. Daily inhaled cannabis use compared with nondaily use was associated with an increased risk of coronary heart disease (2.0% vs 0.9%), myocardial infarction (1.7% vs 1.3%), and stroke (2.6% vs 1.0%). Evidence from randomized clinical trials does not support the use of cannabis or cannabinoids for most conditions for which it is promoted, such as acute pain and insomnia. Before considering cannabis or cannabinoids for medical use, clinicians should consult applicable institutional, state, and national regulations; evaluate for drug-drug interactions; and assess for contraindications (eg, pregnancy) or conditions in which risks likely outweigh benefits (eg, schizophrenia or ischemic heart disease). For patients using cannabis or cannabinoids for treatment of medical conditions, clinicians should discuss harm reduction strategies, including avoiding concurrent use with alcohol or other central nervous system depressants such as benzodiazepines, using the lowest effective dose, and avoiding use when driving or operating machinery. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Evidence is insufficient for the use of cannabis or cannabinoids for most medical indications. Clear guidance from clinicians is essential to support safe, evidence-based decision-making. Clinicians should weigh benefits against risks when engaging patients in informed discussions about cannabis or cannabinoid use.

BACKGROUND:A collective identity is a set of shared values and value propositions that an investigator network projects as they deliver data and knowledge generated through their studies to community partners, policymakers, research participants, public health authorities, and prospective end users. The strategic process of identifying common values and establishing procedures to ensure the consistent communication of a collective identity across a diverse network of research teams is often not considered in research networks' dissemination of results. This paper describes how the HEAL Research on Interventions for Stability and Engagement (RISE) network co-created communication pillars that embody a set of common values and shared research imperatives to frame dissemination activities. METHODS:Early in the development of RISE, project teams participated in an in-person workshop to identify attributes and core values that they believed to be representative of their individual research programs. Dissemination coordinators analyzed and synthesized themes from workshop material, including presentations and posterboard illustrations, and used Mural whiteboarding software to distill these themes into core values and value propositions to collectively share across the research sites. RESULTS:The four communication pillars, which encompass our collective identity and are the foundation of our dissemination program, are (1) Doing Research with Communities, (2) Centering on the Lives and Experiences of People Who Use Drugs, (3) Emphasizing Scientific Rigor and Integrity; and (4) Focusing on Social Determinants. We present examples of how project teams are demonstrating the pillars throughout the research process and outline how the communication pillars inform the planning and dissemination of RISE-produced evidence to end users. CONCLUSIONS:Applying concepts from strategic communication and social marketing, we demonstrate how a research network of independent investigators can create a collective identity, formulate a cogent narrative communicating their contributions to a field of practice, and establish a foundation for a successful research dissemination program.

BACKGROUND/UNASSIGNED:Racial discrimination is associated with health disparities among Black Americans, a group that has experienced an increase in rates of fatal drug overdose. Prior research has found that racial discrimination in the medical setting may be a barrier to addiction treatment. Nevertheless, it is unknown how experiences of racial discrimination might impact engagement with emergency medical services for accidental drug overdose. This study will psychometrically assess a new measure of hesitancy in seeking emergency medical services for accidental drug overdose and examine prior experiences of racial discrimination and group-based medical mistrust as potential corollaries of this hesitancy. METHOD/UNASSIGNED:Cross-sectional survey of 200 Black adults seeking treatment for substance-use-related medical problems (i.e. substance use disorder, overdose, infectious complications of substance use, etc.). Participants will complete a survey including sociodemographic information, the Discrimination in Medical Settings Scale, Everyday Discrimination Scale, Group-Based Medical Mistrust Scale, and an original questionnaire measuring perceptions of and prior engagement with emergency services for accidental drug overdose. Analyses will include exploratory factor analysis, Cronbach's alpha, and non-parametric partial correlations controlling for age, gender, income, and education. CONCLUSIONS/UNASSIGNED:This article describes a planned cross-sectional survey of Black patients seeking treatment for substance use related health problems. Currently, there is no validated instrument to measure hesitancy in seeking emergency medical services for accidental drug overdose or how experiences of racial discrimination might relate to such hesitancy. Results of this study may provide actionable insight into medical discrimination and the rising death toll of accidental drug overdose among Black Americans.

Methadone treatment (MT) for opioid use disorder saves lives, but the US MT system has long been dominated by punitive policies and practices that make MT inaccessible, burdensome, and traumatic for patients. After generations without changes to methadone regulations, a confluence of circumstance-including the COVID-19 pandemic and an overdose crisis that has taken over a million lives-has begun to shift the MT advocacy and political landscape. This commentary describes the building of the "Liberate Methadone" movement; a grassroots effort led by people with lived and living experience with methadone, addiction clinicians, researchers, community leaders, and people with many of these identities. The Liberate Methadone movement is dedicated to building a more accessible, equitable MT system that prioritizes patient health, promotes dignity, and is grounded in evidence. We describe the experience of planning and hosting a national conference and generating proceedings with recommendations for needed incremental and structural reforms within the US MT system. The lessons learned from this movement can motivate others across clinical, research, and policy roles to partner with and learn from patient and community-led groups, guiding needed reforms within systems of care. It is through these joint efforts and listening to those directly impacted groups who have been left out of the conversation for far too long, that we can successfully reduce overdose and suffering, toward better health, dignity, and thriving in our communities.

With the overdose crisis continuing to pose significant challenges in North America, harm reduction strategies are critical for public health systems to reduce mortality and morbidity. Despite the considerable strides in harm reduction research, high-quality evidence for decision-making is limited. This is compounded by a variation in reported outcomes, drug supply, administration changes, and policy and social impacts, which further challenge researchers and practitioners in their efforts to implement effective, nimble harm reduction interventions. Adoption of common data elements (CDEs) and common outcome measures (COMs) helps researchers standardize and enhance data collection and outcome reporting, ultimately improving the comparability and generalizability of research findings. To accelerate the pace and use of CDEs, members of the NIDA HEAL Research on Interventions for Stability and Engagement (RISE) engaged in prospective semantic harmonization and consensus on CDEs and COMs using a rigorous pragmatic Delphi community informed approach. This process resulted in a set of CDEs and COMs that standardized data collection and reporting across 10 harm reduction research projects. This paper describes this process and presents the derived CDEs and COMs, along with key considerations, challenges encountered, and lessons learned.

Death from opioid use is a growing public health concern, with stark racial and ethnic disparities. The randomized controlled trial described here aims to improve initiation and engagement in harm reduction services for Black and Latine people who use drugs to minimize mortality in these populations. The trial is informed by a Community Advisory Board (CAB) of stakeholders from racial and ethnic minoritized backgrounds committed to promoting health equity in populations disproportionately impacted by the drug overdose crisis. CABs are an underutilized mechanism for engaging communities in research to improve health outcomes. Hence, in this manuscript we outline the process and methods employed in creating a CAB, describe its impact on our research study, and recognize the challenges and adaptations made to the CAB during the study.CAB recruitment targeted active community members from Black and Latine communities in the Bronx, NY and New Haven, CT. After attending community organizational meetings in each place, follow-up email efforts were unsuccessful, prompting a revised approach. Emphasizing the study's focus on historically excluded voices, "research-naïve" individuals were sought through online searches and local grassroots organizations, excluding those affiliated with harm reduction groups to minimize bias. Once CAB members were identified, a remote orientation was held, and the CAB began providing regular feedback on research activities, from participant recruitment to educational script details. CAB members' diverse identities and life experiences generated nuanced discussions, which were distilled into feedback improving research materials and recruitment strategies. In the future, the CAB will also guide data analysis and research publications. Other areas of emphasis have included straightforward language in study materials, balanced messaging about harm reduction recommendations, and specific community outreach opportunities. Practical barriers that needed to be addressed for optimal CAB functioning included timely compensation with minimal institutional burden and assistance with meeting coordination and communication.The CAB has ensured that Black and Latine community voices are included in guiding our study, promoting equitable and ethical research. As harm reduction research advances, it is essential to center this work around the intersectional identities of people who use drugs to prevent the disproportionate burden and deaths among Black and Latine people.

OBJECTIVE:This study aimed to describe initial experiences and lessons learned conducting a trial focused on recruiting racially and ethnically diverse hospitalized patients with untreated alcohol use disorder (AUD). METHODS:The parent trial is comparing the effectiveness of strategies including Brief Negotiation Interview (BNI), facilitated initiation of medications for AUD, and computer-based training for cognitive behavioral therapy (CBT4CBT) on AUD treatment engagement post-hospitalization. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced, we catalogued protocol changes and evaluated outcomes using study and electronic medical record data during the first 18 months of recruitment. RESULTS:Recipients: (1) Selected entry criterion to intentionally include individuals most likely impacted by structural racism, (2) developed multipronged recruitment approaches, and (3) selected bilingual, multicultural, and ethnically diverse research staff. Intervention: (1) Added scripts in the BNI to consider how cultural factors influence and how racism may impact, alcohol use, and AUD treatment engagement, (2) offered tablets as a compensation alternative with support for CBT4CBT initiation (as relevant), and (3) anticipate and troubleshoot internet access challenges. Setting: (1) Identified community-based AUD treatment options with Spanish-speaking services and (2) identified resources to address social determinants of health. Study: (1) Audited data to monitor whether diverse enrollment is occurring. Among n = 132 randomized as of March 1, 2024, 25% endorsed Black, 24% endorsed Latine, 58% endorsed White, 1% endorsed Indigenous, and 15% endorsed race not listed or declined to disclose. We observed no difference by race or ethnicity in recruitment or retention experiences. CONCLUSIONS:Multilevel practices within a hospital-based AUD-focused trial can promote recruitment and retention of a racially and ethnically diverse sample.