Adjacent research has found that sleep quality is malleable and thus can be improved even in clinical populations.These findings offer promising evidence for advancement in clinical staging models and future sleep-related therapies for both CHR and overt psychosis, such as an upcoming trial by Waite et al.Another budding direction of research involves computational advances in causal discovery analysis, offering innovative approaches to addressing causality in the context of observational data.Such methods require careful consideration of assumptions and properties underlying the data at hand,but could be utilized in future analyses of these and other prospective longitudinal datasets involving CHR and other clinical populations. Limitations of this study include the use of a self-report to assess sleep. The PSQI and the RU-SATED have high validity and reliability and subjective sleep problems have been the primary focus of sleep treatments. Such assessments, however, are fundamentally different from electrophysiological sleep characteristics that may be differentially associated with conversion and symptom levels. Therefore, the use of both self-report and electrophysiological sleep measures over time may inform clinical risk models and constitute targets for intervention. Other notable limitations include the significant dropout rates, the absence of ongoing sleep assessments succeeding the 8-month follow-up, and the relatively small sample size of our converting group . Furthermore, we acknowledge that pre-registering our study hypotheses would have strengthened our findings.The COVID-19 pandemic has produced major disruptions in daily life. A recent review concluded that the world population is experiencing increased stress, anxiety, and depression due to the pandemic and associated mitigation measures . In late June 2020, 40% of U.S. adults reported experiencing mental health symptoms,hydroponic table a stress disorder, or increasing substance use to cope with pandemic-related stress . Individuals with problematic substance use are particularly vulnerable to COVID-19 illness and psychosocial effects of the pandemic, such as stress and substance use treatment disruptions .
Disruptions in treatment increase risk of overdose, a serious complication of substance use disorders . Moreover, depression and anxiety commonly co-occur with substance use disorders . Evidence suggests that in the general population, increases in alcohol consumption during COVID-19 may be driven by stress, depression, and anxiety . Effects may be even more pronounced among individuals with problematic substance use. Periods of intense stress can give light to pre-existing fissures and vulnerabilities in people’s daily lives. A better understanding of substance use problems, depressive symptoms, and anxiety during the COVID-19 pandemic among people with problematic substance use can inform intervention efforts needed now and post-pandemic. Various pandemic-related situational factors may differentially affect substance use problems . According to behavioral economics, the COVID- 19 pandemic and associated mitigation measures may decrease the negative consequences of substance use . Many individuals are now working from home and have a more flexible schedule, making some of the negative consequences of substance use less relevant than before the pandemic. Simultaneously, the pandemic has limited the availability of alternative rewarding activities that are incompatible with substance use . Substance use and associated problems may increase if individuals are home more often and unable to engage in their usual activities, especially in the evenings . Moreover, other responsibilities at home may have increased during the pandemic. New consequences associated with substance use may emerge as lifestyles, schedules, and responsibilities shift. In sum, relationships between pandemic-related lifestyle factors, substance use, and substance use problems are likely complex and multifaceted. To better understand how individuals with problematic substance use are experiencing the pandemic, this exploratory, cross-sectional study examined associations between substance use problems, mental health symptoms, and pandemicrelated increased family responsibilities and stressors. Participants were recruited June 25 to August 18, 2020 for a randomized controlled trial of Woebot for Substance Use Disorders, a novel digital therapeutic for reducing problematic substance use.
Participants were recruited through Qualtrics Research Services, Stanford University listservs, a Facebook advertising campaign, and word-of-mouth. Eligibility criteria were U.S. residence, age 18-65, English literate, owning a smart phone, with past-year use of a substance, and problematic substance use . Exclusion criteria were history of severe alcohol or drug withdrawal, liver conditions, opioid overdose, or psychotic symptoms; past-year suicide attempt; past-year medical problems from drug or alcohol use; opioid use without concurrent medication-assisted treatment; past Woebot use; and pregnancy. The study protocol, approved by Stanford IRB, randomized consented participants to the Woebot for Substance Use Disorders intervention for 8 weeks or to a waitlist control condition. Only baseline measures, completed prior to randomization, were analyzed in the present study. Participants received a $25 Amazon gift card for completing the baseline survey.Correlations between substance use problems, pandemic impacts and behaviors, and mental health symptoms are presented in Table 1. Significant correlations indicated that participants who, during COVID-19, struggled with responsibilities at home, had greater mental health impacts, greater personal growth, frequented bars or large gatherings, and reported more depression and anxiety symptoms had higher SIP-AD scores. Participants who, during COVID- 19, struggled with responsibilities at home, had difficulty getting necessities, had greater mental health impacts, and worried more about their children had higher GAD-7 and PHQ-8 scores. Anxiety and depression scores were highly correlated. Participants who lost a job or income during the pandemic had higher PHQ-8 scores. Struggling with home responsibilities was associated with job or income loss, greater difficulty getting necessities, greater pandemic mental health impacts, less personal growth during the pandemic, avoiding large gatherings, and avoiding school or work. Difficulty getting necessities was associated with greater mental health impacts. Personal growth was associated with lower likelihood of avoiding large gatherings, and worrying about one’s children was associated with greater likelihood of avoiding non-essential travel. The COVID-19 precautions were significantly associated with each other. Multi–variable analyses are presented in Table 2. Participants with greater pandemic related mental health effects had higher SIP-AD, PHQ-8, and GAD-7 scores.
Younger participants had higher SIP-AD scores, and participants without a college degree had higher GAD-7 scores . Age was not associated with GAD-7 or PHQ-8 scores, and education was not associated with SIP-AD or PHQ-8 scores. Sex, race/ethnicity, marital status, and other pandemic-related variables were not associated with SIPAD, GAD-7, or PHQ-8 scores. Because only participants with children completed the “worries about children” measure, we repeated the GAD-7 and PHQ-8 models excluding this variable. In the full sample, females had higher GAD-7 scores than males . Otherwise,grow rack only pandemic-related mental health effects remained associated with GAD-7 and PHQ-8 scores. During the COVID-19 pandemic, 40.6% of surveyed adults with substance use problems reported struggling with responsibilities at home. Struggling with responsibilities at home during the pandemic was associated with more substance use problems and greater depression and anxiety symptoms. Obtaining, using, and recovering from substances can impair one’s ability to fulfill obligations. New responsibilities resulting from the pandemic, such as full-time childcare due to school closures, may be difficult to fulfill while struggling with substance use. Results are consistent with extant literature showing that unpaid caregiving during COVID-19 was associated with increased substance use . Individuals struggling with substance use, anxiety, and depression may need support in meeting their own needs as well as their family’s needs during the pandemic. Additionally, frequenting bars or large gatherings, experiencing negative mental health effects, and perceiving more positive personal growth from the pandemic were associated with more substance use problems. Difficulty getting necessities, experiencing more negative mental health effects, and greater worry about one’s children’s well-being was associated with greater depression and anxiety symptoms. In multi-variable models, controlling for demographic characteristics, negative mental health effects of the pandemic were the strongest correlate of substance use problems, depressive symptoms, and anxiety symptoms. Participants with high scores on this measure reported frequently thinking about COVID-19, worrying about their health and/or the health of their family and friends, experiencing stress due to changes in social contacts and their lifestyles, worsening of their mental/emotional health, and sleep disruptions. Findings suggest that the COVID-19 pandemic is producing major concerns that may contribute to mental health symptoms, including problematic substance use. Many individuals are using substances to cope with stress and uncertainty around the pandemic . A nationally representative sample of U.S. adults conducted early in the pandemic identified increased risk of depressive symptoms among people with lower income, fewer savings, and more stressors . People with problematic substance use may also be at elevated risk for depressive symptoms. While some evidence suggests that pandemic-induced psychological distress is lessening in the United States , people with problematic substance use are vulnerable to the negative effects of the pandemic . In this study, participants with more substance use problems were less likely to avoid bars and large gatherings, corroborating concerns that substance use may increase risk of contracting COVID-19 . Participants struggling to control their substance use may have found it difficult to avoid settings in which they use. Paradoxically, individuals with greater substance use problems also perceived greater personal growth from the pandemic in the forms of strengthened relationships, new possibilities, awareness of personal strength, spiritual change, and increased appreciation of life. People with problematic substance use often experience intense emotions .
Experiencing intense emotions may have led individuals with substance use problems to be deeply affected by both positive and negative pandemic-related changes. Additionally, perceiving greater personal growth was associated with lower likelihood of struggling with responsibilities at home and lower likelihood of avoiding large gatherings. Participants who perceived personal growth may be a subset whose daily lives were less strongly affected by the pandemic. Study data are cross-sectional, and causal pathways cannot be determined. There may be bidirectional relationships between substance use problems and pandemic-related mental health symptoms and stressors. While pandemic-related stress may have worsened mental health symptoms and substance use, it is also plausible that individuals with preexisting mental health symptoms and more substance use problems were negatively impacted by the pandemic than those with milder symptoms. Longitudinal research is needed to fully understand how substance use and pandemic-related circumstances may impact one another. Results are also subject to recall bias, as all measures were self-reported. Participants may have had difficulty accurately reporting their substance use and mental health symptoms from the past two weeks. Data were not collected on general life stressors unrelated to the pandemic. Individuals with high levels of stress may have experienced more pandemic-related stressors, mental health symptoms, and substance use problems. Lastly, the sample was predominantly non-Hispanic white. People of color are at increased risk of contracting and experiencing complications from COVID-19 . Moreover, Hispanic and Black individuals were more likely to report increased substance use than non-Hispanic white or Asian adults, potentially due to increased stress . Different vulnerabilities may interact to influence experiences of the pandemic. All participants were enrolled in a clinical trial, were not experiencing severe medical problems from their substance use, owned smartphones, and were proficient in English. Hence, findings may not generalize to more impoverished, medically complicated, or diverse groups. Future research into pandemic-related stressors and substance use should aim to recruit a more diverse sample. Smoking and alcohol misuse often co-occur. In the United States, the prevalence of nicotine dependence among individuals with alcohol dependence is 45.4%, while the prevalence of any alcohol use disorder among adults with nicotine dependence is 22.8% . These co-dependent individuals have more difficulty quitting smoking . An outstanding problem among those with substance use disorders is their disproportionate valuation of the drug and their disproportionate allocation of resources to obtaining the drug compared to participating in other daily activities . This imbalance between drug-related vs. regular activities reflects reinforced drug consumption patterns , and the differences in how drugs and non-drug reinforcers exhibit differential reinforcement strengths can be operationalized using a concept known as Relative Reinforcing Efficacy . One validated laboratory approach to measuring the RRE of drugs is hypothetical purchasing tasks, which assess changes in drug purchase and consumption as a function of increasing drug price . The consumption pattern can yield the demand curve modeled by Q = Q0∗10k , an exponentiated version of the classic equation by Hursh and Silberberg . Q represents consumption at price C; Q0 represents consumption at or near price zero, α represents the rate of change in demand elasticity, and k is the span of consumption values in log units. Other demand indices derived from the demand curve include: break point , Omax , and Pmax .