Evidence based psychotherapies for trauma that include focus on stress management and interpersonal effectiveness such as Skills Training in Affect and Interpersonal Regulation , may be particularly meaningful for CHR subjects who have a history of childhood trauma. Schafer and Fisher demonstrated the effectiveness and tolerability of STAIR for individuals at clinical high risk for psychosis with history of childhood trauma. However, there has been little research evaluating the effectiveness of evidence-based trauma-focused treatments in this complex population. Studies evaluating the effectiveness of trauma focused interventions may include individuals with psychosis as only a small sub-sample of participants included in the research, but co-occurring psychosis spectrum disorders are often included as exclusionary criteria in evaluation of trauma-focused treatments for individuals with a history of trauma . As previously discussed, compassion training, such as CBCT, may represent a unique category of psychosocial intervention that helps to improve stress reactivity in youth who have experienced early life adversity . Moreover, PoehlmannTynan et al. demonstrated when parents completed 8-10 weeks of CBCT their children demonstrated reduced cortisol, indicating that compassion training for parents may have cascading effects of cumulative stress on their children. Although difficult to achieve, prevention of the occurrence of childhood trauma would be an ultimate goal. Varese et al. maintain that if childhood trauma was removed from the population entirely, the number of individuals presenting with psychosis would be reduced by 33%. Thus, assessment of childhood trauma is an essential first step toward not only early intervention in,cannabis vertical grow racks but also ultimately prevention of psychosis spectrum disorders.Approximately 1 in 10 transitional age youth between the ages of 18 to 24 experience homelessness every year in the United States , representing 3.5 million youth annually.
Prior research has consistently demonstrated an increased prevalence of mental health disorders among this population, including high rates of depression, anxiety, substance use and post-traumatic stress disorder. Overall, the lifetime prevalence of psychiatric conditions among youth experiencing homelessness is twice that of their stably-housed peers. Further, unstably housed TAY experience high rates of co-occurring substance use disorders with either anxiety, or affective disorders including major depressive disorder or bipolar disorder, a phenomenon known as dual diagnosis. Among homeless TAY with multiple comorbid psychiatric conditions, major depressive disorder is the most common diagnosis, affecting anywhere from 41% to 73% of these individuals. Studies have also demonstrated that suicidal ideation and attempt are markedly higher among unstably housed TAY. For instance, 40% to 80% of homeless youth report suicidal ideation, and 23% to 67% report at least one prior suicide attempt. In San Francisco, one study found that the mortality rate among homeless TAY was 10-fold higher than stably-housed, age-matched peers, largely due to increased deaths from suicide and conditions associated with severe substance use disorder. The causes of homelessness among many TAY include violence and abuse, including physical, sexual or emotional abuse experienced in homes of origin. Following the onset of homelessness, many TAY continue to encounter victimization and abuse. For instance, one study found that 83% of youth reported one or more instances of physical or sexual victimization while living on the streets, which contributes to poor mental health outcomes. Experiences of violence and victimization vary by sexual orientation. For instance, lesbian, gay, bisexual or transgender youth are more likely to face sexual victimization and harassment from police compared to their counterparts, increasing their vulnerability to developing mental health disorders such as anxiety, PTSD and depression. Further, other homeless LGBT TAY report higher rates of depression and suicidality compared to their heterosexual and cisgender peers. While the high prevalence of various mental health disorders among unstably housed TAY is well-established in the literature, few studies to our knowledge have employed a syndemic approach to understand how the co-occurrence of anxiety, PTSD symptoms and poly substance use impact depression. Originally conceived in the early years of the HIV/AIDS pandemic by Merrill Singer, Syndemic Theory is a model for conceptualizing how two or more co-occurring health conditions can interact synergistically within a specific population and social context to mutually increase the overall burden of deleterious health outcomes.
Notably, the term ‘syndemics’ is not a synonym for comorbidities, but rather a phenomenon that develops under the co-occurrence of various adverse socio-structural conditions which in turn increases the risk of developing negative health outcomes. Since its conception, Syndemic Theory has been widely applied in medical, anthropological, and public health research to better understand the impact of disease clustering. Leveraging this framework to understand the synergistic effects of anxiety, PTSD and poly substance use on depression among unstably housed TAY may help inform service delivery methods to improve the overall health of this marginalized population.To address this knowledge gap, we studied marginally housed and homeless TAY between the ages of 18 and 24 in San Francisco, California to identify the prevalence and correlates of being at risk of clinical depression. Additionally, we employed a syndemics framework to examine whether the co-occurrence or clustering of multiple adverse psychosocial factors, including symptoms of moderate or severe anxiety, symptoms of PTSD and polysubstance use, had a synergistic effect on being at risk of clinical depression among high risk youth. We hypothesized that the prevalence of being at risk of clinical depression would be high and associated with a greater number of syndemic factors. As such, this study fills an important gap in research on how syndemic experiences fuel inequalities in psychological and socio-behavioral outcomes among marginally housed and homeless TAY in San Francisco, CA.We utilized baseline data from a Substance Abuse and Mental Health Services Administration funded study designed to assess mental health, substance use and HIV risk behaviors among marginally housed and homeless TAY at Larkin Street Youth Services in San Francisco, CA. Participants were considered eligible if they were: 1) between the ages of 18 and 24, and 2) clients of Larkin Street Youth Services. Larkin Street Youth Services is a community based organization that provides a wide variety of services, including housing, case management, education and employment training programs, and medical care for marginally housed and homeless youth in San Francisco.From May 2017 through April 2018, 100 TAY were recruited from various Larkin Street Youth Service sites, including transitional housing sites, one of which was designed for youth living with HIV, and drop in-centers.
Recruitment strategies involved posting recruitment flyers, giving presentations at community meetings for Larkin Street clients,commercial marijuana vertical growing and coordinating closely with Larkin Street staff to recruit participants.Surveys were administered by trained interviewers with extensive experience working with high-risk TAY. All interviews were conducted in a private setting and lasted approximately 90 minutes. Data were collected using a computer assisted survey information collection method administered on iPads. Participants received a $30.00 drugstore gift card for their participation. Participation in the survey had no bearing on individuals’ ability to obtain services at Larkin Street.Data on age in years, race/ethnicity and gender were collected. Sexual orientation was measured by creating a dichotomous variable for those who identified has being heterosexual versus gay, lesbian, bisexual, or pansexual . Participants were asked to describe where they live by selecting one of the following responses: 1) In my own apartment, 2) In a relative’s home, 3) In a group home, 4) In a campus/dormitory housing, 5) In a foster care, 6) homeless or in a shelter, and 7) other. From these responses, a categorical measure of housing stability was created with the following categories; stably housed , unstably housed and homeless or living in a shelter. Data on ever having been incarcerated for three or more days and self-reported HIV serostatus were also collected.Symptoms of post-traumatic stress disorder in the past month were assessed via the 20-item PCL-5. Total scores range from 0–80, and a standard cutoff of 33 was used to create a dichotomous measure of PTSD symptoms. We used the Generalized Anxiety Disorder 7-item , to measure symptoms consistent with anxiety in the past two weeks. Total scores range from 0–21 and designated cutoffs for minimal , mild , moderate and severe were used to create a categorical measure of symptoms of anxiety. A dichotomous measure of symptoms of moderate or severe anxiety was created for those with scores of 10 or greater. We measured any exposure to traumatic events prior to the age of 18 using the Adverse Childhood Experiences instrument. Traumatic events assessed included experiences of emotional, physical and sexual abuse. A cutoff of 4 or more was used to create an indicator variable for greater adverse childhood experiences . These instruments were not used as diagnostic tools, they were used to evaluate the presence of symptoms consistent with the mental health conditions assessed to decide whether further psychiatric evaluation was needed.Drug and alcohol use were assessed using the NIDA-Modified ASSIST. Participants were asked if they used any of the following drugs: cannabis, cocaine, prescription stimulants, methamphetamine, inhalants, sedatives, hallucinogens, street opioids, prescription opioids or other drugs in the past three months . Consistent with prior research on poly substance use and syndemics, polysubstance use was defined as using three or more of the drugs listed above in the past three months .
Consistent with other research on syndemics, a composite syndemic score ranging from 0–3 was created by summing dichotomous measures of; moderate or severe anxiety, PTSD symptoms and poly substance use. We selected these factors based on a priori hypotheses related to broader mental health disease clustering and their confirmed association with the outcome of interest . Factors that were not significantly associated with being at risk of clinical depression in bivariate analyses were not included the syndemic score. A nominal syndemic variable was also created to identify those with zero, one, two or three syndemic factors.We used descriptive statistics to describe the study sample and examine the prevalence of various mental health factors, substance use and sociodemographic characteristics. We generated frequencies, percentages and depending on distributional assumptions for continuous data means, standard deviations or medians and interquartile ranges . We calculated pairwise correlation coefficients and corresponding p-values to estimate the level of clustering among the syndemic factors included in this study and to ensure they are true syndemic factors. Then, we examined the prevalence of being at risk of clinical depression by number of syndemic factors . We also graphed one’s depression score by the number of syndemic factors .We used modified Poisson regression with robust error variances to estimate the relative risk of being at risk of clinical depression by various sociodemographic, mental health, substance use and syndemic factors. Per Zou and colleagues recommendation, this method was used to yield more precise estimates including, smaller confidence intervals. Each primary exposure that was significantly associated with being at risk of clinical depression at the bivariate level including: symptoms of moderate or severe anxiety, symptoms of PTSD, polysubstance use, the composite syndemic score and the nominal syndemic variable, was explored further in multi-variable Poisson regression models. As recommended by Westreich and colleagues,each primary effect measure was modeled separately in order to yield total effect estimates and avoid multicollinearity. Multivariable models controlled for the following correlates of depression: age in years, gender, race/ethnicity and sexual orientation. Interactions were tested between each primary exposure and sexual orientation. All analyses were performed using Stata 16.1.Among a total of 100 participants, the average age was 22 , 67% were male, 38% were Multiracial, 28% were Black, 22% were White and 12% identified as other or declined to state their race/ethnicity. Over half identified as gay, bisexual or pansexual, 13% were unstably housed and 50% were homelessness. Nearly a quarter were living with HIV and almost a third had ever been incarcerated for at least three days . The median CESD score was 25.3 and 74% met symptom criteria for clinical depression evidenced by having a score of 16 or greater. Anxiety symptoms ranged from 23%with minimal, 26% with mild, 25% with moderate, 25% with severe and 51% with moderate or severe anxiety symptoms. The mean PCL-5 score was 54.6 and 80% had a PCL-5 score of 33 or greater which is indicative of probable PTSD . The mean ACEs score was 5.8 and 77% had an ACEs score of 4 or more which is indicative of significant abuse, neglect and/or household dysfunction .