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Although the lack of mental health services available to all youth has been exposed as a result of COVID-19, this is particularly problematic for LGBTQ+ youth.

 Specifically, transgender and gender-diverse (TGD) youth experience higher rates of depression, suicidal behaviors, and self-injury than their cisgender peers (see 

A recent survey of adolescents across the United States indicated that about 2% of middle and high school students identify as transgender or gender diverse,

 a number that has been increasing over time.

 Importantly, although many TGD individuals feel a strong discomfort with their body and change their gender expression and roles and/or physical characteristics to align with their identity, not everyone experiences the distress related to the clinical diagnosis of 

With increased research looking at the experiences of TGD individuals separately from their sexual minority peers, we have begun to better understand cooccurring issues for this distinct population. Specifically, depression, self-injurious behaviors, 

, disordered eating, and anxiety have been reported, as have high suicide attempt rates: These rates are at least 3 times higher than those of cisgender peers.

Why are we now seeing such increased rates of comorbidities with TGD individuals? Proposed by Hendricks and colleagues,

 the Gender Minority Stress and Resilience Model (GMSRM) is a framework through which we can understand the unique internal and external stressors that impact TGD individuals, as well as factors that contribute to resilience. The authors posit that external experiences of discrimination, victimization, rejection, and nonaffirmation of gender identity combine with internalized transphobia, negative expectations of the world and others, and concealment; these leave TGD individuals at risk for the development of negative mental health symptoms such as 

, suicidality, and self-injurious behavior.

Therefore, when working with TGD individuals, we need to assess for the internal mechanisms related to any psychiatric diagnosis, but also the external/environmental factors that are contributing to and maintaining the symptoms. For example, numerous studies have looked at the relationship between invalidation and victimization in schools, hospitals, and therapy that led to individuals dropping out of school, not accessing care, or ending treatment.

 In addition, we must continuously use an intersectional lens to be able to understand how additional identities that have been marginalized (eg, race, ethnicity, sexual orientation, ability, religion) may also be impacting the individual’s functioning, as well as the level of gender dysphoria the individual is experiencing. Attention to all these contributing/maintaining factors—both internal and external—is necessary for the best treatment.

Consider this metaphor: If you have to put out a fire, it is important to understand what caused the fire in the first place. Putting water on a grease fire will not only not help—it can make it worse. Similarly, trying to use typical interventions for depression for dysphoria not only will not help, but may also invalidate the patient and make them feel worse about not being seen or heard.

“Max” is an affirmed male (assigned female at birth), aged 14 years, who presented to our program to discuss gender-affirming care. Max reported that he had always known he was a boy and had preferred stereotypical masculine clothing, mannerisms, and activities for as long as he could remember. Max was raised by his maternal aunt “Linda,” who was his sole custodian. Both of Max’s parents had struggled with substances since he was a young child, and they did not have secure housing. None of Max’s family consistently used his chosen name or pronouns, although teachers and peers regularly used them in school. Linda was convinced that Max’s identity was “just a phase” and that the real presenting problem was that he had an eating disorder and was depressed. Linda wanted Max to be admitted to an inpatient unit, as she believed he needed “to get more meds.” She was very upset that the school was “reinforcing ‘her’ issues.”

Upon further discussion alone with the patient, he reported he was restricting food intake because he wanted to stop his menses, as it was very distressing, and he wanted to prevent his chest from growing, as he did not have access to a binder to compress his chest area. He experienced a lot of gender dysphoria when thinking about or discussing his body/bodily functions. Max also reported that he felt like his family would never understand him, use his name or pronouns, or allow him to proceed with any medications to stop his menses, let alone masculinize his body. To “let out” some of his pain, Max would use pencil sharpeners to cut his arms and thighs. Although he felt supported by friends and teachers at school, he felt his family would never accept him, would always make fun of him, and would never support who he is.

In this case example, we see issues such cooccurring gender dysphoria (eg, discomfort with body, effects of estrogen-based pubertal development), symptoms of depression, and restrictive eating. Max’s discomfort with his body and attempts to align his body with his gender identity appear to be directly impacting his eating. Therefore, traditional treatment for an 

 would not work with Max, and it could potentially lead to more gender dysphoria, depressive symptoms, and self-injurious behavior.

Relatedly, Max’s nonaffirmation at home, negative expectations about his future ability to identify as male in the eyes of his family, and negative expectations about treatment appear to be directly related to some of his depressive symptoms and self-injurious behaviors. In addition to a traditional 

, dialectical therapy, or assertive community therapy approach, understanding the GMSRM and educating the family members on the importance of using chosen name/pronouns to decrease depression and suicidal ideation would be imperative to share, as would the general importance of family and peer support.

To conceptualize the presenting problem as well as understand any maintaining factors, clinicians should consider exploring the following issues:

 What has their journey exploring their gender identity looked like? Who has been supportive of this exploration? How has society impacted their views on gender?

 What are their experiences of discrimination, rejection, victimization, and/or nonaffirmation in school? At home? With peers? With immediate as well as extended family members?

 Who is supportive of the youth, their gender journey, and the way they choose to express themselves? Are there differences by domain (eg, family, peers, school, online)?

 Is the youth experiencing negative mood, anger, or thoughts of suicide? How are these feelings related to their gender identity, internalized transphobia, or the felt need to conceal who they are for fear of repercussions or other fears of victimization/nonaffirmation?

 Have they experienced any traumatic events related to their gender identity or expression that may be impacting their sleep, eating, or ability or concentrate?

 Have they been controlling their eating to change their body shape or functions to be more congruent with their gender identity (eg, restricting food to stop menses or decrease curves or eating more to increase curves)?

 How does the youth experience gender joy? How does this impact mood? Can the youth experience gender joy in a safe manner?

TGD youth experience numerous environmental stressors (eg, victimization, invalidation, rejection) as well as gender dysphoria that can contribute and add to preexisting conditions (eg, depression, suicidality, self-injurious behavior, etc).

As clinicians, it is our duty to assess these various contributing factors and ensure the best treatment options for our patients by utilizing the most up-to-date data and protocols. We also have the unique opportunity to potentially be the first person who says to a trans young person, “I see you,” “You are valid,” and most importantly, “There is a future in which you can exist as the person you know you are.”

The advocacy work necessary in providing support for TGD youth allows us to show our patients that they matter and deserve rights. It also shows them that they are not alone on their gender journey.

is associate professor of psychiatry at Yale School of Medicine, and director and cofounder of the Yale Pediatric Gender Program. She is also a Public Voices fellow of the OpEd Project.

is a predoctoral fellow at Yale School of Medicine.

Supporting youth mental health during the COVID-19 pandemic.

2. National survey on LGBTQ youth mental health. The Trevor Project. 2021. Accessed January 3, 2022. 

https://www.thetrevorproject.org/survey-2021/

Substance abuse prevention, assessment, and treatment for lesbian, gay, bisexual, and transgender youth.

Exploring cross-sectional predictors of suicide ideation, attempt, and risk in a large online sample of transgender and gender nonconforming youth and young adults.

6. Marshall E, Claes L, Bouman WP, et al. 

Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature.

7. Johns MM, Lowry R, Andrzejewski J, et al. 

Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students – 19 states and large urban school districts, 2017.

Transgender population size in the United States: a meta-regression of population-based probability samples.

9. Thoma BC, Salk RH, Choukas-Bradley S, et al. 

Suicidality disparities between transgender and cisgender adolescents.

Suicide attempts among a cohort of transgender and gender diverse people.

11. Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. 

Professional Psychology: Research and Practice. 

12. Austin A, Craig SL, D’Souza S, McInroy LB.

 Suicidality among transgender youth: elucidating the role of interpersonal risk factors

13. James S, Herman J, Rankin S, et al. The report of the 2015 US transgender survey. National Center for Transgender Equality. 2016. Accessed January 3, 2022. 

https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

14. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation’s Schools. A report from GLSEN. 2020. Accessed January 3, 2022. 

https://www.glsen.org/sites/default/files/2020-10/NSCS-2019-Full-Report_0.pdf

15. Austin A, Craig SL. Transgender affirmative cognitive behavioral therapy: clinical considerations and applications. 

Professional Psychology: Research and Practice.

16. Russell ST, Pollitt AM, Li G, Grossman AH. 

Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

17. Bochicchio L, Reeder K, Aronson L, et al. 

Understanding factors associated with suicidality among transgender and gender-diverse identified youth.

18. Price MN, Green AE. Association of gender identity acceptance with fewer suicide attempts among transgender and nonbinary youth. 

19. Price MA, Hollinsaid NL, Bokhour EJ, et al. Transgender and gender diverse youth’s experiences of gender-related adversity. 

Transgender and gender-diverse youth experience higher rates of depression, suicidal behaviors, and self-injury than their cisgender peers. Here's what you need to know.  

Disentangling the Web: Comorbidity Issues in Gender-Diverse Youth

Psychiatric and medical comorbidities can complicate the differential diagnosis and hamper treatment success. Thus, investigators around the globe continue to examine how these comorbidities interact with each other. In this Research Roundup, 

 looks at clinical issues and implications of comorbidities associated with depression, eating disorders, COVID-19, and more.

Depression, Bipolar Disorder, and Sleep in Children and Adolescents

Recently, investigators conducted a narrative literature review of affective disorders and sleep difficulties in children and young people, seeking to understand the relationship between sleep and both depression and bipolar disorder.

Monica Comsa, FRACP, of the Child and Adolescent Mental Health Service at Cumbria Northumberland, Tyne and Wear NHS Foundation Trust in the United Kingdom, and colleagues found that parasomnias, narcolepsy, and sleep-related movement disorders are associated with depression in children and adolescents. Additionally, children and adolescents with depression can present with a number of sleep difficulties, which are also associated with several other issues such as more severe depression, greater fatigue, suicidal ideation, physical complaints, pain, and decreased concentration.

, obstructive sleep apnea, and circadian rhythm disorders are associated with both depression and bipolar disorder in children and adolescents. Sleep difficulties can occur before, during, and after an episode of depression or bipolar disorder.

“Sleep disturbances among adolescents with 

 can affect the severity of depressive and manic symptoms, are a poor prognostic indicator, and have been associated with social and academic impairment,” said Comsa and colleagues.

These sleep difficulties may be the result of medication. According to the investigators, antidepressants and antipsychotics can directly affect sleep architecture, and clinicians should be cognizant of this problem when prescribing and might instead consider nonpharmacological interventions. These interventions for sleep problems might minimize the risk of relapse in affective disorders.

Investigators suggested that a multimodal approach to target both the affective and specific sleep disorders is the ideal treatment plan. “Psychoeducation, consistent sleep-wake schedules, and tailored interventions for addressing sleep problems should play an important role in the prevention and treatment of mental health difficulties, at any age,” they wrote. “Concomitantly addressing sleep problems can lead to an increased remission rate of depression.”

More research is required to understand the impact of combined interventions on clinical outcomes, concluded investigators.

“Of most importance is the impact of specific treatment for sleep disorders on the long-term outcome of affective disorders. Clinicians need to know if better nights reliably lead to better days.”

1. Comsa M, Anderson KN, Sharma A, et al. 

The relationship between sleep and depression and bipolar disorder in children and young people.

Impulse Control Disorders and Behavioral Addictions in Patients With Eating Disorders

There is a moderate prevalence of impulse control disorder (ICD) and behavioral addiction (BA) comorbidities in individuals with 

 (EDs), investigators have found in a first-of-its-kind meta- analysis.

Because the prevalence has never been systematically examined, Daniel J. Devoe, PhD, MSc, and colleagues performed a series of random effects meta-analyses of peer-reviewed literature reporting prevalence of ICDs or BAs in individuals with EDs. The investigators included 35 studies with a total of 9646 individuals who had an ED and analyzed the prevalence of different behavioral addictions among these individuals. The mean age of participants was 25.5 years (range, 16.7-43.9), and 97.7% were female.

Results showed that stealing/shoplifting behaviors were the most common form of behavioral addictions in individuals with EDs, with a prevalence of 30%. Devoe et al also noted prevalence of pathological/compulsive buying at 19%, kleptomania at 18%, and pathological internet use at 12%. Intermittent explosive disorder, trichotillomania, and gambling had prevalence rates of 5%, 3%, and 2%, respectively.

ICDs are more closely associated with bulimia nervosa and binge-purge subtype than other ED diagnoses and behaviors, the investigators noted. This finding supports previous research indicating that individuals with binge-purge subtypes are more likely to have ICDs, partly due to impulse control difficulties and greater emotion regulation. The investigators also noted that certain personality traits (eg, perfectionism, impulsivity), psychiatric comorbidity, age of onset (eg, early age of onset may worsen prognoses), and concurrent substance use disorders may also play a role in deteriorating ED prognoses. They suggested that future research explore common underlying pathomechanisms.

“Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs,” Devoe et al concluded.

1. Devoe DJ, Anderson A, Bahji A, et al. 

The prevalence of impulse control disorders and behavioral addictions in eating disorders: a systematic review and meta-analysis.

First-of-Its-Kind Study of Antidepressant Use in Patients With Depression and Type 2 Diabetes

Although treatment guidelines do not provide specific prescribing recommendations for antidepressants in individuals with 

, effective treatment of depression in patients with comorbid depression and type 2 diabetes is important for both conditions.

In a first-of-its-kind study looking at the prevalence of antidepressant prescribing and associated patient characteristics, Jeffrey et al

 searched 7 databases using terms related to depression, type 2 diabetes, and antidepressant medication. From the 9 utilized reports, the investigators determined that the prevalence of antidepressant prescribing varied considerably between studies—from 18% to 87%.

“This review has highlighted the gap in our knowledge about which antidepressant agents are being used in adults with comorbid depression and [type 2 diabetes], and alongside which concurrent medications and comorbidities. Thus, we are unaware of the extent to which such individuals are at risk from the risks associated with polypharmacy and other 

Investigators also found that women with type 2 diabetes are more likely to be prescribed antidepressants versus men; however, the difference is less than in the general population. Additionally, individuals with more advanced type 2 diabetes mellitus who use insulin were as likely to be prescribed antidepressants as those who did not use insulin.

“This is the first systematic review to our knowledge that investigates the prevalence and characteristics of 

 prescribing in adults with comorbid depression and [type 2 diabetes],” the study authors wrote. They added that, “There is an urgent need for longitudinal studies to inform guidelines on the long-term safety and effectiveness of antidepressant prescription in persons with comorbid depression and [type 2 diabetes].”

With a lack of evidence to support the long-term use of antidepressants in individuals with type 2 diabetes, special care should be taken when prescribing antidepressants—especially in more complex patients who have higher risks of potential adverse events.

1. Jeffrey A, Maconick L, Francis E, et al. 

Prevalence and characteristics of antidepressant prescribing in adults with comorbid depression and type 2 diabetes mellitus: a systematic review and meta-analysis.


COVID-19 Mortality Risk in Patients With Psychiatric Disorders

Patients with psychiatric disorders who were hospitalized for 

experienced higher mortality rates, but not due to their underlying psychiatric disorders, study results show.

The study, led by Nicolas Hoertel, MD, PhD, MPH, of Paris University and Corentin-Celton Hospital in Issy-les-Moulineaux, France, explored previous research indicating a connection between psychiatric disorders and increased mortality in patients with COVID-19. Hoertel et al conducted an observational multicenter respective cohort study of patients who had received a laboratory-confirmed diagnosis of COVID-19. The study included 15,168 patients who were hospitalized with COVID-19, of whom 857 also had received a diagnosis of a psychiatric disorder. Of this population, 59.6% had a substance- or illness-induced psychiatric disorder; 46.4% had a primary psychiatric disorder; and 6.1% had both types of disorders.

The investigators found that across a mean follow-up period of 14.6 days (SD = 17.9 days) 38% of patients with a psychiatric disorder died, compared with 8.9% of patients without a psychiatric disorder (odds ratio [OR] = 6.27; 95% CI; 5.40-7.28; P < 0.01). Individuals with a psychiatric disorder had a 6-fold higher risk of mortality than those without a psychiatric disorder, and this risk remained higher when adjusting for factors such as sex, age, and current smoking status in individual psychiatric diagnoses (adjusted OR [AOR] = 3.27; 95% CI; 2.78-3.85; P < 0.01). However, when adjusting for obesity and other medical comorbidities, the investigators found no statistically significant association with increased mortality in individuals with psychiatric disorders compared with individuals without psychiatric disorders (AOR = 1.02; 95% CI; 0.84-1.23; P = 0.86). Notably, diagnosis of a mood disorder was associated with reduced mortality, which the investigators suggested could be related to use of certain antidepressants such as fluvoxamine and fluoxetine, which may have anti-inflammatory or antiviral effects.

The investigators concluded that the risk of COVID-19–related mortality may be higher in individuals with psychiatric disorders due to the overall higher prevalence of obesity and medical conditions in this population—which also increases the risk of developing severe cases of COVID-19—rather than factors related to the psychiatric disorders themselves.

“Future studies including data on outpatients and inpatients with and without 

 and taking into account main medical risk factors of severe COVID-19 (ie, age, medical comorbidities, and obesity) will be important to determine whether the risk of hospitalization and mortality due to SARS-CoV-2 infection is similar or different across psychiatric diagnoses and psychotropic medications prescribed,” Hoertel et al concluded.

1. Hoertel N, Sánchez-Rico M, Muela P, et al. 

Risk of death in individuals hospitalized for COVID-19 with and without psychiatric disorders: an observational multicenter study in France


Psychiatric Comorbidities Affect Psychotic Depression Outcomes

Results of a recent study on gender and psychiatric comorbidities in individuals with psychotic depression (PD) found that comorbidities have significant implications for PD age of onset and outcomes.

Using the Northern Finland Birth Cohort 1966 and other national registers, Miika Nietola of the Department of Psychiatry at the University of Turku and colleagues analyzed 12,058 individuals who had been followed since they were in utero for lifetime psychiatric diagnoses, age of illness onset, hospitalizations, disability pension rate, and mortality. Fifty-eight individuals in the sample had received a lifetime diagnosis of PD (male, n = 23; female, n = 35); the lifetime prevalence of PD in the participants was 0.5%; and the median age of PD onset for participants was 40.2 years.

In comparing outcome variables in subgroups for gender and comorbid PD or 

(AUD), the investigators identified the prevalence of comorbid personality disorders at 38% and comorbid AUDs at 41%. Results showed that psychiatric hospitalization was more strongly associated with male gender (P = .03), personality disorder (P < .01), and comorbid AUD (P < .01). Comorbid PD also was associated with earlier onset (P < .01) and higher mortality (P = .03) and was more common in men than women at 61% and 29% (P = .03), respectively. However, Nietola et al found no statistical difference related to gender in the disability pension rate for individuals with PD.

Since little is known about the effects of gender and comorbid psychopathologies on PD prognoses, the investigators stated that this study’s findings highlight a need for further research on these effects in individuals with PD and on PD in general—especially since comorbid personality disorders have been associated with poorer outcomes in individuals with nonpsychotic depression. They also suggested that clinicians control the effects of gender and comorbidity as confounding factors in PD trajectories.

“Clinical implications of high alcohol use and personality disorder comorbidity in PD include rigorous assessment of these disorders in everyday practice and active implementation of effective treatments,” Nietola et al wrote. “There are potential possibilities to improve outcomes of PD by focusing more on those detrimental comorbidities that appear to associate with a malign course of illness.”

1. Nietola M, Nordström T, Miettunen J, et al. 

Effects of gender and psychiatric comorbidity on the age of illness onset and the outcome of psychotic depression—a birth cohort study

Catch up on all the latest in psychiatric comorbidities. 

Research Roundup: Psychiatric Comorbidities in the News

 is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.

 The most prevalent comorbid disorders among adults with 

 (SMI) are substance use disorders (SUDs).

 Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for 

 Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as 

 is inadequate to capture the range of symptoms and impairments of this diverse patient population.

 Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.

Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate 

 (TIC) in both SUD and psychiatric settings,

 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the 

 the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.

Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.

 Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.

 As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.

There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.

 Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about 

 Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.

 Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.

Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased 

 Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.

Recognize Trauma as a Primary Pathway to Substance Use

For decades, the pervasive narrative around 

 was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.

 Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.

 Conversely, marijuana use has been associated with reductions in 

Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.

 There is clearly an association between experiences of trauma and 

, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.

 Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.

One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.

 ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.

As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.

 Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that 

 may have been the only accessible and available coping tool at that time.

When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and 

Partner With Patients Across Multiple Pathways to Recovery

Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.

Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.

 Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.

 In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and 

 are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.

Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.

Approach With Unconditional Positive Regard

When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an 

art to facilitating an informative interview

. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.

Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.

Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.

 There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.

Engage in Ongoing Knowledge and Skill Development

A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.

 Formal educational opportunities including fellowships in 

, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.

 All health care providers practicing clinically are required to participate in continuing education. Due to the 

, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.

There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,

 which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.

As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work.

is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.

Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review.

2. Integrated treatment for co-occurring disorders. Substance Abuse and Mental Health Services Administration. 2009. Accessed January 7, 2022. 

https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf

3. Rasmussen IS, Arefjord K, Winje D, Dovran A.

 Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment.

Trauma-informed care for individuals with serious mental illness: an avenue for community psychology’s involvement in community mental health.

5. Beckett P, Holmes D, Phipps M, et al. 

Trauma-informed care and practice: practice improvement strategies in an inpatient mental health ward.

Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology.

8. Brunette MF, Oslin DW, Dixon LB, et al. 

The opioid epidemic and psychiatry: the time for action is now.

9. McCauley JL, Killeen T, Gros DF, et al. 

Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment.

10. Nöel W, Wang J. Is cannabis a gateway drug? Key findings and literature review. National Institute of Justice. 2018. Accessed January 7, 2022. 

https://www.ojp.gov/pdffiles1/nij/252950.pdf

30% to 60% of individuals seeking treatment for SUD also meet criteria for PTSD.

Comorbidity

Disentangling the Web: Comorbidity Issues in Gender-Diverse Youth

Research Roundup: Psychiatric Comorbidities in the News

Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder

Need Your Sleep: DTx for Treating Comorbid Insomnia and Psychiatric Disorders

A Simple Concept With Complex Implications

Comorbidity Issues in Gender Diverse Youth: The Tangled Web

Sleepy Link: Sleep, Depression, & Bipolar Disorder in Children and Adolescents

First of Its Kind Study of Antidepressant Use in Comorbid Depression and Type 2 Diabetes Mellitus

From Day 1: ADHD and Comorbid Conditions

5 Medical Comorbidities Linked to Depression in Older Patients