Such targeted examination will help provide a foundation for prospective work on AS and the etiology and maintenance of sleep pathology, with a long-term goal of guiding intervention development. Because AS serves to amplify fearful responses, it was hypothesized that AS would be associated with decrements in global sleep quality. In addition, we sought to conduct exploratory analyses on the relations between AS and each of the specific components of global sleep quality. Based on previous research that suggested that age, gender, ethnicity , and negative affect were related to sleep disturbance, these factors were examined as potential covariates. Given that participants were categorized based on their cannabis use, and due to the elevated prevalence of alcohol use, both of which may impact sleep disturbance , these were also considered as potential covariates.Prior research examining the comorbidity of psychiatric conditions and substance use disorders suggests that alcohol use disorders are significantly comorbid with depression . In the United States, 7% of adults aged 18 or older had major depressive episodes in 2014–2015, and the prevalence of AUDs among adults with major depressive episodes was 14%, twice as prevalent with depression as any other SUD . Given the substantial comorbidity of depression and AUD, the characteristics and subsequent outcomes of persons with these disorders have become high priorities for prevention and treatment research. The significant comorbidity of depression and AUD found in the general population is more striking in clinical populations. specifically, studies conducted with either psychiatry or addiction treatment seeking samples have found 50–70% of patients with depression had AUDs . In addition, hydroponic tables canada patients with depression and AUDs who present for psychiatry treatment have higher rates of drug use, more severe depressive symptoms, and functional impairment than patients with depression but without AUDs .

A general population-based study found that individuals with co-occurring alcohol and marijuana use disorders were more likely to have major depressive episodes relative to those with either alcohol or marijuana use disorder alone . Longitudinal studies indicate that patients with both depression and AUDs continue to demonstrate greater depressive symptoms and functional impairment over time than patients with depression alone . Less is known, however, about the extent of drug use over time, and whether it has differential effects on clinical outcomes for those with depression and AUDs. Although a review by Conner et al. concluded that drug use was associated with greater depression severity and functional impairment in treatment seeking patients with depression and AUD, this review is almost 10 years old and was limited to cross-sectional studies. To our knowledge, there has been no recent longitudinal examination of symptom and functional outcomes in terms of marijuana use among psychiatry outpatients with depression and AUD. Marijuana is the most commonly used drug in the U.S. , with 8.3% of adults reporting past month use. General population-based research among individuals with depression has found no association between marijuana use and depression pathology over time . Yet, research in clinical samples has shown that marijuana use is associated with worse overall psychopathology and poorer functioning among psychiatry patients with depression, and that these adverse clinical outcomes persist over time . Psychiatry patients with comorbid depression and AUD may have additional problems related to marijuana use, owning to its association with poor clinical outcomes among clinical samples . A study focused on marijuana use in psychiatry patients with depression and AUD may characterize an important subgroup at risk of poor clinical outcomes and contribute information to future prevention and intervention strategies.

We explored whether marijuana use was associated with clinically problematic outcomes for patients with depression and AUD by analyzing 6 month follow up data in a secondary analysis of 307 individuals who participated in a randomized trial for substance use treatment, delivered in a psychiatry outpatient setting. This larger question was addressed through carrying out three study aims. First, we examined whether differences in marijuana use existed at baseline between patients with and without AUD. Second, we examined whether differences in marijuana use existed over 6 months between patients with and without AUD. Finally, we investigated whether differences existed between patients with and without AUD in terms of marijuana use, depressive symptom and functional outcomes over the follow-up. Building on our prior work showing that marijuana use has adverse effects on depression , findings will provide important information about the differential impact of marijuana use on those with comorbid depression and AUD, and inform drug use prevention and intervention efforts.Data for this secondary analysis were drawn from individuals who had participated in a randomized controlled trial of motivational interviewing for substance use treatment for patients with depression, delivered in an outpatient psychiatry setting. Patients were recruited from Kaiser Permanente Southern Almeda Medical Center Department of Psychiatry in Union City and Fremont, California. These psychiatry clinics provide evaluation, psychotherapy, and medication management for patients with a range of mental health conditions. These psychiatry clinics do not provide specialized services for individuals who present for treatment with serious substance use problems. At these psychiatry clinics, individuals are screened by telephone prior to intake, and those reporting serious alcohol or drug problems are referred to the Kaiser Chemical Dependency Recovery Program , located in the Union City medical center in a separate building from the psychiatry clinic. The parent MI trial sought to provide substance use services to psychiatry patients who used drugs or alcohol but who are not referred to CDRP for treatment. The results and methodological details of the parent MI trial are reported elsewhere . In brief, a total of 307 participants were recruited from the previously mentioned Kaiser psychiatry clinics. Participants were identified via provider referrals and self-referral in response to flyers in clinic waiting areas.

Study clinicians followed up by phone with patients who were interested in the study and determined eligibility based on inclusion criteria, which required patients to be ≥ 18 years old, have Patient Health Questionnaire score ≥ 5 indicating at least mild depression, and endorse hazardous drinking or illicit drug use within the past 30 days. The parent trial used a hazardous drinking standard slightly more conservative than that recommended for the general population because psychiatry patients are frequently prescribed antidepressants and other psychotropic medications that can have adverse interactions with alcohol and other drugs . Similarly, the depression score cutoff for enrollment was relatively low to capture a range of severity levels in the sample who might benefit from substance use reduction, and to include those in the maintenance phase of depression treatment as well as higher acuity patients starting care in psychiatry. Patients with mania or psychosis were excluded as such patients would likely require more intensive substance use services than the brief MI intervention model was designed to provide. The current analytic sample consisted of all 307 patients with depression who enrolled in the parent trial: 149 with AUD , and 158 without AUD. Participants who enrolled in the parent trial used laptop computers to complete the baseline measures , including self-report assessments of past 30 day illicit drug and alcohol use, the PHQ-9, and the Mental Health Sub-scale of the Short Form Health Survey . Then, participants were re-assessed using the same self-report substance use, symptom,microgreen rack for sale and functional assessments every 3 months via telephone interviews by trained raters and study clinicians during the 6 month study. Patients were offered $50 gift cards for completing each interview. After completing the baseline interviews, participants in the parent trial were randomized to one of two study arms, either MI or usual care. The MI intervention consisted of one 45-min session followed by two 15-min telephone “booster” sessions , about two weeks apart. MI sessions were delivered within 6 weeks of enrollment, based on MI counseling approach principles by Miller and Rollnick . Participants in the control group were given a 2-page brochure, produced by the National Institute of Health National Office of Drug Control Policy as part of their Fast Fact Series , on use risks specific to the substances reported at baseline . Patients also continued to receive usual depression care based on current best practices for medication management and evidence-based psychological treatment . All patients provided written informed consent at an in-person appointment in the same psychiatry clinic where they received usual care. Procedures were approved by the University of California, San Francisco and Kaiser Permanente Institutional Review Boards.Past 30-day alcohol and drug use were assessed during study interviews via patient self-report. specifically, patients were asked: “How many days in the past 30 days have you used alcohol” and “How many days in the past 30 have you used drugs ”. Patients were coded as using if they endorsed any use , providing dichotomous measures.Marijuana use was a predictor/outcome under study in longitudinal analyses, and alcohol use was a covariate.These analyses began with conditional growth models predicting symptom and functional outcomes from time and time-varying marijuana use , to investigate the effect of marijuana use on these clinical outcomes.

We continued to build upon the previous conditional models by predicting symptom and functional measures from time and a time × AUD interaction, to investigate whether these clinical outcomes varied by patients with and without AUD over the study. Finally, moderated analyses were conducted, predicting clinical outcomes from time and a time × AUD × marijuana use interaction, to determine whether continued marijuana use had different effects on the clinical outcomes of those with and without AUD. Conditional growth models adjusted for age, gender, race, employment status, marital status, treatment assignment, time varying psychiatry visits, time-varying alcohol use, as well as the initial levels of the outcome variable under study . As with the marijuana use outcome models, the expectation maximization method was used to handle missing data during maximum likelihood estimation at the time of analysis.Drug use is often comorbid with both depression and AUD, and may negatively affect the outcomes of patients receiving psychiatric services. We conducted secondary analyses of 307 patients with depression and AUD from a trial of substance use treatment for depression, and examined marijuana use, depressive symptoms, and functional outcomes over 6 months. Consistent with prior research on alcohol and drug use among psychiatry patients with depression , approximately half the sample met DSM-IV criteria for AUD at baseline, with a relatively high proportion of patients reporting marijuana use . Overall, this proportion was slightly higher than documented in prior studies among psychiatry treatment samples and may reflect normalizing views about marijuana within California . Over 6 months, the proportion of patients in our overall sample who used marijuana significantly declined. Yet the proportion of patients with AUD who used marijuana significantly increased over the followup compared to patients without AUD. These findings extend prior work showing a decreasing trend in psychiatry patients using marijuana post-treatment , as well as work showing variability in marijuana use by psychiatric diagnosis over time . As expected from prior work with this sample , patients who used marijuana had worse symptoms and poorer functioning. Patients with AUD who used marijuana had worse symptoms and functional impairment than those without AUD who used marijuana. Our findings reinforce prior work with clinical samples showing poor clinical outcomes in patients with AUD and depression , as well as work showing adverse effects of marijuana use among patients with depression . The present study has implications for future drug use prevention and treatment efffforts initiated in psychiatry settings. Patterns of marijuana use are rapidly changing as legislation to legalize use for recreational and medical purposes spreads . This has considerable implications for health systems, as evidenced by the recent increases in emergency department services observed for patients using marijuana with psychiatric conditions . The observation of high emergency department utilization among this population may be explained by associations of marijuana use with adverse health effects, such as addiction to other drugs, high prevalence of AUD, poor functioning, and worse depression severity . Although medical marijuana proponents often suggest that the drug may be used to effectively treat depression , its safety and efficacy in depression treatment has not been thoroughly examined or established . In addition, research with medical dispensary clients has found depressive symptoms to be associated with marijuana use problems, with only about 10% of clients reporting a reduction of symptoms as a primary benefit of use .