It is also important to highlight the complexity of poly substance use in the context of a cross-sectional, retrospective study. Despite this, lifetime MA use disorder was retained in the multiple regression model, while the other substances did not. Due to limited data on participants who met criteria for a current substance use disorder or other measurements of current substance use parameters, our finding cannot speak to other potential factors associated with poly substance use that may explain differences in sleep between MA+ and MA− groups. Future studies to formally investigate poly substance use in more detail is needed to futher confirm our findings. In addition, we did not find associations between age, sex, or sexual orientation on sleep quality, which is contrary to well established literature on these topics . We suspect that the presence of other clinical risk factors for poor sleep, including those identified in this study , may be masking the detection of these variables traditionally known to impact sleep quality. There also remains the possibility that other unmeasured factors such as homelessness and/or SES may account for the observed relationship that MA was related to sleep in PWH that should be explored further in future studies. Lastly, the PSQI questionnaire is based on self-report, which is subject to recall and reporting bias. While there is merit in characterizing perceived sleep quality in vulnerable populations, as even the perception of poor sleep can influence mood and physical health , subjective measurements are just one facet of sleep quality and the inclusion of objective measurements such as actigraphy would enhance understanding of sleep in PWH and substance using populations. Importantly,cannabis dry rack the global PSQI score demonstrates strong sensitivity and specificity in distinguishing good from poor sleepers among the general population . While the sensitivity in detecting an insomnia diagnosis in PWH remains high , the specificity drops considerably .

This suggests that the PSQI may not just be capturing sleep quality in PWH and raises the question as to whether items such as “trouble staying awake during the day” or “trouble keeping enthusiasm” are purely a function of poor sleep or a result of HIV-infection, prescribed medications, and/or associated psychosocial factors. Studies investigating the quality of the PSQI sub-components in capturing sleep quality within PWH using factor analyses may be a natural next step for future research.For people with substance use disorders, denial of untoward consequences from their actions is common and can affect commitment to treatment. In 2019, 96% of untreated individuals with a substance use disorder in the previous year denied needing treatment.Psychodynamic approaches toward addiction encourage accountability and minimizing denial; and 12-step programs, such as Alcoholics Anonymous, target denial by encouraging clients to acknowledge that they have lost control over addictive behavior, with a focus on accountability-centered goals. Among participants who had poly substance misuse and attended Alcoholics Anonymous or Narcotics Anonymous, the number of days in attendance was associated with decreased self-deception measured in a followup assessment.The transtheoretical model of behavior change likewise posits that changing addictive behavior relies on a transition from lack of recognition that a problem exists to increased awareness and motivation to change.The rostral anterior cingulate cortex , which participates in self-related processing, including self-awareness, has been implicated in personal relevance of drug-related stimuli, as is the ventromedial prefrontal cortex, which contributes to decision making.In an fMRI study, denial of methamphetamine-related problems was negatively related to resting-state connectivity between the rACC and precuneus. Among participants who met diagnostic criteria for Methamphetamine Dependence ,denial of methamphetamine-related problems correlated negatively with overall cognitive function and with rACC connectivity to frontal lobe regions, including the precentral gyri, left ventromedial prefrontal cortex, and left orbitofrontal cortex.These data implicate the rACC and its connections in a person’s ability to acknowledge problematic aspects of their substance use.

One of the most important clinical measurements, the diagnosis of a substance use disorder, involves clinical judgment, but self-reports are very important. Structured diagnostic interviews, such as the Structured Clinical Interview for DSM-IV or Mini-International Neuropsychiatric Interview , query self-reports of symptoms indicating craving, tolerance, withdrawal, and interference with activities of daily living. Although interview guidelines encourage the use of referral notes, records, and observations of friends and family,diagnosis often relies on interview with the client alone. In these interviews, denial of problems related to substance use is common and can alter diagnosis. This study sought to clarify how a diagnostic measure of Methamphetamine Dependence that relies on self-report is related to a participant’s denial of his or her addiction problem. Participants comprised a sample of 69 individuals who acknowledged enough symptoms on the SCID to meet criteria for the diagnosis of Methamphetamine Dependence. They also completed the University Rhode Island Change Assessment Scale , which assesses motivation for change by providing scores on 4 stages of change: Precontemplation, Contemplation, Action and Maintenance. The Precontemplation score measures the respondent’s denial that their drug problem warrants change,and is based on a transtheoretical model of addiction.In a prior study, the Precontemplation score was positively related to years of heavy methamphetamine use and arrests for drug offenses,supporting the notion that high scores reflect denial rather than the absence of problems. We hypothesized the Precontemplation score would correlate negatively with symptom severity, confounding the diagnosis.It is estimated that homelessness affects 3.5 million youth between the ages of 18 to 25 annually in the United States. Sexual and gender minority youth are over represented in homeless populations, with research indicating that between 30% and 40% of service-using homeless youth identify as SGM, within the context of approximately 6.4% of youth aged 18 to 29 identifying as SGM nationwide.

SGM youth include individuals who identify as lesbian, gay, bisexual, and transgender as well as gender queer, non-binary, agender, asexual, or another sexual or gender identity that is either or both non-heterosexual or non-cisgender . Previous studies examining pathways into homelessness among youth have repeatedly demonstrated that SGM youth are more likely to enter homelessness as a result of family members who are unaccepting of their gender identity and sexuality compared to heterosexual cisgender peers, demonstrating how SGM status is itself a risk factor for becoming homeless. In addition to disproportionately high representation among all unstably housed youth, SGM youth experiencing homelessness also face increased health risks compared to their heterosexual cisgender peers. With regards to mental health, lesbian, gay, bisexual, and transgender youth who are homeless are more likely to experience substance use and use a greater number of substances than heterosexual cisgender peers experiencing homelessness. Given these documented disparities, SGM homeless youth may be at higher risk for negative health outcomes related to substance use, such as HIV and viral hepatitis, which can further serve as a barrier to maintaining stable housing. Sexual and gender minority youth experiencing homelessness also report worse mental health outcomes, including increased suicidal ideation and more severe depressive symptoms, increased anxiety, and higher rates of post-traumatic stress disorder. One proposed model for conceptualizing these observed health disparities among SGM youth is the minority stress model, which acknowledges that SGM communities face an excessive burden of daily stigma and discrimination from living in a heterosexist, transphobic society, resulting in detrimental effects to their emotional, psychological, and physical health. These experiences of stigma and discrimination among SGM youth have been documented to occur in a wide variety of settings, including family rejection, homophobic bullying in community settings such as schools, and discrimination from clients and staff in emergency shelters. In addition to the violence and discrimination faced due to their sexual orientation or gender identity, SGM youth experiencing homelessness often hold multiple identities that place them into further marginalized groups, such as their racial and ethnic backgrounds. Youth of color, particularly Black youth, are more likely to experience homelessness compared to white peers. Furthermore, SGM youth of color face more difficult exits from homelessness compared to their white, heterosexual, cisgender peers.

Black LGBT youth experiencing homelessness are more likely to experience harassment from police and community members,trimming tray as well as increased sexualization and invisibility, which collectively make LGBT youth of color more vulnerable to various mental health disparities, such as increased substance use and prevalence of mood disorders. Policy agendas aimed at addressing the health disparities faced by SGM youth experiencing homelessness have emphasized the need to understand SGM youth as non-homogenous micro-communities with unique experiences, risk factors, and social environments. Previous studies of youth experiencing homelessness in San Francisco, the location of this study, have revealed high burdens of substance use and mental health conditions in line with national trends. In the San Francisco 2019 Homeless Unique Youth Count & Survey, one in five homeless individuals on a single night was under the age of 25. Of these unstably housed youth, nearly half identified as LGBTQ+. One in three surveyed youth reported ongoing drug or alcohol use, and 13% reported substance use as a cause of their homelessness. Mental health was another commonly reported cause of homelessness, with 30% of all San Francisco homeless youth indicating that their mental health was a contributing cause of homelessness. Symptoms of depression, PTSD, and anxiety among service-seeking San Francisco youth experiencing homelessness are correlated with increased prevalence of opioid and stimulant use, demonstrating the inter-connectedness of substance use and mental health outcomes. The high health burden of substance use and mood disorders is also tied to increased mortality among San Francisco youth experiencing homelessness, who experience mortality rates 10 times in excess of their stably housed, age-matched peers, with a majority of deaths resulting from substance use or suicide. While the disparities in the prevalence of substance use and negative mental health outcomes among SGM youth experiencing homelessness compared to heterosexual cisgender peers are well-described in the literature, a comparative understanding of downstream harms associated with use of specific substances between SGM and heterosexual cisgender youth experiencing homelessness remains poorly characterized. In this study, we employ a tool that quantifies the burden of negative impacts associated with use of a specific substance. Using a cross-sectional analysis of a racially diverse group of service-seeking youth experiencing homelessness ages 18 to 24 in a dense, urban environment, we examine risks of harmful use associated with specific substances among SGM youth experiencing homelessness compared to their heterosexual cisgender peers. Alongside substance use, we examined whether symptoms of depression, anxiety, and PTSD differed between SGM and heterosexual cisgender youth who sought services at a community-based site. We expected that SGM youth would exhibit greater health risks associated with substance use across all substances surveyed, as well as more severe symptoms of mental illness when compared with their heterosexual cisgender peers. All data were collected from a capacity-building initiative at a partnering multi-site, non-profit community based organization in San Francisco, California.Our study was designed as a cross-sectional investigation of youth aged 18 to 24 who utilized services from Larkin Street Youth Services, a community-based organization in San Francisco. Each year, Larkin Street serves 2,500 to 3,000 youth aged 12 to 24 years old. Clients include individuals who live outside or in a car, a shelter, a transitional living program, permanent supportive housing, a single-room occupancy hotel, a unit partially paid for using subsidies, or who are otherwise unstably housed. The organization also offers a wide array of programming, including emergency and transitional housing, basic needs services such as access to food, showers, laundry, and harm reduction supplies, educational and employment training programs, medical care, behavioral health services, case management, street outreach, and a youth leadership development program. Larkin Street also offers resources and programming specifically for SGM youth, and staff members undergo LGBTQ cultural competency trainings. In order for participants to qualify for our survey, they needed to be between 18 and 24 years of age and utilize services at Larkin Street. Recruitment strategies included posting flyers within the CBO’s residential and clinical spaces, referrals of participants from frontline workers, case managers, counselors, and group facilitators, and presentations at community housing meetings. Of note, a small subset of participants were surveyed at a service site that only serves youth living with a HIV diagnosis, but the majority of participants were recruited from Larkin Street’s other sites that serve all youth, including daytime drop-in centers, health clinics, and transitional housing spaces.