Excellent. So, hello and welcome. I'm Dr. John Torres, Director of the Division of Digital Psychiatry at Beth Israel Deaconess Medical Center and the technology expert for SMI Advisor. I'm pleased that you've joined us for today's SMI Advisor webinar, entitled Digital Interventions for Substance Use and Co-Occurring Psychiatric Disorders. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get answers you need to care for your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for partaking in today's webinar will be available until May 8th of this year. Next slide, please. Slides from today's presentation are available in the handout area found in the lower portion of your control panel. Select the link to simply download the PDF. Next slide, please. Please feel free to submit your questions at any time throughout the presentation by typing into the question area found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes at the end for your question and answer. Next slide, please. Now I'd like to introduce you to our faculty for today's webinar, Dr. Dawn Sugarman. Dr. Sugarman, PhD, is a research psychologist in the Division of Alcohol, Drugs, and Addiction at McLean Hospital. She's also an assistant professor at Harvard Medical School, and she also serves as a managing editor for a journal entitled The Harvard Review of Psychiatry. Dr. Sugarman's research primarily focuses on the use of technology and increasing access to evidence-based treatments for substance use disorders. Her work emphasizes special populations such as women and individuals with substance use and co-occurring psychiatric disorders. So, Dr. Sugarman, thank you so much for leading today's webinar, and I'll let you take it away. Thank you, John, for that introduction. So I'll start by just saying that I don't have any relationships or conflicts of interest related to the presentation. I will be discussing some digital applications, but I don't have any financial relationships with any of those programs. These are the learning objectives for today's presentation, and I just want to provide you with an overview of what I will be talking about. I'm first going to go over the prevalence of substance use disorders and the co-occurrence of substance use and psychiatric disorders. Then I'll talk about the evidence first for the efficacy of digital interventions for substance use alone, and then what we know about the evidence for digital interventions for co-occurring substance use and psychiatric disorders. And then I'll finish up by going through some of the research that we do in my lab around developing a gender-specific digital intervention for women and also for young women with co-occurring disorders. So as I said, I'm going to start first with the prevalence. So just to orient you to this, this is data from the National Survey on Drug Use and Health that SAMHSA put out. This is from 2019, and you can see here the larger blue circle. This is adults 18 or over who had any mental illness diagnosis, but not substance use disorder. And then the smaller yellow circle is those who had a substance use disorder, but not a mental illness. And then what's notable here, though, is that when you look at this green section, it's nearly half of those with a substance use disorder that have co-occurring mental illness. So there's quite a high prevalence of co-occurrence among those who have substance use disorder. I also want to show you what this looks like when we just pull out serious mental illness. So now the larger circle in the blue is adults who have substance use disorder, but not SMI. And the smaller yellow circle is those who have SMI diagnosis, but not substance use disorder. And what you see is that about a third of those with serious mental illness also have substance use disorder. So the first two graphs focused on substance use disorder, and what this is showing now is just substance use. Again, this is data from the National Survey on Drug Use and Health from 2019, and it breaks it down by status of mental illness. So for illicit drugs, marijuana, and opioids, they're looking at past year, any use of these substances. And then for binge alcohol and cigarettes, the timeframe is past month. And just as a note, binge alcohol refers to for men having five or more drinks on one occasion and for women having four or more drinks on one occasion in the past month. And what I want to draw your attention to is that there's a noticeable pattern with the light blue bar, which is serious mental illness, in that across every category of substances, they have higher rates of use. So it's worth looking at what is the relationship between substance use disorders and SMI. And a lot of people want to know what came first, what causes the other one. And there's really two main hypotheses. One is that someone has a serious mental illness and that they use the substances to alleviate the symptoms of that illness, and that leads to the substance use disorder. So this is what's commonly known as the self-medication hypothesis. The other pathway would be that someone has a substance use disorder, the substance that they're using induces psychosis, which leads to the psychotic disorder. And it's possible that you can think of clients that you've seen that fit either of these profiles. But the main takeaway point is really that neither one of these models fully captures what's going on, and that's much more complex bidirectional relationship. First, serious mental illness is a really broad category that encompasses several different psychiatric disorders. In the same way, substance use disorders also is varied in the types of substances that people are addicted to, and each of those substances have different psychoactive properties and pharmacological properties that affect psychiatric symptoms in different ways. There's also common ideological factors between these two groups of disorders. There's overlapping regions in the brain of involvement for these disorders. This relationship could also be mediated by another condition, something like chronic pain or HIV. And also, common environmental factors can affect the presentation as well. So if you think of like stress and homelessness. So regardless of which came first or how this relationship plays out, I think the important point is that they affect each other and can exacerbate each other. And in fact, what we see is that when we look at people who just have substance use disorder only compared to those who have co-occurring substance use and SMI, those with the co-occurring disorders have higher rates of hospitalization, suicide, relapses, trauma, homelessness, sexually transmitted infections, and poor treatment outcomes. So they're a much more at-risk population. We know that it's important for people with co-occurring disorders to have treatment for both or all of the disorders that they're presenting with. The problem is that people don't often get that treatment that they need. So this looks at data from 2015 to 2019. And just to orient you, the bottom line here with the squares, this is people who receive treatment for both the substance use and mental health treatment. And you can see that it's really low and it doesn't really change over the years. We're not really getting any better at that. By 2019, this was under 13% of people that received treatment for both. And also notable here, the red line is people who received no treatment at all. And that is a pretty sizable chunk of people who aren't getting any treatment. There are really three different models for treating co-occurring disorders. And I'm going to go through a little bit about each of these. So the first is what's called the sequential or serial model. And this is the idea of treating one disorder at a time. And there's problems with this in the sense that treatment for one disorder can often make the other disorder worse. So if you think about somebody who has, say, PTSD, and they're going through exposure therapy, well, that can lead to increased anxiety. And for someone who has a co-occurring substance use disorder, they may be using the substance to alleviate the anxiety. So they may increase their substance use. The second model, which is a little better than the sequential model, is treating both the disorders at the same time. So that's an improvement. But they're treated by either separate providers or in separate systems. So there's no collaboration between care. So one provider may be prescribing medication for the substance use disorder. Another one's providing medication for the primary psychiatric disorder. And they're not talking to each other. And that can lead to issues in treatment. So the third treatment model, which really has the best outcomes, is what's called integrated treatment. So that's treating both disorders through either a single provider or a team of providers who are working together. And what we know about integrated treatment is that it leads to better outcomes for substance use and for psychiatric symptoms and increased quality of life for people who engage in integrated treatment. So it's really thought to be the best option for people with co-occurring disorders. Unfortunately, there are few providers who are trained in integrated treatment protocols. And there are fewer clinics that provide sort of this integrated treatment model. And that leads into the next piece, which is how we can think about how technology can improve some of these gaps in treatment that we're seeing for individuals with co-occurring disorders. So this will not be a surprise for people who are attending this webinar, but the demand for mental health treatment in this country has outpaced our workforce. These are data from a recent survey of outpatient clinics in Massachusetts, where they found that for every 10 clinicians entering the workforce in mental health, 13 were leaving. And you can see on the right here that there's a significant amount of people reporting being put on wait lists and that the average wait times are quite substantial. So for ongoing therapy, the average wait time is 12 weeks, and that's a long time for people to wait when they're in distress. So certainly technology is not going to solve all of our problems with the mental health system, but there are ways that technology can help. For one, it can reach more people. It can also help reduce geographic barriers, so particularly in rural settings where people are driving long distances to see providers or there's just a lack of any providers available. It's cost effective. Important for this presentation, it can be individualized. So as I said earlier, SMI is a broad category, substance use is a broad category, and there are people who fall in different combinations of that. And through a technology-based program, you could customize and individualize the program to address the things that are most salient to that person. These programs can also provide in-the-moment support. It's often been referred to as a therapist in your pocket because most people carry around their mobile phones and they can engage with these programs in their own environment when they need it. This is really important to think about, fidelity of evidence-based treatments. So when you deliver a treatment or a program through a technology platform, it's being delivered the same way every time. And that's important because when we study treatments and we study effectiveness of treatments, they're studied in very rigorous settings. So the treatment is standardized, people are following a manual, and then that is how we know whether it works or not. And that's how the treatment is delivered. But then once that treatment is disseminated in real-world settings, it often gets diluted. And they've done studies where they record, they asked providers who said they were doing cognitive behavioral therapy or CBT, they recorded the sessions, they coded them all to see how many elements of CBT were actually in the sessions. And what they found was that there was very few elements of CBT for people who said they were delivering CBT. So with these technology-based programs, you know that they're delivered the same way every time. It allows people to engage anonymously. There's an enormous stigma with mental health. And once you add substance use disorder on that, it's even greater. So someone's not ready to engage in in-person treatment, this may be a way to sort of get a foot in the door and provide some support for them. You can also collect objective data through these programs. You can see how many steps people are taking to get a sense of how much they're moving during the day. You can get their GPS activity, heart rate, things like that. So I want to spend just a brief minute talking about the terminology because digital health in itself is a pretty big umbrella term that encompasses a lot of things. And these terms also change quite a bit. So at the top, you see computer-assisted therapies. That's a much older term back when we were delivering these things via CDs, for those of you old enough to remember. But digital health also includes things like the electronic health record, telehealth, wearables, mHealth or mobile apps, AI, and virtual reality. So it's a big term. And what I'm going to focus mostly on today is technology-based interventions or digital interventions that are web-based or mobile apps, as well as what we now call digital therapeutics. And that is platforms that are evidence-based, that go through the FDA process. They're disease-specific, so they're not just focused on increasing general health and wellness. They're focused on specific disorder and have gone through the FDA process. You could also think of these as synchronous and asynchronous. Synchronous being something like telehealth, where you're engaging in a live interaction through a technology-based platform. And asynchronous, where someone is engaging with a program outside of a therapy or live interaction on their own in a self-guided way. And so what I will be focusing on mostly is asynchronous programs. So now I want to go over a little bit about what's the evidence for these programs, how well do they work? And I'll start, as I said earlier, with looking at substance use disorder programs first, and then I'll get into programs for co-occurring disorders. So this is a list of evidence-based substance use disorder treatments that have been adapted to different technology-based platforms. The earlier work came in screening and brief intervention programs. And this is a place where technology has been really beneficial because there's, particularly in college settings or primary care settings, where there's a push to have universal screening for people to see what their risk level is for substance use and provide some brief intervention. And you'll see that there's a common theme with this check up, check your drinking. So it's people, these self-guided programs where people put in information about the amount that they're drinking and the substances that you're using, and they get some feedback about their risk level and then a brief intervention if warranted. So what the evidence shows that these programs are good at reducing risky or harmful alcohol use. They're not effective for people with alcohol use disorder. And these effects are really short term. They don't seem to be long lasting and there really isn't evidence that they work well for changing illicit drug use. But it's helpful for people who are risky drinking so that you can intervene before they get to the point where they need, they have a severe alcohol use disorder. There have been several different programs focused on substance use disorders for the purposes of today. I'm just going to give you some examples of some that are evidence-based. So for the first one, I'll give an example of this web-based program and then I'll talk about a mobile app. So this is CBT for CBT, which is a computer-based training for cognitive behavioral therapy. This was developed by Kathy Carroll at Yale and colleagues. And what they did is they made these little movie vignettes. So it's applicable to people with low literacy levels. There are seven modules and they show these video clips of people in these different situations. And then the purpose is to teach them skills. So then they show the vignette again with the person using the skills. And it's meant to be self-guided. This and all of the programs I'm going to talk about are in addition to treatment as usual. They're not standalone treatments. And so what they found was that in multiple studies, when they compared people who use the program to those who didn't, that they found greater reductions in drug use for those who use the program in addition to their treatment. They have a version for buprenorphine, which is a medication treatment for opioid use disorder. That's an effective treatment. And so they also studied the program as a part of office-based buprenorphine treatment and found better retention in treatment and lower rates of substance use. They do also have a Spanish version and they have a alcohol version. This one may be more familiar to people. This is the Reset mobile app for substance use disorders. This got a lot of attention because it's the first FDA approved mobile app for treating substance use disorder. I think it was approved in 2017. And what it is, you can see here, the mobile app has different treatment modules. I think there's 60, 61 or 62 modules that they go through. There's also a clinician dashboard. So this is meant to be used in conjunction with their clinician. The clinician can see their progress and track how they're doing. And so because it's FDA approved, it can be prescribed as a medication is prescribed. So people who can, you can download it from the app store, but you can't access it without the access code that you're provided with the prescription. But having the prescription also means that it can be reimbursed by insurance. So the FDA approved, interestingly, approved this mobile app based on research from the web-based version, which was called TES or the Therapeutic Education System. And those studies found higher abstinence rates for the program in nine to 12 weeks, but there wasn't any difference for longer term. They have a version for opiates disorder called Reset-O. As you can see here, there's notifications to take medication and check in. If they didn't take their medication, why not? And again, there's a clinician dashboard where the clinicians can track this. This app is specifically intended for increasing retention and treatment because the research actually did not find that it decreased illicit drug use or improved abstinence for patients with opiates disorder, but it did increase retention and treatment. So to summarize what we know about these digital interventions for substance use disorders, the effect sizes are generally small and there's better evidence in the short term than the long term. Interventions that are guided, meaning there's not necessarily a clinician all the time, but even a peer guide helping guide them using the interventions do better. And adherence is better if they're used as adjunct to treatment. So if it's part of their treatment to use the digital application, there's generally more adherence to the program. So now I'm gonna get to what we know about digital interventions for substance use and co-occurring disorders. So myself and colleagues did a review in 2017 of this literature. And what we found was that there were several interventions focused on adapting integrated treatments into digital platforms. And as I spoke about earlier, really integrated treatments are really the best option for individuals with co-occurring disorders. So this is a way to potentially increase access to these integrated treatments by adapting them to digital platforms. What we saw was that the strongest support was for digital interventions that address problematic alcohol use in a co-occurring disorder or depression, anxiety and a co-occurring substance use disorder. At the time, this is in 2017, we found no studies that were focused on co-occurring serious mental illness and substance use disorders. So since then, there have been several more studies around co-occurring depression, anxiety and substance use that feel this is continuing to grow. So what I wanted to do is see, is there any new updates around these interventions for SMI and co-occurring substance use? And there were two recent reviews for cannabis use and SMI in 2020 and 2022 here. So looking at both of these reviews, there were four distinct digital interventions that were covered in these two papers for individuals with co-occurring cannabis and SMI. Again, this is just focused on cannabis, not substance use in general. What they found was that these interventions were really limited in the technology aspects. It was mostly psychoeducation videos and automated calls. So they weren't very sophisticated. And unfortunately, there are modest or no improvements for cannabis use outcomes or psychiatric symptoms. So in looking at what else is out there beyond cannabis use, I found a few recent studies of mobile apps. This one is what's called Chill Time for individuals with psychotic disorders and co-occurring substance use disorders. This group is out of Canada, I believe, as you can see the screenshot that it's in French. But the app promotes learning emotion regulation strategies to address the co-occurring disorders. This was a small open pilot study, meaning there's no control group. And average use of the app was pretty low, it was 33% over 30 days. But people really liked it, the acceptability was high. Unfortunately, they found no significant difference in pre to post scores of substance use and any clinical symptoms. This is the other one that I found, it's a mobile app for smoking cessation that was tailored to individuals with SMI. And this group actually did a lot of formative work in meeting with end users and people with lived experience to understand the needs and to tailor the app specifically for them. So this is what they call the Learn to Quit app. This is a larger pilot study and it was randomized control trial. So they compared it to another smoking cessation app that was non-tailored, so not specifically tailored for people with SMI. And they had pretty good outcomes. They found higher engagement with the tailored app and 61% completed all 28 modules. So that's a much higher completion than we saw with the other app. They found significant reductions in average cigarettes per day, but no differences in clinical symptoms. So that seems harder to change with these programs. I think this is an important area because although we see declining rates in smoking for the general population, that has not declined for people with SMI. So it's an area where it's important to address. Overall, this looking at digital interventions for the combination of SMI and substance use disorder, I think is still an emerging field. I found a couple, these are a couple of protocols of studies that are in the works. So I think people are doing this research and I'm hopeful that this will be an area where in a few years we'll have more to say, but it's still really emerging right now. So in this last section, I wanna talk about some other research we've done in developing a digital intervention for young adult women with co-occurring disorders. And I'll first just by, first just wanna talk about why, oops, did I? Why focus on co-occurring disorders? I mean, sorry, why focus on this young adult population? So if you look at this graph, this is comparing substance use disorders for men and women between 2013 and 2019. And for the larger grouping of age 12 and over, 18 or over, you see this pattern where men have higher rates. But what's notable is that when you get into this younger age range, in 2013, they were nearly equivalent for men and women. And then by 2019, women were surpassing men. And you see that across multiple substances. Alcohol in particular, we used to see this big gender gap where men had higher rates of use and higher rates of disorders. And over the past couple of decades, that gap has been narrowing and narrowing. So I think it's important to give a definition of what I mean by gender-specific treatment for women. This quote comes from SAMHSA's publication on addressing the needs of women and girls. And gender-specific treatment really came out of the fact that many of our treatments for substance use disorders were developed and studied in VA settings. And those settings were primarily male-dominated at the time. So the studies had very few women in them. And it was just thought that they showed that the treatments worked, and so they work for everybody. And what we found is that that's not the case, that women do have unique needs that need to be addressed as part of their substance use treatment. So what this says is women, pregnant or not, have unique needs that should be addressed during substance use disorder treatment. Effective treatment should incorporate approaches that recognize sex and gender differences, understand the types of trauma women sometimes face, and provide added support for women with childcare needs, and use evidence-based approaches for treatment of pregnant women. I think what I would add to this is that in the work we do, our gender-specific treatment also focuses on the co-occurring disorders that are most prominent for women with substance use disorders. And that tends to be depression, anxiety, PTSD, and eating disorders. However, when we look at access to this type of treatment, so this is percent of substance use treatment facilities that offer specifically tailored programs. So just under half offer programs tailored to women. A little more for co-occurring disorders, and then when you see it goes down from there, in particularly low rates of addressing intimate partner violence or sexual abuse, which are really common among women with substance use disorders. So that's where we think we can do something with technology. We can increase access to this gender-specific treatment. So we know that the gender-specific treatment for women with substance use disorders leads to better outcomes. We in our McLean program, Dr. Shelley Greenfield has developed and studied the Women's Recovery Group, which is an evidence-based treatment. It was developed to be a group treatment. There's 12 sessions that women go through, and we found that it's been effective for women. However, most women are receiving their care in mixed gender settings, and they're not getting these women-specific treatments. So how can we adapt this to a technology-based platform? And so the Women's Recovery Group really has two main components. There's the all-women group composition, and there's the women-focused group content. So for this, to start, we're focusing on the content, not because we don't think the group composition is important, because it is, but as a first step, we want to see, can we take this content and adapt it to a technology-based platform and deliver it to women who aren't getting gender-specific treatment? So we did this in two phases. We first took three of the modules from the group treatment and adapted them, collected some data on that, and then modified and added two additional topics. So these are just some screenshots of what it looks like. There's a welcome screen. There's a summary of what they're going to learn about. There's interactive questions that we put throughout. This is on the module on women and partners, so it has them think about how their partner affects their substance use. There's take-home messages. And then we have these knowledge check questions, again, to have more interactivity and also to see how much of the material they're understanding. So in the first phase, we recruited 30 women in our inpatient program. Our inpatient program generally has a short stay of four to five days, so it's an area where it's been difficult to implement any sort of extended group therapy. So that was an ideal spot to start this. And then in the pilot study, we looked to see if we could do it across our inpatient, partial, and outpatient programs. And we kept the inclusion criteria broad. So the program isn't focused specifically on co-occurring SMI. We include co-occurring disorders, but we didn't exclude by SMI. We only excluded if somebody was impaired to the point that they couldn't participate in the program, so if they were acutely psychotic at the time. The sample characteristics were similar for both studies. On average, age of about 40. Unfortunately, we didn't have much diversity as far as race or ethnicity. And we did get about 43% in the pre-pilot and 32% in the pilot study that had a partner that uses substances, which is significant for women in that women who have a partner that uses substances have poorer treatment outcomes than those who don't. You can see the comorbidity is quite high. This isn't, we didn't do any diagnostic interview. This is self-report of mental health problems, but they could choose multiple options. And you can see there's a high rate of anxiety, depression, and PTSD, which is what we would expect for women with substance use disorders. We found that people were really satisfied with the program. Out of a possible score of 40, it was about 35, rated 35 for both of the studies. In particular, they thought it was easy to use, visually appealing, and they liked the gender-specific information. This is a single session brief program. So it took about 26 minutes for them to go through the version that had three topic modules and about 40 minutes for the five topics. We did not find any difference in satisfaction by level of care, meaning inpatient versus partial hospitalization or outpatient. We asked them to rate elements of the program that were most relevant to their recovery. And we found that really, in both, it was mostly around the co-occurring disorders, the link between their substance use and mental health, and then depression, anxiety, and then for both, self-care came up as a really important topic. I wanna share a little bit of the qualitative feedback. One of the things we were concerned about since we were just starting with adopting the psychoeducation material, would people say that they already know this, this is something, this is information that's not new to them, and we didn't find that. This woman had said, just learning all this information is crucial. For all women, I was unaware of a lot of it. This person felt like the survey program explained their problem as a woman with addiction to a tea. And then this last quote really speaks to the technology piece, in that this person is saying, in the groups, it's great to discuss these things with other people, but it's easy to miss something. So having it all laid out on an iPad is really helpful to remember everything and also see it visually. So we took all that, and we ran that in our substance use disorder program, but we have a lot of women that come into the hospital for a primary psychiatric disorder who also have co-occurring substance use who aren't receiving treatment for the substance use. So we wanted to tailor it particularly for that young adult age range that we know is at risk who have co-occurring disorders. So the first step to do that was we did a needs assessment. And we interviewed women in the young adult age range who were admitted to inpatient or residential treatment at McLean Hospital for primary psychiatric disorders, but they also had problematic substance use. And so we took all of those, we recorded all those interviews, we transcribed and coded them for themes. And one of the themes that came up was around the lack of treatment addressing the co-occurring disorders, which was not a surprise to us. So two thirds of participants mentioned ways that the substance use was not adequately addressed. This person says, I'm clearly addicted, and I think it's a huge part of PTSD, but that's not really addressed in any of the classes or anything. And then a third of the participants mentioned the lack particularly of integrated treatment. So this person says, it's hard to treat all of my other issues when there's substance use in the background. That would be helpful to look at substance abuse in conjunction with my other psychiatric and medical conditions. And then this last one, I have to kind of seek help on my own, which can be difficult and intimidating. It's been kind of strange breaking it down, figuring out whether or not hallucinations are from drug use or mental health issues. It's been a process figuring it out alone. So feeling like there wasn't support to really understand how the substance use might be affecting the symptoms and which was substance use and which was the psychiatric disorder. So based on all of the information we got from the needs assessment, we made several adaptations to the program that we had previously tested. So we expanded information on the connections between substance use and co-occurring disorders. We increased the interactivity and that's something we notice every time we do these studies, people want it to be more interactive. So going beyond just the psychoeducation, we added coping skills practices to the program. And one theme that came up a lot with this younger age group was navigating peer relationships. And these are, as I said, women who were inpatient and in residential treatment. So there was a lot of concern about when they leave the treatment setting, how they will navigate that and not use substances. So we added information around that. And then we also had several women who noted that they felt there was a relationship between their menstrual cycle and substance use and craving. So we added some material on that. So after we adapted the program, we did a pilot study where we enrolled 44 women. Again, these are similar to what we did the needs assessment. These are women who were in inpatient and residential treatment for a primary psychiatric disorder and who also had problematic substance use. So they didn't have to necessarily have a substance use diagnosis. These are women who are identified by their clinician as having problematic substance use. And in fact, some of the women themselves did not feel like the substance use was problematic. So it's still a predominantly white sample, a little more diverse than what we saw in our previous research. Most of these were students who had some college education, and the primary treatment was around mood and anxiety disorders for most of these women. And you can see the substance use severity, Audit C is a measure of alcohol use, and the DAS-10 is for drug use. And so the average score were above the threshold for further follow-up. So as expected from the sample. So we looked at satisfaction overall, the majority of people said they were either very satisfied or mostly satisfied with about 18% being indifferent or mildly dissatisfied. And we did have a very dissatisfied option that nobody chose, so that's good. We asked them pre and post-intervention about their interest in making changes in their substance use and their willingness to make changes in their substance use, and both of those increased from pre to post. So that's encouraging. Of course, this is not a controlled, randomized trial. And it would be good to do this in an RCT study and also to be able to follow them after they leave treatment, because they're in a controlled setting right now. So we can't get data on substance use. We also, as we did in the previous study, we collected qualitative feedback. We coded all that feedback for themes. And so what people liked about the intervention, they liked that it was informative. People thought they could relate to the topics. They liked the interactivity. And they liked that we included these real-life scenarios, and those were things particularly around the topic around navigating peer relationships. We gave them these scenarios of, say, you're out with friends and someone offers you substances, how would you deal with that? And they inputted that information into that. And so they really liked that piece. We also looked at suggestions for change. As I said before, people always want more interactivity. That's something we're always trying to increase. There were suggestions around content and wording changes. They liked the scenarios, but they wanted some of the scenarios they felt were too black and white, that they offered suggestions for making them more nuanced. And the program does include LGBTQ content and resources, but people wanted even more of that. So to summarize all of this, research on the digital interventions for co-occurring substance use disorders, and particularly SMI, it's still a very emerging field. The evidence really is on acceptability and satisfaction and usability of these tools. People generally like them, they're not harmful in any way, but there's not really evidence right now to support their effectiveness in really changing substance use and making any changes to psychiatric symptoms. So I think it's still a really emerging field that has the potential to grow in the next few years, and that we need more randomized trials to better understand these types of interventions. I just want to acknowledge my mentors, collaborators, and all the staff that help, as well as the funding sources for the research. And these are the references, and I am ready for questions. Excellent. So thank you so much for leading today's webinar. I know we can quickly pull back up the slides, perfect. So right before we jump into question and answer, I want to take a moment to let you know that SMI Advisor is accessible from your mobile device, certainly appropriate for today's talk. You can use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download the app at smiadvisor.org app. So now I'll jump to the questions, and if anyone else wants to put questions, you have a chance to do it now. But I think the first question I see, Dr. Sugarman, is in terms of what vision do you see kind of happening in the next years of how clinicians begin to use technology? Are we looking at a more integrated approach, a more self-help approach, a step-care approach? What is kind of your vision of where this goes? Yeah, that's a good question, because I think that, as I said previously, when these are integrated into the therapy interaction, that people do better and adhere to it. I didn't present the research here, but we've also interviewed clinicians a lot as we create these programs. And one of the main concerns for clinicians is sort of the burden of this, and getting all this data and what to do with it, and having time to do that, and that the programs don't always integrate, most often don't integrate with the electronic medical record, so logging into a separate system. So I think it's great if that can be integrated into the clinical interaction, but I think it's also really difficult for people. And so I think probably the self-guided model with support and encouragement to use is more feasible at this point. That makes sense. And some other questions looking at, clearly, as you said, even when you're focusing on what are called specialty populations, or say just even women's health, women's mental health, and substance abuse, that there's many different types of people with different backgrounds, different severity of illnesses, different comorbidities. Is there any population, I guess, the first person that you think is kind of really great to start with digital tools, and are there other people that you kind of go, maybe digital tools are not the right thing when you kind of first meet them? I think you can, it's hard, I don't want to categorize, you know, this sort of people are not a good fit because, you know, I think there's always this sort of assumption like older adults aren't good with technology, and I think that older adults can use these programs as well. And that's been shown, and maybe sometimes more coaching is involved in that. So I think that it gets tricky when you try to sort of say, like, this group of people definitely know, and this definitely know, I think it's helpful to have a conversation with clients about their, well, their interest in doing it, and also how much they use their, you know, devices. If it's something that they use in their regular life, some people are more, you know, clicked into that. One of the things that, one of the challenges sometimes with the substance use disorder population is when we look at access to technology, in general, you know, if you look at, in the United States, there's high access overall to internet or mobile phones, but then there's sort of within that subpopulations that are more difficult, and for substance use disorders, when we ask people about their access, they generally would say, yes, I have access to a mobile phone. The other issue is that it's not always consistent, and so one study found that people changed their phone three times in the past year, or more times, so that, so being able, so assessing for that, do they have consistent access to a mobile device is important, because if they don't, then this is obviously not going to be something that's going to work for them, and just assuming, and not assuming that because they have access to a phone today means that they're going to have it later. Now, that makes sense, and I think if anyone else is listening, the FCC has been called the Affordable Connectivity Program, that sometimes you can help patients get very low-cost devices from as well. This is actually Don Moore commented, saying, how can we access the app that you and your team are researching? We would love to be able to offer it to our clients at the SS Star in Fall River, which is close by in Massachusetts for those that don't go to state, so it sounds like the question is, can any people maybe access your research or partner with you to use the innovative things that you're developing? That's a great question, and actually, Star was a site for the Women's Recovery Group in-person studies, so they were, it was really great to partner with them for that. Right now, we don't, we're still in the process of researching and developing this program, so it's not ready for dissemination, but we'd certainly love to partner on research for that, and I encourage people to reach out to me for that, but thank you for the interest. This is a different question, so thank you. How much do you feel people, and women in particular, may be in unsatisfactory relationships and are bored, disappointed with partners or spouses, and turn to, for example, alcohol use and as a digital approach, incorporate those issues, not only anxiety and depression and PTSD, et cetera? So I think I missed, I think, the middle part that you said. So how much do you feel people, and women in particular, may be in unsatisfactory relationships, I guess, or may be disappointed or having different relationship issues, and then turn to alcohol use, and do the digital approaches, I guess, talk more about relationships and other issues as well, beyond classic anxiety, depression, or PTSD? Yes, we do, in the program that we developed, we have an entire topic on women and partners, and we look at partners broadly, so not just like a spouse or anything, but more at to the relationship with the partner and how the interactions with the partner affect the substance use. So I think that would address some of what, if I understand the question correctly, because we do find that having a partner and also not having a partner can affect substance use. So we have a branching logic that people go through to say if they have a partner or not a partner, and the program branches depending on that, to be more customized to their needs. Got it. And this is perhaps a follow-up saying, do you think there is some perhaps disempowerment to make choices if people have a history of adverse childhood events, or are kind of feeling stuck in relationships, unable to leave? Does that make it harder or easier to use any of these programs? I think that there are certainly concerns with women who are in intimate partner violence settings around using digital tools that their partner might have access to and might use in a way against them. I think that there's certainly a concern around that. I have a colleague who is not a digital program for developing a group treatment, particularly for women with substance use and intimate partner violence. And when they had switched to Zoom during the pandemic, there was a lot of considerations around making that a safe space for them. So I think there's certainly, and I know that there are some digital tools that will have a quick escape button so that women can get out of it quickly so that their partner can't access the information and use it in a way against them. And this question is perhaps related. It says, I have a woman-specific virtual substance abuse program, and we do use the Greenfield curriculum. Is the digital app, could it be used as a supplement for what you're working on? Yeah, I think that that's probably, it would be a great supplement to people in the group. We actually did, we had a subgroup of people who had done the women's recovery group who engaged with the program and still felt like it was applicable and helpful to them as a refresher of the information. But I think also now that we've added more of the coping skills, it's definitely a way to, for them to practice those skills outside of the group setting. So I think it could be used well as an adjunct to that. And this question says, have your interactive components or vignettes, including people with lived experiences, peers, do well in established long-term recovery? We have not done that, but that is a great suggestion as we move forward with that. We had developed the scenarios based on the interviews that we did with the women and the information that they gave us about problematic situations that were tricky for them. And sort of talking them through the situation, having them think about the situation, how they would react, and then providing some coping skill information based on that. But I think that it would be great to incorporate peers as well. And then a related question also saying, what are the tensions you've kind of found out as someone doing technology research, clearly being a clinician, what are kind of things that you would want other people to know if they want to embark on this route and begin to build things? Yeah, I think the biggest part, honestly, it's difficult to, it takes a lot of time to develop these things. You know, to develop them well, to do a lot of, we do a lot of formative work to make sure that they're applicable to the people who will ultimately be using them. And I think that, you know, there's also concerns around making sure that you're not discounting the, you know, the live interaction and with participants. And I think it's really important to emphasize that these are adjunct tools for what we do. It's not a replacement of therapy and to not let clients feel like it's something that you're offering as a replacement to what they would get in the treatment setting, but that this is something that can be added to their treatment to enhance their outcomes, to help them further, particularly since, you know, they generally will see you in an outpatient setting maybe once a week or less. And so being able to take something out of that and have it in their own environment can be really powerful. And I think it's important to talk to people about that. This is a question saying, I guess I'll summarize. For people that may have trouble with medication adherence, do you ever find those people also have trouble saying adhering to technology or do the same challenges come up? There are some people who maybe have trouble taking medication. Is the technology easier in some cases for them? That's an interesting question. I'm not sure I've noticed that. I think they're sort of different pathways. And, you know, with technology, you can ping people, which is helpful for medication reminders, but also helpful reminders to use the program. And I think probably the reasons that people have trouble adhering to their medications are different than reasons people would adhere to a program. I think, you know, unfortunately, with a lot of mobile apps, engagement is a major issue. As you know, it drops off quite quickly after people will download something if they're not getting anything immediate from it. And as I said multiple times, I think the interactivity piece is a key. People really, the more engaging it is, the more likely they'll do it. And also, if the program has any sort of rewards, and I'm not talking about like contingency management where you're giving people actual rewards, but even apps where you just get, you know, points or stars, like people really like that. And it really helps increase engagement, even though, you know, they can't cash that in or anything. That makes perfect sense. So, I think maybe we'll actually advance to the next slides and begin to wrap up because we had a lot of great questions. So, thank you. So, if there are any topics covered in the webinar you'd like to discuss with colleagues in the mental health field, you can post a question on SMI Advisor's Webinar Roundtable Discussion Board. It's an easy way to network and share ideas with other clinicians who participated in this webinar. If you have a question about the webinar or any other topic related to evidence-based care or SMI, you can get an answer within one business day from SMI Advisor's national team of experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have serious mental illness. It's completely free and, as always, it is confidential. So, we'll quickly go to the next slide. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available through the Homeless and Housing Resource Center, the Center of Excellence for Behavioral Health Disparities and Aging, the Suicide Prevention Resource Center, the Peer Recovery Center of Excellence, the Mental Health Technology Transfer Center. These initiatives cover a broad range of topics relevant to practice. And we'll go to the next slide, please. To claim credit for partaking in today's webinar, you'll need to have met the requisite attendance thresholds for your own profession. Verification of attendance may take up to five minutes, then you'll be able to select next to advance and complete the program evaluation before claiming your credit. And we'll go to the very next slide and the last slide. So, please feel free to join us next week on March 17th as Rip Bobkins, Eric Eason, and Wendy Teagan present Peer Specialists Enriching the Crisis Continuum, which will be a very exciting talk. Again, this free webinar will be on March 17th from 12 to 1 Eastern time on Friday. So, thank you again for joining us. Thank you to Dr. Sugarman, and thank you again. So, take care. Thank you. Thank you.

Digital Interventions

Substance Use

Co-Occurring Psychiatric Disorders

Dr. Dawn Sugarman

Unique Needs

Different Populations

Technology-Based Interventions

Evidence-Based Care

Web-Based Programs

Mobile Apps