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Goals of this study were to examine the frequency of depression and related constructs of suicidal ideation and hopelessness in a sample of homeless older adolescents and their associations with behaviors that may increase the risk of sexually transmitted disease (STD). Diagnostic interviews and blood/urine samples were obtained from 523 homeless adolescents (mean age=17.8). Overall, 12.2 per cent had a current DSM-IV diagnosis of major depression and 6.5 per cent had dysthymia, with higher rates for female and older participants. Depression appeared to precede rather than follow homelessness and was associated with biologically verified STDs (in older participants), infrequent condom use, a non-heterosexual orientation (in older participants), and lifetime homosexual experience. Unlike depression, suicidal ideation and hopelessness were associated with higher rates of intravenous drug use but lower rates of multiple sex partners and, in young homeless women, less sexual coercion. Depression is frequent in homeless older adolescents and has a complex association with STD-related behaviors.

Purpose: To explore the relationship of sexual orientation and gender to four sets of factors: (a) family history, (b) incarceration, (c) substance use, and (d) depression and suicide, in a population of homeless adolescents. Methods: A sample of homeless adolescents was recruited in Portland, Oregon and assessed using semi-structured interviews at baseline, three months and six months. A total of 532 youths (216 females and 316 males) provided data on sexual orientation and other variables. Heterosexual ( n = 391) and non-heterosexual youths ( n = 141) were compared on all sets of factors, primarily using logistic regressions. Results: 44.9% of females identified as lesbian or bisexual, while only 13.9% of males identified as gay or bisexual. Gay, lesbian, bisexual, and "unsure" (GLBU) youths were less likely to have been in foster care or arrested, but were more likely to have spent time in a locked mental health treatment facility. More than one-third of all participants reported use of injection drugs. GLBU youths were more likely to have recently used amphetamines and to have injected drugs, however, gay-bisexual males were less likely to have recently used marijuana. GLBU status was associated with recent measures of depression and suicidal ideation, but not with lifetime measures. Associations of sexual orientation with several lifetime measures were different than with prospective measures, demonstrating the limitations of using lifetime measures rather than recent or prospective measures. Conclusions: This population of homeless adolescents appears to be higher in its high rate of injection drug use and the large proportion of females who identify as lesbian or bisexual than found in other studies. The high rates of depression and suicidal ideation, especially among GLBU youth, are of great concern.

High rates of unprotected intercourse and illegal drug use have been reported among homeless adolescents. As a transient population with the potential to act as disease vectors from one location to another, incidence and prevalence of sexually transmitted infections in this population are of particular concern.To assess a homeless adolescent population for incidence and prevalence of Chlamydia trachomatis, herpes simplex virus type 2, hepatitis B virus, hepatitis C virus, HIV, and psychosocial correlates of the acquisition of sexually transmitted infections.Longitudinal with assessments at baseline, 3 months, and 6 months (n = 536; 319 males and 217 females).Baseline prevalence of C trachomatis was 4.17% for males and 6.30% for females. Prevalence of herpes simplex virus type 2 was 5.73% for males and 12.50% for females. Hepatitis B virus and hepatitis C virus prevalences were 3.60% and 5.0%, respectively. HIV seroprevalence was 0.3%. The incidence of sexually transmitted infections was significantly higher among females than among males (16.7% versus 9.8%) and was associated with inconsistent condom use and, for females, number of partners and sex with older partners. Incident hepatitis B virus and hepatitis C virus infection rates were 3.44% and 6.61%, respectively; both were associated with injection drug use.Among females, the incidence of herpes simplex virus type 2 (25%) and C trachomatis (12%) was relatively high. Inconsistent condom use was the primary factor associated with a significantly greater risk of incident sexually transmitted infections. This was especially true for females with multiple partners. Homeless adolescents also are at high risk for hepatitis B virus and hepatitis C virus infection, primarily associated with self-reported injection drug use.

A five-session behavioral intervention to reduce risky sexual behavior was evaluated in a randomized controlled trial, in which 339 adolescents, ages 15 to 19 years, were recruited in public sexually transmitted disease clinics and randomly assigned to receive the intervention or usual care. The intervention targeted (a) decision-making about safer sex goals, (b) social skills for achieving safer sex, and (c) acceptance of negative thoughts and feelings. Compared to the control group at 6-months follow-up, treatment participants reported fewer sexual partners, fewer nonmonogamous partners, and fewer sexual contacts with strangers in the past 3 months, and less use of marijuana before or during sex. Treated adolescents also performed better on a taped situations test of skill in handling difficult sexual situations. Strongest intervention effects were for male and nonminority youth. Further research is needed to develop interventions with strong, durable effects across gender and ethnic groups that can be delivered cost-effectively within existing service systems.

Intellectual performance and the associations of IQ with the quality of psychosocial functioning were studied in a sample of homeless older adolescents. Fifty homeless older adolescents (ages 16-21) completed the Wechsler Adult Intelligence Scale-Revised (WAIS-R) and a questionnaire assessing psychosocial functioning and sexual risk factors. The WAIS-R scores were comparable to population means, with performance IQ scores tending to be higher than verbal IQ scores. The IQ was unrelated to the duration of homelessness. Higher IQ scores were significantly correlated with only a minority of the measures of psychosocial functioning, including less self-reported depression and lower reported delinquency, but also less self-control in high-risk sexual situations, less perceived peer support for safer sex, and a higher perceived likelihood of acquiring HIV.

Sexual coercion and its relationship to high-risk sexual behavior were examined in five samples of young women. Sample 1 (N = 22) consisted of sexually active adolescents aged 15 to 19. Samples 2 (N = 206) and 3 (N = 70) were recruited from among patients at three sexually transmitted disease clinics. Sample 4 (N = 51) consisted of young homeless women living on the street in a large city. Sample 5 (N = 51) was recruited from among young women on a college campus. Across all samples, 44.4% of women indicated that they had been forced into some form of sexual activity against their will. Self-reports of sexually coercive experiences were consistently related to risky sexual behavior. It appears that many young women are coerced into engaging in high-risk sexual behavior. This implies the need for greater attention to male coercive sexual behavior and women's skills for coping with such behavior.

Relationships among risky sexual behaviors, other problem behaviors, and the family and peer context were examined for two samples of adolescents. Many adolescents reported behaviors (e.g., promiscuity or nonuse of condoms) which risked HIV or other sexually transmitted disease infection. Such risky behaviors were significantly intercorrelated. Consistent condom use was rare among those whose behavior otherwise entailed the greatest risk of infection. In both samples, an index of high-risk sexual behavior was significantly related to antisocial behavior, cigarette smoking, and illicit drug or alcohol use. Social context variables, including family structure, parenting practices, and friends' engagement in problem behaviors, were associated with high-risk sexual behavior. Finally, for sexually active adolescents, problem behaviors and social context variables were predictive of nonuse of condoms. Results were consistent across the two studies and regression weights held up well under cross-validation.

Subject attrition threatens the internal validity of substance abuse prevention studies because differences in the rate of attrition and the substance use behavior of remaining subjects in the different conditions could account for any differences found in substance use rates. Attrition threatens the external validity of prevention studies because, to the extent that study dropouts are different from remaining subjects, the results of the study may not be generalizable to study dropouts. Analysis of these threats to the validity of prevention studies should be routinely conducted. However, studies of alcohol and drug abuse prevention have generally failed to report or analyze subject attrition. Smoking prevention studies have more frequently reported attrition, and they have recently begun to analyze the degree to which attrition may affect the internal and external validity of the study. Evidence thus far suggests that differences in attrition across conditions do occur occasionally. The evidence is substantial that study dropouts are systematically more likely to smoke, to use other substances, and to score highly on other risk-taking measures.

This study evaluates the effects of a school-based smoking prevention program after 1 year, using school (22 middle/elementary schools, 15 high schools) as both the unit of randomization and the unit of analysis. The multigrade level (grades 6 through 9) intervention was designed to address comprehensively the social influence factors that encourage smoking. Teacher survey data indicated that treatment schools had a median of 10 classroom sessions devoted to tobacco/drug use education, 5 of which were the sessions designed for this evaluation, and control schools had also dedicated a median of 10 classroom sessions to tobacco/drug education. Thus, the study evaluated the incremental effects of the social influence intervention compared to "standard-care" curricula. Among those who reported smoking one or more cigarettes in the month prior to the intervention, there was a significant treatment effect on rate of smoking at one year, but no grade level, gender, or interaction effects. The 1-year covariate-adjusted smoking rate among pretest smokers in the treatment schools was 76.6 cigarettes per month, compared to 111.6 cigarettes per month in control schools, a 31.4% difference. These effects were not accounted for by differential subject attrition. The analyses for nonsmokers, however, showed no significant effects, and the program did not affect self-reported alcohol or marijuana use. Taken together with the results of other prevention studies, these results point to the need for the development and evaluation of new initiatives to prevent substance use.

Objective. —To evaluate the efficacy of a new transdermal nicotine system for smoking cessation. Design. —Two 6-week, randomized, double-blind, placebo-controlled, parallel group trials were conducted. Successful abstainers from both trials enrolled in a third trial for blinded downtitration from medications (6 weeks) and subsequent off-drug follow-up (12 weeks). Setting. —Nine outpatient clinics specializing in the treatment of smoking cessation. Patients. —Healthy volunteers who smoked one or more packs of cigarettes daily and wanted to participate in a smoking cessation program. Intervention. —Patients were randomly assigned to a transdermal nicotine system delivering nicotine at rates of 21,14, or 7 mg (in trial 1 only) over 24 hours or to placebo. Group counseling sessions were provided to all participants. Main Outcome Measure. —Rates of continuous smoking abstinence were determined during 6 weeks of full-dose treatment, a 6-week weaning period (through week 12), and a 3-month follow-up receiving no therapy (through week 24). Abstinence was defined by patient diary reports of no smoking during the designated periods, confirmed by expired-breath carbon monoxide levels of 8 ppm or lower. Results. —The centers enrolled 935 patients. Cessation rates during the last 4 weeks of the two 6-week trials (pooled data) were 61%, 48%, and 27% for 21-and 14-mg transdermal nicotine and placebo, respectively ( P ≤.001 for each active treatment vs placebo). Six-month abstinence rates for 21-mg transdermal nicotine and placebo were 26% and 12%, respectively ( P ≤.001). All transdermal nicotine doses significantly decreased the severity of nicotine withdrawal symptoms and significantly reduced cigarette use by patients who did not stop smoking. Compliance was excellent, and no serious systemic adverse effects were reported. Conclusions. —Transdermal nicotine systems show considerable promise as an aid to smoking cessation. ( JAMA . 1991;266:3133-3138)