Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Substance use in adolescents with mental illness in Durban,South Africa

Comorbid substance use in adolescents with mental illness is often an indicator of poor treatment outcome. This study aims to determine the prevalence of, and associated risk factors for, substance use in adolescents with mental illness attending a mental health service. Data was collected from hospital records of 162 adolescents, using a structured data sheet, over a two-year period. Substance use was more significant in older adolescents and those with severe mental illness. Sixty-two (38.3%) adolescents used substances. Thirty-seven (38.1%) male adolescents reported substance use compared to 25 (38.5%) female adolescents. Alcohol was the most commonly used substance (n = 48; 29.6%), followed by cannabis (n = 32; 19.8%). There were significant direct associations between substance use and history of abuse or neglect, forensic history, educational setting, admission status, and the psychiatric diagnoses of schizophrenia, other psychotic disorders, and bipolar mood disorder. Inverse associations were found between substance use and adjustment disorders, attention deficit hyperactivity disorder, and intellectual disability. The results of this study indicate an urgent need for substance misuse programmes for at risk youth, and the introduction of dual diagnosis intervention programmes in this age group.     

Patterns of substance use in adolescents attending a mental health department

This study aimed to describe patterns of substance use in adolescents initiating mental health treatment and analyse factors associated with a high-risk pattern of substance use differentially by gender. Two hundred and thirty-seven 12- to 17-year-old new patients in an urban public mental health service were prospectively recruited and evaluated using semi-structured interviews and standardized questionnaires to obtain socio-demographic, psychopathological, family, school and substance use data. The most prevalent primary diagnoses among males were attention deficit disorder and conduct disorder, while among females they were eating disorders, affective and conduct disorders. Substance use disorder was diagnosed as follows: cannabis in 10.1% of the sample, alcohol in 3.4% and other drugs in 0.4%. A pattern of substance use with high risk of developing problems (at least regular use of alcohol or occasional use of cannabis or other illegal drugs) was found in 48.9% of the sample. After adjusting for age in the multivariate logistic regression, this pattern of risky use of drugs was found to be associated with Youth Self-Report scales of thought problems, delinquent and aggressive behaviour, in both genders. Altered family structure, having had to repeat a school grade and Youth Self-Report attention problems were only significantly associated with risky drug consumption in females. The high prevalence of risky and problematic substance use in adolescents entering mental health treatment warrants early systematic screening and specific preventive and therapeutic interventions, addressing mental health psychoeducation and motivation to avoid drugs, as well as differential associated risk factors for males and females.     

Relations of Personality to Substance Use Problems and Mental Health Disorder Symptoms in Two Clinical Samples of Adolescents

There is a high overlap between substance misuse and mental health disorders in adolescents. Certain personality traits (i.e., sensation seeking, impulsivity, hopelessness, and anxiety sensitivity) may be related to increased risk for mental health symptoms and/or substance misuse. The current study examined the relationships between personality and both substance use problems and externalizing and internalizing mental health symptoms in two clinical samples of adolescents. One sample consisted of adolescents receiving treatment for a primary mental health disorder, while the other sample included adolescents receiving treatment for a primary substance use disorder. A total of 116 participants (58 for each sample) completed the Substance Use Risk Profile Scale (SURPS), to examine personality factors, the Brief Child and Family Phone Interview- Self-Report, to examine mental health disorder symptoms, and the Personal Experience Screening Questionnaire, to examine substance use problems. After controlling for age, gender, and sample, sensation seeking and impulsivity were positively related to substance use problems, impulsivity was positively related to symptoms of externalizing disorders, and anxiety sensitivity and hopelessness were positively related to symptoms of internalizing disorders. These findings support the utility of the SURPS in predicting theoretically relevant symptoms in clinical samples of adolescents. Moreover, they extend previous research that has focused on using the SURPS as a predictor of substance misuse to its utility in also predicting mental health disorder symptoms. These findings have implications for improving mental health and addictions treatment services for adolescents.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey.

OBJECTIVE: This study sought to determine how comorbidity of psychiatric and substance abuse disorders affects the likelihood of using mental health services. METHOD: The analysis was based on data on adults aged 18-54 years in the National Comorbidity Survey (N = 5,393). Users and nonusers of mental health and substance abuse services were compared in terms of their demographic characteristics, recent stressful life events, social support, parental history of psychopathology, self-medication, and symptoms of alcohol abuse/dependence. RESULTS: The prevalence of service utilization varied by diagnostic configurations. Comorbid psychiatric or alcohol disorders were stronger predictors of service utilization than a pure psychiatric or alcohol disorder. Factors predicting utilization of services differed for each disorder. CONCLUSIONS: Since comorbidity increases the use of mental health and substance abuse services, research on the relationship of psychiatric and alcohol-related disorders to service utilization needs to consider the coexistence of mental disorders. Attempts to reduce barriers to help seeking for those in need of treatment should be increased.     

Long-Term Health and Psychosocial Status of Youth who Received Substance Abuse Treatment in Adolescence

Alcohol and substance abuse in the adolescent population is a major health concern with a number of harms known to be associated with high levels of use. Few studies report on long-term health status of youth who have received treatment for a substance abuse problem during adolescence. This study aimed to describe the long-term status of a cohort of adolescents who received treatment in an intensive day treatment program situated in a tertiary care paediatric hospital. Youth participated in an interview that collected data using both standardized screening tools (GAIN-SS, AUDIT, CUDIT, DUI) as well as closed and open ended questions about education, employment, and physical and mental health status. Young adults in this sample continue to use alcohol and cannabis, with a proportion reporting problematic use. Their academic achievement is close to expected for their age group. They report concurrent mental health disorders; and as a cohort, access the health care system for both acute and chronic health conditions more than their contemporaries. These findings support the inclusion of academic, mental health and medical components in programs for adolescents with substance abuse, in order to address a broad range of determinants of health outcomes.     

Medicaid eligibility and access to mental health services among adolescents in substance abuse treatment

OBJECTIVE: The co-occurrence of a mental disorder is common among adolescents who present for substance abuse treatment. This study was conducted to determine whether Medicaid eligibility was associated with greater use of mental health services. METHODS: The study used administrative data for 25,813 adolescents in Oregon. Propensity score analysis was used to assess the likelihood that the adolescents would use mental health services, with group differences and mental health need controlled for. RESULTS: Medicaid-eligible youths were nearly five times as likely to receive mental health services in the year they entered substance abuse treatment compared with non-Medicaid-eligible youths. In both groups, there was evidence of racial disparities as well as factors such as foster care that may facilitate access. CONCLUSIONS: The fact that Medicaid-eligible youths have greater access to mental health services should be considered in both state policies and research design. States considering ways to better serve adolescents with co-occurring disorders would do well to examine ways to promote Medicaid enrollment or expand eligibility.     

Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders

This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen’s model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.     

Dysthymia among Substance Abusers: An Exploratory Study of Individual and Mental Health Factors

The purpose of this study was to examine the individual characteristics and mental health factors of dysthymic and nondysthymic substance abusers. Out of a total of 1,209 medical records reviewed to select cases of dysthymic and nondysthymic substance abusers attending a community drug treatment program, 183 medical records were selected, 48% of which were dysthymic substance abusers. Bivariate analyses indicated that dysthymic substance abusers were more likely to be male, older individuals, reported high levels of alcohol dependence, lower quality of life, and higher number of previous substance abuse treatment. Results from hierarchical multiple logistic regression analyses indicated that age, gender, and quality of life were significant predictor for having dysthymia. Implications for the mental health field are discussed, underlining the importance of developing and providing competent treatment for substance abusers with co-occurring disorders.     

Risk of Future Offense Among Probationers with Co-occurring Substance Use and Mental Health Disorders

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.     

Use of mental health and substance abuse treatment services among adults with HIV in the United States

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.     

Consulting for substance abuse: mental disorders among adolescents and their parents

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.     

Mental Health and Substance Abuse Services to Parents of Children Involved with Child Welfare: A Study of Racial and Ethnic Differences for American Indian Parents

American Indian (AI) parents of children involved with child welfare were compared to White, Black and Hispanic parents on mental health and substance abuse problems and access to treatment. Data came from the National Study of Child and Adolescent Well-Being, a longitudinal study of a nationally representative sample of children aged 0–14 years involved with child welfare. Weighted statistics provided population estimates, and multivariate logistic regression was used to predict the likelihood of caregivers receiving mental health or substance abuse services. There were significant disparities in the likelihood of receiving mental health, but not substance abuse, services. Unmet need for mental health and substance abuse treatment characterized all parents in this study. AI parents fared the worst in obtaining mental health treatment. Parents of children at home and of older children were less likely to access mental health or substance abuse treatment.     

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

Substance abuse prevalence and comorbidity with other psychiatric disorders among adolescents with severe emotional disturbances

Among 547 adolescents with serious emotional disturbances, ages 12 to 18, this study assessed (1) prevalence of DSM-III substance use disorders (i.e., alcohol and marijuana abuse/dependence), and (2) comorbidity with DSM-III Axis I disorders. Factors of age, sex, state location, and type of treatment program also were examined. Data were analyzed by logistic regression. Significant factors (p less than 0.05) associated with severe alcohol or marijuana abuse/dependency diagnosis included (1) residential mental health treatment program, 2.37 Odds Ratio (OR); (2) conduct disorder diagnosis, 2.18 OR; (3) depression diagnosis, 1.75 OR; (4) states, 1.43 OR; (5) age, 1.29 OR; and (6) a depression x facility interaction, 1.91 OR.     

Substance abuse relapse in a ten-year prospective follow-up of clients with mental and substance use disorders

OBJECTIVES: This study addressed the rate and predictors of substance abuse relapse among clients with severe mental illness who had attained full remission from substance abuse. METHODS: In a ten-year prospective follow-up study of clients with co-occurring severe mental and substance use disorders, 169 clients who had attained full remission, defined according to DSM-III-R as at least six months without evidence of abuse or dependence, were identified. The Kaplan-Meier survival curve was developed to show the pattern of relapse, and a discrete-time survival analysis was used to identify predictors of relapse. RESULTS: Approximately one-third of clients who were in full remission relapsed in the first year, and two-thirds relapsed over the full follow-up period. Predictors of relapse included male sex, less than a high school education, living independently, and lack of continued substance abuse treatment. CONCLUSIONS: After attaining full remission, clients with severe mental disorders continue to be at risk of substance abuse relapse for many years. Relapse prevention efforts should concentrate on helping clients to continue with substance abuse treatment as well as on developing housing programs that promote recovery.     

Unmet Need For Community-Based Mental Health and Substance Use Treatment Among Rural Adolescents

This research assessed the extent of unmet service need for rural youth with mental health (MH) and/or substance use (SU) problems. All adolescents (12–18 years old) living in a three-county region of Iowa and discharged from outpatient MH or SU treatment were included (n=177). Chart review was used to retrospectively assess service utilization and clinical characteristics at time of admission and discharge. Two-thirds (64%) of adolescents with co-occurring disorders did not receive treatment consistent with widely supported guidelines recommending that individuals with co-occurring disorders receive treatment for both their MH and SU problems. Higher severity of depression, more supports, prior MH service utilization and lower prevalence of prior abuse predicted the receipt of dual services. Finally, adolescents with co-occurring problems who received only MH treatment showed improvement on MH needs at discharge but no improvement on SU needs. Similarly, adolescents with co-occurring problems who received only SU treatment showed improvement on SU needs but not on MH needs. There is considerable unmet treatment need among rural adolescents with co-occurring disorders. Efforts to improve care must focus on adolescent, familial, program, funding and policy factors that act as barriers to unifying philosophies and practices needed to advance appropriate care.     

Effects of ADHD, conduct disorder, and gender on substance use and abuse in adolescence.

OBJECTIVE: The relationships of attention deficit hyperactivity disorder (ADHD), conduct disorder, and gender to substance abuse were studied in a large population-based sample of adolescent twins. METHOD: Structured interviews were administered to 626 pairs of 17-year-old twins (674 girls and 578 boys) and their mothers to generate lifetime psychiatric diagnoses, and computerized measures of current substance use were obtained. Hierarchical logit analyses were performed to assess the independent effects of ADHD, conduct disorder, and gender on current substance use, frequency of substance use, and DSM-III-R diagnoses of substance use disorders. RESULTS: Conduct disorder was found to increase the risk of substance use and abuse in adolescents regardless of gender. In contrast, independent of its association with conduct disorder, an ADHD diagnosis did not significantly increase the risk of substance use problems. CONCLUSIONS: This study found no significant gender differences in the effects of ADHD and conduct disorder on substance use and abuse, although there was some suggestion that girls with ADHD might be at slightly higher risk than boys for substance abuse. In addition, increased risk of substance abuse among adolescents with conduct disorder may be primarily confined to those with persistent conduct disorder.     

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.