Mental Health and Substance Abuse Services in Ten State Medicaid Programs

Program data for 1993 on Medicaid mental health and substance abuse (MH/SA) services and expenditures were developed from Health Care Financing Administration (HCFA) research files for 10 states. These data show that MH/SA service users are 7 to 13% of Medicaid enrollees. The percentage of Medicaid enrollees accounted for by MH/SA users increases with age, reaching a fifth of the 45–64 age group. Across the 10 states, MH/SA spending represents 11% of total Medicaid expenditures. When their expenditures for non-MH/SA services are also considered, MH/SA users account for 28% of total Medicaid expenditures.     

Assessing Administrative Costs of Mental Health and Substance Abuse Services

Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.     

青少年物质滥用与父母物质滥用及精神疾病的关系

目的　分析青少年药物滥用及其他精神行为问题与父母药物滥用及共患精神疾病的关系。方法　研究对象为 181名药物滥用青少年和及其父母 ,根据父母的药物滥用和精神疾病史将青少年分成父母对照组、父母药物滥用组和父母共患组 ,比较了青少年物质滥用及其他精神行为问题和家庭环境在三组间的差异。结果　与父母对照组和父母药物滥用组青少年相比 ,父母共患组青少年行为问题问卷各量表分均大于其他两组 (P <0 .0 1) ,父母共患组家庭矛盾较多、家庭组织性较差 (P <0 .0 1)。结论　父母共患药物滥用和精神疾病的青少年药物滥用者可能属于不同亚群 ,其家庭矛盾较多、家庭组织性较差 ,青少年具有更多的精神行为问题 ,应加强相应的治疗和干预措施。     

Treatment for Dual Diagnosis Patients in the Psychiatric and Substance Abuse Systems

The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.     

Availability of Integrated Care for Co-occurring Substance Abuse and Psychiatric Conditions

The co-occurrence of psychiatric conditions and substance abuse presents significant challenges for behavioral healthcare providers. The need for integrated care has received substantial recent attention from clinical, research, and funding entities. However, the availability of integrated care has been low, carrying potential adverse implications for quality of care and treatment outcomes. This article describes the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs. Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care.Lori J. Ducharme, Hannah K. Knudsen, and Paul M. Roman are affiliated with the Center for Research on Behavioral Health and Human Services Delivery, Institute for Behavioral Research, University of Georgia.     

Substance Abuse And Mental Health Services For Children And Adolescents

This study examines the initial effects of the Massachusetts Mental Health and Substance Abuse Program on 24-hour care for children and adolescents. Analysis of Medicaid claims shows that under managed care, access to 24-hour services, the number of service users, and admissions increased, while length of stay and expenditures decreased. The decomposition of the savings indicated that although the increase in admissions would have added an additional 2.7 million dollars to expenditures without managed care, the carve-out saved 9.1 million dollars in the first year through changes in length of stay, service settings, and price per day. The managed care variable was not significant in the regression models examining rapid readmission.     

Mental Health and Substance Abuse Services Preferences among American Indian People of the Northern Midwest

This study examines factors that influence preferences between traditional cultural and western mental health and substance use associated care among American Indians from the northern Midwest. Personal interviews were conducted with 865 parents/caretakers of tribally enrolled youth concerning their preferences for traditional/cultural and formal healthcare for mental health or substance abuse problems. Adults strongly preferred traditional informal services to formal medical services. In addition, formal services on reservation were preferred to off reservation services. To better serve the mental health and substance abuse treatment needs of American Indians, traditional informal services should be incorporated into the current medical model.Melissa L. Walls, Kurt D. Johnson, Les B. Whitbeck, Dan R. Hoyt are affiliated with the Department of Sociology, University of Nebraska-Lincoln, 711 Oldfather Hall, Lincoln, NE 68588-0324, USA; e-mail: mwalls@unlserve.unl.edu.This research was funded by the National Institute on Drug Abuse (DA13580) and the National Institute of Mental Health (MH67281), Les B. Whitbeck, Principal Investigator.     

Provision of Mental Health Services in South African Substance Abuse Treatment Facilities

To date, South African research has not examined mental health service provision in substance abuse treatment facilities, even though these services improve client retention and treatment outcomes. To describe the extent to which substance abuse treatment facilities in Gauteng and KwaZulu-Natal provinces provide clients with mental health services during the course of treatment and to compare mental health service provision in these settings by type of facility and staff composition. Cross-sectional audits of substance abuse treatment facilities were conducted in Gauteng and KwaZulu-Natal provinces. Data were collected using the Treatment Services Audit Questionnaire. A response rate of 84% was obtained. Few treatment facilities provide clients with access to mental health services. Inpatient facilities are more likely than outpatient facilities to provide clients with access to mental health services. Facilities with for-profit ownership status are more likely than facilities with non-profit status to provide access to mental health care. Based on the above findings, a number of recommendations are made to increase the provision of mental health services during the course of substance abuse treatment.     

Substance Use Disorders in Schizophrenia��Clinical Implications of Comorbidity

Nearly half of the people suffering from schizophrenia also present with a lifetime history of substance use disorders (SUD), a rate that is much higher than the one seen among unaffected individuals. This phenomenon suggests that the factors influencing SUD risk in schizophrenia may be more numerous and/or complex than those modulating SUD risk in the general population. It is critically important to address this comorbidity because SUD in schizophrenic patients is associated with poorer clinical outcomes and contributes significantly to their morbidity and mortality.     

The Need for Substance Abuse Training Among Mental Health Professionals

This study examines substance abuse as encountered by practitioners in six major mental health professions, from private practice to organizational settings. Respective national professional associations surveyed representative samples of their members, including psychiatrists, psychologists, professional counselors, social workers, marriage and family therapists, and substance abuse counselors. About one in five clients seen in private practice of mental health professionals had substance abuse disorders, with somewhat higher rates in organized mental health treatment settings. For a large majority of clients, substance abuse was secondary to a mental disorder. A significant minority of these practitioners reported having little or no training to address substance abuse, either from formal graduate education, internships, or continuing education.     

Multisystemic Therapy (MST) for Youth Offending,Psychiatric Disorder and Substance Abuse: Case Examples from a UK MST Team

Background: The paper illustrates the MST treatment model with three types of presenting problem in young people aged 14–15. Method: The MST model is described and then illustrated with detailed case material from a violent young person convicted of robbery, a young person with a history of serious self‐harming behaviour and hospitalisation, and a young person persistently smoking cannabis. Results: All three cases improved after the MST intervention despite disparate presenting problems that included re‐offending, the elimination of self‐harming behaviour and a significant reduction in the use of cannabis. The three young people were re‐integrated into the education system. Conclusion: This case series illustrates the potential uses of the MST model in CAMHS although RCT data are needed to replicate the effectiveness of MST in the British context.     

Knowledge Transfer,Policymaking and Community Empowerment: A Consensus Model Approach for Providing Public Mental Health and Substance Abuse Services

An important problem in creating new programs and polices is how to encourage the transfer of knowledge in non-hierarchical ways so that new, relevant and specific knowledge is co-created by all interested parties. In this paper, we suggest that a consensus model of policymaking is one response and identify four key structural elements thought necessary for creating such a consensus infrastructure. These are a) a leadership and facilitating capacity for initiating and promoting such an endeavor, b) a network or consortium of key researchers, practitioners, consumers, and policymakers to empower community ownership of the endeavor, c) a process for consensus building and strategic problem-solving for such a consortium, and d) the continued creation of a multi-directional dialogue through information dissemination. We examine these elements in action by describing a particular problem solving and consensus building model for developing and implementing a program, resolving group differences, and evaluating the group's process and products.     

Race,Managed Care,And The Quality Of Substance Abuse Treatment

The adoption of managed behavioral health care by state Medicaid agencies has the potential to increase the quality of treatment for racial minorities by promoting access to substance abuse treatment and creating more appropriate utilization patterns. This paper examines three indicators of quality for white, Black, and Hispanic Medicaid clients who received substance abuse treatment in Massachusetts between 1992 and 1996. It evaluates whether a managed behavioral health care carve-out in FY1993 had a positive or negative effect on access, continuity of care, and 30-day re-admissions. Prior to managed care, access and continuity were worse for minorities than for whites. For all clients under managed care, access and continuity improved between 1992 and 1996. Access improved more for Hispanic clients relative to other racial groups. Continuity improved more for Black clients relative to other racial groups. Although seven-day and 30-day re admissions also increased following managed care, the rate of increase was not significantly greater for minorities. Although managed care had a beneficial impact on the quality of treatment for minority clients, the percent of minority Medicaid-eligible clients who accessed treatment and the percent who achieved continuity of care remained lower than for whites in every year of the study. Managed care reduced, but did not overcome, racial disparities in behavioral health care.Marilyn C. Daley, Ph.D., is a Senior Research Associate at the Schneider Institute for Health Policy in the Heller School for Social Policy and Management at Brandeis University, Waltham, MA. The author would like to acknowledge the important contributions of Donald Shepard, Ph.D., Professor at the Heller School for Social Policy and Management, who was the Principal Investigator on the project, and Yvonne Anthony, Ph.D., who reviewed earlier versions of the paper. Funding for this paper came from the National Institute on Alcohol Abuse and Alcoholism, grant #R01-AA-10880, Managed Care in Michigan and Massachusetts, to Professor Donald Shepard, Ph.D. Address for correspondence: Marilyn C. Daley, Ph.D., Senior Research Associate, Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, MS 035, P.O. Box 9110, 415 South Street, Waltham, MA 02454-9110. E-mail: daley@brandeis.edu.     

Prevalence of Mental Illness and Substance Abuse Disorders Among Incarcerated Juvenile Offenders in Mississippi

The prevalence of psychiatric disorders among incarcerated juveniles in Mississippi was examined. A total of 482 adolescents completed a diagnostic questionnaire and a subset (N = 317) was assessed with face-to-face semi-structured interview. Most of the study participants met criteria for one mental disorder, 71-85% depending on assessment method, one-third have co-occurring mental health and substance abuse disorders. Gender and placement site differences in rates of some psychiatric disorders were also noted. Routine mental health screening should be performed on all juveniles placed in secure detention facilities to identify those who need treatment services.     

Schizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides

Bennett DJ, Ogloff JRP, Mullen PE, Thomas SDM, Wallace C, Short T. Schizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides. Objective: To examine the relationship between committing homicide, the presence of schizophrenia, substance misuse and past criminality. Method: The study employed a data linkage design, using contacts recorded on two statewide databases, one of which recorded public mental health services contacts and the second of which recorded contacts with the police. The estimated rates of schizophrenia disorders, substance abuse and criminal convictions found among a population of 435 homicide offenders were contrasted with estimated rates in two composite comparison samples. Results: Of the 435 offenders, 38 (8.7%) had been diagnosed with a schizophrenia disorder, which was RR 13.11 (95% CI 9.14–18.80) times more likely than a comparison sample. Rates of known substance abuse between homicide offenders with and without schizophrenia and community‐dwelling residents with schizophrenia did not differ significantly. However, these rates were higher than those found in the general community. A similar pattern emerged for comparisons regarding offending histories between these same groups. Conclusion: The association between homicidal violence and having a schizophrenia disorder cannot be explained away simply on the basis of either comorbid substance abuse or prior criminal offending.     

New Anticonvulsants: A Review of Applications for the Management of Substance Abuse Disorders

Substance abuse and related disorders are a major problem in the United States and elsewhere. In many cases, pharmacotherapy has been shown to be useful in the treatment of substance abuse and related disorders, both in detoxification and in the prevention of relapse. However, currently used medications are not ideal, due either to their effectiveness being less than desirable or their side effect profiles being greater than desirable, or both. Medications with increased effectiveness or decreased side effects are needed. This article reviews three anticonvulsant medications, gabapentin, oxcarbazepine, and tiagabine, for possible utility in the treatment of substance abuse and related disorders. The following aspects of each medication are discussed: metabolism and kinetics, dosage and administration, possible interactions, side effects, and applications to substance abuse treatment; the last subject includes discussion of management of withdrawal symptoms, treatment of dual diagnosis, management of substance abuse sleep disorders, direct suppression of substance abuse/relapse prevention, and abuse potential. Each medication appears to have potential advantages for these uses, and further study of these medications in treatment of substance abuse disorders is recommended.     

Unmet need for Substance Abuse Treatment of Adults in Massachusetts

This article presents a methodology to estimate the size and cost of eliminating unmet need for substance abuse treatment services among adults who have clinically significant substance use disorders, and applies the approach to Massachusetts information. Unmet treatment needs were derived using a statewide household telephone survey of 7,251 Massachusetts residents aged 19 and older conducted in 1996–1997, and an index of treatment mix and cost information from state and Medicaid financial data. The study estimates that 39,450 adult state residents (0.81% of the total sample) had a clinically significant past-year substance use disorder, but had not received treatment in the past year. Providing substance abuse treatment and outreach services to them would have required an additional cost of approximately $109 million ($17 per capita), of which the states payer of last resort, the Massachusetts Department of Public Health Bureau of Substance Abuse Services (BSAS), would need to fund $31 million ($5 per capita). The share paid by BSAS (28%) would represent an increase of 42% over its current spending. This paper quantifies an important but sometimes overlooked objective of managed care: to improve access for substance abusers who need but do not seek treatment.Donald S. Shepard, Ph.D., Gail K. Strickler, M.S., Aaron Beaston-Blaakman, M.S.W., M.P.A., and Mohammad Rahman, M.S.S., M.A., are all affiliated with the Schneider Institute for Health Policy in the Heller School for Social Policy and Management at Brandeis University in Waltham, MA. William E. McAuliffe, Ph.D., is in the Department of Psychiatry at Harvard Medical School, North Charles Research and Planning Group, in Cambridge, MA. Teresa E. Anderson, Ph.D., is part of the Office of Statistics and Evaluation in the Center for Community Health at the Massachusetts Department of Public Health in Boston, MA. This research was supported in part by the Massachusetts Department of Public Health and the National Institute on Drug Abuse (Grant R01 DA15744, P.I. is William E. McAuliffe).     

A Publicly Managed Medicaid Substance Abuse Carve-Out: Effects on Spending and Utilization

In 1998, Michigan Medicaid "carved out" substance abuse treatment from its medical plans, transferring the management responsibility and substantial financial risk to 15 specialized local entities called coordinating agencies. All these agencies were either non-profit or publicly owned, unlike carve-out entities in many other states. By the second year of the risk-based carve-out (2000), Medicaid payments per eligible were 9.1% lower than in the last year before the carve-out (1998). Reductions were largely achieved by serving fewer clients, not by reducing payments per client. Agencies faced with revenue reductions or small increases were more likely to reduce treatment spending.     

Substance Abuse in an Adolescent Boy: Waking the Object

The analysis of an adolescent boy abusing alcohol, marijuana, and other drugs is used to discuss unconscious object relationships that can underlie substance dependence. Differentiating experimental from dangerous substance use is particularly challenging in the treatment of adolescents. The boy's escalating substance use is viewed both as an effort to numb himself and to “speak” through symptoms of problems he could not yet name. I utilize Rosenfeld's (1960/1966) view of the relationship of drug addiction to an identification with an ill or dead object to explicate the boy's psychodynamics. In this case, my patient was identified with both an ill mother and a neglectful father. Aspects of containment by the analyst that contribute in different ways to an adolescent's capacity to think about their self-destructiveness are discussed, along with the need for confrontation and the meaning of ancillary care when an adolescent's substance abuse become life threatening.