Use of substance abuse services by young uninsured american adults

OBJECTIVES: This study examined the prevalence and correlates of substance abuse service use among uninsured young adults aged 18 to 34 years (N=24,282). METHODS: Data were drawn from the 1999 National Household Survey on Drug Abuse. Logistic regression was used to identify correlates of substance abuse service use among persons who met DSM-IV criteria for dependence. RESULTS: Among uninsured young adults (N=5,067), 66 percent lacked any health care coverage for at least one year. In this uninsured group, 72 percent were past-year users of alcohol or drugs (N=2,335). Among past-year alcohol users (N=2,273), 12 percent met criteria for alcohol dependence; among past-year drug users (N=864), 21 percent met dependence criteria. Eighty-seven percent of the uninsured young adults with alcohol or drug dependence did not receive any substance abuse treatment services in the previous year. In the uninsured substance-dependent group, women, blacks, and Hispanics were less likely than men and whites to use substance abuse services. Among those with substance dependence, uninsured persons were more likely than privately insured persons to receive substance abuse services from the self-help or human service (nonmedical) sector. Conclusions: Racial, ethnic, and gender disparities in the use of substance abuse services are notable among young adults who lack health insurance.     

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.     

Correlates of health insurance among persons with schizophrenia in a statewide behavioral health care system

This study explored the demographic and service use correlates of insurance status among 539 persons with schizophrenia-spectrum disorders by using the administrative data set of a statewide behavioral health care system. Lack of health insurance was prevalent in the sample (20 percent) and was associated with younger age, Latino ethnicity, and male sex. Persons who did not have insurance were less likely to use a community-based service and more likely to use only crisis or emergency services than persons who had public or private insurance. The findings are consistent with the results of previous research demonstrating that lack of insurance is associated with decreased use of community-based services among persons with severe mental illness.     

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.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Characteristics and service use patterns of nonelderly medicare beneficiaries with schizophrenia.

OBJECTIVE: The authors sought to describe the characteristics of nonelderly Medicare beneficiaries who have a diagnosis of schizophrenia and to assess the impact of Medicare financing on service quality by comparing service use among individuals who were enrolled only in Medicare and those who were enrolled in both Medicare and Medicaid. The authors hypothesized that persons who received only Medicare benefits would use proportionally fewer psychosocial services and less antipsychotic medication than individuals who were dually enrolled. METHODS: Data were drawn from the Medicare Current Beneficiary Survey (MCBS). The study sample consisted of 257 individuals younger than age 65 who were included in the 1995 MCBS sample and who had one inpatient or two outpatient claims for schizophrenia between 1992 and 1996. The variables examined were demographic characteristics, comorbid psychiatric and substance use disorders, activities of daily living, instrumental activities of daily living, self-reported use of prescribed antipsychotic medication, and claims for psychosocial services. A multivariate analysis was also conducted to predict the use of antipsychotic medication from demographic and health status variables. RESULTS: Dually enrolled beneficiaries were significantly more likely to be receiving antipsychotic medication than Medicare-only beneficiaries, even when the analysis controlled for demographic characteristics, health status, and comorbidity. No significant differences were found in the use of psychosocial services. CONCLUSIONS: The findings were consistent with the hypothesis that Medicare financing, which restricts access to many mental health services, is not conducive to good community care for persons with schizophrenia.     

The couch and the cloth: the need for linkage

Data from the Epidemiologic Catchment Area study were used to compare the demographic characteristics and psychiatric symptomatology of persons classified into four groups based on source of mental health services: clergy only, mental health specialists only, both clergy and mental health specialists, and neither source. Those receiving services from both clergy and mental health specialists were more likely to have major affective and panic disorders than those who sought services from clergy or mental health specialists only or who sought services from neither. Those in the care of mental health specialists were more likely to have substance abuse disorders. Those in the care of clergy only were as likely as those seeing mental health specialists only to have serious mental disorders. The data make clear the need for formal linkages between clergy and mental health professionals.     

Comorbidity of major depression with substance use disorders.

OBJECTIVES: In the Canadian adult population, we aimed to 1) estimate the 12-month prevalence of major depressive disorder (MDD) in persons with a diagnosis of harmful alcohol use, alcohol dependence, and drug dependence; 2) estimate the 12-month prevalence of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month and lifetime diagnosis of MDD; 3) identify socioeconomic correlates of substance use disorder-major depression comorbidity; 4) determine how comorbidity impacts the prevalence of suicidal thoughts; and 5) determine how comorbidity affects mental health care used. METHODS: We examined data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). RESULTS: The 12-month prevalences of MDD in persons with a substance use disorder (SUD) were 6.9% for harmful alcohol use (95% confidence interval [CI], 5.2 to 8.5), 8.8% for alcohol dependence (95%CI, 6.6 to 11.0), and 16.1% for drug dependence (95%CI, 10.3 to 21.9). Conversely, the 12-month prevalences of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month diagnosis of MDD were 12.3% (95%CI, 9.4 to 15.2), 5.8% (95%CI, 4.3 to 7.3), and 3.2% (95%CI, 2.0 to 4.4), respectively. Regression modelling did not identify any socioeconomic predictors of SUD-MDD comorbidity. Substance dependence and MDD independently predicted higher prevalence of suicidal thoughts and mental health treatment use. CONCLUSIONS: SUDs cooccur with a high frequency in cases of MDD. Clinicians and mental health services should consider routine assessment of SUDs in depression patients.     

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.     

Substance abuse and mental health status of homeless and domiciled low-income users of a medical clinic

Data were collected on indicators of mental health status and substance abuse among 214 homeless and 250 domiciled but impoverished patients who sought care in a community medical clinic in a California beach community. Although both groups had a high prevalence of problems, homeless patients were significantly more likely to have been hospitalized for alcohol or mental problems, to have been arrested because of drinking, and to have experienced delirium tremens. Homeless persons were also more likely to have made a suicide attempt, to have experienced recent psychotic symptoms, and to be dissatisfied with life. The findings suggest that primary medical care settings serving the poor and homeless may present an excellent opportunity for delivering mental health services and that psychiatrists should expand their involvement in such settings.     

Perceived effectiveness of medications among mental health service users with and without alcohol dependence

OBJECTIVE: No consensus exists on the use of psychiatric medication among patients with co-occurring mental health and alcohol disorders. The authors investigated patterns of use of psychiatric medication and perceived effectiveness of mental health treatment among users of mental health care with and without alcohol dependence. METHODS: Data were obtained from the 2001 to 2003 National Survey on Drug Use and Health. The sample consisted of respondents who reported receiving mental health treatment in the past year (N=11,872). Rates of psychiatric medication use were compared between mental health care patients who were alcohol dependent and those who were not. Patient-reported effectiveness of mental health treatment was examined among alcohol-dependent and non-alcohol dependent patients who did and did not receive psychiatric medication. RESULTS: No statistically significant differences in rates of use of psychiatric medication were found between those with and without alcohol dependence (76.2 percent and 75.9 percent, respectively). Among alcohol-dependent patients, those who received psychiatric medication were significantly more likely than those who did not receive such medication to report that treatment helped a lot or a great deal (OR=2.87, 95 percent CI=1.57 to 2.56, p<.001). Among those who received psychiatric medication, no statistically significant differences were found between alcohol-dependent and nondependent respondents in patients' ratings of treatment effectiveness. CONCLUSIONS: Most alcohol-dependent individuals in mental health treatment received psychiatric medication, despite the lack of guideline support in this area. A large majority of those with alcohol dependence who received psychiatric medication reported that mental health treatment was effective.     

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.     

Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS

OBJECTIVE: To assist in developing public policy about the feasibility of HIV prevention in community mental health settings, the cost of care was estimated for four groups of adults who were eligible to receive Medicaid: persons with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. METHODS: Claims records for adult participants in Medicaid fee-for-service systems in Philadelphia during 1996 (N=60,503) were used to identify diagnostic groups and to construct estimates of reimbursement costs by type of service for the year. The estimates included all outpatient and inpatient treatment costs per year per person and excluded pharmacy costs and the cost of nursing home care. Persons with severe mental illness, HIV infection, or AIDS had received those diagnoses between 1985 and 1996. RESULTS: Persons with comorbid serious mental illness and HIV infection or AIDS had the highest annual medical and behavioral health treatment expenditures (about $13,800 per person), followed by persons with HIV infection or AIDS only (annual expenditures of about $7,400 per person). Annual expenditures for persons with serious mental illness only were about $5,800 per person. The control group without serious mental illness, HIV infection, or AIDS had annual expenditures of about $1,800 per person. CONCLUSIONS: Given the high cost of treating persons with comorbid serious mental illness and HIV infection or AIDS, the integration of HIV prevention into ongoing case management for persons with serious mental illness who are at risk of infection may prove to be a cost-effective intervention strategy.     

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.     

Use of the criminal justice system to leverage mental health treatment: effects on treatment adherence and satisfaction

In efforts to divert persons with mental illness from jails and prisons, the option of community mental health treatment in lieu of incarceration is sometimes offered. In addition, community treatment can be mandated, or "leveraged," as a condition of probation or parole. However, little is known about the characteristics and attitudes of persons who are and who are not leveraged into community mental health treatment via the criminal justice (CJ) system. In the present study, over 1,000 outpatients with mental disorders were queried about their experiences with CJ leverages, as well as their clinical and treatment histories. Persons who had experienced at least one form of CJ leverage were more likely to be younger and male and to have more hospitalizations than persons who had never experienced a CJ leverage. However, leverage experience was not associated with treatment compliance and satisfaction, or perceptions of coercion and mandate efficacy, particularly when demographic characteristics were considered.     

Interpersonal trauma and posttraumatic stress disorder in patients with severe mental illness: demographic, clinical, and health correlates

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent. For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization.     

Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months

OBJECTIVE: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. METHODS: A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. RESULTS: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. CONCLUSIONS: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost.     

Parental arrest and children involved with child welfare services agencies

Data from the National Survey of Child and Adolescent Well-Being show that approximately 1 in 8 (12.5%) children who are subjects of reports of maltreatment investigated by child welfare services (CWS) agencies have parents who were recently arrested. Compared with other children who come to the attention of CWS agencies, those with arrested parents are younger, disproportionately African American, and significantly more likely tp be in out-of-home care. Approximately 2 in 5 children age 2 and older with arrested parents had a clinically significant emotional or behavioral problem, yet only 1 in 10 received mental health care. Although parent characteristics varied by race, rates of substance abuse, serious mental illness, domestic violence, and problems meeting basic needs were higher among arrested parents than among other parents.     

Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders.

OBJECTIVE: Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement. METHODS: Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians. RESULTS: Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were $385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime. CONCLUSIONS: Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests.     

Mental health care for adults with suicide ideation

OBJECTIVE: To estimate mental health and substance abuse services use for adults with and without suicide ideation. METHOD: 2000-2001 follow-up of respondents to a nationally representative survey. Measures include self-reports of suicide ideation, specialty and primary care mental health services use, past year counseling, psychotropic medications and perceived need. RESULTS: The percentage of respondents who reported suicide ideation was 3.6%; 74% of them had a probable psychiatric disorder for which effective treatments exist. Nearly half of those with suicide ideation did not perceive a need for care, including some who received care. Of those with suicide ideation and a probable disorder, almost 40% received no treatment. Of those with suicide ideation who perceived a need for alcohol, drug or mental health (ADM) care, almost 40% received no care or inadequate care. In a multivariate model, having a probable psychiatric disorder, perceived need and being white were associated with increased likelihood of treatment use, among persons with suicide ideation. CONCLUSIONS: Many adults with suicide ideation do not perceive a need for care or receive treatment in the same year. Even among those perceiving a need for care, many experience difficulties in obtaining it. It is critical to understand barriers to treatments for this high-risk group.