Establishing a computerized substance abuse surveillance system for district social workers in the Western Cape Province,South Africa: Methods,successes and challenges

The provision of accurate, in-depth data on substance abuse trends and service needs has become increasingly important in light of the growing wave of substance abuse in South Africa and particularly in the Western Cape Province. This article describes the design and implementation of an electronic substance abuse surveillance system (SASS) between 2007 and 2009. The function of this system is to gather data on substance use, associated problems, service needs and services received on all clients presenting for generic social welfare services at the 16 district social service offices in the Western Cape. This article describes key features of SASS, examines the strengths of this system, reviews the process of implementing SASS and describes major challenges to the effective implementation and use of the system. Major challenges include limited infrastructure, inadequacies in staff capacity and lack of organizational support for the system. Recommendations for addressing these challenges and improving the use of this surveillance system are provided.     

Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students

This research examined 1) the prevalence of substance use behaviors in college students, 2) gender and academic level as moderators of the associations between mental health problems and substance use, and 3) mental health service use among those with co-occurring frequent binge drinking and mental health problems. As part of the Healthy Minds Study, a probability sample of 2843 college students completed an Internet survey on mental health problems, substance use behaviors, and utilization of mental health care. Response propensity weights were used to adjust for differences between respondents and non-respondents. Major depression, panic disorder, and generalized anxiety disorder were positively associated with cigarette smoking. Frequent binge drinking was negatively associated with major depression and positively associated with generalized anxiety disorder, and these associations were significantly stronger for males than females. Among students with co-occurring frequent binge drinking and mental health problems, 67% perceived a need for mental health services but only 38% received services in the previous year. There may be substantial unmet needs for treatment of mental health problems and substance use among college students.     

‘The great unmentionable’: Exploring the pleasures and benefits of ecstasy from the perspectives of drug users

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

What are the implications for clinical management and service development of prevalent comorbidity in UK mental health and substance misuse treatment populations?

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

Use of specialty substance abuse and mental health services in adults with substance use disorders in the community

AIMS: To examine the patterns and correlates of use of specialty substance abuse and mental health services among adults with alcohol or non-alcohol drug abuse or dependence in the community. METHODS: Analyses focused on 5,568 participants with alcohol or non-alcohol drug abuse or dependence drawn from a large representative cross-sectional survey of the US general population-the 2002 US National Survey on Drug Use and Health (NSDUH). RESULTS: Only 9.7% of adults with substance use disorders used specialty substance abuse services in the past year; 22.4% used mental health services. Severity of substance use disorder and less education were associated with using substance abuse services. Whereas psychological distress and impairment in role functioning due to psychological problems were associated with mental health service use. Male gender, black race/ethnicity, and lack of health insurance acted as barriers to using mental health services but not specialty substance abuse services. Past year use of substance abuse services, but not mental health services, was associated with lower likelihood of continued use of substances in the past month. CONCLUSIONS: Individuals with substance use disorders are more likely to use mental health services than specialty substance abuse services. However, only people who use specialty substance abuse services have a lower risk of continued use of substances. Findings highlight the need for integration of substance abuse treatments in the mental health care system and attention to different barriers to the two types of services.     

Design of a behavioral health program for urban American Indian/Alaska Native youths: a community informed approach

American Indian/Alaska Native (AI/AN) urban youths experience significant mental health and substance use problems. However, culturally relevant treatment approaches that incorporate community perspectives within the urban setting are limited. This study analyzes community perspectives from AI/AN parents, AI/AN youths, and services providers within Los Angeles County. Information gathered was utilized to develop a needs assessment for AI/AN youths with mental health and substance use problems and to design a community-informed treatment approach. Nine focus groups and key informant interviews were conducted. The Los Angeles County community strongly expressed the need for providing urban AI/AN youths with traditional healing services and cultural activities within their treatment program. However, various barriers to accessing mental health and substance abuse treatment services were identified. An integrated treatment approach was subsequently designed as a result of input derived from community perspectives. The community believed that providing urban AI/AN youths with an integrated treatment approach has the potential to decrease the risk of mental health and substance abuse problems in addition to enhancing their cultural identity and self esteem.     

Characteristics of transgender individuals entering substance abuse treatment

Little is known about the needs or characteristics of transgender individuals in substance abuse treatment settings. Transgender (n = 199) and non-transgender (cisgender, n = 13,440) individuals were compared on psychosocial factors related to treatment, health risk behaviors, medical and mental health status and utilization, and substance use behaviors within a database that documented individuals entering substance abuse treatment in San Francisco, CA from 2007 to 2009 using logistic and linear regression analyses (run separately by identified gender). Transgender men (assigned birth sex of female) differed from cisgender men across many psychosocial factors, including having more recent employment, less legal system involvement, greater incidence of living with a substance abuser, and greater family conflict, while transgender women (assigned birth sex of male) were less likely to have minor children than cisgender women. Transgender women reported greater needle use, and HIV testing rates were greater among transgender women. Transgender men and women reported higher rates of physical health problems, mental health diagnoses, and psychiatric medications, but there were no differences in service utilization. There were no differences in substance use behaviors except that transgender women were more likely to endorse primary methamphetamine use. Transgender individuals evidence unique strengths and challenges that could inform targeted services in substance abuse treatment.     

Prevalence and correlates of alcohol misuse among returning Afghanistan and Iraq veterans

Objective

Several studies have reported high rates of alcohol misuse and low rates of substance use treatment among OEF/OIF military service members. This study assessed the prevalence and correlates of alcohol misuse and the factors associated with treatment utilization among recently returned National Guard service members.

Methods

The sample included 585 members of the National Guard who volunteered to complete an anonymous survey assessing mental health and substance use problems, functional status, and past treatment experiences. Bivariate and multivariate logistic regression analyses were performed examining the significance of associations between alcohol misuse and mental health service use as outcomes and demographic variables, mental health symptoms, and military service characteristics as predictors. Barriers to treatment and factors facilitating treatment were also examined.

Results

Thirty-six percent of the service members met criteria for alcohol misuse. Of those misusing alcohol, 31% reported receiving any mental health treatment and 2.5% reported receiving specific substance use treatment in the past year. The barrier to treatment most commonly endorsed by those misusing alcohol was concern that the information about treatment would appear in their records. Among those misusing alcohol who had received services, spouses were most commonly endorsed as facilitating the pursuit of care.

Conclusions

Rates of alcohol misuse are high and rates of substance use treatment are low among National Guard service members. Additional research is needed to identify means of overcoming barriers to care and establish more effective approaches to facilitate linkage to care and receipt of appropriate interventions.     

Community Determinants of Substance Abuse Treatment Referrals from Juvenile Courts: Do Rural Youths Have Equal Access?

Many youths in juvenile justice are in need of substance use services, yet referral to services is often inadequate. This study examines the ecological factors related to substance use service referrals made through Tennessee's juvenile courts. A series of hierarchical binomial logistic models indicated that individual-level factors accounted for 31% of the variance among courts in referral rates. Community and court factors accounted for an additional 16% of the variance. Youths were more likely to be referred if they had a higher need, were white, were male, were adjudicated in communities that had a higher service density, and appeared in courts that had good relationships and frequent contact with mental health providers. Controlling for individual need, youths in rural areas tended to have lower referral rates; however, this relationship was mediated by the frequency of contact and the quality of relations between the court and mental health providers and county average socioeconomic status.     

Community Determinants of Substance Abuse Treatment Referrals from Juvenile Courts: Do Rural Youth Have Equal Access?

Many youth in juvenile justice are in need of substance use services, yet referral to services is often inadequate. This study examines the ecological factors related to substance use service referrals made through Tennessee's juvenile courts. A series of hierarchical binomial logistic models indicated that individual-level factors accounted for 31% of the variance among courts in referral rates. Community and court factors accounted for an additional 16% of the variance. Youth were more likely to be referred if they had a higher need, were White, were male, were adjudicated in communities that had a higher service density, and appeared in courts that had good relationship and frequent contact with mental health providers. Controlling for individual need, youth in rural areas tended to have lower referral rates; however, this relationship was mediated by the frequency of contact and the quality of relations between the court and mental health providers and county average SES.     

Using the addiction severity index to predict mental and medical health service utilization

This study assessed the utility of adding the Addiction Severity Index (ASI) to demographic and clinical diagnostic information for the purpose of predicting subsequent substance use disorder service use, and use of other healthcare services by 260 veterans admitted for outpatient substance use disorder treatment. Data collected included demographics, clinical diagnoses, assessment data from the ASI, as well as measures of six-month health service utilization (e.g., substance use disorder services, other mental health services, outpatient medical visits, urgent care visits, inpatient psychiatric and medical). Multivariate analysis using Tobit regression models showed six out of seven ASI scales were significant predictors, and that combining ASI data with demographics and clinical data significantly improved prediction of health care services. It also was found that certain psychiatric and medical diagnoses were related to service use measures, and that a diagnosis of depression was related to overall healthcare utilization.     

Correlates of mental health service utilization and unmet need among a sample of male adolescents

The authors sought to identify the correlates of mental health services utilization and unmet need for these services among a sample of adolescent males. We hypothesized that our findings would replicate and extend those of the recent Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, which found that parental factors play a major role in their children's unmet mental health care needs. Our study involved an evaluation of mental health service utilization and unmet need during the prior 2 years, as reported by the subjects at a follow-up assessment at age 16. Four factors were found to predict increased mental health services utilization, including attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) among the adolescent males, the father's alcohol use disorder, and the mother's amphetamine use disorder. One factor was found to predict decreased utilization, the father's cannabis use disorder. Four factors significantly predicted unmet treatment need, including conduct disorder, the mother's amphetamine use disorder, a higher number of siblings, and a parental history of having had a childhood anxiety disorder. The results of this study suggest that parental psychopathology, parental substance abuse, the presence of conduct disorder, and an increased number of siblings act as barriers to adequate mental health treatment among adolescents. These findings confirm the crucial role that parental factors play in the treatment utilization and the unmet treatment need of their children, and also suggest that an increased number of siblings can also be associated with unmet treatment need.     

“Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a “siloed treatment experience”), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.     

The prevalence and management of co-morbid substance misuse and mental illness: results of a screening survey in substance misuse and mental health treatment populations

A cross-sectional survey of clinical staff was carried out among statutory (public sector) substance misuse services and community mental health teams (CMHTs) in an inner London borough. We identified 368 current patients of drug and alcohol misuse services and 930 current patients of CMHTs. We measured the prevalence of co-morbid substance misuse and mental illness among these patients. We found strong evidence of co-morbid mental health problems in 128 substance misuse patients (34.8%) and evidence of possible co-morbidity in a further 18.5% of cases. Among mental health service patients, 227 (24%) were reported to have current substance misuse problems. Shared care of patients was uncommon and only a minority of co-morbid patients received treatment for both problems or the specialist assessment which key workers felt they needed. The findings suggest that co-morbidity is highly prevalent among mental health and substance misuse patients. Further research is needed to corroborate these findings, but the development and provision of evidence-based treatment and service interventions is likely to become an increasing priority.     

Associations of alcohol use disorder,alcohol use,housing, and service use in a homeless sample of 255 individuals followed over 2 years

Background: Homeless individuals with alcohol use disorders have multiple comorbidities and therefore various service needs. Despite need for services, homeless individuals face numerous barriers to treatment. Little is known about the associations of specific services in relation to homelessness in the context of alcohol problems. The current study analyzed 2-year prospective longitudinal data on a homeless sample, examining relationships between alcohol use disorder, alcohol use, housing status, and service use over time. Methods: Two hundred fifty-five of 400 individuals recruited systematically from shelters and street locations completed 3 annual assessments (69% completion). Data on lifetime and current psychiatric disorders, housing status, and past-year service use were obtained and merged with service use data gathered from local agencies. Generalized estimating equation (GEE) models were created to predict dependent outcome variables of stable housing, alcohol use, and service use in both follow-up years. Results: Lifetime alcohol use disorder was positively associated with substance and medical service use. Alcohol problems did not hinder attainment of stable housing, and placement in housing did not necessarily increase risk for alcohol use. Stable housing was negatively associated with psychiatric and substance service use. In the second year, when alcohol use was finally associated with receiving substance services, it appears that these services provided a gateway to psychiatric services. The psychiatric services in turn appeared to provide a gateway to medical services. Conclusions: Alcohol use behaved differently compared with lifetime alcohol use disorder in relation to service use. Lack of association between alcohol use and housing supports Housing First policy. Obtaining housing may have ameliorative effects on mental health, diminishing perceived need for psychiatric services. Services may also be more accessible during homelessness. Obtaining substance treatment may provide a gateway for those who use alcohol after becoming homeless to connect with psychiatric and medical services, informing policy and practice.     

Association between mental health service utilisation and sharing of injection material among people who inject drugs in Montreal,Canada

BackgroundHigh-risk injection behaviors are associated with high prevalence of mental health problems among people who inject drugs (PWID). However, whether the use of mental health services is associated with lower risk of sharing injection material remains undetermined. This study aims to examine the association between mental health service utilisation and receptive sharing risk, and determine the potential modifying effect of psychological distress on this association.MethodsParticipants answered an interviewer-administered questionnaire at 3-month intervals gathering information on sociodemographic characteristics, substance use and related behaviors, services utilisation and significant mental health markers. Relationship between the use of mental health services and receptive sharing was modeled using the generalized estimating equation (GEE), controlling for age at baseline, gender, and other potential confounders. Psychological distress was estimated using the Kessler Psychological Distress Scale (K10). Effect modification was investigated by adding an interaction term in the univariate GEE analysis.Results358 participants contributed to 2537 visits (median age 40.3, 82% male). Mental health service utilisation was reported in 631 visits (25%), receptive sharing in 321 visits (13%) and severe psychological distress in 359 visits (14%). In multivariate GEE analyses, a significant association was identified between receptive sharing and the use of mental health services (aOR = 0.69; 95% CI = 0.50–0.94). We found no evidence of effect modification by psychological distress.ConclusionAmong PWID, mental health service utilisation was associated with lower likelihood of receptive sharing, regardless of level of psychological distress. These findings should be taken into account when designing harm reduction strategies for this population.