Racial/ethnic disparities in the patterns of co-occurring mental health problems in adolescents in substance abuse treatment

This study examines disparities in co-occurring mental health and substance use problems by race/ethnicity to inform the development of culturally appropriate treatment approaches. Using pooled clinical data collected with the Global Assessment of Individual Needs, we identified racial/ethnic and other factors associated with co-occurring internalizing problems, externalizing problems, and the combination thereof in adolescents in federally funded treatment facilities. Results show that after controlling for demographic and socioenvironmental factors, African Americans, Hispanics, and mixed-race adolescents were more likely than Whites to have co-occurring internalizing problems. African Americans and Native Americans were less likely than Whites to have externalizing problems and to have combined internalizing and externalizing problems. Presence of co-occurring problems was also associated with victimization, homelessness, and family substance abuse. These results indicate that co-occurring mental health problems vary by race/ethnicity, and therefore, refined approaches are needed for culturally appropriate care of patients.     

Comparing barriers to mental health treatment and substance use disorder treatment among individuals with comorbid major depression and substance use disorders

Barriers to both mental health and substance use disorder treatments have rarely been examined among individuals with comorbid mental health and substance use disorders. In a sample of 393 adults with 12-month major depressive episodes and substance use disorders, we compared perceived barriers to these two types of treatments. Data were drawn from the 2005–2011 US National Surveys on Drug Use and Health. Overall, the same individuals experienced different barriers to mental health treatment versus substance use disorder treatment. Concerns about negative views of the community, effects on job, and inconvenience of services were more commonly reported as reasons for not receiving substance use disorder treatment. Not affording the cost of care was the most common barrier to both types of treatments, but more commonly reported as a barrier to mental health treatment. Improved financial access through the Affordable Care Act and parity legislation and integration of mental health and substance use disorder services may help to reduce treatment barriers among individuals with comorbid mental health and substance disorders.     

A case-linkage study of comorbidity in mental health and substance misuse care populations

This study examines the total comorbid care ‘care population’ for one geographical area. It identifies the extent of (often unrecognized) shared care between coterminous ‘care populations’ in the context of the extent of assessed need and so identifies the gap between need and service provision. The study combined anonymized data for the total secondary mental health care population and all six substance misuse agency populations within one health authority population (N?=?646,239) over three years, to identify shared ‘dual agency’ comorbid client groups (all mental health agency clients receiving specialist substance misuse treatment and vice versa). Of the total population of drug agency clients (N?=?1206), 28% had received mental health services, and of alcohol agency clients (N?=?1476), 39% had received mental health services. For a total mental health population (N?=?19,029), 2% had received specialist drug services, and 3% alcohol services. These figures are compared to previous estimates of assessed need in treatment populations to identify gaps in service provision. Two thirds of ‘dual agency comorbid’ clients were male, 40% had attended Accident and Emergency (A&E) and half had been mental health in-patients. Mental health/drug agency populations were younger and mental health/alcohol agency populations received more mental health services.     

A case-linkage study of comorbidity in mental health and substance misuse care populations

This study examines the total comorbid care 'care population' for one geographical area. It identifies the extent of (often unrecognized) shared care between coterminous 'care populations' in the context of the extent of assessed need and so identifies the gap between need and service provision. The study combined anonymized data for the total secondary mental health care population and all six substance misuse agency populations within one health authority population (N = 646,239) over three years, to identify shared 'dual agency' comorbid client groups (all mental health agency clients receiving specialist substance misuse treatment and vice versa). Of the total population of drug agency clients (N = 1206), 28% had received mental health services, and of alcohol agency clients (N = 1476), 39% had received mental health services. For a total mental health population (N = 19,029), 2% had received specialist drug services, and 3% alcohol services. These figures are compared to previous estimates of assessed need in treatment populations to identify gaps in service provision. Two thirds of 'dual agency comorbid' clients were male, 40% had attended Accident and Emergency (A&E) and half had been mental health in-patients. Mental health/drug agency populations were younger and mental health/alcohol agency populations received more mental health services.     

Sex differences in smoking cessation outcomes of a tailored program for individuals with substance use disorders and mental illness

Tobacco use is highly prevalent among individuals with a history of substance use disorders (SUD) and/or mental illness (MI). Despite evidence of differences in smoking cessation (SC) outcomes between women and men, few studies have formally evaluated sex differences among SUD and/or MI populations. For 258 participants (62% male, mean age=48.6 years) with an SUD and/or MI enrolled in a tobacco dependence clinic (TDC) program, we examined SC outcomes and compared men's and women's predictors of end-of-treatment abstinence. Individuals with an MI, social support for quitting, and a greater number of visits to the TDC program were more likely to be female; whereas males were characterized by having an SUD, older age, smoking a greater number of cigarettes per day, and having higher confidence in quitting smoking. In the intent-to-treat analysis, end-of-treatment smoking cessation was 32.2% (females=35.4% vs males=30.2, χ(2)=0.74, df=1, p=.390). Among females, baseline expired carbon monoxide (CO) level and a greater number of visits to the program were significantly predictive of SC; among males, having a history of alcohol, heroin and other opioids, and marijuana use were predictive of unsuccessful SC, whereas baseline expired CO level and a greater number of visits to the program were predictive of SC. These factors may be important in the design of enhanced tailored treatments and development of future SC programs for individuals with SUD and MI.     

Validation and comparison of diagnostic accuracy of four screening tools for mental disorders in people seeking treatment for substance use disorders

This study aimed to validate and compare performance of four screening tools for mental disorders in a heterogeneous population seeking substance use treatment. A total of 544 clients were recruited prospectively from three treatment centres and completed the screening instruments followed by a reference standard psychiatric interview for research diagnosis. Performance relative to the reference standard was compared across instruments using receiver operator characteristic (ROC) analysis. Screening tools included the GAIN-SS-IDScr; the K6, the Psychiatric Sub-scale of the Addiction Severity Index, and the Psychiatric Diagnostic Screening Questionnaire. All the screening tools performed reasonably well detecting broad groupings of disorders—any past-month disorder, any depressive disorder, anxiety disorder or psychotic disorder, with the GAIN-SS-IDScr being most efficient due to its shorter length. Results strengthen previous validation data for each of the tools investigated and support their use in detecting mental disorders in the substance use treatment population specifically.     

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.     

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.     

Advertising representation,treatment menu and economic circulation of substance misuse treatment centers in Iran: A rapid survey based on newspaper advertisements

BackgroundDaily newspapers are the main platform by which substance misuse treatment (SMT) centers in Iran advertise their services. However, these advertisements provide little information on treatment options or costs. The current research aimed to use advertisements to compile a schema of treatment services and to map the extent and nature of drug treatments offered.MethodsDuring a four-week period (April to May) in 2009, the four most popular Persian newspapers printed in Tehran were reviewed. Across these publications 1704 advertisements were posted by 66 SMT centers. Each center was then contacted by telephone to complete a structured interview about services offered and related costs. The advertisements were also decoded through a quantitative contextual analysis method.ResultsOn average, each SMT center published 26 advertisements during the review period, costing 421 US$. In addition, advertisements included word signifiers in six main categories including centers’ introduction (100%), treatment types (91%), treatment duration (68%), medicines (70%), treatment features (60%) and psychological facilities (52%). The three detoxification programs advertised were the rapid method (57% of clinics, 443.23 US$), buprenorphine (68%, 265 US$) and methadone (71%, 137 US$). More than 90% of the centers in Tehran were offering methadone maintenance (99 US$, per month).ConclusionSMT services in the Iranian market ranged from abstinence to maintenance programs, with opiates as the main focus. This review of centers’ advertisements provides an indirect but rapidly obtained picture of the drug misuse treatment network.     

Improving the capability to provide integrated mental health and substance abuse services in a state system of outpatient care

The paper reports on the capability of New York State (NYS) outpatient programs to provide integrated services for co-occurring disorders (COD). Assessments of 447 outpatient clinics, using two dual diagnosis capability indices (one used in addiction settings, the other in mental health settings), produced an overall score of 2.70, interpreted to position NYS clinics closer to “capable” (3.0 = Dual Diagnosis Capable) than to “basic” (1.0 = Alcohol [Mental Health] Only Services). “Assessment” and “Staffing” received the highest scores; i.e., clients with COD were usually identified, and staff (with some additional training and supervision) could treat both disorders effectively. While programs were generally prepared for clients with COD (e.g., welcoming such clients into the program, employing staff with competencies in both disorders, and having established routine screening and assessment to identify COD), results showed that the actual delivery of effective treatment was less satisfactory. The project demonstrated that COD capability can be assessed system-wide, using direct observation.     

Volatile substance misuse among youth in Israel: results of a national school survey

Volatile substance misuse (VSM) among Israeli youth has been identified as widespread and growing. Using data from the 2009 National School Survey of 12-18 year olds (N = 7,166), this study describes VSM prevalence among Jews and Arabs, examining relationships between past-month VSM and sociodemographic, behavioral, psychological, and interpersonal characteristics. Past-month VSM, reported by 7.5% of respondents, was significantly associated with other risky behaviors including past-month illicit drug use (Adjusted odds ratios (AOR) = 5.41, 95% CI: 3.5-8.1), Internet gambling (AOR = 2.12, 95% CI: 1.5-3.1), smoking, binge drinking, and truancy. National drug policy must address VSM and develop strategies to reduce demand and supply. Potential study limitations are noted.     

Correlates of perceiving a need for treatment among adults with substance use disorder: results from a national survey

Although millions of adults meet criteria for substance use disorder (SUD) in the U.S., only a fraction receive treatment. This may be due to individuals with SUD not perceiving a need for treatment. In order to distinguish persons with SUD who perceive a need for treatment from those who do not, correlates for the perceived need for treatment were assessed for respondents with alcohol use disorder only, drug use disorder only and both alcohol and drug use disorder. Data were from the combined 2005-2009 datasets of the National Survey on Drug Use and Health. Logistic regression models were used to calculate odds ratio and 95% confidence intervals. Results demonstrated that among respondents who need treatment but did not receive treatment for alcohol use disorder, drug use disorder and both alcohol and drug use disorders, 3.3%, 8.3% and 12.4% perceived a need for treatment, respectively. No single socio-demographic correlate was predictive of perceiving a need across the three subpopulations suggesting that screenings for substance use disorder should be done in a setting where the general population may be accessed, e.g. primary care settings. Correlates associated with perceiving a need for treatment for all three subpopulations included psychological distress, disorder severity and substance type. Although respondents with greater disorder severity were more likely to perceive a need for treatment, a large proportion of those still do not perceive a need for treatment. Screening and brief interventions would facilitate treatment entry among those with the most severe disorders.     

Empirically supported substance abuse treatment approaches: a survey of treatment providers' perspectives and practices

To better understand the extent that empirically supported and promising substance abuse treatment approaches are implemented in community settings, treatment providers were surveyed regarding their perceptions and use of several psychosocial and pharmacological treatment interventions. Program directors (n=30) and staff members (n=331) from diverse community settings rated the effectiveness and extent of use of various treatment interventions, and provided information on program and workforce characteristics via self-administered questionnaires. On average, program directors and staff rated the psychosocial treatment interventions as effective, with the exception of vouchers/motivational incentives. About half of the treatment providers did not know the effectiveness of certain pharmacological treatments, including buprenorphine and naltrexone. Respondents from the majority of programs (55%-80%) reported using Motivational Enhancement Therapy, Community Reinforcement Approach, and Supportive Expressive Psychotherapy. The extent that programs used several of the treatment interventions was related to organizational training and information resources. The study findings provide important information regarding training and research dissemination efforts.     

Relations among parental substance use, violence exposure and mental health: the national survey of adolescents

OBJECTIVE: To study the relations among parental substance use, violence exposure and psychopathology in a nationally representative sample of adolescents. METHOD: Random digit dialing methodology was used to obtain a nationally representative sample of 4023 adolescents, ages 12-17. Telephone surveys, conducted in 1995, assessed demographics, parental substance use, violence exposure, and three psychiatric disorders: major depressive disorder (MDE), posttraumatic stress disorder (PTSD), and substance abuse/dependence (SA/D). RESULTS: Obtained prevalence rates included: 8.2% for sexual assault, 22.5% for physical assault, and 39.7% for witnessing violence at home or in the community. Substance use by a family member was reported by 18.4% (n=721) of adolescents, with 50.6% reporting parental alcohol use and 19.1% (n=138) reporting parental drug use. Consistent with hypotheses, violence exposure and parental substance use, particularly parental alcohol abuse, were independently associated with outcomes. Additionally, parental substance use emerged as a moderator for MDE, PTSD, and SA/D; however, the moderating relations varied according to the outcome variable investigated. CONCLUSIONS: Violence-exposed adolescents reporting parental alcohol or drug use had the highest rates of psychiatric diagnoses.     

Willingness and appropriateness of peers participating in emerging adults' substance misuse treatment

This study investigates the feasibility of adapting empirically-supported family treatments for emerging adult peer dyads. Data were collected (n = 84) from emerging adults and their peers. Peers completed measures of substance use, willingness to participate in their friends' treatments, and an adapted version of the Significant Other Behavior Questionnaire (SBQ), which measures concerned significant others' (CSO) responses to another's use such a punishing, supporting, or withdrawing from the user. Peers were more likely to support sobriety or enable use, versus punishing use or withdrawing from their friends. Overall, peers were quite willing to assist in treatment, but heavily using peers were less enthusiastic. For some emerging adults, their current peers may represent untapped resources to integrate into treatment, and providing peer-enhanced treatments may expand the reach of services to non-treatment seeking populations.     

Identifying patterns of co-occurring substance use disorders and mental illness in a jail population

Although the co-occurrence of mental health and substance use disorders (SUDs) is well documented among correctional populations, less explored are the actual patterns that exist between specific SUDs and additional mental health disorders in combination. This study examines prevalence and correlates of psychiatric comorbidity in incarcerated men who screened positive for a SUD and the ability of a practical structured interview to document diagnostic indications of SUDs and co-occurring disorders. Comprehensive Addictions and Psychological Evaluation (CAAPE) interview data from 176 substance-dependent male inmates incarcerated in a local jail facility were analyzed. The most common substance dependence diagnoses were for alcohol (81%) and cocaine (35%). Posttraumatic stress disorder (PTSD) was the most common co-occurring mental health condition (55%), followed by antisocial personality disorder and major depressive episodes (51% each). Patterns related to the presence of PTSD and major depressive episodes accounted for a vast majority of inmates with both two and three diagnostic indications. Cronbach's alphas for the individual CAAPE diagnostic subscales ranged from 0.74 to 0.97. The design and implementation of treatment programs for substance-dependent inmates must consider co-occurring mental health issues. Several of the diagnostic categories evinced a bimodal pattern of responses in terms of severity. Negative correlations among many of the SUDs suggest that those with a greater level of severity involving some substances are less likely to manifest dependence and high severity for other substances. The observed Cronbach's alphas for the various subscales demonstrated acceptable preliminary support for the use of the CAAPE as a practical instrument in indentifying co-occurring disorders in a jail setting.     

Sexual orientation and substance abuse treatment utilization in the United States: Results from a national survey

This study examined substance abuse treatment utilization across three dimensions of sexual orientation (identity, attraction, and behavior) in a large national sample of adults in the United States. Prevalence estimates were based on data collected from the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions. The sample consisted of 34,653 adults 20 years and older, and represented a population that was 52% women, 71% White, 12% Hispanic, 11% African American, 4% Asian, and 2% other race/ethnicities. An estimated 2% of the target population self-identified as lesbian, gay or bisexual; 4% reported same-sex sexual behavior, and 6% reported same-sex sexual attraction. Sexual minorities, especially women, had a greater likelihood of lifetime substance use disorders and earlier age of drinking onset. The majority of respondents with substance use disorders were untreated and lifetime substance abuse treatment utilization differed based on sexual orientation. Sexual minorities were found to have more extensive family histories of substance abuse problems. The findings indicate the underutilization of substance abuse treatment among all adults, and highlight some important factors to consider when working with sexual minorities.     

Pathological and problem gambling in substance use treatment: A systematic review and meta-analysis

Pathological and problem gambling refer to a class of disorders, including those meeting criteria for a psychiatric diagnosis (i.e., pathological gambling), and others comprising a spectrum of severity defined by significant personal and social harm (i.e., problem gambling), that may be common in substance use treatment but are frequently unrecognized. This paper presents a systematic review and meta-analysis of available evidence indicating the prevalence of such gambling disorders in substance use treatment. It provides weighted mean estimates from across studies of clinical samples of substance users, and suggests around 14% of patients that demonstrate comorbid pathological gambling. Around 23% suffer conditions along the broader spectrum of problem gambling. The review also highlights important limitations of existing evidence, including scant data on current versus lifetime comorbidity, as well as reliance on convenience samples and self-administered measures of gambling problems. Notwithstanding a concomitant need for caution when applying these results, the findings suggest a strong need to identify and manage gambling comorbidity in substance use treatment. Strategies for identification of gambling disorders, and therapies that may provide useful adjunctive interventions in substance use treatment are discussed.