Persons with dual diagnoses of substance abuse and major mental illness: their excess costs of psychiatric care.

OBJECTIVES. This study examined the costs of psychiatric treatment for seriously mentally ill people with comorbid substance abuse as compared with mentally ill people not abusing substances. METHODS. Three different sources of data were used to construct client-level files to compare the patterns of care and expenditures of 16,395 psychiatrically disabled Medicaid beneficiaries with and without substance abuse: Massachusetts Medicaid paid claims; Department of Mental Health state hospital inpatient record files; and community support service client tracking files. RESULTS. Psychiatrically disabled substance abusers had psychiatric treatment costs that were almost 60% higher than those of nonabusers. Most of the cost difference was the result of more acute psychiatric inpatient treatment. CONCLUSIONS. Although the public health and financial costs of high rates of comorbidity are obvious, the solutions to these problems are not. Numerous bureaucratic and social obstacles must be overcome before programs for those with dual diagnoses can be tested for clinical effectiveness.     

Tobacco and Alcohol Use as an Explanation for the Association Between Externalizing Behavior and Illicit Drug Use Among Delinquent Adolescents

The prevalence and persistence of adolescent substance use and abuse is a national health issue, and substance use among adolescents is frequently comorbid with other psychiatric disorders. Most studies in this area utilize samples of middle or high school students or from inpatient settings. Less is known about substance use and psychiatric comorbidity among delinquent adolescents. The present study examined data from two cohorts of juvenile offenders collected over a 2-year period (n = 245, n = 299). Participants reported frequency of cigarette, alcohol, marijuana, and other substance use. Participants' parents completed a measure of behavior problems. Path analyses suggested that parental reports of externalizing problems were significantly related to self-reported substance use while parental reports of internalizing problems were not. Results also suggested that smoking and alcohol use act as mediators between externalizing problems and marijuana and other drug use. Although there were some mean differences by gender, the pattern of relationships amongst the variables did not differ by gender. Implications of the findings and future directions are discussed.     

Substance use disorders, anorexia, bulimia, and concurrent disorders

BACKGROUND: While the co-prevalence of eating disorders (ED) has been documented in individuals with substance use disorders (SUD), little is known about the co-occurrence of other disorders in this population. Examining this issue is critical for public health policy and treatment success. OBJECTIVE: To identify and evaluate the co-occurrence of ED and other psychiatric disorders in men and women with SUD. METHODS: The sample consisted of individuals seeking treatment for substance use. Semi-structured interviews and the CAMH Concurrent Disorders Screener were completed to assess DSM-IV psychopathology. RESULTS: Chi-square analyses suggested that more women scored positive for ED than men, EDs were more prevalent in both genders than in the general population, and the co-occurrence of other disorders was higher for clients with both SUD and ED than with SUD. DISCUSSION: Individuals with both SUD and ED appear to have multiple needs that may not be readily assessed by existing addiction treatment programs. Assessment issues, treatment, potential prevention and health promotion implications are addressed.     

Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales

STUDY OBJECTIVE: To estimate the annual period prevalence of co-occurring psychiatric illness and substance misuse among patients in primary care. DESIGN: Analysis of the general practice research database. SETTING: England and Wales, 1993-1998. PARTICIPANTS: Registered patients at 230 general practices representing 3.1% of the population. A comorbid case was defined as one with both a psychiatric diagnosis and substance misuse diagnosis (not including alcohol or tobacco) within a calendar year. A potentially chronic comorbid case was one that met this definition and, in addition, was treated in subsequent years for either a psychiatric condition or substance misuse. MAIN RESULTS: The annual period prevalence of comorbidity increased from 50/100 000 patient years of exposure (PYE) to 80/100 000 PYE, an increase of 62% during the study period. Rates of comorbid psychoses, comorbid schizophrenia, and comorbid paranoia increased by 147%, 128%, and 144%. The average age of comorbid cases decreased from 38 years to 34 years. Over 80% of comorbid cases were newly diagnosed in each study year, although many are treated in subsequent years for either psychiatric illness or substance misuse. CONCLUSIONS: This study provides data on the nature and extent of comorbidity in primary care in England and Wales. As the comorbidity rate is increasing by about 10% each year, and as comorbid cases are becoming younger, it is probable that the comorbidity rate will have increased beyond the study end point.     

Performance assessment in community mental health care and at-risk populations

We examine whether community mental health care centers (CMHCs) differ in their ability to serve at-risk populations, including clients with dual diagnoses for substance abuse, comorbid disabilities, and particularly severe functional impairment. Our analysis uses data from Indiana's public mental health system. Although at-risk clients experience, on average, worse outcomes than other clients, we find that some CMHCs achieve statistically significantly better outcomes than others. Although this information is useful to consumers and providers who wish to identify the most effective providers and treatment models for at-risk clients, it is not generated in standard performance assessments.     

Child Anxiety Disorders in Public Systems of Care: Comorbidity and Service Utilization

Little is known about mental health service use among children with anxiety disorders, and even less is known about these children in public sectors of care. In this study, 1,715 children were randomly sampled from one of five public service systems. Psychiatric diagnoses were assessed with a structured interview, and standardized measures were used to assess mental health service utilization. Data from a subsample (n = 779) of youth with psychiatric disorders were analyzed. Analyses revealed that comorbidity among children with anxiety disorders was substantially higher than general population estimates. Approximately 26% of children with anxiety had a comorbid mood disorder, and 62% had a disruptive behavior disorder. Among children with anxiety disorders, those who had comorbid conditions were more likely to receive inpatient services than those without comorbidity. Comorbidity, caregiver strain, and service sector were associated with inpatient and nonspecialty service use in this group. Findings underscore the substantial comorbidity among children with anxiety disorders in public sectors of care and the potential need to adapt evidence-based interventions to meet the complex and multiple needs of these children.     

Toward cost-effective care for persons with dual diagnoses

Implementing services that controlcosts and improve client functioning for persons with both severe psychiatric and substance disorders is paramout in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral sills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.     

Diagnoses, requests and timing of 503 psychiatric consultations in two general hospitals

The high comorbidity of medical and psychiatric diagnoses in the general hospital population requires collaboration between various medical fields to provide comprehensive health care. This study aims to find the rate of psychiatric consultations, their timing and overall diagnostic trend in comparison to previous studies. Tehran University of Medical Sciences has got an active psychiatric consultation-liaison service which includes services provided by four faculty psychiatrists (two full-time and two part-time). This study was done in two general hospitals by simple sampling in available cases. For each consultation, a board-certified faculty psychiatrist conducted a clinical evaluation based on DSM-IV-TR. Other than psychiatric diagnoses, socio-demographic variables, relative consultation rates, reasons for referral, medical diagnoses and the time stay after admission were assessed. Among 503 patients who were visited by the consultation-liaison service, there were 54.3% female with mean age of 39.8 years. In 90.1% of consultations, at least one DSM-IV-TR diagnosis was made. The most frequent diagnosis groups were mood disorder (43.5%), adjustment disorder (10.9%) and cognitive disorder (7.6%). In about 10.9% of the consultations, multiple psychiatric diagnoses were made. The mean length of hospital stay before the consultation was 12.56 days (range=1-90, SD=13). Based on our findings, the mood and cognitive disorders still remain major foci of consultation-liaison practice in general hospitals; however our findings showed high rate of adjustment disorders diagnosis and ambiguous request for psychiatric consultation which need more interdisciplinary interaction.     

Clients with substance abuse and mental health concerns: A guide for conducing intake interviews

Although comorbidity (co-occurrence of a psychiatric and substance use disorder) is a common phenomenon at both mental health and substance abuse treatment agencies, rarely do such agencies thoroughly assess for both types of diagnoses during their standard intake interview. This article describes the development of an intake form designed to guide a comprehensive assessment of both mental health and substance abuse concerns. The form guides intake interviewers toward documenting administrative and demographic information, substance use and mental health concerns, and variables needed for compliance with grant funding sources. Use of the protocol can provide a clinical foundation for treatment planning and continuity of care for clients, while also providing error-free agency data that can be used for administrative, program planning, outcome assessment, and research purposes.     

Strategies for improving comorbidity measures based on Medicare and Medicaid claims data

Claims-based measures of comorbid illness severity have generally relied on the diagnoses listed for a single hospitalization. Unfortunately, such diagnostic information is often limited because patients have not been hospitalized during periods of interest, because of incomplete coding of diagnoses on claims forms, or because listed diagnoses represent complications of the hospitalization rather than pre-existing comorbid conditions. To address these limitations, we developed and tested four comorbidity index scores for patients with breast cancer, each based on different sources of health services claims from Medicare and Medicaid: hospitalization for breast cancer surgery; outpatient care prior to the hospitalization; other inpatient care prior to the hospitalization; and all sources combined. Varying the number and type of sources of diagnostic information yielded only very small improvements in the prediction of mortality at 1 and 3 years. Surprisingly, even simpler measures of comorbidity (crude number of diagnoses) and of prior health care utilization (total days spent in the hospital) performed at least as well in predicting mortality as did the more complex index scores which assigned points and weights for specific conditions. The greatest improvement in explanatory power was observed when another source of clinical information (cancer stage derived from a population-based cancer registry) was used to supplement claims information. Expanding the source of claims diagnoses and focusing on time periods prior to an index hospitalization are insufficient for substantially improving the explanatory power of claims-based comorbidity indices. Other improvements suggested by our results should include: increasing the completeness and accuracy of claims diagnoses; supplementing diagnoses with health care utilization information in claims data; and supplementing claims data with other sources of clinical information.     

Psychiatric comorbidity measures as predictors of retention in drug abuse treatment programs.

OBJECTIVE: To examine lifetime and current psychiatric comorbidity measures as predictors of drug abuse treatment retention, and to test the generalizability of results across treatment agencies in diverse settings and with varying practices. DATA SOURCES/STUDY SETTING: The national Drug Abuse Treatment Outcome Studies (DATOS), a longitudinal study of clients from 96 treatment agencies in 11 U.S. cities. STUDY DESIGN: The design is naturalistic and uses longitudinal analysis of treatment retention in long-term residential, outpatient drug-free, and outpatient methadone treatment modalities; client background (including psychiatric comorbidity) and program service provision are predictors. Clinical thresholds for adequate treatment retention were 90 days for long-term residential and outpatient drug-free, and 360 days for outpatient methadone. Psychiatric indicators included lifetime DSM-III-R diagnoses of depression/anxiety and antisocial personality, and dimensional measures of current symptoms for depression and hostility. DATA COLLECTION/EXTRACTION METHODS: Data include structured interviews with clients, a survey of treatment program administrators, and program discharge records. PRINCIPAL FINDINGS: Dimensional measures of current psychiatric symptoms emerged as better predictors than lifetime DSM-III-R diagnoses. In addition, the predictive association of hostility with retention varied significantly across treatment agencies, both in the long-term residential and outpatient drug-free modalities. Other notable findings were that on-site mental health services in long-term residential programs were associated with better retention for clients with symptoms of hostility. CONCLUSIONS: Assessment issues and stability of results across programs are important considerations for treatment research and practice.     

The long-term treatment outcomes of depression and anxiety comorbid with substance abuse

The impact of the comorbidity of psychiatric disorder and substance abuse on treatment outcomes was estimated using data from a longitudinal survey of 1,920 individuals who were followed nearly 15 years. Individuals with anxiety or depression symptoms at baseline generally experienced increased distress at follow-up; those who received mental health treatment experienced decreased distress at follow-up. Individuals with substance abuse/dependence symptoms who received treatment at baseline had a higher risk of follow-up disability; treated individuals with substance abuse who had comorbid anxiety and depression symptoms at baseline were at lower risk of disability at follow-up. Individuals with anxiety and depression symptoms at baseline had a higher incidence of chronic illness during follow-up; those who received treatment or had substance abuse symptoms did not. The results may improve understanding of the degree to which treatment of a primary disorder may prevent the incidence or reduce the prevalence of a secondary comorbid disorder.     

Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans

OBJECTIVE: This study examined eating disorders and their psychiatric comorbidity in a national sample of hospitalized male veterans. METHOD: Review of discharge summaries for 466,590 male patients from Veterans Affairs medical centers for fiscal year 1996 resulted in the identification of 98 men with a current ICD-9-CM diagnosis of an eating disorder. For the comorbidity analyses, eating disorder cases were matched with controls drawn randomly from the pool of male patients without an eating disorder, using age and race as matching variables. RESULTS: There was a high rate of comorbid substance use and mood disorder for men with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Men with AN were also at high risk for comorbid schizophrenia/psychotic disorder, men with BN were at risk for comorbid personality disorder, and men with EDNOS were at special risk for comorbid organic mental disorder and schizophrenia/psychotic disorder. DISCUSSION: For each eating disorder, there was a distinct pattern of psychiatric comorbidity that deserves further study.     

Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity

OBJECTIVE: Using a national sample of hospitalized female and male veterans, this study examined the point prevalence of detected cases of eating disorders and explored psychiatric comorbidity in cases with an eating disorder. METHODS: Prevalence rates were determined by reviewing the discharge diagnoses of 24,041 women and 466,590 men hospitalized in Veteran Affairs medical centers during fiscal year 1996. Comorbidity was examined by individually matching eating disorder cases (N = 161) with patients without an eating disorder, using sex, race, and age as matching variables. RESULTS: On the basis of routine clinical diagnosis, 0.30% of the female veterans and 0.02% of the male veterans were diagnosed with a current ICD-9-CM eating disorder. Women with eating disorders had significantly elevated rates of comorbid substance, mood, anxiety (particularly posttraumatic stress disorder [PTSD]), adjustment, and personality (particularly borderline personality disorder [BPD]) disorders. Men with eating disorders were found to have high rates of comorbid organic mental, schizophrenic/psychotic, substance, and mood disorder. CONCLUSIONS: Our study illustrates the value of administrative data sets for the investigation of uncommon diseases.     

The cost and outcomes of community-based care for the seriously mentally ill.

OBJECTIVE: To examine the cost-effectiveness of community-based mental health care. DATA SOURCES/STUDY SETTING: Administrative data from Medicaid and the Massachusetts Department of Mental Health; primary data from 144 psychiatrically disabled adult Medicaid beneficiaries who lived in Boston, central Massachusetts, and western Massachusetts. STUDY DESIGN: A cross-sectional observational study compared the costs and outcomes of treatment in three different types of public mental health service systems. DATA COLLECTION/EXTRACTION METHODS: Beneficiaries, randomly sampled from outpatient mental health programs, were interviewed about their mental health status. All their acute treatment and long-term continuing care for the preceding year were abstracted from Medicaid and Department of Mental Health files. Costs were extracted from Medicaid paid claims and from Department of Mental Health contracts and other financial documents. PRINCIPAL FINDINGS: Clients in the region allocating a greater proportion of its Department of Mental Health budget to community support services used far fewer hospital days, resulting in lower per person treatment expenditures. Outcomes, however, were not significantly different from outcomes of clients in the other regions. For all regions, substance abuse comorbidity increased hospitalization and total treatment costs. An individual-level cost-effectiveness analysis identified western Massachusetts (community-based care) as significantly more cost effective than the other two regions. CONCLUSIONS: Systems with stronger community-based orientation are more cost effective.     

Alcoholism treatment,severity of alcohol-related medical complications,and health services utilization

In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment. This study was supported by grants R01-AA08732 (Drs. Booth, Cook, and Blow) and P50-AA07378 (Dr. Brow) from the National Institute of Alcohol Abuse and Alcoholism.     

Lymphocyte measures in treatment-naïve 13-15-year old adolescents with alcohol use disorders

Many adolescents have chronic exposure to hazardous levels of alcohol. This is likely to be a significant predictor of health outcomes, including those related to immunity. We assessed substance use and biochemical immunological parameters in heavy drinking adolescents (meeting DSM-IV criteria for alcohol dependence) and light/nondrinking control adolescents in Cape Town. Lifetime alcohol dose, measured in standard units of alcohol, was orders of magnitude higher in alcohol-dependent (AD) participants than controls. All adolescent AD had a “weekends-only” style of alcohol consumption. The AD group was chosen to represent relatively “pure” AD, with minimal other drug use and no psychiatric diagnoses. With these narrow parameters in place, we found that AD adolescents were lymphopenic compared with controls, with significantly lower mean numbers of absolute circulating CD3+, CD4+, and CD8+ T-lymphocytes. On conclusion, we found that adolescent AD individuals with excessive alcohol intake, in a weekend binge-drinking style but without comorbid drug or psychiatric disorders, may be at increased risk of lymphopenia. This alcohol misuse may increase infectious disease susceptibility (including TB and HIV) by reducing immune system capabilities. Complex interactions of alcohol with other documented high-risk activities may further compound health risks.     

Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance

OBJECTIVE: The current study examined comorbidity and clinical correlates of eating disorders in a large sample of individuals with body dysmorphic disorder (BDD). METHOD: Two hundred individuals with DSM-IV (4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 1994) BDD completed reliable interviewer-administered and self-report measures, including diagnostic assessments and measures of body image, symptom severity, delusionality, psychosocial functioning, quality of life (QOL), and history of psychiatric treatment. RESULTS: A total of 32.5% of BDD subjects had a comorbid lifetime eating disorder: 9.0% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. Comparisons of subjects with a comorbid lifetime eating disorder (n = 65) and subjects without an eating disorder (n = 135) indicated that the comorbid group was more likely to be female, less likely to be African American, had more comorbidity, and had significantly greater body image disturbance and dissatisfaction. There were no significant group differences in BDD symptom severity, degree of delusionality, or suicidal ideation or attempts. Functioning and QOL were notably poor in both groups, with no significant between-group differences. However, a higher proportion of the comorbid eating disorder group had been hospitalized for psychiatric problems. This group had also received a greater number of psychotherapy sessions and psychotropic medications. CONCLUSION: Eating disorders appear relatively common in individuals with BDD. BDD subjects with a comorbid eating disorder differed on several demographic variables, had greater comorbidity and body image disturbance, and had received more mental health treatment than subjects without a comorbid eating disorder. These findings have important implications for the assessment and treatment of these comorbid body image disorders.