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.     

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.     

Relationship between diabetes and mortality among persons with co-occurring psychotic and substance use disorders

OBJECTIVE: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. METHODS: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. RESULTS: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12-year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. CONCLUSIONS: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

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.     

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.     

Medical clinic characteristics and access to behavioral health services for persons with HIV

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.     

Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO

OBJECTIVE: Little is known about how psychiatric disorders affect health care costs in Medicaid programs. The prevalence of psychiatric disorders and costs of care for members of a Medicaid health maintenance organization (HMO) who had psychiatric disorders were examined. METHODS: A cross-sectional, observational analysis of adult Medicaid beneficiaries over a 12-month period was conducted by using data from a health plan that has both an HMO and a behavioral health carve-out. Claims data were analyzed for 6,500 adults who were eligible for services in both plans and who received medical or behavioral health services during calendar year 2000. RESULTS: Thirty-nine percent of the 6,500 adults had a psychiatric diagnosis. Of this subset, 67.2 percent had received no specialty mental health care in the previous year. The presence of any psychiatric diagnosis significantly increased total health care costs by a factor of 2.24 ($6,995 compared with $3,121 for persons with no psychiatric diagnosis) and costs to the medical plan by a factor of 1.77 ($4,690 compared with $2,649). For beneficiaries with bipolar or psychotic diagnoses, higher health plan costs were due predominately to increases in pharmacy and specialty mental health costs. In contrast, higher costs for beneficiaries with depression, anxiety, or substance use diagnoses were attributable to greater use of general medical services. CONCLUSIONS: An analysis of claims data showed that adult Medicaid beneficiaries have exceptionally high rates of comorbid psychiatric conditions, which were associated with significantly higher medical and pharmaceutical costs. The high cost of these beneficiaries to the medical plan has policy implications in terms of the importance of addressing mental health issues in Medicaid general medical populations.     

Substance abuse and the transmission of hepatitis C among persons with severe mental illness

OBJECTIVES: The authors sought to better understand the relationship of substance abuse to higher rates of transmission of hepatitis C among persons with severe mental illness. METHOD:S: The authors assessed 668 persons with severe mental illness for HIV, hepatitis B, and hepatitis C infection through venipuncture. Demographic characteristics, substance abuse, and risk behaviors for blood-borne infections were assessed through interviews and collection of clinical data. RESULTS: Eighty-two percent of the assessed persons were not infected, and 18 percent had hepatitis C. Among those with hepatitis C infection, 546 (82 percent) tested negative for all viruses. Of the 122 (18 percent) who had hepatitis C, 53 (8 percent) had only hepatitis C, 56 (8 percent) had both hepatitis C and hepatitis B, three (1 percent) had hepatitis C and HIV, and ten (2 percent) had all three infections. More than 20 percent of the sample reported lifetime intravenous drug use, and 14 percent reported lifetime needle sharing. Fifty-seven percent had sniffed of snorted cocaine, and 39 percent had smoked crack. A stepwise regression model was used to identify interaction effects of these behaviors and risk of hepatitis C infection among persons with severe mental illness. Use of needles and of crack cocaine were associated with a large increase in the likelihood of hepatitis C infection. CONCLUSION:S: The high rates of co-occurring substance use disorders among persons with severe mental illness, coupled with the role of substance abuse as the primary vector for hepatitis C transmission, warrants special consideration.     

Patterns of health care costs associated with depression and substance abuse in a national sample

OBJECTIVE: The associations between self-reported depressive and substance use disorders and estimated health care costs were examined in a representative national sample. METHODS: Data were from the 1994 National Health Interview Survey (N=77,183). Respondents who reported depressive symptoms or major depression (depressive syndromes) or a substance abuse disorder in the past year were compared with respondents who did not report these conditions. The mean number of inpatient days and outpatient visits in both the general medical and the specialty mental health settings were determined, and costs per individual were calculated based on mean costs of such care in each respondent's geographic region. Multivariate models were constructed to calculate mean costs, controlling for demographic variables, insurance coverage, and physical health status. RESULTS: Individuals with self-reported depressive syndromes or substance abuse had mean health care costs that were $1,766 higher than costs for individuals without these conditions. Depressive syndromes were associated with increases in both inpatient and outpatient costs. However, substance abuse was almost exclusively associated with increased inpatient expenditures rather than outpatient costs. The magnitude of increased costs associated with mental disorders was substantially larger for patients in fee-for-service plans than for those in health maintenance organizations. Only 14.3 percent of visits made by individuals reporting depressive syndromes or substance abuse were made to specialty health providers (psychiatrists, psychologists, and social workers). CONCLUSIONS: Health care costs of people with self-reported mental illness varied significantly across diagnoses and systems of care. It is crucial that researchers estimating increased costs associated with mental illness account for both diagnostic and system factors that can influence the estimates.     

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.     

Effect of managed care on access to mental health services among Medicaid enrollees receiving substance treatment

OBJECTIVE: Mental health services are important to treatment retention and positive outcomes for many clients of substance abuse treatment programs. For these clients the implementation of managed care should provide for continued or increased access to mental health treatment, rather than decreased access because of short-term, cost-reduction objectives. This study assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients who were treated for substance abuse. METHODS: Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before beginning treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after the implementation, and a third (N=49) was interviewed three to four years after the implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment. RESULTS: Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. A baseline interview score that was derived from items in the Addiction Severity Index psychiatric section was the only client characteristic that predicted receipt of mental health services. CONCLUSIONS: Although this study was a naturalistic experiment with many methodologic flaws, it provided a unique opportunity to observe whether the introduction of managed care changed access to mental health services among Medicaid enrollees who were being treated for substance abuse.     

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.     

Racial/Ethnic Differences in Contemporaneous Use of Mental Health and Substance Use Treatment Among Individuals Experiencing Both Mental Illness and Substance Use Disorders

This study examined whether the well-established racial/ethnic differences in mental health service utilization among individuals with mental illness are reflected in the treatment utilization patterns of individuals experiencing both mental illness and substance use disorders, particularly in regards to the use of contemporaneous mental health and substance abuse treatment. Using pooled data from the National Survey on Drug Use and Health (2009–2013), the patterns of mental health and substance use treatment utilization of 8748 White, Black, or Latino individuals experiencing both mental illness and substance use disorders were analyzed. Multinomial logistic regression was conducted to test the relationships among racial/ethnic groups and the receipt of contemporaneous treatment, mental health treatment alone, and substance use treatment alone as compared with no treatment utilization. Results indicated that Black and Latino respondents were less likely to receive contemporaneous treatment than Whites respondents. Also, significantly associated with outcomes were several interactions between race/ethnicity and predisposing, need and enabling factors known to be associated with service utilization. The findings suggest that an underlying mechanism of racial/ethnic differences among individuals with co-occurring mental illness and substance use disorders in the treatment utilization may differ by the specific types of treatment and between Blacks and Latinos. Therefore, efforts to reduce these disparities should consider specialty in each treatment settings and heterogeneity within diverse racial/ethnic groups.     

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE: This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up. METHODS: Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up. RESULTS: Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services. CONCLUSIONS: Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.     

Mixing Oil and Water: Integrating Mental Health and Addiction Services to Treat People with a Co-occurring Disorder

Treatments for people with the co-occurring disorders of mental illness and substance use (abuse or dependence) have been evolving and improving since the mid 1980s. During this period substance abuse treatment programs reported between 50 and 75% of the people they served also had a mental health problem. At the same time, mental health programs reported between 20 and 50% of the people they served had a co-occurring problem of substance use or abuse. The proposed solution is to integrate the two treatment systems so as to treat both disorders at the same time. During the 1990s integrated treatment was proposed and several models of integrated care were evaluated. The fallacy of these conceptualizations is that the authors of these models presume that the numerous treatment interventions from both treatment traditions are compatible. This is a critical assumption. What if the two are not compatible? Rather than integrate the two systems of mental health and addiction treatment in whole, I would argue, a model is needed that selects the best interventions from each field and discard the rest. Suggestions are presented here for a beginning inventory of best practice interventions that could be the foundation for effectively treating people with co-occurring disorders.