Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

Personality correlates of outpatient mental health service utilization

OBJECTIVE: The present paper investigated the relationships between several personality constructs and the use of outpatient mental health services. METHODS: Respondents were from the National Comorbidity Survey (NCS) Part II data set and included those with a past-year mood, anxiety, alcohol/substance use disorder (n=1750). Bivariate logistic regressions were used to examine associations between participants' self-reports of personality traits and outpatient mental health service utilization. Similar multivariate analyses were used to investigate these associations after adjusting for sociodemographic variables and the presence of psychiatric disorders and their comorbidity. RESULTS: The bivariate and multivariate analyses revealed significant positive associations between outpatient mental health service utilization and both Powerful Others Locus of Control and Self-criticism. CONCLUSIONS: These findings suggest that personality traits may play a role in treatment seeking behaviors for mental health problems over and above the presence of psychiatric disorders alone. The assessment of relevant personality constructs has the potential to inform and improve treatment outreach efforts.     

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

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

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Mental disorder comorbidity in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE: To show the extent and patterning of 12 month mental disorder comorbidity in the New Zealand population, and its association with case severity, suicidality and health service utilization. METHOD: A nationwide face-to-face household survey was carried out in October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. The measurement of mental disorder was with the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0). Comorbidity was analysed with hierarchy, consistent with a clinical approach to disorder count. RESULTS: Comorbidity occurred among 37% of 12 month cases. Anxiety and mood disorders were most frequently comorbid. Strong bivariate associations occurred between alcohol and drug use disorders and, to a lesser extent, between substance use disorders and some anxiety and mood disorders. Comorbidity was associated with case severity, with suicidal behaviour (especially suicide attempts) and with health sector use (especially mental health service use). CONCLUSION: The widespread nature of mental disorder comorbidity has implications for the configuration of mental health services and for clinical practice.     

Mental health service use: a comparison of treated and untreated individuals with substance use disorders in Ontario.

OBJECTIVE: To determine the prevalence of and factors associated with mental health service use in the past year among respondents with an alcohol or other drug use disorder in a general population survey of Ontario adults. METHOD: Data were obtained from the 1990/1991 Mental Health Supplement to the Ontario Health Survey, which used the University of Michigan Composite International Diagnostic Interview (UM-CIDI). The current study examined 436 respondents aged 15-64 years who met Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria for a substance use disorder in the past year. The 82 respondents who used services for a mental health or substance abuse problem during the past year were compared with the 354 nonusers. Illness severity, disability, health beliefs and attitudes, and predisposing or enabling factors were examined in bivariate and logistic regression analyses. RESULTS: Twenty-two percent of respondents used services in the past year. Having concurrent disorders (comorbidity), troubled relationships with others, and dysfunction in main activity, feeling comfortable talking to a professional about mental health problems, being older and an urban resident, not working or being in school, and having a biological parent with an alcohol or drug problem were all associated with service use. CONCLUSIONS: The results suggest that individual determinants, such as severity of illness, disability, attitudes, and predisposing or enabling variables, all have a role in predicting service use among individuals in the general population who suffer from alcohol and other drug disorders.     

Importance of clinical diagnoses for comorbidity studies in substance use disorders

Many clinical and epidemiologic studies have shown a high frequency of co-occurrence of substance abuse and psychiatric disorders, with important consequences from health and social perspective. However, the identification of reliable and valid diagnosis of psychiatric comorbidity in substance abusers is problematic, mainly because the acute or chronic effects of substance abuse can mimic symptoms of many other mental disorders, making difficult to differentiate psychiatric symptoms that represent effects of acute or chronic substance use or withdrawal, of those that represent an independent disorder. While DSM-IIII-R and earlier nomenclatures were unclear in differentiating independent from other psychiatric disorders, DSM-IV and DSM-IV-TR provided clearer guidelines in diagnosing psychiatric disorders in heavy users of alcohol and drugs, providing three categories: "primary" psychiatric disorders, "substance-induced" disorders, and "expected effects" of the substances, meaning expected intoxication and/or withdrawal symptoms that should not be diagnosed as symptoms of a psychiatric disorder. The use of the "Psychiatric Research Interview for Substance and Mental Disorders (PRISM)", a structured interview developed to improve the diagnosis of co morbidity in drug abusers according DSM-IV, supplies new opportunities in the clinical research in this field.     

Use of health services for major depressive and anxiety disorders in Finland

Factors associated with people suffering from major depressive disorder (MDD) or anxiety disorders seeking or receiving treatment are not well known. In the Health 2000 Study, a representative sample (n=6005) of Finland's general adult (> or =30 years) population was interviewed with the M-CIDI for mental disorders and health service use for mental problems during the last 12 months. Predictors for service use among those with DSM-IV MDD (n=298) or anxiety disorders (n=242) were assessed. Of subjects with MDD, anxiety disorders, or both, 34%, 36%, and 59% used health services, respectively. Greater severity and perceived disability, psychiatric comorbidity, and living alone predicted health care use for MDD subjects, and greater perceived disability, psychiatric comorbidity, younger age, and parent's psychiatric problems for anxiety disorder subjects. The use of specialist-level mental health services was predicted by psychiatric comorbidity, but not characteristics of the disorders per se. Perceived disability and comorbidity are factors influencing the use of mental health services by both anxiety disorder and MDD subjects. However, still only approximately one-half of those suffering from even severe and comorbid disorders use health services for them.     

Use of mental health services and complementary and alternative medicine in persons with common mental disorders

Objective: Few studies investigated the use of complementary and alternative medicine (CAM) by subjects with mental disorders. We examined the relationship between depressive, anxiety and alcohol‐use disorders and their comorbidity, as well as the relationship between use of CAM and use of mental health services. Method: The Finnish adult (≥30 years) population‐based Health 2000 Study (n = 5987) collected information on use of CAM plus health and mental health care services. Results: Generalised anxiety disorder and panic disorder were positively associated and alcohol abuse was negatively associated with use of CAM. The prevalence was highest in persons with comorbidity of anxiety and depressive disorders. The use or perceived usefulness of mental health services did not differ between CAM users and other participants. Conclusion: The relationship between the use of CAM and mental disorders appears to vary depending on the type of mental disorder. Use of CAM seems unrelated to the use and the perceived usefulness of mental health services.     

Use of health services by men with and without antisocial personality disorder who are alcohol dependent

In a sample of 104 medically stable male veterans with alcohol dependence, rates of health service utilization were compared for 48 patients with a primary diagnosis of antisocial personality disorder and 56 patients without this diagnosis. Patients were diagnosed using DSM-IV lifetime criteria; previous utilization of health services was based on self-reports. Although a similar proportion of both groups reported previous service use, patients with antisocial personality disorder reported using more substance abuse treatment services than those with a primary diagnosis of alcohol dependence. Between-group multiple regression analysis showed that an earlier age at onset of alcoholism and a history of a comorbid substance-induced mental disorder best predicted higher rates of use of substance abuse treatment.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Are the responses of clients with psychiatric and addiction disorders using services for the homeless valid?]

OBJECTIVE: To verify the validity of self-reported data on service use from clients with mental or substance abuse disorders in Montreal and Quebec services for homeless individuals. METHOD: To compare the self-reported data from the Enquête chez les personnes itinérantes (Fournier, 2001) on health service use with official data from Quebec health services (MEDECHO and RAMQ). RESULTS: The analysis shows a moderate-to-high level of concordance between the self-reported and the official data. Almost every item analyzed presents moderate but significant intraclass correlation coefficients for general and psychiatric hospitalization and use of psychiatric medication, but lower and nonsignificant coefficients for medical hospitalization. Participant characteristics such as mental disorders, homeless status, and substance abuse problems do not seem to have an impact on data validity. CONCLUSIONS: The answers on health service use from individuals with mental health problems, homeless status, or substance abuse problems are generally valid in the results presented. Thus the self-reported data from these individiuals seems to be a generally valid source of data and an affordable one for research on service use or other domains.     

Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial

This study evaluated the psychiatric symptoms, psychosocial problems, and treatment response of personality-disordered substance abusers receiving services within a homeless drop-in center. Fifty-two homeless clients were assessed after program admission and randomly assigned to receive either individual psychotherapy focused on personality disorder and substance abuse relapse prevention (dual-focus schema therapy [DFST]) or standard group substance abuse counseling (SAC). Client functioning was assessed using measures of personality disorder, psychiatric symptoms, early maladaptive schemas, interpersonal problems, and addiction-related psychosocial impairment. Therapy retention (total weeks in treatment) and utilization (number of weeks in which sessions were attended) were the primary outcomes. Although rates of cluster B personality disorders were comparable to other substance dependent samples, clusters A and C disorders were disproportionately more common. Clients reported significant psychiatric symptoms, criminality, and psychosocial impairment, yet made limited lifetime use of mental health services. Overall, there was greater utilization of individual DFST than group SAC. However, clients with more severe personality disorder symptoms demonstrated better utilization of SAC than DFST.     

Social anxiety disorder: an unrecognized problem in primary care

Social anxiety disorder, or social phobia, is one of the most common mental disorders, yet it remains underrecognized and undertreated. Individuals with social anxiety disorder frequently have psychiatric comorbidity, including mood, anxiety, and substance abuse disorders, that can further impair a person's ability to function. This article reviews the literature on social anxiety disorder and explores questions regarding its prevalence, rates of recognition and treatment, and natural history. The association between social anxiety disorder and psychiatric comorbidity and suicide is reviewed, as well as quality-of-life issues, including the impact of social anxiety disorder on educational attainment, occupational functioning and financial dependency, marital status, and health care utilization. There is a need for further study and greater awareness among primary health care providers about the prevalence and treatment of social anxiety disorder.     

Lifetime and 12-month prevalence of DSM-III-R disorders in the Chile psychiatric prevalence study

OBJECTIVE: Although several epidemiological studies of the prevalence of psychiatric disorders have been conducted in Latin America, few of them were national studies that could be used to develop region-wide estimates. Data are presented on the prevalence of DSM-III-R disorders, demographic correlates, comorbidity, and service utilization in a nationally representative adult sample from Chile. METHOD: The Composite International Diagnostic Interview was administered to a stratified random sample of 2,978 individuals from four provinces representative of the country's population age 15 and older. Lifetime and 12-month prevalence rates were estimated. RESULTS: Approximately one-third (31.5%) of the population had a lifetime psychiatric disorder, and 22.2% had a disorder in the past 12 months. The most common lifetime psychiatric disorders were agoraphobia (11.1%), social phobia (10.2%), simple phobia (9.8%), major depressive disorder (9.2%), and alcohol dependence (6.4%). Of those with a 12-month prevalence diagnosis, 30.1% had a comorbid psychiatric disorder. The majority of those with comorbidity had sought out mental health services, in contrast to one-quarter of those with a single disorder. CONCLUSIONS: The prevalence rates in Chile are similar to those obtained in other studies conducted in Latin America and Spanish-speaking North American groups. Comorbidity and alcohol use disorders, however, were not as prevalent as in North America.     

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.     

Differences in clinical features and mental health service use in bipolar disorder across the lifespan.

OBJECTIVE: Because of the scarcity of research in geriatric bipolar disorder, the authors examined the prevalence, clinical features, and service use of persons with bipolar disorder among older adults treated in a large public mental health system. METHODS: From San Diego County's Adult and Older-Adult Mental Health Services database (N=34,970, fiscal year 2002-2003), the authors selected patients with bipolar disorder, divided them into three age-groups (young: age 18-39, middle-aged: age 40-59, and elderly: age 60+) and compared them on demographic, clinical, and mental health service use characteristics. RESULTS: The authors identified 2,903 patients who received services for bipolar disorder at least once during the fiscal year, accounting for a slightly lower proportion of diagnosis among elderly patients (7.0%) than middle-aged (8.7%) or younger groups (8.3%). Elderly patients were less likely to have substance use disorder comorbidity, but more likely to have a cognitive disorder diagnosis and lower global functioning scores than their younger counterparts. Elderly bipolar patients were less likely than younger groups to use inpatient, outpatient, and emergency room psychiatric care, but more likely to use case-management and conservator services. DISCUSSION: Bipolar disorder was only slightly less common among elderly patients in a large, public mental health system, compared to younger age-groups. Available clinical data revealed a mixed picture of bipolar disorder in late life, with more functional and cognitive impairment and less substance use disorder comorbidity and use of acute psychiatric services. Our findings suggest that older adults with bipolar disorder have unique mental health service needs.     

Pharmacological treatment of psychiatric comorbidity in bipolar disorder: a review of controlled trials

OBJECTIVE: Little is known about the treatment of psychiatric comorbidities in bipolar disorder. The aim of this review was to summarize the literature on controlled pharmacological trials that have been conducted in psychiatric conditions that commonly co-occur in bipolar disorder. METHODS: A Medline search (1980-October 2005) using the terms bipolar disorder and randomized controlled trials, comorbidity, anxiety disorders, alcohol abuse or dependence, substance abuse or dependence, eating disorder, impulse control disorders, attention-deficit disorder, lithium, anticonvulsants, atypical antipsychotic drugs, antidepressants, stimulants was used. RESULTS: The literature establishes a strong association between bipolar disorder and substance abuse/dependence, anxiety disorders, impulse control disorders, eating disorders and attention-deficit hyperactivity disorder. Comorbidity often complicates the diagnosis and the treatment of bipolar disorder and worsens its course of illness and prognosis. Few controlled pharmacological studies have examined the treatment of comorbid conditions in patients with bipolar disorder. CONCLUSIONS: Treatment of psychiatric comorbidities in bipolar disorder is not based on controlled data but is largely empirically based. Controlled trials in patients with bipolar disorder and comorbidity are urgently needed.