Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care.

OBJECTIVE: Recent policy has focused on documenting and reducing ethnic disparities in availability and quality of health care. The authors examined differences by ethnic status in unmet need for alcoholism, drug abuse, and mental health treatment. METHOD: Data were from a follow-up survey of adult respondents to a 1996-1997 national survey. Non-Hispanic whites, African Americans, and Hispanics were compared in access to alcoholism and drug abuse treatment and mental health care (primary or specialty), unmet need for care, satisfaction with care, and use of active treatment for alcoholism, drug abuse, and mental health problems in the prior 12 months. RESULTS: A total of 31.9% of whites, 28.1% of African Americans, and 30.1% of Hispanics had some alcoholism, drug abuse, and mental health care, mostly in primary care. Among those with perceived need, compared to whites, African Americans were more likely to have no access to alcoholism, drug abuse, or mental health care (25.4% versus 12.5%), and Hispanics were more likely to have less care than needed or delayed care (22.7% versus 10.7%). Among those with need, whites were more likely than Hispanics or African Americans to be receiving active alcoholism, drug abuse, or mental health treatment (37.6% versus 22.4%-25.0%). CONCLUSIONS: The authors document greater unmet need for alcoholism and drug abuse treatment and mental health care among African American and Hispanics relative to whites. New policies are needed to improve access to and quality of alcoholism, drug abuse, and mental health treatment across diverse populations.     

Food and drug abuse: the contrasts and comparisons of eating disorders and alcoholism

The authors present a series of comparisons highlighting the similarities and differences between alcoholism and two eating disorders: anorexia nervosa and bulimia nervosa. They suggest that diagnostic, psychodynamic and therapeutic similarities are strong and may relate to a common lack of behavioral inhibition once abnormal drinking or eating patterns become set. They point to recent research suggesting that eating disorder patients are at greater risk for alcoholism later in life. They conclude that a scientific comparison of these disorders may yield new research findings that could advance treatment methods for both types of psychopathology and may prevent later morbidity for the eating disorder group.     

Attention deficit disorder, alcoholism, and drug abuse: MMPI correlates.

Earlier research had demonstrated that alcoholics with attention deficit disorder residual type (ADDRT) differ from other alcoholics on the Minnesota Multiphasic Personality Inventory (MMPI). The purpose of this study was to explore the influence of drug abuse on the relationship of ADDRT and alcoholism as reflected on the MMPI. Groups of 48 male alcoholics, 28 ADDRT alcoholics, 25 ADDRT alcohol and drug abusers and 18 alcohol and drug abusers were all administered the MMPI. Significant differences were found between the alcoholic and ADDRT alcoholic groups on scales Pd, Sc, Si, F, and K. For the ADDRT alcohol and drug abusers versus the alcohol and drug abuser groups, they differed on scales K, Hs, D, Pd, Pa, Pt, Sc, Si, F, K, and L.     

Adolescent alcoholism: Motives and alternatives

Juvenile use of alcoholic beverages has reached an alarming point. It is particularly notable that the number and frequency of female teenagers who drink has increased in the past few years. There has been a considerable shift from drugs to alcohol among North American youth in recent years. In 1975, Chafetz of the NIAAA reported that 1.3 million American youths between 12 and 17 years of age were involved in abuse of alcohol, and 750,000 of them were considered to be “alcoholics.” A large number of these teenagers have been attending an A.A. program while still in high school in some parts of the United States. Illicit use of drugs and alcohol reflects not only a basic insecurity in their world of transition, but also a search for purpose and identity. The use of alcohol and psychoactive drugs is viewed as primarily a problem of volition and personal choice, rather than an inevitable disease. Thus, prevention of alcohol is possible in the context of a realistic and healthy system of education and family life. Positive alternatives with consideration to the physical, emotional, intellectual, social, and spiritual dimensions of human reality and needs for fulfillment are discussed in this paper.     

Severe mental illness and substance use disorders among former Supplemental Security Income beneficiaries for drug addiction and alcoholism

BACKGROUND: Recently enacted federal legislation targeted at curbing perceived abuses of cash benefits for former Supplemental Security Income beneficiaries for drug addiction and/or alcoholism (DA&A) may be creating a residual population that is too seriously impaired to work owing to psychiatric and substance use disorders. METHOD: Data in this report were derived from 1-year follow-up interviews of 204 randomly selected DA&A beneficiaries in Chicago who were initially interviewed between January 1997 and March 1997, immediately following their termination in the Supplemental Security Income DA&A program. Information on subjects' work and benefits status were collected along with DSM-III-R psychiatric and substance use disorder diagnostic information. Urine specimens were also collected and tested for recent use of marijuana, cocaine, opiates, phencyclidine, amphetamines, and methadone. RESULTS: Twenty-six percent had a past-year severe mental illness while 34% met the DSM-III-R criteria for drug dependence. Illegal drug use was also prevalent with about 50% of the sample testing positive for marijuana, cocaine, or opiates. Compared with those working and earning at least $500 a month, unemployed or underemployed subjects who had lost all federal benefits had a much greater likelihood of being dependent on drugs (odds ratio, 5.0; P<.005; 95% confidence interval, 1.6-15.7) and of having 2 or more comorbid psychiatric disorders (odds ratio, 6.9; P<.005; 95% confidence interval, 1.9-24.7). CONCLUSIONS: Those who have lost DA&A disability benefits and who continue to be unemployed or underemployed have elevated rates of drug dependence and psychiatric comorbidities; consequently, helping these cases make the transition from government assistance to sustained employment is increasingly difficult.     

Consulting for substance abuse: mental disorders among adolescents and their parents

Studies conducted outside of Scandinavia indicate that most adolescents with substance misuse problems suffer from co-morbid mental disorders. The present study assessed the mental health of adolescents seeking help for substance misuse problems in a large Swedish city. Parents' mental health was also examined. The sample included 97 girls with their 90 mothers and 52 fathers, and 81 boys with their 72 mothers and 37 fathers. The adolescents completed a diagnostic interview, either the Kiddie-SADs or the Structured Clinical Interview for DSM-IV (SCID) depending on their age. Their parents underwent diagnostic interviews with the SCID. Ninety per cent of the girls and 81% of the boys met criteria for at least one disorder other than substance misuse, and on average, they suffered from three other disorders, most of which had onset before substance misuse began. Almost 80% of the mothers and 67% of the fathers met criteria for at least one mental disorder other than alcohol and drug-related disorders. The findings concur with those reported from studies conducted in North America. The results suggest that in Sweden mental disorders are not being identified and effectively treated among some children and young adolescents who subsequently abuse alcohol and/or illicit drugs. Adolescents who consult for substance abuse problems require assessments and treatment by mental health professionals.     

Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults

Data from the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Program, an epidemiologic survey of five communities, showed that four major disorders commonly begin in late adolescence or young adulthood. The median age at onset for anxiety disorders is 15 years; for major depressive episode, 24 years; for drug abuse or dependence, 19 years; and for alcohol abuse or dependence, 21 years. Findings also suggest that for respondents 18-30 years old, having a major depressive episode or anxiety disorder doubles the risk for later drug abuse or dependence.     

Substance abuse and mental disorders: the dual diagnoses concept

The concept of "dual diagnoses" is reviewed along with its clinical implications. Prevalence studies report substance abuse in psychiatric populations as ranging between 20% and 75%, depending on reporting, demographic variables and the community availability of substances. On the other hand, 20% to 65% of alcoholics entering rehabilitation suffer from another major psychiatric disorder. The clinical impact of dual diagnoses involves the development and expression of psychiatric disorders depending on the choice of drugs, the severity of psychopathology and risk of assaultive behaviour, possible misdiagnosis such as the confusion between alcoholism and affective disorders, the increased use of psychiatric resources including emergency, an earlier onset of symptomatology and poorer prognosis. The evolutionary impact of the concept, reflected in successive psychiatric diagnostic classifications, is discussed along with its bridging influence between the fields of mental health and addictionology. Appropriate assessment tools along with treatment strategies are suggested. Effective features of a group process include a nonconfrontational approach with emphasis on education, an expectation of abstinence as a goal, a discussion of diagnoses and medication and lastly particular attention to vocational rehabilitation and constructive use of leisure time.     

Diagnosis-related groups and general hospital psychiatry: the APA Study

Psychiatric units in general hospitals are exempt from diagnosis-related groups (DRGs), a system of per case prospective payment that is used for the majority of patients covered by Medicare. The American Psychiatric Association purchased a large hospital discharge data base and studied the potential impact of DRGs on psychiatric patients and inpatient psychiatric units in general hospitals. There was substantial inaccuracy in the psychiatric DRGs' prediction of resource use, which could lead to inappropriate discharge of patients and financial risk to hospitals that treat more severe cases. The authors advocate further research because psychiatry must anticipate prospective payment in the future.     

Interactions between eating disorders and drug abuse

To examine the relationship between drug abuse and eating disorders in a longitudinal sample. In a prospective study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for research diagnostic criteria drug use disorder (DUD) every 6-12 months over 8.6 years. Contrary to expectation, DUD did not influence recovery from either eating disorder. Multivariate analyses indicated that alcohol use and suicide attempts over the course of the study, as well as hospitalization for an affective disorder before the study, predicted DUD in anorexia nervosa. For bulimia nervosa, multivariate predictors included the severity of alcohol use and the severity of bulimic symptoms over the course of the study, and a hospitalization before study entry for a nonaffective disorder. Drug abuse in women with eating disorders is an area of clinical concern and should be monitored routinely.     

Prevention of mental disorders, substance abuse, and problem behaviors: a developmental perspective

Robust scientific evidence shows that mental, emotional, and behavioral disorders can be prevented before they begin. This article highlights and expands points from a 2009 Institute of Medicine report to provide a concise summary of the literature on preventing mental illness. Because prevention requires intervention before the onset of illness, effective preventive approaches are often interdisciplinary and developmental. Evidence-based preventive strategies are discussed for the different phases of a young person's life. Specific recommendations to focus on parenting, child development, and the prevention of depression are made for a target audience of practicing psychiatrists and mental health professionals. Further systemic recommendations are to prioritize prevention and to coordinate and facilitate research on preventive practices in order to reduce suffering, create healthier families, and save money.     

Differences in resource use and cost among facilities treating alcohol, drug abuse, and mental disorders: implications for design of a prospective payment system

Specialized psychiatric facilities, including qualified distinct-part units in general hospitals, are exempt from Medicare's diagnosis-related group prospective payment system (PPS). One major reason for continuing the exemption is the redistribution of revenue that would probably occur if a single national price were established for care at the diverse facilities that treat patients with psychiatric and substance abuse disorders. This study investigated the extent of such potential redistribution in a private health insurance data base and found that a PPS would systematically underpay specialized facilities and systematically overpay general hospitals without specialized units. Alternatives for addressing this problem are discussed.