Mental Health Care and Substance Abuse Treatment Use by Adults with Co-Occurring Disorders

1. Mental Health Care and Substance Abuse Treatment Use by Adults with Co-Occurring Disorders Katherine M. Harris, PhD Office of Applied Studies, SAMHSA Mark J. Edlund, MD, PhD Central Arkansas Veteran’s Healthcare System October 7, 2004

2. Background Well known: Mental and substance use disorders co-occur at high rates Data from the National Co-morbidity Survey 50% with lifetime SUD report a lifetime mental disorder 50% with a lifetime mental disorder report a SUD

3. Knowledge Gap Little is known at the population-level about the patterns of substance abuse treatment and mental health care use among those with co-occurring disorders Why? Sample size limits power of epidemiological surveys to examine key subgroups Lack of diagnostic information in administrative data Despite these high rates, relatively little is known about the patterns of substance abuse treatment and mental health care use among the population with co-occurring alcohol, drug, and mental health problems. Why not? Sample size restrictions in epidemiological surveys have limited researchers’ ability to examine the joint and conditional probabilities of service use by the presence and severity of co-occurring disorders. At the same time, a lack of diagnostic information limits the utility of administrative claims data for this purpose. Despite these high rates, relatively little is known about the patterns of substance abuse treatment and mental health care use among the population with co-occurring alcohol, drug, and mental health problems. Why not? Sample size restrictions in epidemiological surveys have limited researchers’ ability to examine the joint and conditional probabilities of service use by the presence and severity of co-occurring disorders. At the same time, a lack of diagnostic information limits the utility of administrative claims data for this purpose.

4. Epidemiological Surveys 1997-98 HCC: Among those with co-occurring disorders (Watkins et al. 2001) 70-80% report no care in the past year Only 8% report using either integrated care or care of both types in the past year MH only 3 time more common than SATx only 1997 NHSDA: Those with co-occurring disorders are more likely to use substance abuse treatment than those with SUD-only (Wu et al. 2003)

5. Objectives Update and expand descriptive information on patterns of mental health care and substance abuse treatment use for a nationally representative sample of adults with co-occurring disorders Compare service use patterns to those with single disorders Primary To describe patterns of mental health care and substance abuse treatment use for a nationally representative sample of adults with co-occurring mental health problems and substance dependence and to compare these patterns to those with single disorders. Point out here that there is overlap here between the NSDUH report quoted in the earlier slides we Use different sample 2001 and 2002 combined (report uses 2002 data) so that we can reliably compare subgroups 2. We focus on drug and alcohol dependence– rather than dependence and abuse Secondary 1. Introduction to service use measures in the NSDUH (formally the NHSDA)– most of the of the audience knows as the survey that measures substance use. 2. Introduction to a new screener for SMI that was added to the survey in 2001. Primary To describe patterns of mental health care and substance abuse treatment use for a nationally representative sample of adults with co-occurring mental health problems and substance dependence and to compare these patterns to those with single disorders. Point out here that there is overlap here between the NSDUH report quoted in the earlier slides we Use different sample 2001 and 2002 combined (report uses 2002 data) so that we can reliably compare subgroups 2. We focus on drug and alcohol dependence– rather than dependence and abuse Secondary 1. Introduction to service use measures in the NSDUH (formally the NHSDA)– most of the of the audience knows as the survey that measures substance use. 2. Introduction to a new screener for SMI that was added to the survey in 2001.

6. Data Source 2001 and 2002 National Survey on Drug Use and Health (NSDUH) Represents the civilian, non-institutionalized residents of the US N=137,055 sample members age 12+ Combined response rate of 75% Substance use, mental health problem, service use questions administered via ACASI

7. Data Strengths Large sample (n=25,900) Yields reliable estimates of conditional probabilities of service use Permits separate analysis of dependent subgroup for whom specialty substance abuse treatment is most likely to be indicated Mental health problem questions can be used to form subgroups on the basis of severity

8. Data Limitations No information on the timing of service use Sequential or concurrent care? Mental health measures lack clinical detail

9. ADM Measures DSM-IV Alcohol and/or drug dependence 3 of 7(6) criteria 1+ Mental disorder symptoms from the CIDI-short form

10. ADM Measures cont’d “K-6” screener for serious mental illness Intended to screen for SMI as defined in PL 102-321: DSM-IV disorder Functional impairment Measures frequency of distress symptoms the “month in the past year” when the respondent was at his or her “worst emotionally” (i.e., nervousness, hopelessness, restlessness, depressed, feeling worthless, feeling that everything is an effort) Clinical validation study reported in Kessler et al., Archives of General Psychiatry, 2003.

11. Service Use Measures Substance abuse treatment users endorsed: Received “treatment or counseling for your use of alcohol or any drug,” in the past 12 months, including “detoxification and any other treatment for medical problems associated” with drug or alcohol use. Focus on paid treatment: Excludes self-help only and ER counseling

12. Service Use Measures Mental health users endorsed one or more: An inpatient stay for mental health treatment in a general or psychiatric hospital Mental health care in a clinic, doctor’s office, day hospital/treatment program, or other location Taking medications prescribed to treat a mental or emotional condition

13. Analytic Sample 25,900 Adults with mental health problems and/or DSM-IV substance dependence

14. Analytic Sample 25,900 Adults with mental health problems and/or DSM-IV substance dependence

15. Past Year Drug or Alcohol Dependence

16. Past Year Mental Health Problems

17. Percent Using MH and SA Tx, by Diagnostic Status

18. Use of Any MH or SA Tx, by Diagnostic Status

19. Conditional Service Use

20. Discussion Low rates of substance abuse use treatment use, especially among mental health care users with COD In contrast to the headline: COD patients more likely to receive care than those with a single disorder SUD+MH were much more likely to receive treatment compared to SUD only By contrast, SUD+MH were somewhat more likely as MH-only to receive mental health care

21. Discussion cont’d Relatively large role of the mental health care system in caring for SUD patients with and without MH problems MH care more likely than substance abuse treatment in all categories