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Behavioral Health, United States, 2012. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013.

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Behavioral Health, United States, 2012.

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4MENTAL HEALTH AND SUBSTANCE USE DISORDERS: TREATMENT LANDSCAPE

Many types of mental health and substance abuse treatments are effective. However, not all people who have a mental health or substance use disorder receive needed services. For those who do get treatment, not all people receive the appropriate type or adequate quantity or quality of care (e.g., Substance Abuse and Mental Health Services Administration [SAMHSA], 2012a).

This section addresses four main questions for behavioral health treatment. First, what proportion of people who have a disorder receive treatment? Second, where do they get treatment? Third, for those who get treatment, how much do they receive? Finally, is the treatment they receive at least minimally adequate? Answers to these questions will help to determine the extent of the unmet need (i.e., not getting the needed amount of behavioral health care) for mental health and substance abuse treatment.

Understanding these issues will be critical as health care coverage is extended through the Affordable Care Act (ACA). This and other recent legislation will likely fundamentally change the rules of and funding mechanisms for behavioral health treatment and so will likely affect the number of people getting treatment, the types and amount of treatment received, and whether the adequacy of care improves.

This section examines data from several sources on the behavioral health treatment that people receive. These studies differ in terms of how mental health and substance use disorders are defined; the measurement of the amount, types, and locations of treatment received; and the determination of whether treatment meets certain guidelines.

The text also discusses treatment for people in special populations who are most in need of behavioral health treatment and yet are often not covered in national surveys. National surveys do not sample populations such as homeless people, people residing in hospitals or residential care facilities, or people incarcerated in prisons or jails. Some of these special populations in particular need services but may be less likely to receive treatment in general or treatment that meets professionally recommended guidelines.

4.1. Adults

4.1.1. Mental Health Treatment

According to the 2011 National Survey on Drug Use and Health (NSDUH), the percentage of adults who receive treatment varies by the severity of impairment associated with their mental illness (Figure 4-1). Impairment in functioning refers to the degree to which a person cannot participate in daily activities, such as those at school, work, or home. Adults with mental illness with serious impairment of their functioning are most likely to receive treatment (65 percent), followed by those with moderate impairment (46 percent), and mild impairment (29 percent). This means, however, that approximately 35 percent of adults with serious impairment received no mental health treatment during the past year.

Figure 4-1 is a bar chart showing past year mental health treatment types among adults by past year mental health status and level of impairment for 2011. Among adults, 7.8% with no mental illness, 28.6% with mental illness with mild impairment, 45.8% with mental illness with moderate impairment, and 64.9% with mental illness with serious impairment received any mental health treatment; 6.3% with no mental illness, 24.3% with mental illness with mild impairment, 39.7% with mental illness with moderate impairment, and 58.2% with mental illness with serious impairment received prescription medication for mental health; 2.9% with no mental illness, 14.9% with mental illness with mild impairment, 26.0% with mental illness with moderate impairment, and 44.1% with mental illness with serious impairment received any outpatient mental health treatment; and 0.2% with no mental illness, 1.2% with mental illness with mild impairment, 2.9% with mental illness with moderate impairment, and 8.8% with mental illness with serious impairment received any inpatient mental health treatment.

Figure 4-1

Past year mental health treatment types among adults, by past year mental health status and level of impairment: 2011. SOURCE: National Survey on Drug Use and Health, 2011 (revised May 2013), Substance Abuse and Mental Health Services Administration, (more...)

The most common type of treatment for those with mental illness, regardless of the level of impairment, is the use of prescription medication, followed by outpatient treatment and inpatient treatment. Treatments are commonly used together; for example, about 16 percent of those with mental illness receive both prescription medication and outpatient treatment (SAMHSA, 2012a).

The reasons given for why people with behavioral health disorders do not receive treatment depend on the data source. The National Comorbidity Survey Replication (NCS-R) suggests that the major reason people with mental health disorders do not receive treatment is that they do not think they need it (Mojtabai et al., 2011). In the NCS-R, among those who had a past year mental health disorder who did not receive treatment but perceived a need for it, wanting to handle the problem on one's own was the most commonly cited reason for not seeking treatment (73 percent). Other common reasons were thinking treatment will not help, being afraid of who will know (i.e., stigma), and thinking that their disorder will improve over time on its own. Less than one-quarter of adults reported barriers such as lack of financial resources, time, or transportation. In NSDUH, however, nearly 50 percent of people with an unmet need for mental health care cited cost as a barrier to care (SAMHSA, 2012a). Because of the discrepancies in reasons for not receiving care between the two surveys, it will be important to determine how much impact efforts to increase treatment access through the ACA will have on mental health and substance use service utilization. For more information on the data sources in this chapter, see Appendix B (Data Source Descriptions).

4.1.2. Substance Abuse Treatment

According to the 2011 NSDUH, only 10 percent of adults with substance use (alcohol use or illicit drug use) disorders receive any past year treatment (Figure 4-2). Adults with illicit drug use disorders are nearly twice as likely to receive substance abuse treatment as adults with alcohol use disorders. Nevertheless, a large majority of people with substance use disorders do not get treatment.

Figure 4-2 is a bar chart showing past year substance abuse treatment types among adults by past year substance use disorder type for 2011. Among adults, 9.5% with an alcohol use disorder, 17.0% with an illicit drug use disorder, and 10.2% with a substance use disorder received any substance abuse treatment; 4.1% with an alcohol use disorder, 8.8% with an illicit drug use disorder, and 4.6% with a substance use disorder received treatment in an outpatient rehabilitation center; 2.8% with an alcohol use disorder, 6.0% with an illicit drug use disorder, and 3.2% with a substance use disorder received treatment in an outpatient mental health center; 2.3% with an alcohol use disorder, 5.4% with an illicit drug use disorder, and 2.7% with a substance use disorder received treatment in an inpatient hospital; 2.8% with an alcohol use disorder, 6.5% with an illicit drug use disorder, and 3.2% with a substance use disorder received treatment in an inpatient rehabilitation center; 1.7% with an alcohol use disorder, 3.5% with an illicit drug use disorder, and 1.8% with a substance use disorder received treatment in an emergency room; 2.1% with an alcohol use disorder, 4.4% with an illicit drug use disorder, and 2.4% with a substance use disorder received treatment in a private doctor's office; 0.7% with an alcohol use disorder, 1.8% with an illicit drug use disorder, and 0.9% with a substance use disorder received treatment in a prison/jail; 5.7% with an alcohol use disorder, 10.5% with an illicit drug use disorder, and 6.1% with a substance use disorder received treatment in a self-help group; 0% with an alcohol use disorder, 0.1% with an illicit drug use disorder, and 0.1% with a substance use disorder received treatment in a church/religious/spiritual organization; and 0.8% with an alcohol use disorder, 2.5% with an illicit drug use disorder, and 0.2% with a substance use disorder received treatment from another source.

Figure 4-2

Past year substance abuse treatment types among adults, by past year substance use disorder type: 2011. 1 Substance use disorder includes disorders for alcohol use and illicit drugs. Illicit drugs include marijuana/hashish, cocaine (including crack), (more...)

Research from NSDUH and the NCS-R suggests that the major reason for not getting treatment for substance use disorders is that people do not think they need it (Edlund, Booth, & Feldman, 2009). In the 2011 NSDUH, the most prevalent reasons for persons aged 12 or older identified as needing but not receiving substance abuse treatment were not ready to stop using (39 percent), fear of having a negative effect on job (14 percent), and fear of negative judgments from neighbors/community (12 percent). Other people reported that they do not know where to get treatment, think they can handle the substance use problem on their own, find treatment inconvenient/lack transportation, or do not think they have time to seek care.

4.1.3. Amount and Adequacy of Treatment

According to the NCS-R, adults with mental health disorders who receive treatment average about four visits to treatment per year. Those who receive treatment in specialized mental health care settings (e.g., from a psychologist) generally have more visits than those treated in general medical settings (e.g., from a primary care doctor) (Wang et al., 2005b). People treated for substance use disorders average six visits per year, with those receiving care in a specialty setting (e.g., substance abuse treatment center) averaging more visits per year than those receiving care in a general medical setting (e.g., primary care practice).

The available data suggest that most mental health or substance abuse treatment does not meet guidelines to be minimally adequate.1 Adequate treatment in the NCS-R is defined as receiving certain amounts of medication or treatment according to accepted guidelines. Estimates from the NCS-R indicate that less than one-third of adults with mental health disorders receive a minimally adequate type or amount of treatment (Wang et al., 2005b). Adults with mood disorders are most likely to get levels of care that meet guidelines (39 percent), adults with anxiety disorders are slightly less likely (34 percent), and adults with substance use disorders are the least likely to get minimally adequate treatment (29 percent). Rates of minimally adequate treatment are highest in the specialty mental health sector and lowest in the general medical care sector.

It is important to note that these data on mental health care adequacy come from the NCS-R, which was conducted prior to the enactment of the ACA, the Mental Health Parity and Addiction Equity Act, and other legislation that greatly affects behavioral health care. At the time of the NCS-R (2001–2002), many insurance policies had more limited coverage for behavioral health conditions than for other medical conditions. For example, the number of covered visits for mental health conditions may have been lower than the number of covered visits for other medical conditions. Additional research using nationally representative data sources is needed to determine the effect of this parity legislation and the continued rollout of the ACA on receiving guideline-concordant behavioral health care. With these additional studies, it also will be important to determine whether all need for care is being satisfied, rather than just a minimally adequate amount.

4.1.4. Special Populations

The above results are from surveys of households, and so exclude many people who do not live in a residential household. These people include those who are homeless or living in prisons or jails, long-term mental health or substance abuse treatment facilities, or nursing homes. It is particularly important to understand whether these special populations are receiving needed care because they are more at-risk for having mental health or substance use disorders than other adults. For example, roughly half of prisoners and nearly two-thirds of jail detainees reported a mental health problem in the year prior to arrest or since admission or have experienced symptoms of a mental health disorder in the past year (James & Glaze, 2006).

Despite the high prevalence of mental health disorders in these populations, only about 33 percent of inmates in state prisons and 18 percent of inmates in local jails report receiving mental health treatment since being incarcerated (James & Glaze, 2006). In addition, about three-quarters of inmates with mental health problems also have substance use problems (James & Glaze, 2006).

Adults who are homeless or reside in long-term treatment facilities or nursing homes are at elevated risk for mental health or substance use disorders. While it is recognized that homeless individuals have higher rates of mental illness and substance use disorders than the general population (Bassuk, Weinreb, Buckner, Browne, Salomon, & Bassuk, 1996), little is known about whether they receive needed care. Similarly, limited data are available on whether mental health or substance use care received by these populations in hospitals or residential mental health or substance abuse treatment facilities is adequate. Results from the 2004 National Nursing Home Survey suggest that nearly two-thirds of nursing home residents have a mental disorder other than mental retardation, senile dementia, or organic brain syndrome (Centers for Disease Control and Prevention, 2013).

4.2. Adolescents and Children

4.2.1. Mental Health and Substance Abuse Treatment

4.2.1.1. Treatment for Adolescents

Data on treatment for mental health and substance use disorders are more limited for children and adolescents than for adults. Parents or primary care providers may have difficulty identifying behavioral health disorders or helping children and adolescents access the right types of treatment. On average, as reported in the NCS-R, the time from the onset of a mental disorder, which many experience first during childhood or adolescence, to first getting treatment is nearly 10 years (Wang et al., 2005a). This delay may lead to less effective treatments and poor outcomes.

Research suggests that many children and adolescents with mental health needs historically have not received mental health services. A study using data from three nationally representative household surveys conducted from 1996 to 1998 found that of the 15 percent to 21 percent of children and adolescents aged 6 to 17 who were described as having a need for mental health care in the past year, only 20 percent received mental health services in the past year (Kataoka, Zhang, & Wells, 2002).

Similarly, according to the National Comorbidity Survey–Adolescent Supplement (NCS-A), 64 percent of adolescents aged 13 to 18 with a mental health or substance use disorder have never received professional mental health treatment for their particular diagnosis (Merikangas et al., 2011). Furthermore, only about half of adolescents with mental health or substance use disorders that are accompanied by severe impairment have received treatment.

The likelihood of receiving care differs by the type of disorder. According to the NCS-A, while about 60 percent of adolescents with attention-deficit/hyperactivity disorder (ADHD) receive treatment, only about 45 percent of adolescents with behavioral disorders and 38 percent with mood disorders such as depression or bipolar disorder get care. Adolescents with anxiety disorders (18 percent), substance use disorders (15 percent), and eating disorders (13 percent) are the least likely (among disorders measured in the NCS-A) to get treatment for their specific disorder. The 2011 NSDUH found that about 38 percent of adolescents aged 12 to 17 with past year major depressive episode (MDE) receive past year treatment (Figure 4-3), and about 12 percent of adolescents with a past year substance use disorder receive past year treatment (Figure 4-4).

Figure 4-3 is a bar chart showing past year depression treatment types among adolescents aged 12 to 17 with major depressive episode for 2011. Among adolescents aged 12 to 17, 38.4% received any mental health treatment, 16.3% received prescription medication, 0.6% received treatment from a healing professional, 6.5% received treatment from a religious or spiritual advisor, 3.1% received treatment from a health professional, 3.4% received treatment from a mental health professional, 21.3% received treatment from a counselor, 6.2% received treatment from a social worker, 9.2% received treatment from a psychiatrist, 12.1% received treatment from a psychologist, 1.4% received treatment from a medical doctor, and 8.1% received treatment from a general practitioner.

Figure 4-3

Past year depression treatment types among adolescents aged 12 to 17 with past year major depressive episode: 2011. SOURCE: National Survey on Drug Use and Health, 2011 (revised May 2013), Substance Abuse and Mental Health Services Administration, Center (more...)

Figure 4-4 is a bar chart showing past year substance abuse treatment types among adolescents aged 12 to 17 by past year substance use disorder type for 2011. Among adolescents aged 12 to 17, 11.2% with an alcohol use disorder, 14.7% with an illicit drug use disorder, and 12.0% with a substance use disorder received any substance abuse treatment; 3.1% with an alcohol use disorder, 4.2% with an illicit drug use disorder, and 3.3% with a substance use disorder received treatment in an outpatient rehabilitation center; 2.1% with an alcohol use disorder, 4.3% with an illicit drug use disorder, and 3.3% with a substance use disorder received treatment in an outpatient mental health center; 2.9% with an alcohol use disorder, 2.7% with an illicit drug use disorder, and 2.5% with a substance use disorder received treatment in an inpatient hospital; 3.2% with an alcohol use disorder, 4.2% with an illicit drug use disorder, and 3.3% with a substance use disorder received treatment in an inpatient rehabilitation center; 1.6% with an alcohol use disorder, 2.2% with an illicit drug use disorder, and 1.6% with a substance use disorder received treatment in an emergency room; 1.7% with an alcohol use disorder, 2.3% with an illicit drug use disorder, and 1.8% with a substance use disorder received treatment in a private doctor's office; 0.6% with an alcohol use disorder, 1.0% with an illicit drug use disorder, and 0.7% with a substance use disorder received treatment in a prison/jail; and 4.4% with an alcohol use disorder, 6.0% with an illicit drug use disorder, and 4.4% with a substance use disorder received treatment in a self-help group.

Figure 4-4

Past year substance abuse treatment types among adolescents aged 12 to 17, by past year substance use disorder type: 2011. 1 Substance use disorder includes disorders for alcohol use and illicit drugs. Illicit drugs include marijuana/hashish, cocaine (more...)

4.2.1.2. Treatment for Children

Less is known at a national level about mental health and substance use service use in younger children than is known for older children. According to a special supplement to the 2001–2004 National Health and Nutrition Examination Surveys (NHANES), about half of children aged 8 to 11 with a past year mental health disorder receive treatment (Merikangas et al., 2010). Treatment rates are highest for those with ADHD (48 percent) and lowest for those with anxiety disorders (32 percent). The 2001–2004 NHANES supplements also show that children with mental health disorders accompanied by severe impairment have only slightly higher rates of treatment (53 percent).

4.2.1.3. Types and Locations of Treatment Received

Children and adolescents receive treatment in a variety of locations, including specialty settings (e.g., child psychiatrist's office) and nonspecialty settings (e.g., school). Based on analysis of NCS-A data, more than 46 percent of adolescents with any lifetime mental health or substance use disorder have ever received treatment in a mental health specialty setting. More than one-third of adolescents with a mental health or substance use disorder ever received mental health care at school (Merikangas et al., 2011). The most recent published NSDUH data show that about 12 percent of all adolescents (with or without diagnosed disorders) received mental health care in a school setting in the past year (SAMHSA, 2012a).

About 87 percent of schools in the United States in 2002–2003 provided assessment for emotional or behavioral disorder, and 84 percent provided referrals to specialized programs and services (Foster, Rollefson, Doksum, Noonan, Robinson, & Teich, 2005). Overall, almost half of school districts (49 percent) used some contracts or other formal agreements with community-based organizations and/or people to provide mental health services to their students. A majority of schools surveyed in 2002–2003 and schools surveyed in the 2006 School Health Policies and Programs Study also provided individual counseling, case management, and group therapy (Brener, Weist, Adelman, Taylor, & Vernon-Smiley, 2007; Foster et al., 2005). About half of schools in either sample provided substance use services.

NSDUH measures past year MDE and treatment among adolescents aged 12 to 17 (the data do not measure any or serious mental illness for this age group). Estimates from the 2011 survey indicate that the most common types of depression treatment for adolescents with MDE include counselors (21 percent) and prescription medication (16 percent) (see Figure 4-3). Some adolescents receive more than one type of treatment; very few receive prescription medication without also talking with a medical doctor or counselor. Like adults, substance abuse treatment among adolescents is generally more common for drug use disorders (15 percent) than alcohol use disorders (11 percent) (see Figure 4-4).

4.2.2. Adequacy of Treatment

As reported in the NCS-A, the majority (68 percent) of adolescents who receive behavioral health services have fewer than six visits with a behavioral health provider over their lifetime (Merikangas et al., 2011). Whether this amount meets minimum standards for adequacy is unknown because few national mental health quality measures exist (Zima et al., 2013). Robust measures of quality of care are not currently being collected in nationally representative surveys or monitored at the national level (Institute of Medicine and National Research Council, 2011).

A study that analyzed NSDUH data on adolescents with MDE defined adequate care by using Agency for Healthcare Research and Quality and American Psychiatric Association recommendations and findings from clinical trials. Adequate care was defined as the receipt of medication with at least four past year visits to a psychiatrist, psychologist, or general practitioner or at least eight past year visits to a provider in a mental health care specialty setting. According to this definition, 34 percent of adolescents with past year MDE had received adequate past year depression treatment (Alexandre et al., 2009, 2010).

The American Academy of Child & Adolescent Psychiatry guideline for children and adolescents with depressive disorders states that medication should only be used after trying psychotherapy or in addition to psychotherapy (see, e.g., Mark, 2008). A study of children and adolescents with either Medicaid or private insurance claims found that, among those receiving mental health medication, few also receive any psychotherapy within 6 months of starting medication (Mark, 2008). Only 28 percent of those covered by Medicaid and 34 percent of those covered by private insurance met these guideline levels.

4.2.3. Special Populations

Some subgroups of children and adolescents are more likely to have mental health problems but are less likely to receive any treatment or adequate treatment. These include children of minority race/ethnicity (Kataoka, Zhang, & Wells, 2002; Wells, Hillemeier, Bai, & Belue, 2009), uninsured children (Kataoka, Zhang, & Wells, 2002), children with parents who have mental health or substance use disorders (Whitson, Connell, Bernard, & Kaufman, 2011), children in the child welfare system (Burns et al., 2004), and children in the justice system (Abram, Paskar, Washburn, & Teplin, 2008).

Compared with the general population, for example, a greater proportion of adolescents in the justice system need treatment: 70 percent of youth in the juvenile justice system have a mental health disorder, and 27 percent have a mental disorder that results in serious functional impairment (Cocozza & Shufelt, 2006; Shufelt & Cocozza, 2006). These rates may underestimate the true nature of mental health treatment needs of youth in the juvenile justice system since diagnostic interviews may not be completed until youth are adjudicated and put in an out-of-home placement. Additional studies of youth in placement, such as the Survey of Youth in Residential Placement, have found that more than half report symptoms of depression and anxiety, and almost half of these youth need mental health treatment (Sedlak & McPherson, 2010). Mental health services that were provided to youth in custody generally fell short of recommended practices. In particular, suicidal feelings and attempts were much higher in these youth compared with national samples. One-fifth of youth reported two or more recent suicidal feelings, and nearly the same amount (22 percent) reported past suicide attempts, which is nearly 4 times the rate reported by national samples of youth in the general population.

4.3. Summary

The majority of adults who have mental health or substance use disorders do not get corresponding treatment. Furthermore, less than one-third of adults get minimally adequate care, as defined by guidelines specified by various national organizations. Relatively little is known about the amount, type, and quality of care received by special populations, some of whom have particularly high rates of mental health and substance use disorders.

Recent research suggests that a majority of children and adolescents with mental health or substance use disorders do not receive treatment. The likelihood of receiving treatment appears to be related in part to the specific mental health or substance use disorder diagnosis, but it does not appear to be highly associated with severity of disorder. Most who receive care do so in mental health specialty settings, although schools have been playing an increasing role in providing behavioral health care to children and adolescents.

For people of all ages, there have been several recent efforts to increase access to community-based mental health and substance abuse treatment services through legislation such as the Mental Health Parity and Addiction Equity Act and the ACA. Some experts argue, however, that these policies will do little to improve access if communities lack sufficient infrastructure in terms of appropriate treatment facilities and trained psychiatrists, psychologists, and other mental health professionals to provide care to children and adolescents who need it (Cummings, Wen, & Druss, 2013). Nonetheless, improvements to the provision of care to children and adolescents in particular continue to be targeted through services provided through the Children's Health Insurance Program (CHIP) and Medicaid (Bazelon Center for Mental Health Law, 2008). One study conducted using NSDUH data showed that adolescents with coverage through CHIP or Medicaid had significantly increased odds of receiving adequate mental health care for MDE (Alexandre et al., 2009). In addition, SAMHSA recently awarded up to $3.5 million in systems of care grants to children and families through the Expansion of the Comprehensive Community Mental Health Services for Children and their Families program (SAMHSA, 2012b). Studying changes to mental health and substance use care for people of all ages will be important as these programs are fully implemented over the next several years.

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Footnotes

1

The NCS-R defined minimally adequate treatment as receiving either pharmacotherapy (≥2 months of an appropriate medication for the mental health disorder plus >4 visits to any type of physician) or psychotherapy (≥8 visits with any health care or human services professional lasting an average of ≥30 minutes), based on available evidence-based guidelines from organizations such as the American Psychiatric Association (1998, 2000, 2002, 2004), the Agency for Healthcare Research and Quality (formerly known as the Agency for Health Care Policy and Research) (1993), and the National Committee for Quality Assurance (1997).

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