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Serious Mental Illness and Its Co-Occurrence with Substance Use |
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Joan
Epstein
Peggy Barker
Michael Vorburger
Christine Murtha
DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Office of Applied Studies
This report was prepared by the Division of Population Surveys, Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA), and by RTI International, a trade name of Research Triangle Institute, of Research Triangle Park, North Carolina, under Contract No. 283–98–9008. At SAMHSA, Joan Epstein and Peggy Barker authored the report. Joseph Gfroerer provided review comments. At RTI, Christine Murtha was the task leader for its production and coauthored the report with Michael Vorburger. Mary Ellen Marsden reviewed the report; other contributors and reviewers at RTI include Jeremy Aldworth, Katherine R. Bowman, Walter R. Boyle, James R. Chromy, Andrew Clarke, Steven L. Emrich, Jennie L. Harris, David C. Heller, Jennifer J. Kasten, Larry A. Kroutil, Brian Newquist, Lisa E. Packer, Michael R. Pemberton, Michael A. Penne, Jill Webster, and Li-Tzy Wu. At RTI, Richard S. Straw edited the report; Diane G. Caudill and Dayle Johnson prepared the graphics; Brenda K. Porter formatted the tables; Joyce Clay-Brooks, Debbie F. Bond, and Loraine G. Monroe formatted and word processed the report; and Pamela Couch Prevatt, Teresa F. Gurley, Kim Cone, Sonja E. Douglas, and Shari B. Lambert prepared its Web and press versions. Final report production was provided by Beatrice A. Rouse, Coleen Sanderson, and Jane Feldmann at SAMHSA.
All material appearing in this report is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration. However, this publication may not be reproduced or distributed for a fee without specific, written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human Services. Citation of the source is appreciated. Suggested citation:
Epstein J., Barker, P., Vorburger, M., & Murtha, C. (2004). Serious mental illness and its co-occurrence with substance use disorders, 2002 (DHHS Publication No. SMA 04–3905, Analytic Series A-24). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
June 2004
1. Introduction
1.1. Purpose of This Report
1.2. Background on the Definition
of Serious Mental Illness
1.3.
Prior Estimates of Serious Mental Illness and Its Co-Occurrence with a Substance
Use Disorder and Treatment
1.4.
Prior Estimates of Co-Occurring Disorders
1.5.
Organization of This Report
2. Data and Methods
2.1. Summary of National Survey on
Drug Use and Health
2.2.
Limitations of the Data
2.3.
Measures and Statistical Methods
2.3.1
Definition and Measurement of Serious Mental Illness
2.3.2
Definition of Substance Use Disorder and Nicotine (Cigarette) Dependence
2.3.3
Definitions of Mental Health Treatment and Substance Use Treatment
2.3.4
Social and Demographic Variables
2.3.5
Use of Alcohol, Cigarettes, Tobacco, and Illicit Drugs
2.4.
Statistical Methods
2.4.1
Descriptive Analysis
2.4.2
Model-Based Analysis
3. Serious Mental Illness
3.1. Characteristics of Adults With
and Without Serious Mental Illness
3.2.
Prevalence of Serious Mental Illness among Demographic and Socioeconomic Subgroups
3.3. Serious Mental Illness and Substance
Use
3.3.1
Serious Mental Illness and Illicit Drug Use
3.3.1.1
Characteristics of Adults with Serious Mental Illness and Illicit Drug Use
3.3.1.2
Prevalence of Serious Mental Illness among Illicit Drug Users
3.3.2
Serious Mental Illness among Cigarette and Alcohol Users
3.4.
Serious Mental Illness and a Co-Occurring Substance Use Disorder
3.4.1
Characteristics of Adults with Co-Occurring Serious Mental Illness and a Substance
Use Disorder
3.4.2
Prevalence of Serious Mental Illness among Adults with a Substance Use Disorder
3.5. Multiple Logistic Regression
Models for Serious Mental Illness
4. Mental Health Treatment
and Substance Use Treatment
4.1.
Mental Health Treatment among Adults with Serious Mental Illness
4.1.1
Characteristics of Adults with Serious Mental Illness, by Receipt of Mental Health
Treatment in the Past Year
4.1.2
Rates of Mental Health Treatment among Adults with Serious Mental Illness, by
Sociodemographic
Characteristics
4.1.3
Mental Health Treatment among Adults with Serious Mental Illness Who Did and Did
Not Use Illicit Drugs
4.2.
Use of Treatment Services among Adults with Serious Mental Illness and/or a Co-Occurring
Substance Use Disorder
4.3.
Multiple Logistic Regression Models
4.4.
Discussion
A Description of the Survey, Limitations of the Data, and Statistical Methods
1. Serious Mental Illness among Adults Aged 18 or Older, by Age and Gender: 2002
2. Serious Mental Illness among Adults Aged 18 or Older, by Perceived Health Status: 2002
3. Serious Mental Illness among Adults Aged 18 or Older, by Social Support: 2002
4. Serious Mental Illness among Adults Aged 26 to 49, by Marital Status: 2002
5. Serious Mental Illness among Adults Aged 26 to 49, by Family Income: 2002
6. Serious Mental Illness among Adults Aged 26 to 49, by Health Insurance Status: 2002
7. Serious Mental Illness among Adults Aged 26 to 49, by Current Employment Status: 2002
8. Serious Mental Illness and Past Year Illicit Drug Use among Adults Aged 18 or Older: 2002
9. Serious Mental Illness, by Type of Substance Used among Adults Aged 18 or Older: 2002
13. Serious Mental Illness among Adults Aged 18 or Older, by Substance Dependence or Abuse: 2002
14. Mental Health Treatment among Adults Aged 18 or Older with Serious Mental Illness, by Age: 2002
A.1 Required Effective Sample as a Function of the Proportion Estimated
A.1 Summary of 2002 NSDUH Suppression Rules
A.2 Weighted Percentages and Sample Sizes for 2002 NSDUH, by Screening Result Code
A.3 Weighted Percentages and Sample Sizes for 2002 NSDUH, by Final Interview Code
A.4 Response Rates and Sample Sizes for 2002 NSDUH, by Demographic Characteristics
This report presents information on the prevalence and treatment of serious mental illness (SMI) and their association with substance use and co-occurring substance use disorders based on the 2002 National Survey on Drug Use and Health (NSDUH). The survey, formerly known as the National Household Survey on Drug Abuse (NHSDA), is a project of the Substance Abuse and Mental Health Services Administration (SAMHSA). For this report, a substance use disorder is defined as dependence on or abuse of alcohol or illicit drugs.
NSDUH is an annual survey of the civilian, noninstitutionalized population of the United States aged 12 years old or older. Conducted by the Federal Government since 1971, it is the primary source of statistical information on the use of illegal drugs by the U.S. population. Estimates in this report are based on data from the 2002 survey for adults aged 18 or older. Because of changes to the 2002 survey, this report's estimates should not be compared with estimates from previous survey years.
National estimates for the prevalence and treatment of SMI are presented. The prevalence of treatment for substance use and mental health disorders among persons with SMI and co-occurring substance use disorders also is examined by demographic, socioeconomic, substance use, and substance dependence or abuse characteristics.
Estimates of the prevalence of serious mental illness (SMI) provide a measure of the population with the most severe mental health problems and indicate those persons who are most in need of treatment. SMI is defined in this report as having at some time in the past year a diagnosable mental, behavioral, or emotional disorder that met the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association [APA], 1994), that resulted in functional impairment that substantially interfered with or limited one or more major activities. Studies have shown that mental disorders co-occurring with substance use disorders are more chronic than mental disorders alone and that the co-occurrence between a mental disorder and a substance use disorder can create serious complications for treatment (Kranzler & Liebowitz, 1988). Adults with SMI and a co-occurring substance use disorder may have a greater need for treatment than adults with a less severe mental disorder co-occurring with a substance use disorder.
This report presents national estimates from the 2002 National Survey on Drug Use and Health (NSDUH)1 of the prevalence and treatment of SMI and of co-occurring SMI and substance use disorders (dependence on or abuse of illicit drugs or alcohol) among adults aged 18 or older. The prevalence of treatment for substance use and mental health problems among persons with co-occurring SMI and substance use disorders also is examined by socioeconomic and demographic characteristics. The following is a list of the major research questions addressed by this report.
Public Law (P.L.) 102–321, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act, established a block grant for States to fund community mental health services for adults with SMI. The law required States to include incidence and prevalence estimates in their annual applications for block grant funds. The law also required SAMHSA to develop an operational definition of SMI and to establish an advisory group of technical experts to develop an estimation methodology based on this definition for use by the States. The definition of SMI stipulated in P.L. 102–321 requires the person to have at least one 12–month disorder, other than a substance use disorder, that met DSM-IV criteria (APA, 1994) and to have "serious impairment." A SAMHSA advisory group suggested that the term "serious impairment" be defined as impairment equivalent to a Global Assessment of Functioning (GAF) score of less than 60 (Endicott, Spitzer, Fleiss, & Cohen, 1976).
Based on the definition presented in Section 1.2, a group of technical experts developed a methodology for estimating SMI (Kessler et al., 1996a) that used data from the National Comorbidity Survey (NCS) and the Baltimore Epidemiologic Catchment Area (ECA) survey. Using this methodology, they estimated that 10.0 million adults aged 18 or older had SMI in 1990 (5.4 percent of adults). Furthermore, they estimated that 1.1 percent of adults had both SMI and a substance use disorder. This represents 14.7 percent of all adults with SMI and 17.2 percent of all adults with a substance use disorder. They also estimated that 46.6 percent of the persons with SMI used professional services for a mental health problem in the 12 months prior to the interview.
Questions to measure SMI were added by SAMHSA to the NSDUH for the first time in 2001 (Office of Applied Studies [OAS], 2002). These questions, which asked respondents how frequently they experienced symptoms of psychological distress, were based on a methodological study designed to evaluate several screening scales for measuring SMI in the NSDUH. Based on this study, which included clinical assessments on survey respondents, these questions were shown to be a valid indicator of SMI (Kessler et al., 2003). Although estimates of SMI were produced for 2001, due to changes in the study, the 2001 estimates cannot be compared with estimates from 2002, which are presented in this report. (See Section 2.1 for further details on the reasons why they cannot be compared.)
Although this report focuses on the population with the most severe mental problems, there also is interest in the larger population with any mental disorder and the co-occurrence of substance use disorders among its members. According to a U.S. Surgeon General's report, co-occurring disorders have been estimated to affect from 7 million to 10 million adult Americans in any year (U.S. Department of Health and Human Services [DHHS], 1999; see also SAMHSA National Advisory Council, 1998). An estimated 41 to 65 percent of persons with a lifetime substance use disorder have a lifetime history of at least one mental disorder, and about 51 percent of those with one or more lifetime mental disorders also have a lifetime history of at least one substance use disorder (U.S. DHHS, 1999). Studies in both clinical samples (Ross, Glaser, & Germanson, 1988; Rounsaville et al., 1991; Wolf et al., 1988) and general population studies (Boyd et al., 1984; Helzer & Pryzbeck, 1988; Kessler et al., 1994; Regier et al., 1990) show that comorbidity is highly prevalent among individuals with mental disorders.
Data on co-occurring disorders can be obtained from the NCS, the ECA, and the NHSDA. These surveys define mental disorders and substance use disorders based on meeting specific DSM-IV criteria (APA, 1994). The NCS, carried out between 1990 and 1992, surveyed a nationally representative sample of persons aged 15 to 54. It found that 42.7 percent of individuals with a 12–month addictive disorder had at least one mental disorder, and 14.7 percent of individuals with a mental disorder had at least one 12–month addictive disorder (Kessler et al., 1996b). The ECA was carried out between 1980 and 1984 in five geographic areas and included adults aged 18 or older living in the community and various institutional settings. It reported that 47 percent of persons with schizophrenia also had a substance use disorder in their lifetime and 61 percent of individuals with a bipolar disorder also had a substance use disorder in their lifetime (Regier et al., 1990). The 1994 through 1997 NHSDAs included questions on four mental disorders in addition to questions to measure dependence on alcohol or illicit drugs. The 1994 survey found that 19 million adults in the population had dependence on illicit drugs or alcohol, and among these individuals, 13 percent had a major depressive episode disorder, 5.9 percent had a panic attack, 3.8 percent had a generalized anxiety disorder, and 3.7 percent had agoraphobia in the past year (OAS, 1996).
This report is divided into five chapters. NSDUH measures and statistical methods are described in Chapter 2. Chapter 3 presents findings on the prevalence and correlates of SMI among adults, including substance use and substance use disorders. Chapter 4 presents findings on the prevalence of mental health treatment and substance use treatment among adults with SMI and a substance use disorder. A summary and conclusions are presented in Chapter 5. Appendices provide technical details on the survey methodology and selected tables.
This report uses data on adults aged 18 or older from the 2002 National Survey on Drug Use and Health (NSDUH). NSDUH is an annual survey of the civilian, noninstitutionalized population of the United States aged 12 or older. Prior to 2002, the survey was called the National Household Survey on Drug Abuse (NHSDA).
NSDUH is the primary source of statistical information on the use of illegal drugs by the U.S. population. Conducted by the Federal Government since 1971, the survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at the respondents' places of residence. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and is planned and managed by SAMHSA's Office of Applied Studies (OAS). The data collection is conducted by RTI International. This section briefly describes the survey methodology. A more complete description is provided in Appendix A.
NSDUH collects information from residents of households, noninstitutional group quarters (e.g., shelters, rooming houses, dormitories), and civilians living on military bases. Persons excluded from the survey include homeless persons who do not use shelters, military personnel on active duty, and residents of institutional group quarters, such as jails and hospitals.
Since 1999, the NSDUH interview has been carried out using computer-assisted interviewing (CAI). The survey uses a combination of computer-assisted personal interviewing (CAPI) conducted by an interviewer and audio computer-assisted self-interviewing (ACASI). Use of ACASI is designed to provide a respondent with a highly private and confidential means of responding to questions and to increase the level of honest reporting of illicit drug use and other sensitive behaviors.
Consistent with the 1999 through 2001 surveys, the 2002 NSDUH employed a 50–State sample design with an independent, multistage area probability sample for each of the 50 States and the District of Columbia. The eight States with the largest population (which together account for 48 percent of the total U.S. population aged 12 or older) were designated as large sample States (California, Florida, Illinois, Michigan, New York, Ohio, Pennsylvania, and Texas). For these States, the design provided a sample sufficient to support direct State estimates. For the remaining 42 States and the District of Columbia, smaller, but adequate, samples were selected to support State estimates using small area estimation (SAE) techniques. The design also oversampled youths and young adults, so that each State's sample was approximately equally distributed among three major age groups: 12 to 17 years, 18 to 25 years, and 26 years or older.
Nationally, 136,349 addresses were screened for the 2002 survey, and 68,126 completed interviews were obtained. Among adults aged 18 or older, 54,351 persons were selected, with 44,467 interviews completed. The survey was conducted from January through December 2002. Weighted response rates for household screening and for interviewing were 90.7 and 78.9 percent, respectively; the weighted interview response rate for adults aged 18 or older was 77.2 percent.
Although the design of the 2002 NSDUH is similar to the design of the 1999 through 2001 surveys, important methodological differences in the 2002 survey affect the 2002 estimates. Besides the name change, each NSDUH respondent was given an incentive payment of $30. These changes, both implemented in 2002, resulted in a substantial improvement in the survey response rate. The changes also affected respondents' reporting of many critical items that are the basis of prevalence measures reported by the survey each year. Further, the 2002 data could have been affected by improved data collection quality control procedures that were introduced in the survey beginning in 2001. In addition, new population data from the 2000 decennial census recently became available for use in NSDUH sample weighting procedures, resulting in another discontinuity between the 2001 and 2002 estimates. Analyses of the effects of each of these factors on NSDUH estimates have shown that 2002 data should not be compared with 2001 and earlier NHSDA data to assess changes over time.
All data from NSDUH are based on retrospective reports by survey respondents and are subject to recall and reporting biases. First, some degree of underreporting on drug use, mental health problems, and mental health treatment measures might occur because of the social unacceptability of drug use and the stigma of mental health problems and treatment. Self-reported data also are influenced by memory and recall errors, including recall decay (tendency to forget events occurring long ago) and forward telescoping (tendency to report that an event occurred more recently than it actually did).
Second, the NSDUH target population focuses on civilian, noninstitutionalized household residents. Although it includes almost 98 percent of the U.S. population aged 12 or older, some population subgroups that may have different drug-using patterns are excluded, such as active military personnel, people living in institutional group quarters, and homeless persons not living in identifiable shelters. Thus, generalization of the findings to the excluded subgroups is limited. Further, the estimates for drug use should be considered conservative.
See Appendix A for additional discussion of data limitations, including the effect of nonresponse on analyses presented in this report.
Serious mental illness, or SMI, is defined in this report according to the definition stipulated in Public Law (P.L.) 102–321, that is, having at some time during the past year a diagnosable mental, behavioral, or emotional disorder that met the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association [APA], 1994) and resulted in functional impairment that substantially interfered with or limited one or more major life activities.
SMI was assessed in the 2002 NSDUH using the six-item K6 scale (Kessler et al., 2003) that was used for the first time in 2001. These six questions ask respondents how frequently they experienced symptoms of psychological distress during the 1 month in the past year when they were at their worst emotionally. This scale has been shown to be a valid indicator of SMI, based on clinical assessments done on survey respondents (Kessler et al., 2003). The six questions and a discussion of the scale are given in Appendix A.
In this study, an adult is defined as having a substance use disorder in the past year if he or she was dependent on or abused alcohol or an illicit drug in the past year. The 2002 NSDUH included a series of questions to assess dependence on or abuse of an illicit drug or alcohol based on DSM-IV criteria (APA, 1994). The seven substance dependence criteria are (1) tolerance; (2) withdrawal or avoidance of withdrawal; (3) persistent desire or unsuccessful attempts to cut down or stop substance use; (4) spending a lot of time using the substance, obtaining the substance, or recovering from its effects; (5) reducing or giving up occupational, social, or recreational activities in favor of substance use; (6) impaired control over substance use; and (7) continuing to use the substance despite physical or psychological problems. A respondent was considered to be dependent on a substance when he or she reported having at least three of the dependence criteria.
The four substance abuse criteria are (1) having serious problems due to substance use at home, work, or school; (2) the use of that substance putting the respondent in physical danger; (3) substance use causing the respondent to be in trouble with the law; and (4) continuing to use the substance despite having substance use-related problems with family and friends. A respondent was classified with abuse when he or she reported having at least one of the four abuse criteria.
The 2002 NSDUH included a series of questions to assess nicotine (cigarette) dependence based on the Nicotine Dependence Syndrome Scale (NESS) (Hoffman, Hick Cox, Gnus, Patty, & Tassel, 1995; Hoffman, Patty, Tassel, Gnus, & Settler-Segal, 1994; Hoffman, Waters, & Hick Cox, 2003) and the Firestorm Test of Nicotine Dependence (FIND) (Heatherton, Kozlowski, Wrecker, & Firestorm, 1991). A respondent was classified with nicotine (cigarette) dependence based on criteria derived from the NESS and the FIND.
Mental health treatment is defined as treatment or counseling for problems with emotions, nerves, or mental health in any inpatient or outpatient setting or use of prescription medication to treat a mental or emotional condition in the 12 months prior to the interview.
Specialty substance use treatment (for alcohol or illicit drug use) is treatment received at a specialty substance abuse facility to reduce or stop drug or alcohol use, or for medical problems associated with the use of drugs or alcohol in the past 12 months. "Specialty" substance abuse facilities include rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), or mental health centers. "Any treatment" refers to treatment received to reduce or stop drug or alcohol use, or for medical problems associated with the use of drugs or alcohol in the past 12 months at any location, including specialty facilities and emergency rooms, private doctor's offices, self-help groups, or prison/jails.
Use of alcohol refers to any use of alcohol in the past 12 months. Binge alcohol use is defined as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days. Heavy alcohol use is defined as drinking five or more drinks on the same occasion on at least 5 days in the past 30 days.
Cigarette use refers to the use of cigarettes on at least 1 day in the 12 months preceding the interview date.
Illicit drug use is defined as any use in the past year of the following drugs: marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or any nonmedical use of a prescription-type psychotherapeutic. Psychotherapeutics includes pain relievers, tranquilizers, stimulants, or sedatives and does not include any over-the-counter drugs.
The statistical analysis used descriptive statistics to characterize the prevalence and distribution of SMI and of treatment for SMI, and logistic regression models were used to predict SMI and treatment for SMI. The descriptive analysis produced prevalence rates and percent distributions by various explanatory variables, while the logistic regression modeling produced odds ratios (Ores) in the prevalence rates for each of the explanatory variables. All estimates were weighted, and all standard errors (Sees) were calculated using Taylor series linearization for nonlinear statistics and an approach that recognized the sample structure. The software package used was SUDAAN® (RTI, 2001). In the modeling, an explanatory variable was identified as a statistically significant predictor of SMI if the associated Chi-square test was significant at the 0.05 level. In the descriptive analyses, log-linear Chi-square tests of independence of the explanatory variables and SMI were conducted first to control the error level for multiple comparisons. If the Chi-square test indicated overall significant differences, comparisons between specific levels of the classification variables then were made using t tests.
Demographic and socioeconomic characteristics were compared for the following groups of adults: (1) those with and without SMI in the past year; (2) those who did and did not use illicit drugs among adults with SMI; (3) those with and without a substance use disorder among adults with SMI; and (4) those who received and did not receive mental health treatment in the past year among adults with SMI.
To examine how the prevalence of SMI in the past year varied among subgroups of adults, prevalence rates of SMI by demographic and socioeconomic characteristics are presented. To examine how the prevalence of SMI in the past year varied by use of substances, as well as by substance use disorders, prevalence rates of SMI are compared for use of alcohol, tobacco, any illicit drugs, and specific illicit drugs; dependence on or abuse of alcohol and/or illicit drugs; and cigarette dependence. Significant differences in rates among subgroups of persons also were identified with Chi-square tests and t tests.
To examine how the prevalence of mental health treatment in the past year varied among subgroups of adults with SMI, prevalence rates of mental health treatment in the past year among adults with SMI by demographic and socioeconomic characteristics are presented. To examine how the prevalence of mental health treatment varied by illicit drug use and by a substance use disorder among adults with SMI, rates of mental health treatment among adults with past year SMI were compared for those using and not using illicit drugs and for those with and without a substance use disorder. Rates of specialty substance use treatment among adults with a substance use disorder were compared for those with and without SMI to examine how the prevalence of substance use treatment among adults with a substance use disorder varied by SMI.
Two logistic regression models were run using the SUDAAN LOGISTIC procedure. The first model was developed for all adults aged 18 or older to examine the Ores for each of the characteristics believed to be associated with SMI after controlling for confounding variables. For the first model, past year SMI was the dependent variable, and the independent variables included each of the characteristics believed to be associated with SMI. The second model was developed for all adults with past year SMI to determine the odds of receiving mental health treatment for characteristics believed to be associated with the receipt of treatment and controlling for potential confounding variables. For this model, receipt of mental health treatment was the dependent variable.
This chapter presents national estimates from the 2002 National Survey on Drug Use and Health (NSDUH) of the prevalence of past year serious mental illness (SMI) by demographic and socioeconomic characteristics among adults aged 18 or older in 2002, and it examines the relationship of SMI to substance use and substance use disorders. Characteristics of adults with and without SMI in the past year are compared. Estimates of the past year prevalence of SMI are presented among demographic and socioeconomic subgroups, as well as by the type of substance used in the past year. Among adults with SMI, the characteristics of those using and not using illicit drugs are compared, and the characteristics of those with and without a substance use disorder are compared.
In 2002, there were 17.5 million adults aged 18 or older with SMI during the 12 months prior to being interviewed. This represents 8.3 percent of all adults in the United States. On average, adults with SMI were younger, less educated, and more likely to be female than adults without SMI. The percentage of young adults aged 18 to 25 was higher among persons with SMI (23.4 percent) than among those without SMI (14.0 percent). In contrast, the percentage of older adults (aged 50 or older) was lower among those with SMI (22.1 percent) than among those without SMI (39.0 percent) (Table B.1b).
Among those with SMI, 65.4 percent were female, which was higher than the percentage of females among those without SMI (50.8 percent). Adults with SMI were more likely to have not completed high school (20.5 percent) than those without SMI (17.4 percent) and less likely to have graduated from college (17.5 percent) than those without SMI (25.7 percent). Although a similar proportion of adults with and without SMI were employed full or part time, persons with SMI were more likely to be unemployed or not in the labor force (36.4 percent) than were persons without SMI (31.2 percent).
Adults with SMI were less likely to be from large metropolitan areas (45.7 percent) than adults who did not have SMI (50.2 percent) (Table B.2b). There were no differences observed by geographic region.
Rates of SMI in the adult U.S. population varied by age and gender. Of the three age groups considered here, adults aged 18 to 25 had the highest rate of SMI (13.2 percent), followed by adults aged 26 to 49 (9.5 percent) and adults aged 50 or older (4.9 percent) (Table B.3b). Overall, the rate of SMI was almost twice as high among females (10.5 percent) as it was among males (6.0 percent). The rate of SMI by age and gender was highest for females aged 18 to 25 (16.3 percent) (Figure 1).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Among racial and ethnic groups, adults reporting more than one race and American Indians and Alaska Natives had the highest prevalence of SMI (13.6 and 12.5 percent, respectively) (Table B.3b).
Prevalence rates of SMI did not vary significantly by geographic region. The rate was 8.5 percent in the Northeast and Midwest, 8.4 percent in the South, and 7.8 percent in the West (Table B.4b).
The prevalence of SMI varied by perceived health status and social support (Table B.5b). Adults who perceived their overall health as fair or poor were more than 3 times as likely to have SMI (16.9 percent) than those who perceived their health to be excellent (5.1 percent) (Figure 2). Likewise, those who reported no social support were about twice as likely to have SMI as those who reported social support (15.2 vs. 7.6 percent, respectively) (Figure 3).
Estimates of SMI by health insurance, marital status, and family income are only presented for persons aged 26 to 49. Among adults aged 26 to 49, divorced or separated adults were more than twice as likely to have SMI in the past year (16.0 percent) as married adults (7.1 percent) (Table B.5b, Figure 4).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
SMI also varied with socioeconomic status (SES) among adults aged 26 to 49. In this age group, adults with lower SES were more likely to have SMI than those with higher SES (Table B.5b). The prevalence of SMI was highest among those with the lowest family income level (less than $20,000) at 16.3 percent and lowest among those with the highest income level ($75,000 or more) at 6.4 percent (Figure 5). Also, among adults aged 26 to 49, the prevalence of SMI was higher among persons with Medicaid coverage (20.7 percent) and lower among persons with private health insurance (8.1 percent) (Figure 6). Similarly, the SMI rate was higher among persons who were unemployed or had "other" employment status (i.e., not in the labor force)3 (14.2 and 15.5 percent, respectively) than among persons who worked full time (7.9 percent) (Table B.3b, Figure 7).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
In this section, the characteristics of persons with SMI who used and did not use illicit drugs are compared. In addition, the prevalence rates of SMI are presented for persons using specific types of illicit drugs, heavy alcohol users, and cigarette users.
In 2002, there were 5 million adults aged 18 or older who had SMI and used an illicit drug in the past year (Table B.6a, Figure 8). This represented 28.9 percent of all persons with SMI. Adults with SMI who used illicit drugs were younger than those with SMI who did not use illicit drugs. Among adults with SMI and illicit drug use, 38.8 percent were 18 to 25 years old compared with 17.1 percent of persons with SMI but no illicit drug use; also, 7.2 percent of adults with SMI and illicit drug use were aged 50 or older compared with 28.2 percent with SMI but no illicit drug use (Table B.6b).
Adults with SMI who used illicit drugs in the past year were more likely to be male than those with SMI who did not use illicit drugs (45.1 vs. 30.3 percent). They also were more likely to be in the labor force than those with SMI but no illicit drug use: 67.0 percent of adults with SMI and past year illicit drug use were employed full or part time compared with 62.2 percent of those with SMI only, and 10.8 percent were unemployed compared with 4.3 percent of adults with SMI only. Consequently, adults with SMI only were more likely to be out of the labor force (33.5 percent) than those who had SMI and used an illicit drug in the past year (22.2 percent).
Note: Circles are not drawn to scale.
Source: SAMHSA, Office of Applied Studies,
National Survey on Drug Use and Health, 2002.
SMI is correlated with illicit drug use. The prevalence of SMI was more than twice as high among those who used an illicit drug during the past year than it was among those who did not (17.1 vs. 6.9 percent). This relationship was observed across most demographic and socioeconomic subgroups (Tables B.8b and B.9b).
The prevalence of SMI varied by the type of substance used. The rate of SMI was 16.7 percent among those who used marijuana, 20.5 percent among those who used any illicit drug other than marijuana, 22.0 percent among those who used cocaine, and 29.9 percent among those who used crack cocaine (Table B.10b, Figure 9). For those who used hallucinogens, the SMI rate was 19.7 percent, and for inhalants, it was 20.6 percent. For all nonmedical use of psychotherapeutics, the rate of SMI was 21.8 percent; the rate of SMI was 33.6 percent for those who used sedatives, 28.8 percent for those who used stimulants, 26.5 percent for those who used tranquilizers, and 22.4 for those who used pain relievers. The rate for those who used methamphetamine was 31.8 percent.
The prevalence of SMI varied between past year cigarette smokers and nonsmokers, but no differences were observed between past year alcohol users and nonusers. The rate of SMI was 13.0 percent among adults who smoked cigarettes in the past year and 6.1 percent among those who did not smoke (Table B.11b, Figure 9). Although the rate of SMI did not vary by past year alcohol use (8.5 percent for users vs. 8.0 percent for nonusers), adults who were heavy alcohol users in the past month were more likely to have SMI than those who were not heavy alcohol users in the past month (11.1 vs. 8.1 percent).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
In this section, adults with SMI are classified by whether or not they had a substance use disorder, that is, whether they were dependent on or abused alcohol or illicit drugs. Those with SMI and a substance use disorder are further classified by whether they were dependent on or abused alcohol only, illicit drugs only, or both illicit drugs and alcohol.
In 2002, there were 33.2 million adults aged 18 or older with SMI or a substance use disorder (Table B.12a). Of these adults, 13.4 million (40.4 percent) had SMI but no substance use disorder (SMI only), 15.7 million (47.4 percent) had a substance use disorder but no SMI (substance use disorder only), and 4.0 million (12.2 percent) had both SMI and a substance use disorder (i.e., co-occurring disorders) (Table B.12b, Figure 10).
Note:
Circles are not drawn to scale.
Source: SAMHSA, Office of Applied Studies,
National Survey on Drug Use and Health, 2002.
The 4.0 million adults with SMI and a co-occurring substance use disorder represented 23.2 percent of all adults with SMI (Table B.13b) and 20.4 percent of all adults with a substance use disorder in 2002 (Table B.16b). Among these adults with SMI and a substance use disorder, 0.9 million were dependent on or abused illicit drugs only, 2.4 million were dependent on or abused alcohol only, and 0.8 million were dependent on or abused alcohol and illicit drugs (Table B.13a, B.13b, and B.16b, Figure 11).
The 17.5 million adults with SMI in 2002 can be examined as to whether they had a substance use disorder in the past year and by whether they used illicit drugs. As previously mentioned, there were 4.0 million adults with SMI who had a substance use disorder. Thus, 13.4 million adults with SMI (76.8 percent) did not have a substance use disorder. Among these adults with SMI but without a substance use disorder, 2.3 million used an illicit drug in the past 12 months and 11.1 million did not (Figure 12).
In 2002, adults with SMI and a substance use disorder were more likely to be younger and more likely to be male than adults with SMI but no substance use disorder. Among adults with SMI and a substance use disorder, 36.3 percent were aged 18 to 25 compared with 19.5 percent among adults with SMI but no substance use disorder. The percentage of males among adults with SMI and a substance use disorder was higher than the corresponding percentage among adults with SMI but no substance use disorder (52.1 vs. 29.3 percent) (Table B.14b).
Figure 11. Type of Substance Use Disorder among Adults Aged 18 or Older with Both Serious Mental Illness and a Co-Occurring Substance Use Disorder: Numbers in Thousands, 2002
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Adults with SMI and a substance use disorder were more likely to be in the labor force than those with SMI only: 69.0 percent of adults with SMI and a substance use disorder were employed full or part time compared with 62.0 percent of those with SMI but no substance use disorder, and 10.1 percent were unemployed compared with 5.0 percent of adults with SMI but no substance disorder. Thus, adults with SMI but no substance disorder were more likely to be out of the labor force (33.1 percent) than adults with SMI and a substance use disorder (20.9 percent) (Table B.14b).
Among adults with SMI, the comparison of the socioeconomic and demographic characteristics between those with and without a substance use disorder is strikingly similar to the comparison in Section 3.3.1.1 between those who used and did not use illicit drugs (Table B.6b).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
The prevalence of SMI among adults with a substance use disorder varied by age and gender. Among persons with any illicit drug or alcohol dependence or abuse, women had a higher prevalence of SMI than men (30.3 vs. 15.7 percent), and women aged 26 to 49 had the highest rate of SMI (32.2 percent) (Table B.16b).
Rates of SMI were relatively low (7.0 percent) among adults who did not have a substance use disorder (Table B.17b, Figure 13). The rate was much higher among those with alcohol dependence or abuse (19.0 percent) and was even higher among those with illicit drug dependence or abuse (29.1 percent). The rate of SMI was highest among adults who met the criteria for both drug and alcohol dependence or abuse (30.1 percent).
The rate of SMI among adults with dependence on or abuse of an illicit drug other than marijuana (33.4 percent) was higher than the rate for those with illicit drug dependence or abuse (29.1 percent) and the rate for those with marijuana dependence or abuse (27.3 percent) (Table B.17b).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
The estimated strength of the associations between past year SMI with past year use of illicit drugs, illicit drug dependence or abuse, alcohol dependence or abuse, and socioeconomic and demographic characteristics was determined via a multiple logistic regression model. SMI was the dependent variable, and the other characteristics were the independent variables.
Possible confounding variables are variables in the model other than the independent variable of interest that are believed to be associated with both the dependent variable and the independent variables of interest. Adjusted odds ratios (Ores) denote the estimated association between SMI and a particular category of a variable while controlling for possible confounding variables. This section discusses the associations between SMI and characteristics believed to be associated with SMI in terms of their Ores. (See Appendix A, Section A.5.4, for a discussion of logistic modeling and the interpretation of adjusted Ores.)
Several sociodemographic variables were associated with SMI according to the descriptive analyses that also were associated with SMI based on their adjusted Ores. These variables included age, gender, race/ethnicity, marital status, perceived overall health, and social support. The Ores indicated that compared with adults aged 50 or older, adults aged 18 to 25 and adults aged 26 to 49 were more likely to have SMI in the past year (OR = 2.5 and 2.3, respectively) (Table B.M1). Females were more than twice as likely as males to have SMI. Compared with non-Hispanic whites, non-Hispanic blacks (OR = 0.7) and Hispanics (OR = 0.6) were less likely to have had SMI (Table B.M1).
The Ores for the levels of perceived health demonstrate that the more poorly persons perceived their health to be, the more likely they were to have had SMI. Compared with adults who perceived their health as excellent, adults who perceived their health as fair or poor (OR = 4.1), those who perceived their health as good (OR = 1.9), and those who perceived their health as very good (OR = 1.3) were more likely to have had SMI (Table B.M1).
SMI was highly correlated with illicit drug dependence or abuse and with alcohol dependence or abuse. It also was significantly associated with nicotine (cigarette) dependence. The Ores for use and for dependence on or abuse of illicit drugs show that adults with any illicit drug dependence or abuse in the past year were more likely to have SMI than adults with no illicit drug use in the past year (OR = 2.8) and than adults with illicit drug use but no dependence or abuse (OR = 1.9 calculated by dividing 2.75 by 1.43) (Table B.M1). Adults with past year illicit drug use who were not dependent on or abusing illicit drugs were more likely to have SMI in the past year than adults with no illicit drug use (OR = 1.4). The Ores for alcohol use and for dependence on or abuse of alcohol show that adults with alcohol dependence or abuse were more likely to have SMI than adults with no alcohol use (OR = 1.8) and more likely to have SMI than adults who used alcohol but who had no dependence or abuse (OR = 2.0 calculated by dividing 1.77 by 0.89). Adults with nicotine (cigarette) dependence in the past year had higher odds of having SMI than those without nicotine (cigarette) dependence (OR = 1.5).
This chapter presents national estimates from the 2002 National Survey on Drug Use and Health (NSDUH) of the past year prevalence of mental health treatment and substance use treatment among adults with serious mental illness (SMI) and a substance use disorder. The social and demographic characteristics of adults with SMI who received mental health treatment are compared with those who did not receive mental health treatment. Prevalence rates of mental health treatment among adults with SMI by social and demographic characteristics also are presented. Estimates of mental health treatment are given for adults with SMI according to whether they used illicit drugs. Estimates of the prevalence of mental health treatment and/or specialty substance use treatment in 2002 also are presented for adults aged 18 or older with SMI and a substance use disorder, with SMI but no substance use disorder, and with a substance use disorder but no SMI. The prevalence of mental health treatment for those with SMI co-occurring with a substance use disorder is compared with the prevalence among those with SMI but no substance use disorder. Similarly, the prevalence of specialty substance use treatment for those with SMI co-occurring with a substance use disorder is compared with those having a substance use disorder but no SMI.
In 2002, an estimated 8.4 million of the 17.5 million adults with SMI received mental health treatment in the 12 months prior to their interview (Table B.18a). When compared with adults with SMI who did not receive treatment, those who did receive treatment were more likely to belong to the following sociodemographic groups: aged 26 or older, female, non-Hispanic whites, and college graduates. About 62 percent of adults with SMI who received treatment were 26 to 49 years of age compared with about 48 percent of those who did not receive treatment. Females accounted for 71.6 percent of those who received treatment and 59.9 percent of those who did not receive treatment. Non-Hispanic whites made up 78.4 percent of those who received treatment and 66.6 percent of those who did not (Table B.18b). An estimated 21 percent of adults with SMI who received treatment were college graduates compared with 14 percent of those who had not received treatment. Adults with SMI who received treatment were more likely than those who did not to be from small metropolitan counties (34.5 vs. 29.3 percent, respectively), but there were no significant differences by geographic region.
In 2002, an estimated 47.9 percent of adults with SMI received mental health treatment in the 12 months prior to their interview (Table B.19b). The prevalence of mental health treatment among adults with SMI varied by demographic, social, and health characteristics. Among adults with SMI, those aged 26 to 49 had the highest rate of mental health treatment of any age group (54.4 percent) (Figure 14). The rates of mental health treatment among adults with SMI were 46.4 percent for adults aged 50 or older and 34.2 percent for those aged 18 to 25. Females with SMI were more likely than males with SMI to receive mental health treatment (52.3 vs. 39.5 percent, respectively) (Figure 15). More than half of white non-Hispanics with SMI received mental health treatment (51.9 percent) (Figure 16). In comparison, fewer than 40 percent of black non-Hispanics and Hispanics with SMI received mental health treatment (36.9 and 37.8 percent, respectively).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
In 2002, the prevalence of mental health treatment was 48.7 percent for adults with SMI who received social support and 44.0 percent for adults with SMI who did not receive social support (Table B.20b). Adults with SMI who perceived their health as poorer had higher rates of mental health treatment than those who perceived their health to be better. The rate of mental health treatment was highest at 56.0 percent for those with SMI who perceived their health as fair/poor and lowest at 38.7 percent for those who perceived their health as excellent (Figure 17).
Estimates of treatment by health insurance and marital status are presented for persons aged 26 to 49. Among adults aged 26 to 49 years of age with SMI in the past 12 months, rates of mental health treatment varied by health insurance and by marital status (Table B.20b). Those who received Medicaid were more likely to have received mental health treatment in the past 12 months (65.1 percent) than those who had no insurance coverage (37.1 percent) (Figure 18).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
The rate of mental health treatment among persons aged 26 to 49 who were divorced or separated (61.9 percent) was higher than the rate among those who were never married (42.9 percent) (Figure 19).
There was very little regional variation in the prevalence of mental health treatment among adults aged 18 or older with SMI. Rates by geographic region were 50.7 percent in the Northeast, 47.5 percent in the Midwest and South, and 46.3 percent in the West (Table B.21b). By county type, rates of treatment were highest among persons from small metropolitan areas (52.0 percent); rates were similar for large metropolitan areas and nonmetropolitan areas (46.1 and 45.7 percent, respectively) (Figure 20).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Figure 19. Mental Health Treatment among Adults Aged 26 to 49 with Serious Mental Illness, by Marital Status: 2002
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
Among adults with SMI in 2002, the prevalence of mental health treatment did not differ significantly by illicit drug use in the past 12 months. Among the 17.5 million adults who had SMI, 46.0 percent of those using an illicit drug and 48.7 percent of those not using an illicit drug received mental health treatment in the past 12 months (Tables B.22a and B.22b).
This section discusses the prevalence of mental health treatment and specialty substance use treatment received in the past 12 months by three groups: adults who had SMI but no substance use disorder (SMI only), adults who had a substance use disorder but no SMI (substance use disorder only), and adults who had both SMI and a substance use disorder in 2002. Persons with a substance use disorder are those classified as dependent on or abusing alcohol and/or illicit drugs. Mental health treatment for adults with only SMI is described first. Specialty substance use treatment for adults with only a substance use disorder is described next, followed by mental health and specialty substance use treatment for those with both SMI and a substance use disorder. Comparisons of the rates of mental health treatment are made between those with only SMI and those with both SMI and a substance use disorder. Similar comparisons are made for receipt of specialty substance use treatment between adults with only a substance use disorder and with both SMI and a substance use disorder.
As previously noted in Section 3.4, there were 33.2 million adults with either SMI or a substance use disorder in 2002. This includes 13.4 million adults who had only SMI, 4.0 million adults with both SMI and a substance use disorder, and 15.7 million adults who had only a substance use disorder (Figure 10). Among adults with only SMI, almost half (48.4 percent) received mental health treatment in the past year (mental health treatment only, or both mental health and substance use treatment) (Tables B.23a and B.23b). Among adults with SMI and a substance use disorder, 46.0 percent (1.9 million) received mental health treatment, and 13.7 percent (0.6 million) received specialty substance use treatment. An estimated 11.8 percent of adults with SMI and a substance use disorder (0.5 million) received both types of treatment (Figure 21). The prevalence of specialty substance use treatment among adults with only a substance use disorder was 5.3 percent.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
As previously described in Section 3.4 and Figure 11, among the 4.0 million adults with SMI and a substance use disorder, there were 0.9 million adults who were dependent on or abused illicit drugs only, 2.4 million who were dependent on or abused alcohol only, and 0.8 million who were dependent on or abused alcohol and illicit drugs. The prevalence of mental health treatment was 53.6 percent among those adults who had both SMI and were dependent on or abused only illicit drugs, but not alcohol (Table B.25b). This was higher than the prevalence of mental health treatment among those with SMI and dependence on or abuse of alcohol only (42.6 percent), but it was not significantly different from the prevalence of mental health treatment among adults with SMI and no substance use disorder (48.4 percent).
There was very little difference in the prevalence of mental health treatment in the past 12 months among adults with SMI who did or did not have a substance use disorder. Although not significant, the prevalence of mental health treatment was lower among adults with SMI and any substance use disorder than among those with only SMI (46.0 vs. 48.4 percent, respectively) (Table B.25b). However, the prevalence of past year specialty substance use treatment was higher among adults with SMI and a substance use disorder than among adults with only a substance use disorder (13.7 vs. 5.3 percent, respectively) (Figure 21).
The results also indicate that the rate of mental health treatment among adults with only SMI was roughly 9 times higher than the rate of specialty substance use treatment among adults with only a substance use disorder (48.4 vs. 5.4 percent) (Figure 21). Although about 48 percent of adults with both disorders received some type of treatment (mental health or specialty substance use treatment), only 11.8 percent of adults with both disorders received both types of services (Figures 21 and 22, Tables B.23a and B.23b). These results highlight the importance of treating more people who have co-occurring substance use and mental health disorders for both disorders. Similar results were obtained when the analysis was performed using any substance use treatment instead of specialty substance use treatment (Tables B.24a and B.24b).
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002.
The estimated strength of the association between the receipt of mental health treatment among adults with SMI in the past year and various characteristics believed to influence receipt of mental health treatment was determined via multiple logistic regression procedures. Past year receipt of mental health treatment was the dependent variable in the model; any illicit drug or alcohol dependence or abuse, cigarette (nicotine) dependence, and various sociodemographic characteristics were among the independent variables in the model. Adjusted odds ratios (Ores) are presented. (See Appendix A, Section A.5.4, for a discussion of logistic modeling and the interpretation of adjusted Ores.)
The adjusted Ores from the logistic regression models, which controlled for confounding variables, confirmed that, among adults with SMI, the odds of receiving mental health treatment varied by age, gender, Hispanic origin and race, education, employment status, marital status, health insurance coverage, and perception of overall health. However, the odds of receiving mental health treatment among this group did not vary significantly based on geographic region, county type, family income, receipt of social support, nicotine dependence, or any illicit drug/alcohol dependence or abuse.
Examining the adjusted Ores from these models of receiving mental health treatment demonstrates that among adults with SMI, adults aged 26 to 49 were more likely to receive treatment than those aged 50 or older (OR = 1.7) (Table B.M2). No other age groups showed significant differences. With regard to gender and race/ethnicity, females were more likely to receive mental health treatment than men, with an OR of 1.6, and non-Hispanic whites were more likely to receive mental health treatment than any other category of Hispanic origin and race. (The Ores for each of these groups compared with whites are as follows: black or African American, 0.5; Hispanic or Latino, 0.7; and other or more than two races, 0.6.)
When comparisons were made with adults with SMI who graduated from college, those with SMI who did not graduate from high school were less likely to receive mental health treatment (OR = 0.44), as were those with SMI who were high school graduates but had no further education (OR = 0.55). However, the odds of receiving treatment did not vary significantly between adults with SMI who had some college and those who graduated from college.
Among adults with SMI, these models indicate that employment status had an effect on the odds of receiving mental health treatment. Those who were either employed part time or not in the labor force were more likely than those working full time to receive mental health treatment (Ores = 1.6 and 1.5, respectively). However, the odds of receiving treatment for those who were unemployed were not significantly different from those who were employed full time. Adults with SMI who were either divorced or separated were more likely to receive mental health treatment than those who were married (OR = 1.6) and those who had never married (OR = 2.0 calculated by dividing 1.60 by 0.81).
Among adults with SMI, those with private health insurance had twice the odds of receiving mental health treatment as those with no insurance. Similar results were obtained when comparing adults who received Medicaid or adults in the Children's Health Insurance Program (CHIP) with adults having no insurance.
These models also indicated that the perception of overall health status affected the odds of receiving mental health treatment for adults with SMI. When comparisons were made with adults with SMI who perceived their overall health as excellent, all other persons with SMI were more likely to receive mental health treatment. Those who perceived their health as fair or poor had an OR of 2.6, whereas those who perceived their overall health as either good or very good had Ores of 1.6 and 1.4, respectively.
The
results of the modeling also showed that when controlling for confounding variables,
illicit drug or alcohol dependence or abuse was not associated with receipt of
mental health treatment among adults with SMI (
2
= 6.0).
Results from the 2002 NSDUH signifying that individuals with a substance use disorder are more likely to receive specialty substance use treatment if they have a co-occurring SMI are consistent with results from the National Comorbidity Survey-Replication (NCS-R) and Communities Survey (U.S. Department of Health and Human Services, 1999).
According to the 2002 National Survey on Drug Use and Health (NSDUH), there were 17.5 million adults estimated to have a serious mental illness (SMI) in 2002, representing 8.3 percent of all adults in the United States. Adults with SMI were more likely to have each of the following demographic characteristics when compared with adults without SMI: they were younger, female, less educated, non-Hispanic white, unemployed, and not in the labor force. The prevalence of SMI was shown to vary by age, gender, race, education, and employment, as well as by perceived health, social support, marital status, and the use of specific substances. SMI was correlated with illicit drug use, and the prevalence of SMI varied by the type of illicit drug used.
Among adults with SMI, almost 30 percent (5.0 million adults) used illicit drugs. Adults with SMI who used illicit drugs in the past year were more likely than those not using illicit drugs to have each of the following characteristics: male, some college, and employed full or part time. Among adults with SMI who used illicit drugs in the past year, 2.3 million had no substance use disorder.
An estimated 4 million adults had SMI and a substance use disorder in 2002. There were 13.4 million adults with only SMI and 15.7 million adults with only a substance use disorder. The characteristics of adults with SMI and a substance use disorder were similar to the characteristics of adults with SMI and illicit drug use.
The adjusted odds ratios (Ores) from the modeling also showed that SMI is correlated with past year alcohol dependence or abuse, past year illicit drug dependence or abuse, and past year illicit drug use with no substance use disorder. The Chi-square tests of association from the modeling indicated that SMI also is associated with the following characteristics: age, gender, race/ethnicity, education, marital status, health insurance, perceived health, social support, and nicotine (cigarette) dependence.
Almost 50 percent of adults with SMI received mental health treatment. When compared with adults with SMI who did not receive treatment, adults with SMI who received treatment were more likely to belong to each of the following demographic subgroups: aged 26 to 49, female, non-Hispanic white, and college graduates. The past year prevalence of mental health treatment among adults with SMI was highest in each of the following subgroups: aged 26 to 49, female, non-Hispanic white, college graduates, and perceived health fair or poor. For adults aged 26 to 49 with SMI, the prevalence of mental health treatment was highest among those who received Medicaid and among those who were divorced or separated.
The prevalence of mental health treatment in the past year among adults with SMI but no substance use disorder was shown to be much higher than the prevalence of substance use treatment among adults with a substance use disorder but no SMI. In addition, adults with SMI but no substance use disorder were just as likely to receive mental health treatment as those with both SMI and a substance use disorder. However, adults with a substance use disorder and SMI were more likely to receive specialty substance use treatment than adults with a substance use disorder but no SMI. Only a small proportion of persons with SMI and a substance use disorder received both specialty substance use treatment and mental health treatment.
The modeling showed that, among adults with SMI, mental health treatment is associated with each of the following characteristics: age, gender, race, education, current employment, marital status, health insurance, and perceived health, after controlling for possible confounding variables.
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