Transcript The Epidemiology of Co

The Epidemiology of
Co-Occurring Disorders
H. Westley Clark, MD, JD, MPH
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
There is no single road to Recovery. No absolute path. Each
person must identify that which works. Some roads are paved,
some are rough, and others are ill defined. No matter. Recovery
works, but the burden rests on the individual, the family and the
community.
Two Major Contemporary Surveys of
Co-Occurring Disorders
• General
– National Survey of Drug Use and Health
(NSDUH)
• Specific
– National Epidemiologic Survey of Alcohol
Related Conditions (NESARC)
National Survey on Drug Use and Health
•Representative nationally and in each State
•Civilian, non-institutionalized population
•Aged 12 or older
•Face-to-face interview
•Computer-assisted, self-administered
•67,784 respondents in 2003
•2003 data comparable with 2002 data, but not with data
prior to 2002
NATIONAL EPIDEMIOLOGIC SURVEY
ON ALCOHOL AND RELATED
CONDITIONS (NESARC)
• Nationally representative face-to-face survey of
43,093 respondents, 18 years and older.
• Conducted by NIAAA in 2001-2002
• Civilian, non-institutionalized population in United
States in housing, including group quarters.
– Includes Alaska and Hawaii
– Hospitals, jails and prisons not among the group quarters
sampled
• Oversampling of:
– Blacks
– Hispanics
– Young Adults aged 18-24
NSDUH vs. NESARC
• NSDUH 2003 like it’s predecessors is
symptom driven
• NESARC is diagnosis driven
NSDUH: Serious Mental Illness
(SMI)
• Definition: DSM-IV mental disorder and
impairment in past year
• Measurement: K-6 distress scale
• Prevalence in 2003: 19.6 million adults with
SMI (9.2%)
Rates of SMI among Adults Aged 18
or Older, by Age: 2002 and 2003
Percent with Past Year SMI
16.0
13.2
14.0
2002
2003
13.9
12.0
10.0
8.3
9.5
9.2 
10.4 
8.0
5.9
6.0
4.9
4.0
2.0
0.0
18 or Older
,  = Significant change 2002 to 2003
18-25
26-49
Age in Years
50 or Older
Substance Use among Adults
Aged 18 or Older, by SMI: 2003
Percent Using
60.0
53.2 53.9
50.0
44.2
40.0
30.0
20.0
27.3
28.9
25.2
23.5
12.5
10.0
0.0
Past Year Illicit
Drug Use
Past Month
Cigarette Use
Had Past Year SMI
Past Month
Alcohol Use
Past Month Binge
Alcohol Use
Did Not Have Past Year SMI
Treatment for Mental Health Problems
among Adults Aged 18 or Older, by Type of
Treatment and Past Year SMI: 2003
Percent Receiving Treatment in the Past Year
14.0
13.2
No Past Year SMI
Past Year SMI
12.0
10.9
10.0
8.0
7.2
6.0
4.0
2.0
0.8
0.0
Any Treatment
Inpatient
Outpatient
Type of Treatment
Prescription
Medication
Reasons for Not Receiving Treatment in the Past Year
among Persons Aged 18 or Older with SMI Who Did Not
Receive Treatment but Perceived an Unmet Need for
Treatment in the Past Year: 2003
Cost/Insurance Barriers
51.4
Did Not Feel Need for Treatment/
Could Handle the Problem without Treatment
32.7
Did Not Know Where to Go for Services
28.1
Stigma
26.9
Did Not Have Time
16.0
Treatment Would Not Help
11.1
Fear of Being Committed/
Have to Take Medicine
10.5
Other Access Barriers
4.1
0.0
10.0
20.0
30.0
40.0
Percent
50.0
60.0
Substance Dependence or Abuse among Adults
Aged 18 or Older, by SMI: 2003
Percent Dependent or Abusing in Past Year
25.0
21.3
20.0
17.0
15.0
10.0
5.0
8.6
6.7
7.9
2.0
0.0
Any Illicit Drug
Had Past Year SMI
Alcohol
Alcohol or Any Illicit
Drug
Did Not Have Past Year SMI
Co-Occurrence of SMI and Substance Use
Disorders among Adults
Aged 18 or Older: 2003
15.2
Million
Substance
Use
Disorder
Only
15.4
Million
4.2
Million
Co-Occurring
Disorders
SMI
Only
Past Year Treatment among Adults Aged 18 or Older
with Co-Occurring SMI and a Substance Use
Disorder: 2003
Treatment Only
for Mental Health
Problems
Treatment for Both
Mental Health and
Substance Use
Problems
39.8%
7.5%
3.7%
No Treatment
49.0%
4.2 Million Adults with Co-Occurring SMI and
Substance Use Disorder
Substance Use
Treatment Only
Most Adults Who Needed Treatment for Substance Use
Problems Did Not Feel A Need for Treatment
16%
7%
6%
4%
Felt Need for
TX, but untreated
Received TX
78%
Illicit Drugs
Felt No Need for TX
89%
Alcohol
2003 NSDUH
Past Year Receipt of and Perceived Need for
Treatment for Mental Health Problems among
Persons Aged 18 or Older with SMI: 2003
Treated
(9.2 Million)
47%
13%
40%
19.6 Million with SMI
Not Treated,
Perceived
Unmet Need
(2.5 Million)
Not Treated,
No Perceived
Unmet Need
(7.8 Million)
NESARC
Diagnosis Specific
• Used DSM-IV Criteria to Establish
Diagnosis
• Addressed specific diagnostic conditions
and subsets of those conditions
– Mood Disorder
• From Depression to Dysthymia
– Anxiety Disorder
• From Panic to GAD
Prevalence of Mood & Anxiety Disorders
• “Of the approximately 19.3 million adults who had a
current mood disorder, only 202,211 experienced
episodes that were classified exclusively substance
induced.”
• Of the approximately 23 million adults with a
“current anxiety disorder”, only 50,980 experienced
episodes that were exclusively substance induced.
• Of those respondents who were classified as having
at least one current independent mood or anxiety
disorder, only 7.35% and 2.95%, respectively,
experienced independent and substance induced
episodes in the year preceding the survey
Twelve Month Prevalence of
Independent Mood Disorders Among
Those with Substance Use Disorders
SUD
Substance Abuse
Substance Dependence
Percentage
35
30
25
20
15
29.19
21.82
19.67
14.5
12.33
8.85
10
8.25
3.54
5
5.43
4.94
2.08
2.39
+Dysthymia
+Mania
3.3
4.94
2.04
0
+Mood
Disorder
+Major
Depression
+Hypomania
Twelve Month Prevalence of DSM-IV
Substance Use Disorders Among Those
with Independent Mood Disorders
+SUD
+Substance Abuse
+Substance Dependence
27.91
Percentage
30
25
19.97
15
10
20.3
19.2
20
12.91
26.62
18.07
17.33
12.59
12.07
7.05
6.61
6
Mood
Disorder
Major
Depression
Dysthymia
7.61
9.29
5
0
Mania
Hypomania
Twelve Month Prevalence of
Independent Anxiety Disorders Among
Those with Substance Use Disorders
SUD
Substance Dependence
24.54
17.71
10.54
4.72
7.82
+Specific Phobia
3.09
+Social Phobia
2.661.38
+Panic
Disorder-Agora
+Panic
Disorder+Agora
1.46 1 2.05
4.79
6.83
14.06
4.2
6.74
2.24
+GAD
12.45
+Anxiety
Disorder
Percentage
30
25
20
15
10
5
0
Substance Abuse
Twelve Month Prevalence of DSM-IV
Substance Use Disorders Among Those
with Independent Anxiety Disorders
+Substance Abuse
+Substance Dependence
24.15
5.99
13.83
10.12
13.34
8.04
4.69
5.93
5.79
5.74
GAD
9.92
12.6
Specific Phobia
9.02
19.08
16.05
Social Phobia
14.83
17.3
Panic DisorderAgora
14.96
Panic
Disorder+Agora
30
25
20
15
10
5
0
Anxiety
Disorder
Percentage
+SUD
TREATMENT SEEKING
INDIVIDUALS
Locations Where Past Year Substance Treatment
Was Received among Persons Aged 12 or Older:
2002 and 2003
2,021
1,911
Self-Help Group
Outpatient Rehabilitation
Inpatient Rehabilitation
752
Mental Health Center
729 
859
587
523
Hospital Inpatient
Private Doctor's Office
377
469
251
259
206
Emergency Room
Prison or Jail
0
,  = Significant change 2002 to 2003
1,243
1,094
1,536
1,016
2002
2003
300
600
900 1,200 1,500 1,800 2,100 2,400
Numbers (in Thousands) Receiving Treatment
Those with Independent Mood Disorders Who
Seek Treatment For that Disorder Who Also Have:
A Substance Use Disorder, An Alcohol Use
Disorder or A Drug Use Disorder, by Percentage
30
25.81
25
20.78
20
17.48
15
10
7.96
5
0
Any Mood
Disorder
+Substance use
+Alcohol
+Drugs
Those with Any Independent Anxiety Disorder
Who Seek Treatment For That Disorder Who Also
Have: A Substance Use Disorder, An Alcohol Use
Disorder or A Drug Use Disorder, by Percentage
18
16.51
16
14
12
12.49
12.13
10
7.26
8
6
4
2
0
Any Anxiety
+Substance use
+Alcohol
+Drugs
Independent Mood or Anxiety Disorders
Among Those with Drug Use Disorders
who Sought Treatment
Percentage
70
60
60.31
55.16
50
42.63
40
30
20
13.1
10
0
+Mood
Disorder
+Anxiety
+Alcohol
Drugs
21. 3 % (4.2 million people)
Mental
Health
Disorder
60%
19. 6 million people
Substance
Use
Disorder
General Population Survey
(NSDUH)
Drug Use Disorder
Treatment Seeking
Population (NESARC Study)
(16.7 million people )
Mood
Disorders
15%
6%
7%
4%
Felt Need for TX, but
did not receive
Treatment
Received TX
(6 million people need
care for illicit drug use)
79% Felt No Need for TX
Illicit Drugs
89%
Alcohol
2003 NSDUH
64
Significance of NESARC for SAMHSA
• Mood and anxiety disorders are more common
among persons who have substance abuse disorders
than among those who do not. This increase appears
to be independent of the substance of abuse
• Consistent with NSDUH, only a minority of people
with substance use disorders seek treatment---5.81%
alcohol use disorder, 13.1% drug use disorder
– However, of those who do seek treatment
• Of those with alcohol use disorder, 40.69% have a mood disorder
and 33.38% have an anxiety disorder
• Of those with a drug use disorder, 60.31% have a mood disorder
and 42.63 % have an anxiety disorder
Significance of NESARC to SAMHSA
• Of particularly note for SAMHSA is that while only
25.81% of those with a mood disorder seek
treatment, those who also have a substance abuse
disorder are even less likely to seek treatment:
– 20.78% for any substance use disorder
– 17.45% for any alcohol use disorder
– 7.96% for any drug use disorder
– In other words, the presence of a co-occurring substance
use disorder militates against treatment seeking behavior
among persons with mood disorders, and the service
systems are not adequately responsive to persons with cooccurring mood and substance use disorders.
Significance of NESARC to SAMHSA
• Only 5.81% of those with an alcohol use and
13.10% of those with drug use disorders seek
treatment.
• Those who seek treatment with substance use
disorders increase when there is a co-occurring
mood or anxiety disorder.
Significance of NESARC to SAMHSA
Key Policy Questions
How treatment seeking behavior can be increased
among those with substance use disorders?
What can be done to accommodate greater systems
strain from increased demand?
While 13.1% of those with drug use disorders seek treatment,
86.9% do not
Substance Abuse Prevention and Treatment in
Light of NESARC
• The substance abuse prevention and treatment system
needs to improve the accessibility and quality of
services for those with co-occurring disorders.
• The demand for illicit drugs undoubtedly comes from
those who consume such drugs to the point of abuse or
dependence. Hence the social consequences from drug
use and excessive alcohol use cannot be adequately
addressed unless new strategies evolve to reach the
very large population supporting the illicit drug market
and excessively consuming alcohol to the detriment of
themselves and society.
Other Implications for the Substance Abuse
Treatment Community
• Given the high prevalence of co-occurring mood and
anxiety disorders among treatment seeking clients, it is
clear that the substance abuse treatment community must
be able to assess, diagnose and treat those conditions.
– Treatment strategies must be developed to accommodate
different modalities of intervention such as medications,
cognitive behavioral strategies and other strategies
– Without a clear entry assessment of co-occurring conditions
proper care and treatment cannot be rendered
Implications for the Mental Health
Treatment Community
• People with Mood Disorders or Anxiety
Disorders with co-occurring Drug Use
Disorders are not likely to present for
treatment in a mental health clinic
• Apparently, people with Drug Use
Disorders do not feel welcome in programs
that are primarily mental health treatment
oriented.
Where do we go from here?
Reaching the Untreated Patient Suffering
from Substance Use Disorders
• Addressing State laws that translate “serious
emotional illness” into “serious and persistent
emotional illness”
– Thus, limiting access for those with milder forms of mental
illness
• Promoting screening and brief intervention for those
suffering from substance use disorders
– Thus, reaching those with both mild mental illness and
substance use disorders BEFORE conditions grow more
severe
Community Outreach
• Enlisting the vectors of values in a community to
promote interventions and to facilitate Recovery
–
–
–
–
–
–
–
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Community Based Organizations
Faith Based Organizations
Self Help Groups
Families
Employers/Business/Labor
Recovery Community/Peer Support
Law Enforcement
Child Welfare
Substance Abuse Treatment
Criminal & Juvenile Justice
Prevention
Mental Health
Primary Care
People
in Recovery
Substance Abuse Treatment Capacity
Strategic Prevention Framework
Mental Health System Transformation
Primary healthcare
Child welfare
Criminal & Juvenile justice system
Housing
Education
Business
Labor
Community & Faith-based organizations
Many Pathways to