Prevalence_Treatment_And_Unm.pdf

By Beth Han, Wilson M. Compton, Carlos Blanco, and Lisa J. Colpe

Prevalence, Treatment, And UnmetTreatment Needs Of US AdultsWith Mental Health AndSubstance Use Disorders

ABSTRACT We examined prevalence, treatment patterns, trends, andcorrelates of mental health and substance use treatments among adultswith co-occurring disorders. Our data were from the 325,800 adults whoparticipated in the National Survey on Drug Use and Health in the period2008–14. Approximately 3.3 percent of the US adult population, or7.7 million adults, had co-occurring disorders during the twelve monthsbefore the survey interview. Among them, 52.5 percent received neithermental health care nor substance use treatment in the prior year. The9.1 percent who received both types of care tended to have more seriouspsychiatric problems and physical comorbidities and to be involved withthe criminal justice system. Rates of receiving care only for mentalhealth, receiving treatment only for substance use, and receiving bothtypes of care among adults with co-occurring disorders remainedunchanged during the study period. Low perceived need and barriers tocare access for both disorders likely contribute to low treatment rates ofco-occurring disorders. Future studies are needed to improve treatmentrates among this population.

Substance use disorders and mentaldisorders influence each other, andtheir combined presentation (here-after referred to as co-occurringdisorders) results in more profound

functional impairment; worse treatment out-comes; higher morbidity and mortality; in-creased treatment costs; and higher risk forhomelessness, incarceration, and suicide thaneach of the individual disorders.1–4 Current treat-ment guidelines recommend that people with co-occurring disorders receive treatments for bothdisorders.5–7 However, little is known about thetwelve-month prevalence, service use patterns,correlates of mental health and substance usetreatments, and unmet treatment need amongUS adults with co-occurring disorders.Recent studies indicate that the prevalence of

opioid use disorders and marijuana use amongadults has increased in recent years.8,9 It is im-

portant to determine whether these specific in-creases led to greater overall prevalence of co-occurring disorders, because adults with opioidor marijuana use disorders are likely to have co-occurring mental illness.8,9 Also, two recent stud-ies reported that between 2005–07 and 2014 andbetween 2004 and 2013, respectively, among theoverall US adult population, receipt of mentalhealth care increased (primarily as a result ofincreasing use of psychiatric medications), andreceipt of substance use treatment remainedstable.10,11 However, it is unknown whether therehave been similar changes in patterns of care foradults with co-occurring disorders.The Paul Wellstone and Pete Domenici Mental

Health Parity and Addiction Equity Act of 2008required insurance coverage of mental healthand substance use treatments to be equal to cov-erage of general medical care.12 Moreover, pro-visions of the Affordable Care Act (ACA) may

Beth Han is a researcher atthe Substance Abuse andMental Health ServicesAdministration, in Rockville,Maryland.

Wilson M. Compton([email protected]) isdeputy director of theNational Institute on DrugAbuse, in Rockville.

Carlos Blanco is director ofthe Division of Epidemiology,Services, and PreventionResearch, National Instituteon Drug Abuse.

Lisa J. Colpe is chief of theOffice of Clinical andPopulation EpidemiologyResearch, National Institute ofMental Health, in Bethesda,Maryland.

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facilitate access to and integration of mentalhealth care and substance use treatment foradults with co-occurring disorders.13–17 The ACAexpanded and highlighted parity of insurancecoverage of treatments for mental illness andsubstance use disorders. It also emphasizedexpanding coverage and improving qualitythrough better integration of behavioral withgeneral medical services.14–17 It is unknownwhether these policies have led to changes intreatment rates of co-occurring disorders.Thus, using a large, nationally representative

data set on co-occurring disorders and mentalhealth and substance use treatments, we exam-ined the following understudied questions:Whatwas the recent prevalence of twelve-month co-occurring disorders among adults in the UnitedStates? What were the patterns of mental healthand substance use treatments received by adultswith co-occurring disorders? Did these patternschange during the period 2008–14? What rea-sons for not receiving mental health and sub-stance use treatments were reported by adultswith co-occurring disorders who perceived un-met treatment needs?Addressing the gaps in knowledge inherent

in our research questions may identify wherespecialized services or targeted outreach effortsmight be developed and may improve treatmentrates for both disorders among this population.

Study Data And MethodsData Sources We examined data on adults ageseighteen and older who participated in the Na-tional Survey on Drug Use and Health in theperiod 2008–14. We used that study period be-cause data on mental illness are available start-ing with 2008 and because data on substance usedisorders after 2015 are not comparable withprevious data, because of changes in the surveyitems.The National Survey on Drug Use and Health

was conducted each year by the Substance Abuseand Mental Health Services Administration(SAMHSA). It provides nationally representativedata on mental illness, mental health care, sub-stance use disorders, and substance use treat-ment among the US civilian noninstitutional-ized population ages eighteen and older. Wecalculated an annual mean weighted responserate of 63.5 percent for the 2008–14 surveys,according to the definition of response rate 2of the American Association for Public OpinionResearch.19 Details regarding survey methodshave been published elsewhere.18

Measures▸ MENTAL ILLNESS: Mental illness among

adults ages eighteen and older was defined as

currently having or at any time in the past yearhaving had a diagnosable mental disorder (ex-cluding developmental disorders and substanceuse disorders) of sufficient duration to meet thediagnostic criteria specified in the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edi-tion (DSM-IV).20

Based on data from the 2008–12 MentalHealth Surveillance Study, a model was devel-oped to predict both past-year mental illness sta-tus (yes or no) and serious mental illness status(yes or no) for each respondent in the adultsamples of the National Survey on Drug Useand Health since 2008.21 We used the mentalillness variable to identify respondents withmental disorders, and we used the serious men-tal illness variable to control for the severity ofmental illness in multivariable models.▸ SUBSTANCE USE DISORDERS: The surveys

estimated substance use disorders (dependenceon or abuse of alcohol or an illicit drug) duringthe previous twelve months based on assess-ments of individual diagnostic criteria in theDSM-IV.20 The severity of substance use disor-ders was measured by the number of criteria metacross these substances.22–25

▸ MENTAL HEALTH CARE AND PERCEIVED UN-

MET NEED: All adult survey respondents wereasked to report on their receipt of inpatient oroutpatient care or receipt of prescription medi-cations for mental health problems in the pastyear. Inpatient care includes services received atthe following locations: a psychiatric hospital,the psychiatric unit of a general hospital, themedical unit of a general hospital for mentalhealth treatment, or another type of hospitalfor mental health care. Outpatient care includesservices received at following locations: a com-munity mental health center, the office of a pri-vate therapist for mental health care (a psychol-ogist, psychiatrist, social worker, or counselor),the office of a private physician (nonpsychia-trist), an outpatient medical clinic for mentalhealth care, a day treatment program for mentalhealth care, or another type of facility for mentalhealth care.The surveys asked all adult respondents

whether they perceived that they had had unmetneed for mental health care in the past year.Those who perceived this need for care and didnot receive it were asked to report reasons whythey did not receive it.▸ SUBSTANCE USE TREATMENT AND PER-

CEIVED UNMET NEED: Substance use treatmentrefers to treatment received for the use of illicitdrugs or alcohol or for medical problems associ-ated with that use.26 It includes treatment re-ceived in the past year at a hospital (inpatient),rehabilitation facility (outpatient or inpatient),

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mental health center, emergency department(ED), the office of a private physician, or prisonor jail. The surveys asked adults with substanceuse problems whether they perceived that theyhad had unmet need for substance use treatmentin the past year. Those who perceived unmetneed for that treatment and who had not receivedit were asked to report reasons why they did notreceive it.

▸ HEALTH STATUS: The surveys capturedrespondents’ self-rated health and the numberof ED visits in the past year. Physical co-morbidities were assessed by asking adultrespondents if they had been told by a doctoror other health care professional in the past yearthat they had hypertension, heart disease, diabe-tes, stroke, asthma, bronchitis, sinusitis, pneu-monia, hepatitis, sexually transmitted diseases,HIV/AIDS, ulcers, tuberculosis, sleep apnea, tin-nitus, pancreatitis, cirrhosis, or lung cancer.Weused this list to compute the total number ofphysical comorbidities.

▸ SOCIODEMOGRAPHIC CHARACTERISTICS

AND CRIMINAL JUSTICE INVOLVEMENT: We ana-lyzed respondents’ age, sex, race/ethnicity, edu-cation, employment status, health insurance sta-tus, marital status, annual family income as apercentage of the federal poverty level, residencein any Metropolitan Statistical Area, census re-gion, and survey year. We also assessed justiceinvolvement, which was defined by having hadany arrest and booking, probation, or parole inthe past year.27

Item response rates on the surveys are high.Moreover, missing values are imputed in thesurvey using predictive mean neighborhoods28,29

or a modified version of that method.29

Statistical Analyses Analyses were con-ducted in four stages. First, we estimated thetwelve-month prevalence of co-occurring disor-ders among US adults, the twelve-month preva-lence of receiving mental health care and sub-stance use treatment, and detailed treatment

patterns among adults with co-occurring disor-ders. Second, we assessed the twelve-monthprevalenceof receipt of neithertype of care, men-tal health care only, substance use treatmentonly, and both types of care among this popula-tion, according to sociodemographic character-istics, health status, serious mental illness, se-verity of substance use disorders, and criminaljustice involvement.Third, we used bivariable and multivariable

multinomial logistic regression models to assesscorrelates of receipt of mental health and sub-stance use treatments. Multicollinearity (usingvariance inflation factors) and potential interac-tion effects between examined factors were as-sessed and were not found in the final multivari-able model.Finally, we assessed the prevalence of per-

ceived unmet treatment needs for mental healthcare and for substance use treatment amongadults with co-occurring disorders who did notreceive the corresponding care and who pre-sented their commonly reported reasons fornot receiving the care.We used SUDAAN, version11.0.1,30 to account for the complex sample de-sign and sampling weights of the survey data.Limitations This study had several limita-

tions. First, the surveys did not cover homelesspeople not living in shelters, active-duty mem-bers of the military, or people residing in insti-tutions. However, the surveys covered homelesspeople who lived in shelters and included adultswho had been discharged from institutions at thetime of the survey interview.Second, the surveys did not measure the qual-

ity and exact timing of receipt of mental healthcare and substance use treatment at differentsettings. Third, the surveys did not ask aboutsubstance use treatment provided in outpatientmedical clinics.Fourth, the surveys did not measure the fre-

quency or duration of substance use treatment.Fifth, they did not query for specific mental dis-orders, except for major depressive episode andsubstance use disorders. However, mood disor-ders, anxiety disorder, eating disorder, adjust-ment disorder, and psychotic symptoms (delu-sions, hallucinations, or both) are likely to berepresented among adults with mental illness inthe sample.31

Finally, the survey data were self-reported andsubject to recall bias.

Study ResultsBased on the 325,800 sampled adults ages eigh-teen and older from the 2008–14 surveys, weestimated that an annual average of 3.3 percentof the US adult population, or 7.7 million adults,

Our findingsdocument a large gapbetween theprevalence of co-occurring disordersand treatment rates.

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had co-occurring mental illness and substanceuse disorders in the past year (data not shown).In particular, among the 42.1 million adults withmental illness, 18.2 percent also had substanceuse disorders. Among the 20.3 million adultswith substance use disorders (annual average),37.9 percent also had mental illness. The overallprevalence of co-occurring disorders was gener-ally stable during the study period (for the over-all trend, p = 0.7785).Patterns Of Mental Health And Substance

Use Treatments Among adults with co-occur-ring disorders, 43.6 percent received any mental

health care in the prior year (Exhibit 1), whichwas slightly higher than the correspondingmental health treatment rate among adults withmental illness, regardless of co-occurring status(42.1 percent; data not shown). Also amongadults with co-occurring disorders, 13.0 percentreceived substance use treatment in the past year(Exhibit 1), which was 67 percent higher thanthe corresponding substance use treatment rateamong adults with substance use disorders re-gardless of co-occurring status (7.8 percent; datanot shown).Among adults with co-occurring disorders,

9.1 percent received both mental health careand substance use treatment, 34.5 percentreceived mental health care only, 3.9 percentreceived substance use treatment only, and52.5 percent received neither mental health carenor substance use treatment (Exhibit 1). For de-tailed patterns of receiving outpatient and in-patient mental health care and substance usetreatment, see the online Appendix Exhibit.32

Twelve-Month Prevalence Of TreatmentsExhibit 2 shows that among US adults with co-occurring disorders, the annual rates of receiv-ing neither type of care, mental health care only,substance use treatment only, and both types ofcare remained stable during the study period.Correlates Of Treatments Consistent with

the bivariable results, our multivariable resultsshowed that the adjusted prevalence of receivingneither type of care, mental health care only,substance use treatment only, and both typesof care remained stable during the study period(Exhibit 3).Compared to receiving both types of care, after

adjustment for covariates, the following charac-

Exhibit 1

Mental health and substance use treatment received in the prior year by US adults withco-occurring disorders, 2008–14

Treatment received in the prior yearAnnual averageweighted percentage

Any mental health or substance use treatment 47.5

Any mental health treatment 43.6Any outpatient treatment 24.1Any inpatient treatment 5.5Any prescription medication for mental health problems 37.2

Any substance use treatment 13.0

Both mental health and substance use treatment 9.1

Mental health only 34.5

Substance use only 3.9

Neither mental health nor substance use treatment 52.5

SOURCE Authors’ analysis of data for 2008–14 from the National Survey on Drug Use and Health.NOTES N = 15,800. The Substance Abuse and Mental Health Services Administration requires thatany description of overall sample sizes based on the restricted-use data files be rounded to thenearest 100 to minimize potential disclosure risk. “Any mental health care” is inpatient oroutpatient mental health care or prescription medication for mental health problems (for a fullerdefinition, see the text).

Exhibit 2

Mental health and substance use treatment received in the prior year by US adults with co-occurring disorders, 2008–14

Adults who received:Versus receiving both types of care, oddsratio of receiving:

Year NeitherMentalhealth only

Substanceuse only Both Neither

Mentalhealth only

Substanceuse only

2008 (ref) 54.0% 33.1% 4.1% 8.9% 1.0 1.0 1.0

2009 51.3 35.5 3.9 9.3 0.9 1.0 0.9

2010 51.1 35.8 3.1 10.0 0.8 1.0 0.7

2011 53.2 33.7 4.0 9.2 0.9 1.0 0.9

2012 53.1 33.0 4.9 9.0 1.0 1.0 1.2

2013 51.7 36.9 3.3 8.0 1.1 1.2 0.9

2014 53.3 33.4 3.9 9.5 0.9 0.9 0.9

SOURCE Authors’ analysis of data for 2008–14 from the National Survey on Drug Use and Health. NOTES N = 15,800. The SubstanceAbuse and Mental Health Services Administration requires that any description of overall sample sizes based on the restricted-usedata files has to be rounded to the nearest 100 to minimize potential disclosure risk. Percentages might not sum to 100 because ofrounding. The odds ratios were calculated from bivariable multinomial logistic regressions. None of the differences between thereference year and other years was significant (p < 0:05). None of the unadjusted odds ratios was significant.

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teristics were associated with receiving neithertype of care: having no physical comorbidities,having no serious mental illness, meeting threeor fewer substance use disorder criteria acrosssubstances, having no criminal justice involve-ment, and being uninsured. Similarly, the fol-lowing characteristics were associated with re-ceiving mental health care only: meeting three orfewer substance use disorder criteria across sub-stances and having no criminal justice involve-ment. And the following characteristics were as-sociated with receiving substance use treatmentonly: having no physical comorbidities, havingno serious mental illness, having criminal justiceinvolvement, and being uninsured.

Perceived Unmet Need For Mental HealthCare Among the 7.7 million US adults with co-occurring disorders, 4.3 million (56.4 percent)did not receive mental health care in the pastyear. Among those who did not receive care,1.1 million (24.3 percent) perceived an unmetneed for it in the past year (data not shown)and reported their reasons. The most commonwere inability to afford the treatment cost(52.2 percent), not knowing where to go fortreatment (23.8 percent), and believing at thetime that the problem could be handled withouttreatment (23.0 percent) (Exhibit 4).

Perceived Unmet Need For Substance UseTreatment Among the 7.7 million US adultswith co-occurring disorders, 6.1 million(87.0 percent) did not receive substance usetreatment in the past year. Among those whodid not receive treatment, only 633,000 (9.5 per-cent) perceived an unmet need for it in the pastyear (data not shown) and reported their rea-sons. The most common was not being readyto stop using the substance(s) (38.4 percent),and the second most common was having nohealth insurance and being unable to affordthe cost (35.1 percent) (Exhibit 5).

DiscussionUsing recent nationally representative data, weexamined the annual prevalence, treatment pat-terns, correlates, and unmet treatment needsfor co-occurring disorders among adults in theUnited States. Approximately 3.3 percent of theUS adult population (or 7.7 million adults) hadtwelve-month co-occurring disorders (annualaverages). In contrast to our earlier findingson the increases in opioid use disorders andmarijuana use,8,9 the prevalence of alcohol usedisorders among US adults declined33—whichmay help explain why the prevalence of co-occur-ring disorders was stable during the period2008–14.Despite current treatment guidelines that call

for both types of disorders to be treated whenthey co-occur,5–7 only 9.1 percent of adults withco-occurring disorders received both types ofcare in the past year, and 52.5 percent receivedneither mental health care nor substance usetreatment. Our findings document a large gapbetween the prevalence of co-occurring disor-ders and treatment rates among adults withthose disorders in the United States.Compared to adults with mental illness, adults

with co-occurring disorders had a slightly highermental health treatment rate (43.6 percent ver-

Exhibit 3

Treatment patterns among US adults with co-occurring disorders, by selectedcharacteristics, 2008–14

Versus receiving both types of treatment, adjusted oddsratio of receiving:

Neither typeof treatment

Mental healthtreatment only

Substance usetreatment only

Year

2008 (ref) 1.0 1.0 1.02009 1.0 1.1 0.92010 1.0 1.1 0.82011 1.2 1.1 1.12012 1.1 1.1 1.42013 1.2 1.3 1.02014 0.9 0.9 1.2

Number of physical comorbidities

0 (ref) 1.0 1.0 1.01 0.7* 1.1 0.5**2 0.5*** 0.9 0.63 or more 0.9 1.0 0.9

Serious mental illness

Yes 0.3**** 0.8* 0.4****No (ref) 1.0 1.0 1.0

Number of substance use disorder criteriaa met

1–3 (ref) 1.0 1.0 1.04–6 0.4*** 0.4*** 1.17–9 0.1**** 0.2**** 0.910 or more 0.1**** 0.1**** 0.9

Criminal justice involvementb in prior year

Yes 0.3**** 0.4**** 1.5**No (ref) 1.0 1.0 1.0

Type of health insurance

Private only (ref) 1.0 1.0 1.0None 2.1**** 1.0 1.7**Medicaid 0.9 1.0 1.3Other 1.0 0.9 1.3

SOURCE Authors’ analysis of data from the 2008–2014 National Survey on Drug Use and Health.NOTES N = 15,800. The Substance Abuse and Mental Health Services Administration requiresthat any description of overall sample sizes based on the restricted-use data files be rounded tothe nearest 100 to minimize potential disclosure risk. Odds ratios were adjusted for all of thevariables in Exhibit 3 and also controlled for age, sex, race/ethnicity, education, employment,marital status, family income as a percentage of the federal poverty level, census region,residence in any Metropolitan Statistical Area, self-rated health, and the number of emergencydepartment visits in the past year. aCriteria for substance use disorder from AmericanPsychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Note 20 in text).bAny arrest and booking, probation, or parole. *p < 0:10 **p < 0:05 ***p < 0:01 ****p < 0:001

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sus 42.1 percent). Compared to adults with sub-stance use disorders, adults with co-occurringdisorders had a 67 percent higher substanceuse treatment rate (13.0 percent versus 7.8 per-cent). We found that adults with co-occurringdisorders who received both types of care tendedto have more serious psychiatric problems and

physical comorbidities and to be more likely tobe involved with the criminal justice system thanthose who did not receive both types of care. Thissuggests that appropriate services are reachingsome of the people in most need. However, lowperceived need (especially for treating substanceuse disorders) and barriers to care access forboth disorders likely contribute to low treatmentrates of co-occurring disorders.Low perceived need has consistently been a

major barrier to treatment seeking.34 The Na-tional Comorbidity Survey Replication studiesfound that low perceived need was reported by44.8 percent of respondents with a disorder whodid not seek treatment34 and that 23.1–47.3 per-cent of people with lifetime substance use disor-ders never made treatment contact.35 We foundthat almost a quarter of adults with co-occurringdisorders who did not receive mental health careperceived an unmet need for that care. Of those,more than half reported an inability to afford thetreatment cost, and almost another quarter didnot know where to go for treatment—which sug-gests a need to improve the awareness of treat-ment locations. By contrast, among adults withco-occurring disorders who did not receive sub-stance use treatment, fewer than a tenth per-ceived an unmet need for substance use treat-ment. This indicates that increasing theperception of need for treatment may be evenmore critical in the case of substance use disor-ders to increase treatment rates.Without perceiv-ing need for treatments for both types of disor-ders, it is unlikely that these adults will seek orreceive timely substance use treatment and men-tal health care.In addition to low perceived need among

adults with co-occurring disorders, financial bar-riers can impede treatment seeking.13–15,36,37 Con-sistent with the results of these previous studies,we found that among adults with co-occurringdisorders who perceived a need for mental healthcare but did not receive it, 52.2 percent reportedthat they could not afford the cost. Also amongadults with co-occurring disorders who per-ceived a need for substance use treatment butdid not receive it, 35.1 percent reported that theyhad no health insurance and could not affordthe cost.Importantly, this study found that treatment

rates of all types for adults with co-occurringdisorders did not change significantly duringthe period 2008–14. Although barriers may begreater for substance use treatment than formental health care,11 for adults with co-occurringdisorders, we did not find an increase in receiptof only mental health care, either. In contrast,other research has found that receipt of mentalhealth treatment increased among the overall

Exhibit 4

Percentages of adults with co-occurring disorders and a perceived unmet need for mentalhealth care who reported common reasons for not receiving that care in the prior year

SOURCE Authors’ analysis of data for 2008–14 from the National Survey on Drug Use and Health.NOTES N = 2,500. The Substance Abuse and Mental Health Services Administration requires that anydescription of overall sample sizes based on the restricted-use data files be rounded to the nearest100 to minimize potential disclosure risk. The percentages were annual average weighted estimates.

Exhibit 5

Percentages of adults with co-occurring disorders and a perceived unmet needs forsubstance use treatment who reported common reasons for not receiving that treatmentin the past year

Authors’ analysis of data for 2008–14 from the National Survey on Drug Use and Health. NOTESN = 600. The Substance Abuse and Mental Health Services Administration requires that any descrip-tion of overall sample sizes based on the restricted-use data files be rounded to the nearest 100 tominimize potential disclosure risk. The percentages were annual average weighted estimates.

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adult population10,11,38 and among mentally illbaby boomers and Generation X38 during thistime period, although substance use treatmentin these groups remained unchanged.11 Also, wefound that the interaction effect between surveyyear and health insurance status was not signifi-cant, which indicates that the impact of healthinsurance status on treatment outcomes amongadults with co-occurring disorders did not varyby survey year.Thus, it appears that implementing the Mental

Health Parity and Addiction Equity Act and theACA created incentives for health care systemsto address behavioral health issues14–16 that mayhave had an impact on overall mental healthservice delivery but might not yet have affectedpeople with substance use disorders, includingthose with co-occurring disorders. Future re-search is needed to continue to assess trendsin mental health care and substance use treat-ments among this population and examinewhether current incentives in the parity lawand the ACA are insufficient, may need moretime to have an impact, or may vary across states.The percentage of mental health facilities in

the United States offering programs for patientswith co-occurring disorders decreased from58.4 percent in 2010 to 53.0 percent in 2014,although the percentage of substance use treat-ment facilities offering such programs increasedfrom 37.2 percent in 2008 to 44.2 percent in2014.39,40 We found that among adults with co-occurring disorders, 34.5 percent received men-tal health care only, and 3.9 percent receivedsubstance use treatment only. Thus, treatmentrates of co-occurring disorders could be im-

proved if patients entering treatment for mentaldisorders were screened for substance use disor-ders and given high-quality substance use treat-ment in mental health care settings. Specialtytreatment programs for substance use problemsdo increasingly offer evaluation and treatment ofco-occurring mental disorders. Adults who arereferred to specialty substance use treatmentmay be more likely to receive treatment for co-occurring mental disorders. Future research isneeded to understand why the percentage of USmental health facilities offering programs forpatients with co-occurring disorders is declin-ing, and why fewer than half of US substanceuse treatment facilities offer programs for pa-tients with co-occurring disorders.Furthermore, we found that 52.5 percent of

adults with co-occurring disorders received nei-ther mental health care nor substance use treat-ment in the past year. Our results suggest a needto screen for and treat co-occurring disorders.Given the prevalence of these disorders, this ap-proach should be taken not just by specialty be-havioral health practitioners, but by cliniciansthroughout medicine.16 Efforts to integrate be-havioral health screening, referral, and treat-ment into general medical settings may benefitthis vulnerable population. However, some pa-tients with co-occurring disorders have complexneeds and may require specialty care.

ConclusionThis study provided recent national estimates onthe twelve-month prevalence of co-occurring dis-orders among US adults, twelve-month patternsand correlates of mental health care and sub-stance use treatments, and unmet treatmentneeds among adults with co-occurring disordersin the United States. Despite current treatmentguidelines, fewer than 10 percent of adults withco-occurring disorders receive treatment forboth disorders, and fewer than 50 percent re-ceive treatment for just one disorder. Further-more, these treatment rates do not seem to haveimproved over time. Our study highlights thefact that low perceived need (especially for treat-ing substance use disorders) and barriers to careaccess for both disorders likely contribute to lowtreatment rates of co-occurring disorders. Ourresults suggest a need to screen for and treatthese disorders. Future studies are needed toidentify effective approaches to increasing treat-ment rates of co-occurring disorders amongadults in the United States. ▪

More than half ofadults with co-occurring disordersreceived neithermental health care norsubstance usetreatment in the pastyear.

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Unrelated to the submitted work, WilsonCompton reports ownership of stock inGeneral Electric Co., 3M Co., and PfizerInc. Carlos Blanco reports ownership ofstock in General Electric Co. and Eli LillyInc. The findings and conclusions of this

study are those of the authors and donot necessarily reflect the views of theSubstance Abuse and Mental HealthServices Administration, the NationalInstitute on Drug Abuse of the NationalInstitutes of Health, or the National

Institute of Mental Health of theNational Institutes of Health, within theUS Department of Health and HumanServices.

NOTES

1 Compton WM, Thomas YF, StinsonFS, Grant BF. Prevalence, correlates,disability, and comorbidity of DSM-IV drug abuse and dependence in theUnited States: results from the Na-tional Epidemiologic Survey on Al-cohol and Related Conditions. ArchGen Psychiatry. 2007;64(5):566–76.

2 Mojtabai R, Chen LY, Kaufmann CN,Crum RM. Comparing barriers tomental health treatment and sub-stance use disorder treatmentamong individuals with comorbidmajor depression and substance usedisorders. J Subst Abuse Treat. 2014;46(2):268–73.

3 Grant BF, Stinson FS, Dawson DA,Chou SP, Dufour MC, Compton W,et al. Prevalence and co-occurrenceof substance use disorders and in-dependent mood and anxiety disor-ders: results from the National Epi-demiologic Survey on Alcohol andRelated Conditions. Arch Gen Psy-chiatry. 2004;61(8):807–16.

4 Hartz SM, Pato CN, Medeiros H,Cavazos-Rehg P, Sobell JL, KnowlesJA, et al. Comorbidity of severe psy-chotic disorders with measures ofsubstance use. JAMA Psychiatry.2014;71(3):248–54.

5 Watkins KE, Hunter SB, BurnamMA, Pincus HA, Nicholson G. Reviewof treatment recommendations forpersons with a co-occurring affectiveor anxiety and substance use disor-der. Psychiatr Serv. 2005;56(8):913–26.

6 Pettinati HM, O’Brien CP, DundonWD. Current status of co-occurringmood and substance use disorders: anew therapeutic target. Am J Psy-chiatry. 2013;170(1):23–30.

7 Pettinati HM, Oslin DW, KampmanKM, Dundon WD, Xie H, Gallis TL,et al. A double-blind, placebo-con-trolled trial combining sertralineand naltrexone for treating co-occurring depression and alcoholdependence. Am J Psychiatry. 2010;167(6):668–75.

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32 To access the Appendix, click on theDetails tab of the article online.

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United States: results from the 2014National Survey on Drug Use andHealth [Internet]. Rockville (MD):Substance Abuse and Mental HealthServices Administration; 2015 Sep.Figure 33: alcohol use disorder in thepast year among people aged 12 orolder, by age group: percentages,2002–2014; [cited 2017 Sep 5].(HHS Publication No. SMA 15-4927). Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm#idtextanchor061

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36 Han B, Gfroerer J, Kuramoto SJ, AliM, Woodward AM, Teich J. Medicaidexpansion under the Affordable Care

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39 Substance Abuse and Mental HealthServices Administration. NationalMental Health Services Survey, 2010and 2014 [Internet]. Rockville (MD):SAMHSA; [cited 2017 Sep 6]. Avail-able from: https://wwwdasis.samhsa.gov/dasis2/nmhss.htm

40 Substance Abuse and Mental HealthServices Administration. NationalSurvey of Substance Abuse Treat-ment Services, 2008–14 [Internet].Rockville (MD): SAMHSA; [cited2017 Sep 6]. Available from: https://wwwdasis.samhsa.gov/dasis2/nssats.htm

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