Mental health treatment utilization among Gulf War era veterans with probable alcohol use disorder

INTRODUCTION

Alcohol use disorder (AUD) is prevalent among veterans, and excessive alcohol use is associated with significant mental and physical health consequences. Currently, the largest cohort of veterans seeking services at the VA are those from the 1990s Gulf War Era. This cohort of veterans is unique due to the nature of their deployment resulting in a myriad of unexplained symptoms collectively known as "Gulf War Illness" and higher rates of mental health problems. The present study sought to examine the association between probable AUD and mental health treatment utilization in a sample of 1126 (882 male) Gulf War-era veterans.

METHODS

Veterans completed a self-report survey including the AUDIT-C, questions about mental health treatment engagement, and demographic questions.

RESULTS

Results demonstrated that approximately 20 % of the sample screened positive for probable AUD, determined by standard AUDIT-C cutoff scores. Among those screening positive for AUD, 25 % reported engaging in mental health treatment in the past year. Veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Use of mental health services was associated with mental health comorbidity and identifying as Black/African American.

CONCLUSIONS

The results of the present study highlight a significant unmet need for mental health treatment among Gulf War-era veterans with AUD.

What Attributes of Integrated Health Care for Mental Health Are the Most Important to Potential Consumers? A Relative Ranking Study

Integrated health care (IHC) is efficacious, cost-effective, and more attractive to some consumers than traditional standalone psychotherapy, but the specific characteristics of IHC that drive this enhanced attraction have yet to be explored among potential future mental health consumers. As such, this brief report documents the results of a survey of 428 US adults who were asked to rank order the relative personal importance of seven characteristics (e.g., self-stigma mitigation, prompt appointment, saving money). These seven characteristics have been characterized in the IHC literature as potential beneficial elements of seeking mental health care from a provider in certain integrated health care settings. Getting sufficient information about one's health and treatment from one's provider was rated as most important, whereas co-location of mental/medical care and treatment privacy were rated as least important. The authors found evidence for select hypothesized demographic effects (e.g., interprovider communication rated more important for older adults) on how these factors were ranked. Professionals invested in developing and improving mental health care systems that are attractive and accessible to consumers in need of mental health care can consider the present findings when making decisions about which characteristics (e.g., getting sufficient information) should be maximized in the design and marketing of such systems. Future research, particularly longitudinal studies that assess prospective treatment seeking behavior, can build on the present study by examining the degree to which these attributes attract consumers to IHC settings.

Addiction Medicine Treatment Utilization by Race/Ethnicity Among Adolescents With Substance Use Problems Before Versus During the COVID-19 Pandemic

PURPOSE

To examine changes in addiction medicine treatment utilization during the COVID-19 pandemic among adolescents (aged 13-17 years) and differences by race/ethnicity.

METHODS

We compared treatment initiation (overall and telehealth), engagement, and 12-week retention between insured adolescents with substance use problems during pre-COVID-19 (March to December 2019, n = 1,770) and COVID-19 (March to December 2020, n = 1,177) using electronic health record data from Kaiser Permanente Northern California.

RESULTS

Compared to pre-COVID-19, odds of treatment initiation, overall (adjusted odds ratio [95% confidence interval] = 1.42 [1.21-1.67]), and telehealth (5.98 [4.59-7.80]) were higher during COVID-19, but odds of engagement and retention did not significantly change. Depending on the outcome, Asian/Pacific Islander, Black, and Latino/Hispanic (vs. White) adolescents had lower treatment utilization across both periods. Changes in utilization over time did not differ by race/ethnicity.

DISCUSSION

Addiction medicine treatment initiation increased among insured adolescents during the pandemic, especially via telehealth. Although racial/ethnic disparities in treatment utilization persisted, they did not worsen.

Working Through the Pain: A Cross-Sectional Survey on Musculoskeletal Pain Among Surgeons and Residents

INTRODUCTION

While prior studies have reported that over 80% of surgeons report musculoskeletal pain, to our knowledge, the degree of care required to manage these symptoms has not been discussed. Here, we present granular data on musculoskeletal treatment modalities used by surgeons and residents at a single institution.

METHODS

We distributed a survey to assess the prevalence of musculoskeletal pain and treatment utilization to surgery attending and residents at a single institution.

RESULTS

Fifty-five out of 115 residents and attending (47.8%) responded to our survey. Among the respondents, 87.3% reported pain within the past week and 76.4% (42/55) of respondents required treatment for musculoskeletal pain and injuries: 63.6% had taken over the counter pain medication, 10.9% had taken prescription pain medication, 25.5% required physical therapy, 14.5% required orthopedic surgery, 23.6% made an appointment with a specialist, and 21.8% required additional testing (i.e., imaging, labs). Interestingly, treatment utilization overall and by modality was similar between residents and attending surgeons.

CONCLUSIONS

Our study mirrors the high prevalence of musculoskeletal pain in surgeons that has been previously reported in the literature. Among survey respondents, 76.5% of surgeons and 76.2% of residents required some form of treatment. These findings suggest a significant burden of musculoskeletal disorders of likely multifactorial etiologies including operating room ergonomics. Therefore, comprehensive ergonomics programs to measure, prevent, and treat musculoskeletal injury may help to fulfill a compelling need to ensure health and career longevity of the surgical workforce.

Prevalence, Correlates, and Impact of Psychiatric Disorders and Treatment Utilization Among Muslims in the United States: Results from the National Epidemiological Survey of Alcohol and Related Conditions

There is a paucity of research on the true prevalence of psychiatric disorders in Muslim Americans. This research aims to explore the prevalence, correlates and impact of mood disorders, anxiety disorders, and posttraumatic stress disorders (PTSD) in Muslims as compared with a non-Muslim sample. We used propensity scores to match 372 individuals who self-identified as Muslims from The National Epidemiologic Survey on Alcohol and Related Conditions III with a control group (n = 744) from the same dataset. The prevalence of psychiatric disorders was similar in Muslim Americans and non-Muslims. Help-seeking was generally low, but Muslims with a lifetime history of PTSD were less likely than non-Muslims with PTSD to seek help through self-help groups (2.2% vs. 21.1%, p < 0.05). Moreover, Muslims with mood disorders experienced lower mental health scores compared to non-Muslims with mood disorders. Efforts need to be made to identify psychiatric disorders in this faith group and engage in treatment.

Prognostic analysis and treatment utilization of different treatment strategies in elderly esophageal cancer patients with distant metastases: a SEER database analysis

PURPOSE

The purpose of this study was to explore which therapeutic strategy is more beneficial for elderly esophageal cancer (EC) patients with distant metastasis, the treatment utilization status and the screening of factors related to prognosis, so as to better guide the treatment of these patients.

METHODS

Patients in the Surveillance Epidemiology and End Results (SEER) database were divided into chemoradiotherapy (Group A), chemotherapy (Group B), radiotherapy (Group C), and no treatment (Group D) according to different treatment methods. Propensity score matching (PSM) was performed to adjust for baseline differences between the two groups. Overall survival (OS) and esophageal cancer-specific survival (ECSS) was calculated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

A total of 7027 patients were included in this study, 5739 males (81.7%) and 1288 females (18.3%) with the median age was 70 (60-98). In the original cohort, the number of patients in the four groups was 2260 (Group A), 2087 (Group B), 945 (Group C) and 1735 (Group D), respectively. After PSM, there was no significant difference in mean OS (A vs B, 13.5 months VS 13.4 months, P = 0.511) and mean ECSS (A vs B, 15.6 vs 15.5 months, P = 0.374), while both OS (B vs C, 7 vs 3 months, P < 0.001) and ECSS (B vs C, 8 vs 3 months, P < 0.001) of chemotherapy alone were significantly better than those of radiotherapy alone. Subgroup analysis of patients older than 80 years showed that the median OS (A vs B, 7 vs 6 months) and median ECSS (A vs B, 8 vs 7 months) of Group A were significantly better than those of Group B (P < 0.05). In addition, all patients were randomly divided into a training set and a validation set with a ratio of 7:3. Based on the independent risk factors for OS, a nomogram model was constructed and validated.

CONCLUSION

For elderly EC patients with distant metastasis, aggressive treatment was still necessary after a comprehensive assessment of the patient's physical condition, especially for patients over 80 years old, and chemoradiotherapy maybe still the first choice. In addition, a nomogram model was constructed to intuitively and accurately evaluate the prognosis of this population.

Factors associated with receipt of minimally adequate psychotherapy for PTSD at the Veterans Health Administration

BACKGROUND

Despite Veterans Health Administration (VHA) efforts, many Veterans do not receive minimally adequate psychotherapy (MAP) for posttraumatic stress disorder (PTSD). It is important to understand factors associated with receipt of PTSD MAP (at least eight sessions) so that we may tailor efforts to increase treatment utilization for those who experience the greatest barriers to care.

METHODS

Participants were 2008 post-9/11 Veterans who participated in a nationwide survey and had a PTSD diagnosis documented in the VHA electronic health record (EHR) before 2018. Participants self-reported sociodemographic information and trauma history. Service utilization data (e.g., PTSD MAP) were obtained from EHR. Logistic regression was used to model factors associated with PTSD MAP.

RESULTS

Only 24% of Veterans (n = 479) received PTSD MAP. Veterans who reported that they were not employed and had reported history of military sexual trauma were more likely to have received PTSD MAP.

CONCLUSIONS

Understanding and addressing barriers to PTSD care for Veterans who are employed could help improve PTSD treatment utilization for this group.

Sexual minorities and substance use treatment utilization: New evidence from a national sample

INTRODUCTION

Minority stress theory suggests that sexual minorities would be, on average, less likely than heterosexual individuals to seek out substance use treatment (due to concerns of stigma and rejection). However, prior research on the subject is mixed, and largely dated. In light of historic increases in societal acceptance and legal protections for sexual minorities, the field needs an up-to-date assessment of treatment utilization among this population.

METHODS

This study used data from the 2015-2019 National Survey on Drug Use and Health to examine the association between key independent variables (sexual identity, gender) and substance use treatment utilization using binary logistic regression. We conducted analyses using a sample of adults with a past-year substance use disorder (N = 21,926).

RESULTS

Controlling for demographic factors, with heterosexual individuals as the comparison group, gay/lesbian individuals (AOR = 2.12, CI = 1.19-3.77) were significantly more likely and bisexual individuals (AOR = 0.49, CI = 0.24-1.00) significantly less likely to report treatment utilization. Bisexual individuals were also less likely than gay/lesbian individuals to report treatment utilization (AOR = 0.10, CI = 0.05-0.23). Interaction tests examining sexual orientation and gender showed no difference in treatment utilization between gay men and lesbian women, and revealed that bisexual identity was associated with decreased likelihood of treatment utilization for men (p = .004) but not for women.

CONCLUSION

Sexual orientation, particularly in the context of social identity, plays a significant role in substance use treatment utilization. Bisexual men face unique barriers to treatment, which is concerning given the high rates of substance use among this and other sexual minority populations.

Epidemiology of type 2 diabetes mellitus and treatment utilization patterns among the elderly from the first wave of Longitudinal Aging study in India (2017-18)using a Heckman selection model

INTRODUCTION

Unmanaged Type 2 diabetes mellitus (T2DM) substantially contributes to the multi-morbidity of the elderly. Fewer research has concentrated on understanding the determinants of treatment utilization among older people, with even lesser concerns about missing data in outcome variables leading to biased estimates. The present study intends to evaluate the epidemiology of T2DM in the elderly in India and explore the socioeconomic and behavioral risk factors determining the treatment utilization among the elderly > 60 years in India by addressing the missing data to generate robust estimates.

METHODS

The secondary analysis used data from the Longitudinal Ageing Study in India. The key dependent variables were the presence or absence of T2DM and treatment utilization. Descriptive statistics were used to understand the differences in the prevalence of diabetes and the utilization of treatment across various socio-demographic characteristics. Heckman's statistical technique evaluated the predictors of T2DM and treatment utilization. Analysis was done using STATA software version 14.0.

RESULTS

Almost 14% elderly reported to be living with T2DM. The odds of living with T2DM increased with non-working status, a sedentary lifestyle, and a higher BMI. A higher proportion of the elderly was on oral drugs than insulin and had been practicing lifestyle modifications to control their disease. The probability of developing T2DM was lower among females than males, but females had better odds for treatment utilization of health medication than males. Lastly, treatment utilization was significantly affected by socio-demographic characteristics like education and monthly per capita expenditure.

CONCLUSIONS

Treatment utilization by the elderly living with T2DM is significantly affected by socio-demographic characteristics. Keeping in mind the increasing proportion of the geriatric population in our country, it is pertinent to tailor-made counseling sessions for the elderly to improve medication utilization and adherence and realize our goals concerning non-communicable diseases.

Alcohol use and treatment utilization in a national sample of veterans and nonveterans

BACKGROUND

Research comparing prevalence of alcohol use problems and alcohol treatment utilization between veterans and nonveterans is lacking. Whether predictors of alcohol use problems and alcohol treatment utilization differ in veterans vs. nonveterans is also unclear.

METHODS

Using survey data from national samples of post-9/11 veterans and nonveterans (N = 17,298; 13,451 veterans, 3847 nonveterans), we investigated associations between veteran status and 1) alcohol consumption, 2) need for intensive alcohol treatment, and 3) past-year and lifetime alcohol treatment utilization. We also investigated associations between predictors and these three outcomes in separate models for veterans and nonveterans. Predictors included age, gender, racial/ethnic identity, sexual orientation, marital status, education, health coverage, financial difficulty, social support, adverse childhood experiences (ACEs), and adult sexual trauma.

RESULTS

Population weighted regression models demonstrated that veterans reported modestly higher alcohol consumption than nonveterans, but were not significantly more likely to need intensive alcohol treatment. Veterans and nonveterans did not differ in past-year alcohol treatment utilization, but veterans were 2.8 times more likely to utilize lifetime treatment than nonveterans. We found several differences between veterans and nonveterans in associations between predictors and outcomes. For veterans, being male, having higher financial difficulty, and lower social support were associated with need for intensive treatment, but for nonveterans, only ACEs were associated with need for intensive treatment.

CONCLUSIONS

Veterans may benefit from interventions with social and financial support to reduce alcohol problems. These findings can help to identify veterans and nonveterans who are more likely to need treatment.

Mental Health Service Utilization and Disparities in the U.S: Observation of the First Year into the COVID Pandemic

This study examined mental health service utilization and disparities during the first year of COVID. We analyzed data from all adult respondents with any mental illness in the past year (n = 6967) in the 2020 National Survey on Drug Use and Health to evaluate if mental health service utilization differed by geographic areas, race/ethnicity, and age groups. Only 46% of individuals with any mental illness had received mental health treatment. Compared to non-Hispanic Whites, Asian and Hispanics were less likely to receive outpatient services and prescription medicine. Rural residents received less outpatient treatment compared to large metropolitan residents. No difference was found in telemedicine utilization across area types and race/ethnicity groups. Older individuals were less likely to utilize telemedicine services. Our findings highlighted continued mental health treatment disparities among race/ethnic minorities and other sub-populations during COVID. Targeted strategies are warranted to allow older populations to benefit from telemedicine.

Alcohol-related consequences and the intention to seek care in treatment naïve women and men with severe alcohol use disorder

INTRODUCTION

Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations.

METHODS

The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored.

RESULTS

Subjects (n = 349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men.

CONCLUSION

Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

Risk for PTSD symptom worsening during new PTSD treatment episode in a nationally representative sample of treatment-seeking U.S. veterans with subthreshold PTSD

Previous research has examined risk factors associated with poorer treatment outcomes for military Veterans with PTSD. However, work has not examined risk for symptom worsening among Veterans with subthreshold PTSD. The aim of this study was to examine demographic, psychiatric, physical health, and pre-treatment PTSD symptom clusters associated with clinically significant worsening of PTSD among a nationally representative sample of United States (U.S.) Veterans with subthreshold PTSD. Participants were Veterans (weighted N = 3162; unweighted N = 236) with subthreshold PTSD entering a new episode of treatment at U.S. Veterans Affairs PTSD specialty clinics during fiscal years 2018 and 2019. Data was collected as part of the Veterans Outcome Assessment, a yearly baseline and 3-month follow-up telephone survey. Analyses used weighted calculations to support the use of VOA data to draw inferences about all eligible Veterans, and binary logistic regression was used to examine risk factors for symptom worsening. Over 1/3 (37.7%) of Veterans with subthreshold PTSD experienced clinically significant symptom worsening from baseline to follow-up. Adjusted analyses revealed several risk factors for symptom worsening, including demographic (e.g., male sex, White race), psychiatric (personality and anxiety disorders), health care utilization (e.g., more primary care encounters in the previous year), physical health disability, and specific baseline PTSD symptom clusters (negative affect and anxious arousal). Findings suggest that Veterans with subthreshold symptoms seeking treatment for PTSD are at risk for symptom worsening, and highlight the importance of assessment, prevention, and treatment in targeting veterans with PTSD symptoms below the diagnostic threshold.

Factors related to initial treatment for adhesive capsulitis in the medicare population

BACKGROUND

Primary adhesive capsulitis (AC) is not well understood, and controversy remains about the most effective treatment approaches. Even less is known about the treatment of AC in the Medicare population. We aimed to fully characterize initial treatment for AC in terms of initial treatment utilization, timing of initial treatments and treatment combinations.

METHODS

Using United States Medicare claims from 2010-2012, we explored treatment utilization and patient characteristics associated with initial treatment for primary AC among 7,181 Medicare beneficiaries. Patients with primary AC were identified as patients seeking care for a new shoulder complaint in 2011, with the first visit related to shoulder referred to as the index date, an x-ray or MRI of the shoulder region, and two separate diagnoses of AC (ICD-9-CM codes: 726.00). The treatment period was defined as the 90 days immediately following the index shoulder visit. A multivariable logistic model was used to assess baseline patient factors associated with receiving surgery within the treatment period.

RESULTS

Ninety percent of beneficiaries with primary AC received treatment within 90 days of their index shoulder visit. Physical therapy (PT) alone (41%) and injection combined with PT (34%) were the most common treatment approaches. Similar patient profiles emerged across treatment groups, with higher proportions of racial minorities, socioeconomically disadvantaged and more frail patients favoring injections or watchful waiting. Black beneficiaries (OR = 0.37, [0.16, 0.86]) and those residing in the northeast (OR = 0.36, [0.18, 0.69]) had significantly lower odds of receiving surgery in the treatment period. Conversely, younger beneficiaries aged 66-69 years (OR = 6.75, [2.12, 21.52]) and 70-75 years (OR = 5.37, [1.67, 17.17]) and beneficiaries with type 2 diabetes had significantly higher odds of receiving surgery (OR = 1.41, [1.03, 1.92]).

CONCLUSIONS

Factors such as patient baseline health and socioeconomic characteristics appear to be important for physicians and Medicare beneficiaries making treatment decisions for primary AC.

Repeal of state laws permitting denial of health claims resulting from alcohol impairment: Impact on treatment utilization

BACKGROUND

Many states in the U.S. still have Alcohol Exclusion Laws (AELs), which allow insurance companies to deny health claims resulting from alcohol impairment. There are concerns that this form of structural stigmatization affects alcohol treatment-seeking behaviors. We examined the effects of AEL repeal on treatment admissions for alcohol use disorder (AUD).

METHODS

Data on alcohol treatment admissions from 1992 to 2017 were obtained from the Treatment Episode Data Set. The state-level aggregate number of treatment admissions was derived, including healthcare professional referrals only, self-referrals only, and both self-referral and healthcare professional referrals. The number of treatment admissions by health insurance status (private, public, and uninsured) was also calculated. The study used a difference-in-differences (DID) quasi-experimental design.

RESULTS

The DID analysis showed that the number of admissions for alcohol treatment from healthcare professional referrals increased 16% in the AEL repeal states compared to states with AELs or that never had AELs (IRR=1.16, 95% CI=1.07, 1.25). These results were consistent for analysis by payment sources. In particular, treatment admissions from healthcare professional referrals for patients covered by private insurance increased about 38% in states with AEL repeal (IRR=1.38, 95% CI=1.17, 1.64) compared to states without AEL repeal. However, the findings were no longer significant when the state-specific time trends were taken into account.

CONCLUSIONS

This study documented that AEL repeal may have had a significant impact on the number of treatment admissions for AUD. These findings suggest that AELs function as a barrier to treatment-seeking behavior.

Drug and alcohol treatment utilization and barriers among Black, American Indian/Alaskan Native, Latine, Asian/Pacific Islander/Native Hawaiian, and White adults: Findings from NESARC-III

BACKGROUND

Existing epidemiological data suggest differences across racial/ethnic groups in drug and alcohol treatment utilization and barriers to treatment and typically include only Black, Latine, and White adults. The objective of this study was to examine whether disparities remain for DSM-5 lifetime alcohol use disorder (AUD) and drug use disorder (DUD) treatment utilization and barriers across Black, American Indian/Alaska Native (AI/AN), Latine, Asian/Pacific Islander/Native Hawaiian (Asian/PI/NH), and White adults.

METHODS

The current study conducted secondary analyses on data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III). Regression analyses, followed by pairwise comparisons, investigated differences across racial/ethnic groups.

RESULTS

Analyses indicated differences across racial/ethnic groups in AUD treatment utilization. White and AI/AN adults were more likely to utilize a health care professional than were Black adults. Asian/PI/NH and Latine adults were more likely to endorse language as a barrier to AUD treatment than were White adults. Black adults were more likely to use 12-step programs for DUD treatment utilization than were White and Latine adults, and Black and White adults were more likely to use outpatient programs than were Latine adults. Further, Black adults were more likely than Asian/PI/NH and Latine adults to use specialty DUD treatment. AI/AN, Asian/PI/NH, and White adults were more likely to endorse fear of what others would think as a barrier to DUD treatment relative to Black adults. AI/AN adults were more likely to endorse fear of being hospitalized relative to Black, Latine, and White adults. Asian/PI/NH and Latine adults were more likely to indicate that the hours were inconvenient relative to Black and White adults. White adults were more likely to endorse a family member objected relative to Black adults. AI/AN and White adults were more likely to endorse they stopped on their own relative to Black, Asian/PI/NH, and Latine adults. Further, AI/AN and White adults reported the greatest number of barriers to DUD treatment.

CONCLUSIONS

Differences remain across racial/ethnic group in drug and alcohol treatment utilization and barriers to treatment. Future research aimed at increasing treatment utilization across racial/ethnic groups should focus on social determinants of health.

Missed opportunities by health care providers to reduce racial/ethnic disparities in the use of alcohol treatment services

OBJECTIVE

The objectives of this study were to: (1) investigate racial/ethnic differences in being offered information on alcohol treatment options by a health care provider; and (2) conduct stratified subgroup analyses to explore racial/ethnic differences in the use of alcohol treatment utilization among those who have received information on alcohol treatment services by a health care provider.

METHODS

Data from National Survey on Drug Use and Health (2015-2017) was used. Analyses were restricted to adult White, Black, and Latino participants who met diagnostic criteria for a past-year alcohol use disorder (AUD) and reported visiting a health care provider in the past-year (n = 4,939). A multivariable logistic regression model was estimated to investigate differences in being offered information on alcohol treatment by a health care provider by race/ethnicity. A sub analysis that was limited to participants who reported receiving information on alcohol treatment services by a health care provider (n = 481) was also conducted to explore racial/ethnic differences in treatment utilization.

RESULTS

Overall, health care providers rarely provided information on alcohol treatment services to persons with AUD. In multivariable analyses, Latinos were less likely to receive information on alcohol treatment services than Whites, but no White-Black differences were documented. When analyses were restricted to those who had received information on alcohol treatment options, no racial/ethnic differences in the use of alcohol treatment services were found.

CONCLUSIONS

Health care providers can potentially encourage use of alcohol treatment among those in need and contribute to reducing existing alcohol-related racial/ethnic disparities.

Determining the sex-specific distributions of average daily alcohol consumption using cluster analysis: is there a separate distribution for people with alcohol dependence?

BACKGROUND

It remains unclear whether alcohol use disorders (AUDs) can be characterized by specific levels of average daily alcohol consumption. The aim of the current study was to model the distributions of average daily alcohol consumption among those who consume alcohol and those with alcohol dependence, the most severe AUD, using various clustering techniques.

METHODS

Data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used in the current analyses. Clustering algorithms were applied in order to group a set of data points that represent the average daily amount of alcohol consumed. Gaussian Mixture Models (GMMs) were then used to estimate the likelihood of a data point belonging to one of the mixture distributions. Individuals were assigned to the clusters which had the highest posterior probabilities from the GMMs, and their treatment utilization rate was examined for each of the clusters.

RESULTS

Modeling alcohol consumption via clustering techniques was feasible. The clusters identified did not point to alcohol dependence as a separate cluster characterized by a higher level of alcohol consumption. Among both females and males with alcohol dependence, daily alcohol consumption was relatively low.

CONCLUSIONS

Overall, we found little evidence for clusters of people with the same drinking distribution, which could be characterized as clinically relevant for people with alcohol use disorders as currently defined.

Does symptom severity matter in stepped and collaborative care for depression?

BACKGROUND

We investigated the differential effectiveness of a stepped and collaborative care model (SCM) vs. treatment as usual (TAU) for primary care patients with various depression severity degrees and explored whether subgroups received distinct evidence-based treatments.

METHODS

Subgroup analyses of a RCT were calculated applying a multiple linear mixed model with the factors 1. group (SCM; TAU), 2. severity ((mild-moderate (MMD); severe depression (SD)) and their interaction, with PHQ-9 as primary outcome. Utilization of treatments was analyzed descriptively.

RESULTS

For the 737 participating patients (SCM: n = 569; TAU: n = 168), availability of data substantially varies between subgroups at 12-month follow-up ranging between 37% and 70%. ITT-analysis (Last-observation-carried-forward) revealed a significant interaction for group x severity [p = 0.036] and a significant difference between groups in symptom reduction for MMD (-3.9; [95% CI: -5.1 to -2.6, p < 0.001; d = 0.64] but not for SD (-1.6; [95% CI: -3.4 to 0.2, p = 0.093; d = 0.27]. Sensitivity analyses (multiple imputation, completer analysis, pattern mixture model) didn`t confirm the interaction effect and showed significant effects for both severity groups with slightly higher effect sizes for MMD. Differences between SCM and TAU in the percentage of patients utilizing depression-specific treatments are larger for MMD.

LIMITATIONS

There was a high proportion of missing values among severely depressed patients, especially in SCM.

CONCLUSION

SCM is effective for both MMD and SD. Utilization patterns might help explain the higher effects for MMD. Various strategies of replacement of missing values lead to slightly divergent results due to selective drop out between severity groups.

military veterans with suicidal ideation: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Despite advances in the treatment of suicidality over the last decade, a significant proportion of veterans with suicidal ideation do not utilize mental health treatment. To date, however, few population-based studies have examined factors that may facilitate or impede mental healthcare engagement among veterans currently contemplating suicide. This study examined barriers and facilitators of current mental healthcare utilization in a nationally representative sample of U.S. military veterans who endorsed current suicidal ideation.

METHODS

Using data from the National Health and Resilience in Veterans Study (n = 3157), collected in 2011, multivariable analyses were conducted to identify predisposing (e.g., age), enabling (e.g., social support), and need (e.g., psychiatric history) characteristics, as well as perceptions of stigma and barriers to care, associated with current mental healthcare utilization.

RESULTS

A total of 7.3% (n = 231) of veterans endorsed current suicidal ideation, of which 36.1% (n = 84) were engaged in current mental health treatment. Younger age, female sex, current depression, lifetime suicide attempt(s), and number of lifetime traumas and medical problems were associated with treatment utilization. Mistrust of mental health providers and fear of treatment harming one's reputation were associated with lower likelihood of treatment engagement, over and above the effects of these predisposing, enabling, and need characteristics.

DISCUSSION

More than 3 of 5 U.S. veterans endorsing current suicidal ideation are not engaged in mental health treatment. Results underscore the importance of multi-modal suicide prevention and treatment engagement efforts that target need-based factors, and perceptions of stigma and negative beliefs about mental healthcare in this population.

Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies

BACKGROUND

Many people who need specialty treatment for substance use disorders (SUDs) do not receive it. Clinical interventions could increase treatment utilization but are not routinely used. This systematic review aimed to describe clinical interventions that may increase SUD specialty treatment utilization (i.e., treatment initiation, attendance, meaningful engagement) and to determine which intervention(s) most consistently increase treatment utilization.

METHODS

We conducted a systematic review of clinical intervention studies (published in English between 2000 and 2017) reporting outcomes relevant to specialty SUD treatment utilization. Outcomes were treatment initiation, attendance, and meaningful engagement. Risk of bias was assessed using Cochrane guidelines and randomized controlled trials (RCTs) with bias scores < 3 were included in a synthesis of results. Proportions of positive to negative utilization outcomes were calculated for each low-bias RCT; studies with 50% positive outcomes or more were considered "majority-positive". Studies were categorized by theory-based approach.

RESULTS

Twenty-three RCTs had low risk of bias and were synthesized. Among intervention types with two or more studies, cognitive-behavioral (100% majority-positive) and coordinated care (67% majority-positive) interventions were most likely to increase treatment initiation, while 12-step promotion interventions were most likely to increase treatment attendance (50% majority-positive). One study (12-step promotion) measured meaningful engagement, with majority-positive outcomes.

CONCLUSIONS

A systematic review and narrative synthesis of clinical interventions promoting specialty SUD treatment utilization provided preliminary evidence that cognitive-behavioral and coordinated care interventions may increase treatment initiation, while 12-step promotion interventions may promote treatment attendance. More quality studies and greater consistency in treatment utilization measurement are needed.

Differences in Distress and Utilization of Mental Health Services between 2005 and 2018: a Potential Trend?

This study examined possible differences in self-reported psychological distress and need of treatment in two samples of well-educated adults, which were obtained from two larger studies that were conducted separately in 2005 and 2018. Psychological distress and need for treatment were reported using the Langner Symptom Survey, a psychometrically robust measure of nonspecific distress that provides validated cutoff scores for those in need of receiving mental healthcare services. Treatment utilization was examined through self-report in which respondents indicated whether they had never received treatment, previously received treatment, or were currently receiving treatment. Results suggested that a larger percentage of respondents from the 2018 sample reported current counseling (11.8%) compared to the 2005 sample (4.0%), and they were almost twice as likely to be classified as distressed and in need for treatment than their 2005 counterparts (51.9% compared to 33.2% in 2005; odds ratio = 2.17, 95% CI: 1.59-2.97). Implications for these findings are discussed at length.

Treatment utilization and treatment barriers in individuals with body dysmorphic disorder

BACKGROUND

Although effective treatments are available, most individuals with body dysmorphic disorder (BDD) do not receive an appropriate diagnosis or treatment. We aimed to examine treatment utilization and barriers to treatment, and to identify associated socio-demographic and clinical characteristics.

METHODS

German individuals completed an online self-report survey of appearance concerns. A sample of N = 429 individuals met criteria for BDD. We examined the frequency of treatment utilization and barriers, analyzed comparisons between treated and untreated individuals and assessed the relationships of socio-demographic and clinical features with mental health treatment utilization and treatment barriers, respectively.

RESULTS

Only 15.2% of the individuals with BDD had been diagnosed with BDD, and lifetime rates of mental health treatment were low (39.9%). Individuals endorsed multiple barriers to mental health treatment, especially shame, low perceived need and a preference for cosmetic and medical treatments. Associated features were identified, including age, a BDD diagnosis, body dysmorphic symptom severity, a likely major depressive disorder, prior cosmetic surgery, and insight.

CONCLUSIONS

The results of this largest study to date highlight that BDD is still underrecognized and undertreated even in a country with extensive mental health care and few financial barriers. We discuss modifiable factors and strategies to foster awareness of BDD in sufferers and professionals to improve treatment dissemination and to reduce treatment barriers.

Health Insurance and Mental Health Care Utilization Among Adults Who Identify as Transgender and Gender Diverse

OBJECTIVE

Transgender people are less likely to have health insurance, which has been associated with reduced utilization of health care. In the current study, the authors sought to assess the role of health insurance in mental health care utilization among transgender individuals.

METHODS

A total of 4,334 adults who self-identified as transgender or gender diverse (neither male nor female) participated in the 2017 Trans Lifeline Mental Health Survey, which included self-report measures of current insurance type and lifetime history of having seen a therapist or psychiatric provider. Logistic regression analyses assessed the association of insurance status with lifetime utilization of a mental health therapist or psychiatric provider.

RESULTS

Although only 8% of the sample were uninsured, these individuals were significantly less likely to have seen a therapist or psychiatric provider in their lifetime compared with those with health insurance, even after the analyses were adjusted for sociodemographic factors. Conversely, those with insurance through the military or the Veterans Health Administration were more than twice as likely as those with employer-provided insurance to have seen a therapist or psychiatric provider. There were no significant differences in mental health care utilization between those with employer-provided insurance versus public or privately purchased insurance.

CONCLUSIONS

Rates of being uninsured were lower than in earlier assessments of transgender adults and adults who identify as gender diverse. However, type of health insurance also appeared to be a notable structural factor contributing to disparities in mental health care utilization among transgender individuals.

Help seeking behaviors of Latinos with substance use disorders who perceive a need for treatment: Substance abuse versus mental health treatment services

OBJECTIVE

Perceiving a need for substance abuse treatment is a strong predictor of substance abuse treatment utilization among those with substance use disorders (SUD). Studies have found that when persons with SUD perceive a need for treatment, they are more likely to use mental health treatment rather than substance abuse treatment. Substance abuse treatment utilization is low among Latinos, relative to other racial/ethnic groups. It is unknown if Latinos with SUD who perceive a need for treatment are more likely to use mental health or substance abuse treatment.

METHODS

Data were pooled from the National Survey on Drug Use and Health survey years 2014, 2015, 2016, and 2017. Analyses were limited to adult Latino participants who met DSM-IV criteria for a past-year substance use disorder (n = 1889). Multinomial logistic regression analyses examined the role of perceived treatment need on the past-year use of (1) no treatment, (2) substance abuse treatment only, and (3) mental health treatment only. Important covariates included socio-demographics, problem severity, currently being on parole or probation, and poor mental health status.

RESULTS

Only 5% of Latinos with SUD reported perceiving a need for treatment. Treatment utilization was also low: 83% reported not using any treatment in the past-year. In multinomial logistic regressions, compared to not using any treatment, Latinos with SUD who perceived a need for substance abuse treatment were more likely to report using mental health treatment only. Perceiving a need for treatment and using substance abuse treatment services only was not statistically different from not using any treatment.

CONCLUSIONS

Findings underscore the need for better integration of substance abuse and mental health treatment services to address the health needs of Latinos.

Underutilization of Early Intensive Behavioral Intervention Among 3-Year-Old Children with Autism Spectrum Disorder

Funding for early intensive behavioral intervention (EIBI) for children with autism spectrum disorder is rapidly expanding. Yet we know little about children's utilization, and research on inequities in utilization is lacking. We examined the relationship between utilization during the first year of EIBI and (a) child race-ethnicity and (b) neighborhood characteristics. Using a sample of children eligible for a Medicaid waiver through a novel policy of presumptive eligibility (N = 108), we estimated a series of two-level growth curve models. Children's average utilization ranged between 24 and 48% of weekly hours, and utilization did not differ by race-ethnicity or neighborhood during the first year. Findings underscore the need to monitor utilization of EIBI and warrant research on the feasibility of EIBI provision in the general population.

Examining the role of a brief online alcohol use risk feedback on accessing information about available treatment resources for alcohol issues

Research suggests college-aged young adults are hesitant to seek treatment for alcohol use disorder and highlights barriers contributing to a gap in treatment utilization. One barrier to treatment utilization is the lack of information about available treatment resources. Motivated by the literature on web-based screening and brief interventions (eSBIs), the current study examined whether providing a brief online feedback of one's alcohol use risk severity will make college students more likely to access information about available treatment options for alcohol-related issues. College students (N = 724) who responded to the Alcohol Use Disorder Identification Test (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001) were randomly assigned to receive a brief online feedback on their alcohol use risk or to a no-feedback condition. Overall, only 20% of all participants opted to view available treatment services for alcohol issues. Participants in the feedback group (15%) were significantly less likely to view information for available services compared to the no-feedback group (24%). A significant feedback condition x stigma interaction effect was found, such that those with average and high stigma towards substance use scores were less likely to view treatment information when provided feedback. Without a thorough discussion of individual risks and without the safeguards against psychological reactance present in eSBIs, providing college students with brief online feedback about their alcohol use risk severity made them less likely to access information concerning available on-campus mental health resources for alcohol issues. On the other hand, improving help-seeking attitudes could help increase treatment utilization.

A current re-examination of racial/ethnic disparities in the use of substance abuse treatment: Do disparities persist?

OBJECTIVE

Racial/ethnic disparities in the use of substance abuse treatment services have been documented. The objective of this study was to re-examine if racial/ethnic disparities in the use of treatment still exist using current data collected post-implementation of the Affordable Care Act.

METHODS

Data were pooled from the National Survey on Drug Use and Health survey years 2015, 2016, and 2017. Analyses were limited to adult White, Black, and Latino participants who met DSM-IV criteria for a past-year substance use disorder (n = 12,070). Hierarchical multivariate logistic regression models examined the role of race/ethnicity on past-year use of (1) any substance abuse treatment services and (2) specialty treatment. Important covariates included socio-demographics, problem severity, and perceived treatment need. A sub-analysis was also conducted that was limited to participants who reported having health insurance to explore the role of insurance status on treatment utilization by race/ethnicity.

RESULTS

Findings showed that Latinos and Blacks significantly underutilized specialty treatment relative to Whites. These relationships were statistically significant after controlling for socio-demographic characteristics, problem severity, and perceived treatment need. However, when analyses were limited to only those with health insurance, Black-White disparities became non-significant, while Latino-White disparities persisted.

CONCLUSIONS

Findings highlight that Black-White and Latino-White disparities in the use of substance abuse treatment still persist. However, Black-White disparities may be limited to only those who are uninsured. Public health implications are discussed.

Using Machine Learning to Classify Individuals With Alcohol Use Disorder Based on Treatment Seeking Status

OBJECTIVE

The authors used a decision tree classifier to reduce neuropsychological, behavioral and laboratory measures to a subset of measures that best predicted whether an individual with alcohol use disorder (AUD) seeks treatment.

METHOD

Clinical measures (N = 178) from 778 individuals with AUD were used to construct an alternating decision tree (ADT) with 10 measures that best classified individuals as treatment or not treatment-seeking for AUD. ADT's were validated by two methods: using cross-validation and an independent dataset (N = 236). For comparison, two other machine learning techniques were used as well as two linear models.

RESULTS

The 10 measures in the ADT classifier were drinking behavior, depression and drinking-related psychological problems, as well as substance dependence. With cross-validation, the ADT classified 86% of individuals correctly. The ADT classified 78% of the independent dataset correctly. Only the simple logistic model was similar in accuracy; however, this model needed more than twice as many measures as ADT to classify at comparable accuracy.

INTERPRETATION

While there has been emphasis on understanding differences between those with AUD and controls, it is also important to understand, within those with AUD, the features associated with clinically important outcomes. Since the majority of individuals with AUD do not receive treatment, it is important to understand the clinical features associated with treatment utilization; the ADT reported here correctly classified the majority of individuals with AUD with 10 clinically relevant measures, misclassifying < 7% of treatment seekers, while misclassifying 38% of non-treatment seekers. These individual clinically relevant measures can serve, potentially, as separate targets for treatment.

FUNDING

Funding for this work was provided by the Intramural Research Programs of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA) and the Center for Information Technology (CIT).

RESEARCH IN CONTEXT

Evidence Before This Study: Less than 10% of persons who meet lifetime criteria for Alcohol Use Disorder (AUD) receive treatment. As the etiology of AUD represents a complex interaction between neurobiological, social, environmental and psychological factors, low treatment utilization likely stems from barriers on multiple levels. Given this issue, it is important from both a research and clinical standpoint to determine what characteristics are associated with treatment utilization in addition to merely asking individuals if they wish to enter treatment. At the level of clinical research, if there are phenotypic differences between treatment and nontreatment-seekers that directly influence outcomes of early-phase studies, these phenotypic differences are a potential confound in assessing the utility of an experimental treatment for AUD. At the level of clinical practice, distinguishing between treatment- and nontreatment-seekers may help facilitate a targeted treatment approach. Previous efforts to understand the differences between these populations of individuals with AUD leveraged the multidimensional data collected in clinical research settings for AUD that are not well suited to traditional regression methods.Added Value of This Study: Alternating decision trees are well suited to deep-phenotyping data collected in clinical research settings as this approach handles nonparametric, skewed, and missing data whose relationships are nonlinear. This approach has proved to be superior in some cases to conventional clinical methods to solve diagnostic problems in medicine. We used a decision tree classifier to understand treatment- and non-treatment seeking group differences. The decision tree classifier approach chose a subset of factors arranged in an alternating decision tree that best predicts a given outcome. Assuming that the input measures are clinically relevant, the alternating decision tree that is generated has clinical value. Unlike other machine learning approaches, in addition to its predictive value, the nodes in the tree and their arrangement in a hierarchy have clinical utility. With the "if-then" logic of the tree, the clinician can learn what features become important and which recede in importance as the logic of the tree is followed. The decision tree classifier approach reduced 178 characterization measures (both categorical and continuous) in multiple domains to a decision tree comprised of 10 measures that together best classified subjects by treatment seeking status (yes/no).Implications After All the Available Evidence: We leveraged a large data set comprised of 178 clinical measures and using the decision tree approach, we have reduced these to a subset of 10 measures that accurately classified individuals with alcohol dependence by treatment utilization. From this analysis, drinking behavior variables and depression measures are strong treatment seeking predictors. Having identified a cluster of factors that predicts treatment seeking, we can assess the influence of these factors directly on the clinical study outcome measures themselves. In clinical practice these factors can be separate targets for treatment. In clinical research, the group differences my directly influence research outcomes for treatment of AUD.

Treatment Utilization Trajectories among Children with Autism Spectrum Disorder: Differences by Race-Ethnicity and Neighborhood

Health coverage of early intensive behavioral intervention (EIBI) for children with autism spectrum disorder is expanding. Yet there is no longitudinal research on patterns of or inequities in utilization of EIBI. We integrated state administrative records with Medicaid and Census data for children enrolled in an EIBI Medicaid waiver (N = 730) to identify and describe the type and prevalence of treatment utilization trajectories, and to examine the association between trajectory types and (a) child race-ethnicity and (b) neighborhood racial composition, poverty, affluence, and urbanicity. We identified four utilization trajectories (Low, Low-Moderate, Moderate, and High users). Race-ethnicity and neighborhood affluence were associated with trajectory membership. As coverage expands, policy makers should consider strategies to improve overall treatment utilization and enhance equity.

Psychotic experiences in the context of mood and anxiety disorders and their associations with health outcomes among people of color in the United States

BACKGROUND

Psychotic experiences appear to increase risk for health outcomes above and beyond mood/anxiety disorders. However, existing studies that have found this association were conducted mostly in low- and middle-income countries, calling for more studies to explore the association in other contexts, such as the U.S., where people of color face considerable health disparities.

MATERIALS/METHODS

Data from the National Latino and Asian American Survey, and the National Survey of American Life were analyzed. After restricting the analytic sample to individuals with at least one mood or anxiety disorder (N = 2929), multivariable logistic regression was used to examine the associations between psychotic experiences and health outcomes, disabilities, and help-seeking behaviors, adjusting for socio-demographic characteristics and psychiatric disorders.

RESULTS

Among people of color with mood/anxiety disorders, 16.58% (n = 519) of the weighted analytic sample reported psychotic experiences. Psychotic experiences were associated with 1.75 times greater odds (95% CI: 1.24-2.47) for reporting a lifetime health condition, with varying odds depending on the specific conditions (e.g. arthritis, heart disease, ulcers, and asthma), and specific disabilities (e.g. cognition, mobility, social interaction, and time out of role). Psychotic experiences were associated with 1.66 times the odds of seeking any treatment (95% CI: 1.20-2.29), and the perceived need for help among people who did not seek treatment (e.g. feeling the need for treatment, being encouraged to seek treatment by others).

CONCLUSIONS

Mental health practitioners serving people of color who have mood/anxiety disorders should routinely screen for psychotic experiences, which may suggest health problems and disabilities that warrant integrated healthcare.

Prediction of psychotherapy process and outcome with the Personality Assessment Inventory

The Personality Assessment Inventory (PAI; Morey, 1991) contains scales that were designed to make predictions about how an individual might respond to treatment, thereby allowing clinicians to attune treatment plans to a client's specific needs. The present study utilized two features of the PAI as predictors of treatment process and outcome in a sample of 47 outpatient veterans: the Treatment Rejection (RXR) scale and the Treatment Process Index (TPI). Data were collected for three treatment process and outcome measures: treatment utilization (ratio of appointments attended to appointments scheduled), therapist-rated therapeutic alliance, and symptom change over time. Results indicated that RXR significantly predicted utilization over and above the TPI. The TPI significantly predicted the rate of distress symptom decline over time, but RXR did not. Lastly, neither RXR nor the TPI were significant predictors of therapist-rated alliance.

Predictors of treatment initiation for alcohol use disorders in primary care

BACKGROUND

We identified predictors of receiving treatment (brief therapy [BT] and/or extended-release injectable naltrexone [XR-NTX]) for the treatment of alcohol use disorders (AUDs) in primary care. We also examined the relationship between receiving BT and XR-NTX.

METHODS

Secondary data analysis of SUMMIT, a randomized controlled trial of collaborative care. Participants were 290 individuals with AUDs who reported no past 30-day opioid use and who were receiving primary care at a multi-site Federally Qualified Health Center. Bivariate and multivariate analyses examined predictors of BT and/or XR-NTX.

RESULTS

Thirty-two percent (N = 93) received either BT or XR-NTX, 28% (N = 82) received BT and 13% (N = 37) received XR-NTX; 9% (N = 26) received both BT and XR-NTX. Older age, white race, talking with a professional about alcohol use and having more negative consequences all predicted receipt of evidence-based treatment; being homeless was a negative predictor. The predictors of receiving BT included not being homeless and previously talking with a professional; the predictors of receiving XR-NTX included older age, white race and experiencing more negative consequences. In 80% of those who received both BT and XR-NTX, receipt of BT preceded XR-NTX.

CONCLUSIONS

Patient factors were important predictors of receiving primary-care based AUD treatment and differed by type of treatment received. Receiving BT was associated with subsequent use of XR-NTX and may be associated with a longer duration of XR-NTX treatment. Providers should consider these findings when considering ways to increase primary-care based AUD treatment.

Understanding barriers to specialty substance abuse treatment among Latinos

BACKGROUND

National studies have documented that Latinos are less likely to use specialty substance abuse treatment (e.g., rehabilitation programs, in/out-patient services) than other racial/ethnic groups. Disparities in treatment utilization are particularly pronounced between Latinos and Whites. Few national studies have explicitly examined barriers to treatment by race/ethnicity, and current results are inconclusive. The purpose of this study was to gain a better understanding of barriers to specialty substance abuse treatment among Latinos.

METHODS

In 2017-2018, in-depth qualitative interviews were conducted with 54 White, Black, and Latino participants who met eligibility criteria for a recent substance use disorder. Participants were recruited via online ads and screened for eligibility through an online survey. Interview questions were grounded in the Theory of Planned Behavior (TBP): Participants were asked about treatment-related barriers in the domains of attitudes, subjective norms, and perceived control. Interviews were transcribed verbatim and coded by two independent coders. Barriers were compared across all interviews and by race/ethnicity.

RESULTS

Latinos were significantly more likely to report attitudinal and subjective norm barriers than their White and Black counterparts. Within the attitudes domain, results suggested that Latinos largely avoided specialty treatment due to barriers stemming from cultural factors, perceived treatment efficacy, recovery goals, and perceived treatment need. In the area of subjective norms, stigma and perceived lack of social support from family were more pervasive among Latinos' narratives. Lastly, in terms of perceived control, a minority of Latinos reported logistical barriers to treatment.

CONCLUSION

Specialty substance abuse treatment services have been found to be effective regardless of race/ethnicity. Understanding why Latinos use specialty treatment at low rates is key to reducing existing racial/ethnic disparities related to substance abuse. This study identified several malleable barriers that interventions can target to increase Latinos' utilization of treatment. These barriers may also be key to explaining Latino-White disparities in treatment utilization.

Prevalence and predictors of no lifetime utilization of mental health treatment among people with mental disorders in France: findings from the 'Mental Health in General Population' (MHGP) survey

PURPOSE

No lifetime utilization of mental health treatment (NUMT) is an indicator of the treatment gap among people in need of treatment. Until now, the overall prevalence and predictors of NUMT have never been explored in France.

METHODS

In a 39,617-respondent survey, participants were assessed for NUMT, i.e., no lifetime psychotherapy, psychopharmacotherapy, or psychiatric hospitalization. Mental disorders were investigated using the Mini International Neuropsychiatric Interview (MINI 5.0.0). MINI diagnoses were grouped into five categories: mood disorders (MDs); anxiety disorders (ADs); alcohol use disorders (AUDs); substance use disorders (SUDs); and psychotic disorders (PDs). Using multivariable logistic regression models, we explored the factors associated with NUMT among the MINI-positive respondents. The odds ratio and 95% confidence interval were calculated for each factor.

RESULTS

In total, 12,818 (32.4%) respondents were MINI-positive, 46.5% of them reported NUMT (35.6% for MDs, 39.7% for PDs, 42.8% for ADs, 56.0% for AUDs, and 56.7% for SUDs). NUMT was positively associated with being male [OR 1.75 (1.59-1.91)] and practising religion [OR 1.13 (1.02-1.25)] and negatively associated with ageing [per 10-year increase: OR 0.88 (0.85-0.91)], being single [OR 0.74 (0.66-0.84)], being a French native [OR 0.67 (0.60-0.75)], and experiencing MDs [OR 0.39 (0.36-0.43)], ADs [OR 0.47 (0.43-0.52)], AUDs [OR 0.83 (0.73-0.96)], SUDs [OR 0.77 (0.65-0.91)], or PDs [OR 0.50 (0.43-0.59)].

CONCLUSIONS

In France, NUMT rates were the highest for AUDs and SUDs. Additionally, suffering from MDs or ADs increased the lifetime treatment utilization for people having any other mental disorder. This finding emphasizes the need to better screen AUDs and SUDs among people treated for MDs or ADs.

Past-Year Treatment Utilization Among Individuals Meeting DSM-5 PTSD Criteria: Results From a Nationally Representative Sample

OBJECTIVE

Little is known regarding treatment utilization among individuals meeting DSM-5 criteria for posttraumatic stress disorder (PTSD).

METHODS

Data were analyzed from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample using DSM-5 criteria.

RESULTS

Factors related to increased odds of PTSD treatment utilization for individuals meeting lifetime criteria included some college education versus less than a high school degree (odds ratio [OR]=3.17), having health insurance versus no insurance (OR=2.86), having a comorbid phobia disorder versus not having a phobia disorder (OR=1.36), and greater PTSD symptom count (OR=1.11). Older age (OR=.40), identifying as black or Asian versus white non-Hispanic (OR=.70 and OR=.28, respectively), and greater social functioning (OR=.98) were associated with decreased odds of PTSD treatment utilization.

CONCLUSIONS

Results highlight factors that may be useful in identifying population subgroups with PTSD that are at risk for underutilization of services.

Predictors of Utilization of an Addiction-Specific Behavioural Couple Therapy in Alcohol Dependence

PURPOSE

The aim of this study was to examine predictors that lead to the utilization of Behavioural Couple Therapy (BCT) for patients with alcohol dependence (AD) in a -European health care system and to identify groups that have a low probability of utilizing BCT.

METHODS

Using routinely collected data from a German rehabilitation clinic, a sample of 1,843 inpatients with AD living in a couple relationship was examined. Each patient could freely choose to participate in an addiction-specific BCT as a voluntary additional intervention during an inpatient treatment program.

RESULTS

The logistic regression analysis indicated that female gender, older age and a higher number of comorbid disorders were associated with a decreased probability of utilizing BCT. The decision tree found that for men, the lowest utilization rate was in the age range of 51-54 and from the age of 58 years; women with higher pressure by their partner in combination with more than 1 comorbid mental disorder and women with lower pressure by their partner (regardless of comorbid disorders) showed the lowest utilization rate.

CONCLUSIONS

Certain subgroups of patients with AD are less likely to participate in BCT during inpatient treatment.

Treatment seeking as a mechanism of change in a randomized controlled trial of a mobile health intervention to support recovery from alcohol use disorders

BACKGROUND

We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking.

METHODS

We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization.

RESULTS

Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%.

CONCLUSIONS

The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

Predictors of treatment utilization and unmet treatment need among individuals with posttraumatic stress disorder from a national sample

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a chronic psychiatric condition associated with significant disability that often remains untreated. Sociodemographic and family-level factors may serve as predictors of unmet treatment need, identifying groups that would most benefit from policies aimed at increasing access to the mental health care system.

METHOD

Data from the nationally representative Collaborative Psychiatric Epidemiologic Surveys were used to identify predictors of mental health treatment utilization, both with a mental health specialist and with a general health practitioner, and self-reported unmet treatment need among individuals who endorsed past-year PTSD. We defined unmet treatment need as self-reporting a mental health problem and not accessing mental health care in the general or specialty mental health care system.

RESULTS

Among 600 participants, predictors of unmet treatment need included being non-Latino black [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.25-3.54], having a high school education versus some college (OR 2.45, 95% CI 1.34-4.48), and being employed or unemployed versus not being in the workforce (OR 1.74, 95% CI 1.00-3.02 and OR 4.95, 95% CI 1.60-15.34, respectively). Recursive partitioning identified younger age and being married as predictors of low treatment utilization.

CONCLUSIONS

Future research should elucidate barriers to accessing treatment among those with PTSD in these underserved groups.

Alcohol problem recognition and help seeking in adolescents and young adults at varying genetic and environmental risk

INTRODUCTION

Alcohol use disorder symptoms frequently occur in adolescents and younger adults who seldom acknowledge a need for help. We identified sociodemographic, clinical, and familial predictors of alcohol problem recognition and help seeking in an offspring of twin sample.

METHOD

We analyzed longitudinal data from the Children of Alcoholics and Twins as Parents studies, which are combinable longitudinal data sources due to their equivalent design. We analyzed respondents (n=1073, 56.0% of the total sample) with alcohol use disorder symptoms at the baseline interview. Familial characteristics included perceptions of alcohol problems and help seeking for alcohol problems within the immediate family and a categorical variable indicating genetic and environmental risk. We used logistic regression to examine predictors of alcohol problem recognition and help seeking.

RESULTS

Approximately 25.9% recognized their alcohol problems and 26.7% sought help for drinking. In covariate-adjusted analyses, help seeking among family members predicted problem recognition, several clinical characteristics predicted both problem recognition and help seeking, and familial risk predicted help seeking. Alcohol problem recognition mediated the association between alcohol use disorder symptoms and incident help seeking.

CONCLUSIONS

Facilitating the self-recognition of alcohol use disorder symptoms, and perhaps the awareness of family members' help seeking for alcohol problems, may be potentially promising methods to facilitate help seeking.

Interventions for Increasing Alcohol Treatment Utilization Among Patients with Alcohol Use Disorders from Emergency Departments: A Systematic Review

AIM

Alcohol use disorders (AUDs) are characterized by low treatment coverage. Emergency departments (EDs) have great potential to increase alcohol treatment coverage. While ED-based brief interventions (BIs) are rarely effective for reducing alcohol use and related consequences in people with AUDs, utilization of formal alcohol treatment has been demonstrated to be useful. Thus we conducted a systematic review to determine efficacious interventions for increasing subsequent alcohol treatment from EDs.

METHODS

A systematic search of the literature up to 31 December 2013 was undertaken in three electronic databases: PubMed, PsycINFO and The Cochrane Library. Only randomized controlled trials (RCTs), controlled clinical trials (CCTs) and non-randomized controlled trials (NRCTs) were included. A meta-analysis was judged inappropriate because of substantial discrepancies in term of interventions' characteristics across studies.

RESULTS

From the 2182 identified records, 7 studies (4RCTs, 2 CCTs, 1NRCT) met inclusion criteria. Onsite brief advice (BA) was found efficacious in comparison to no active control condition, but no evidence of efficacy was found when compared to active control conditions. Referral to post-discharge BIs was not found efficacious either used alone or in addition to onsite BA. There is evidence, albeit limited, suggesting that more intensive interventions, such as referral to extended post-discharge interventions and onsite extended BI, might be useful.

CONCLUSIONS

Based on the available evidence, onsite BA with leaflets appears to be the minimum level of intervention since it enables to actively intervene while fitting in the time concerns experienced in EDs. Further research is needed to confirm these findings given the limited quantity and quality of existing data and to determine whether more intensive interventions could actually be useful.

Predicting use of assistance when quitting: a longitudinal study of the role of quitting beliefs

BACKGROUND

A growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments.

PURPOSE

To examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit.

METHODS

The present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting.

RESULTS

The hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance.

CONCLUSIONS

The present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

Latent class analysis of alcohol treatment utilization patterns and 3-year alcohol related outcomes

People who obtain treatment for alcohol use problems often utilize multiple sources of help. While prior studies have classified treatment use patterns for alcohol use, an empirical classification of these patterns is lacking. For the current study, we created an empirically derived classification of treatment use and described how these classifications were prospectively associated with alcohol-related outcomes. Our sample included 257 participants of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who first received alcohol treatment in the 3-year period prior to their baseline interview. We used latent class analysis to identify classes of treatment users based on their patterns of treatment use of 13 types of alcohol treatment. Regression models examined how classes of treatment use at baseline were associated with alcohol-related outcomes assessed at a 3-year follow-up interview. Outcomes included a continuous measure of the quantity and frequency of alcohol use and DSM-IV alcohol use disorder status. Four classes of treatment users were identified: (1) multiservice users (8.7%), (2) private professional service users (32.8%), (3) alcoholics anonymous (AA) paired with specialty addiction service users (22.0%), and (4) users of AA alone (36.5%). Those who utilized AA paired with specialty addiction services had better outcomes compared to those who used AA alone. In addition to elucidating the most common treatment utilization patterns executed by people seeking help for their alcohol problems, the results from this study suggest that increased efforts may be needed to refer individuals across sectors of care to improve treatment outcomes.

The moderating role of social networks in the relationship between alcohol consumption and treatment utilization for alcohol-related problems

Many individuals wait until alcohol use becomes severe before treatment is sought. However, social networks, or the number of social groups an individual belongs to, may play a moderating role in this relationship. Logistic regression examined the interaction of alcohol consumption and social networks as a predictor of treatment utilization while adjusting for sociodemographic and clinical variables among 1,433 lifetime alcohol-dependent respondents from wave 2 of the National Epidemiologic Survey on Alcohol Related Conditions (NESARC). Results showed that social networks moderate the relationship between alcohol consumption and treatment utilization such that for individuals with few network ties, the relationship between alcohol consumption and treatment utilization was diminished, compared to the relationship between alcohol consumption and treatment utilization for individuals with many network ties. Findings offer insight into how social networks, at times, can influence individuals to pursue treatment, while at other times, influence individuals to stay out of treatment, or seek treatment substitutes.

Spatial accessibility of drug treatment facilities and the effects on locus of control, drug use, and service use among heroin-injecting Mexican American men

BACKGROUND

This study explores the spatial accessibility of outpatient drug treatment facilities and the potential relationship with drug use-related outcomes among Mexican American heroin users.

METHODS

Secondary data on 219 current and former heroin-injecting Mexican American men aged 45 and older were drawn from a research study in Houston, Texas. We used geographic information systems (GIS) to derive two spatial accessibility measures: distance from one's place of residence to the closest drug treatment facility (in minutes); and the number of facilities within a 10-minute driving distance from one's place of residence. Exploratory logistic regression analyses examined the association between the spatial accessibility of drug treatment facilities and several drug use-related outcomes: internal locus of control (LOC); perceived chances and worries of injecting in the next six months; treatment utilization; and location of last heroin purchase.

RESULTS

Participants with greater spatial access to treatment programs were more likely to report a higher chance of injecting in the near future. However, while current heroin users were more worried about injecting in the next six months, greater spatial access to treatment programs seemed to have a buffering effect. Finally, those who lived closer to a treatment programs were more likely to have last purchased heroin inside the neighborhood versus outside the neighborhood. Spatial accessibility was not associated with internal LOC or treatment utilization.

CONCLUSION

The findings showed that the presence of outpatient treatment facilities-particularly services in Spanish-may influence perceived risk of future heroin use and purchasing behaviors among Mexican American men. Implications for future spatially-informed drug use research and the planning of culturally and linguistically responsive drug treatment programs are discussed.