Behavioral Health Disorders and Treatment Gaps: Calls to Action for SAMHSA's MFP Fellows

by Robin R. LaSota

There are many opportunities for Fellows in SAMHSA's Minority Fellowship Program to contribute to improvements in behavioral health. This article highlights some of those opportunities, given trends in substance use disorders, mental health disorders, and co-occurring disorders, and gaps in treatment for those disorders.

Substance Use Disorders and
Treatment Gaps
The 2015 National Survey on Drug Use and Health (NSDUH) reported that about 21.7 million people in the United States ages 12 and older required treatment for a substance use disorder involving alcohol or illicit drugs in the past year, which is about 8.1 percent of the population (Center for Behavioral Health Statistics and Quality [CBHSQ], 2016a). Only 10.8 percent (or 2.3 million) of these people received substance use treatment in the past year.

The large majority (95.4 percent) of individuals diagnosed with a substance use disorder did not believe they needed treatment (Lipari et al., 2016). Some of the most common reasons for this thinking included not being ready to stop, not being able to afford treatment, a possible negative effect on employment, and concern about the negative opinion of others (Han et al., 2015).

Alcohol use disorders are the most prevalent of the substance use disorders, with one fourth (or 66.7 million) of the U.S. population 12 and older reporting binge drinking in the past month, based on 2015 data (CBHSQ, 2016). An additional 17.3 million (or 6.5 percent of the population 12 and older) reported heavy alcohol use, defined as binge drinking during 5 or more of the past 30 days. (Binge drinking for men is defined as drinking five or more drinks on the same occasion on at least 1 day in the past month. For women, it is four drinks.)

Tobacco use is the next most common substance use disorder, with 52 million people 12 and older reporting they were current smokers in 2015 (about 20 percent of the population) [CBHSQ, 2016]. Tobacco use disorders are highly correlated with mental health disorders in both genders and across age groups. While one in four U.S. adults smoked cigarettes in 2015, one third of people with any mental illness smoked (Lipari & Van Horn, 2017).

The most commonly used illicit drug in the United States is marijuana, followed by prescription pain relievers (hydrocodone, oxycodone, and methadone).

Among people 12 and older in the United States, 22.2 million reported using cannabis in the past 30 days (about 8 percent) [CBHSQ, 2016], and 10.7 million reported current misuse of prescription pain relievers (4.1 percent) [Lipari & Hughes, 2017].

Perceptions of the risks involved in marijuana use vary substantially across states, the District of Columbia (D.C.), and subregions. Regions in which more people perceive higher risk of harm from marijuana use have lower rates of cannabis use disorders, compared to regions with more people who perceive low risk of harm from marijuana use (Hughes et al., 2016). The highest rates of marijuana use were reported in 16 regions: D.C., 3 regions in Colorado, 3 in Rhode Island, 2 in California, 2 in Vermont, and 1 each in Alaska, Maine, Massachusetts, Oregon, and Washington (Hughes et al., 2016).

Based on combined NSDUH data from 2013 and 2014, slightly more than half (50.5 percent) of all people who misused prescription pain relievers obtained them from a friend or relative for free, and nearly one fourth (22 percent) of the 10.7 million people who misused prescription pain pills obtained them from a doctor (Lipari & Hughes, 2017). The remainder bought the pills from a friend or relative (11 percent), bought them from a drug dealer or other stranger (4.8 percent), took them from a friend or relative without asking (4.4 percent), obtained them from more than one doctor (3.1 percent), or got them from another source (4.1 percent) [Lipari & Hughes, 2017].

Higher rates of substance use disorders occur among people in the mining industry (17.5 percent were heavy alcohol users), construction industries (16.5 percent were heavy alcohol users), and accommodations and food services industries (19.1 percent were illicit drug users) [Bush & Lipari, 2015].

Rates of heroin, cocaine, and crack use in 2015 were similar to rates in the prior several years for people 12 and older. Less than 1 percent of the U.S. adult population use hallucinogens, inhalants, or methamphetamines (CBHSQ, 2016). Although heroin misuse occurs in only 0.1 percent of the population (CBHSQ, 2016), overdose deaths from opioids (including heroin and prescription pain relievers) have nearly quadrupled since 1999 (Department of Health and Human Services [HHS], 2016).

Call to Action for MFP Fellows. Current and former MFP Fellows have many opportunities to address these trends, by increasing access to treatment as practitioners, developing new interventions to reduce substance misuse, or expanding and strengthening effective interventions and programs.

For instance, considerable work is needed to prevent substance use disorders among U.S. children and youth through school- and community-based educational interventions (Salerno, 2016), and in reaching out to vulnerable populations in rural areas.

More rigorous evaluations of interventions are needed to inform decisions on resource allocation and which programs to scale up. For example, a meta-analysis of 34 experimental studies showed positive effects with psychosocial interventions such as cognitive–behavioral therapy (CBT) and contingency management (Dutra et al., 2008).

More information is also needed on the effectiveness of culturally competent interventions to improve treatment outcomes for racial and ethnic minorities (e.g., Guerrero et al., 2017).

Mental Health Disorders and
Treatment Gaps
In 2015, nearly one fifth of the U.S. population age 12 or older (43.4 million people) had a mental illness, which NSDUH defined as the presence of any mental, behavioral, or emotional disorder in the past year that met DSM–4 criteria (CBHSQ, 2016). Of those with any mental illness, 9.8 million, or 4 percent, of the U.S. adult population had a severe mental illness (CBHSQ, 2016).

The prevalence of U.S. adults with any mental illness or a severe mental illness in 2015 was similar to prevalence rates from 2008 to 2014. However, only 43 percent of adults with any mental illness and about two thirds (65.3 percent) of adults with severe mental illness received mental health services in the past year, based on 2015 NSDUH data (CBHSQ, 2016).

Suicide rates steadily rose from 1999 to 2014 for a wide age range (10 to 74) and for both sexes (Curtin et al., 2016). In 2014, the age-adjusted suicide rate for the U.S. population was 13 per 100,000—24 percent higher than the rate in 1999, when there were 10.5 deaths per 100,000 people (Curtin et al., 2016). However, based on data from three population surveys from 2001 to 2012, the odds of mental health treatment have increased by 14 percent among individuals with past-month significant psychological distress or past-year depressive symptoms (Mojtabai & Jorm, 2015).

From 2000 to 2014, economic adversity was highly correlated with frequent depression and limitations in functional health (Charara et al., 2016). According to Charara and colleagues, poor mental health varied by state of residence, demographic characteristics, and socioeconomic/unemployment status.

For example, being divorced, African American, or Native American was associated with higher risk of functional health problems. Although insurance coverage for mental health treatment has increased among adults ages 18 to 64 based on NSDUH data for 2005–14, disparities in treatment access remain among whites, Latinos, and African Americans (Creedon et al., 2016).

African Americans have not increased their participation in treatment or completed treatment at the same rates as whites and Latinos (Creedon et al., 2016; Fortuna et al., 2010; Han et al., 2014). A large statewide survey of California found adults ages 18 to 72 who received mental health and/or substance use treatment and who perceived discrimination based on race/ethnicity or insurance status experienced negative treatment outcomes and early termination of treatment (Mays et al., 2017).

Among the U.S. adult population, based on the 2004–05 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), African Americans had the highest rate (8.7 percent) of lifetime prevalence of posttraumatic stress disorder (PTSD) compared with Latinos (7 percent), whites (7.4 percent), and Asians (4 percent) [Roberts et al., 2011]. Some interventions, such as CBT, can be effective in reducing PTSD symptoms for African Americans (Stecker et al., 2016). Roberts and colleagues (2011) found lower rates of treatment seeking among racial and ethnic minorities. Research has suggested different reasons for this, including stigma surrounding mental illness, reluctance to seek help from nonfamily members, mistrust of physicians, perceived racial and ethnic bias in treatment, and reduced access to care in poor communities.

Based on U.S. population data from 2012–13, 6.9 percent of adult veterans ages 18 and older experience lifetime PTSD. The disorder is highly comorbid with all lifetime substance use disorders and aggregate psychiatric disorders (Smith et al., 2016). Smith and colleagues found veterans who experienced more co-occurring disorders (for example, six or more) were more likely to seek treatment. Even though effective therapies such as prolonged exposure and CBT exist, access to evidence-based treatments is limited (Foa et al., 2016).

Call to Action for MFP Fellows. Although access to and participation in mental health treatment have increased in recent years, the effectiveness of some treatments is unknown, and treatment disparities continue between whites and racial and ethnic minorities. MFP Fellows can play an important role in closing the gaps to effective treatment, particularly for racial and ethnic minorities.

Differences in treatment retention across racial and ethnic groups demonstrate increased need for culturally competent care. For instance, when describing successful care, minorities place more importance on provider knowledge of discrimination and prejudice and having a racial match in their provider than do whites (Meyer & Zane, 2013).

Knowledge gaps remain about the effectiveness of culturally and clinically competent treatments or the prevalence and application of cultural competency training among treatment providers (Kalibatseva & Leong, 2014; Sue et al., 2012; Yamada & Brekke, 2008). This is an area where MFP Fellows can contribute significantly.

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