Patterns of Mental Health Service Utilization and Substance Use Among Adults, 2000 and 2001

NOTICE: Public reporting for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930–0110); Room 16–105; Parklawn Building; 5600 Fishers Lane; Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930–0110.

PRESS [ENTER] TO CONTINUE.

ENTER MM-DD-YYYY

DEFINE CALCAGE:

CALCAGE = AGE CALCULATED BY "SUBTRACTING" DATE OF BIRTH FROM DATE OF INTERVIEW.

1     YES
2     NO
D/REF

AGE:       [RANGE: 1 – 110]
DK/REF

DEFINE CURNTAGE:

IF CALCAGE > 11 AND CONFIRM = 1, CURNTAGE = CALCAGE
IF CALCAGE > 11 AND CONFIRM = DK/REF AND DKREFAGE > 11, CURNTAGE = DKREFAGE
IF AGE1 = DK/REF AND DKREFAGE > 11, CURNTAGE = DKREFAGE
ELSE RESPONDENT IS INELIGIBLE; ROUTE TO ENDAUDIO

1     YES
2     NO

1     YES
2     NO

1     YES
2     NO

NOTE: IF FIPE3 = 1, SET THE FLAG TO ADMINISTER THE PARENTING EXPERIENCES MODULE DURING ACASI.

INTERVIEWER: RECORD RESPONDENT'S SEX.

5     MALE
9     FEMALE
DK/REF

1     YES
2     NO
DK/REF

TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR BETWEEN EACH CATEGORY YOU SELECT.

1     MEXICAN / MEXICAN AMERICAN / MEXICANO / CHICANO
2     PUERTO RICAN
3     CENTRAL OR SOUTH AMERICAN
4     CUBAN / CUBAN AMERICAN
5     OTHER (SPECIFY)
DK/REF

TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR BETWEEN EACH CATEGORY YOU SELECT.

RESPONDENTS WHO REPORT THEIR RACE AS NATIVE AMERICAN SHOULD BE INCLUDED IN RESPONSE CATEGORY 3.

1     WHITE
2     BLACK / AFRICAN AMERICAN
3     AMERICAN INDIAN OR ALASKA NATIVE
4     NATIVE HAWAIIAN
5     OTHER PACIFIC ISLANDER
6     ASIAN (FOR EXAMPLE: ASIAN INDIAN, CHINESE, FILIPINO, JAPANESE, KOREAN, AND
       VIETNAMESE)
7     OTHER (SPECIFY)
DK/REF

TO SELECT MORE THAN ONE CATEGORY, PRESS THE SPACE BAR BETWEEN EACH CATEGORY YOU SELECT.

1     ASIAN INDIAN
2     CHINESE
3     FILIPINO
4     JAPANESE
5     KOREAN
6     VIETNAMESE
7     OTHER (SPECIFY)
DK/REF

OTHER ASIAN GROUP:                     
DK/REF

OTHER RACIAL GROUP:                     

1     WHITE
2     BLACK / AFRICAN AMERICAN
3     AMERICAN INDIAN OR ALASKA NATIVE
4     NATIVE HAWAIIAN
5     OTHER PACIFIC ISLANDER
6     ASIAN INDIAN
7     CHINESE
8     JAPANESE
9     FILIPINO
10     KOREAN
11     VIETNAMESE
12     OTHER ASIAN
13     IF QD05 = 7, FILL TEXT FROM QD05OTHR
         IF QD05 NE 7 FILL WITH "OTHER (SPECIFY)"
14     IF QD05ASIA = 7, FILL TEXT FROM OTHASIA
         IF QD05ASIA = BLANK, FILL WITH "NOT APPLICABLE"
DK/REF

[NOTE: ONLY CODES FOR RESPONSE CATEGORIES ENTERED IN QD05 OR QD05OTH OR QD05ASIA OR OTHASIA WILL BE ACTIVE FOR THIS QUESTION. IF THE INTERVIEW ENTERS AN INACTIVE RESPONSE CATEGORY, THE RANGE ERROR BOX WILL APPEAR.]

1     MARRIED
2     WIDOWED
3     DIVORCED OR SEPARATED
4     NEVER MARRIED
DK/REF

INTERVIEWER NOTE:

If the respondent is divorced but currently remarried, code as married. By "divorce" we mean a legal cancellation or annulment of a marriage. By "separated" we mean legally or informally separating due to marital discord.

NUMBER OF TIMES:            [RANGE: 1 – 9]
DK/REF

1     YES
2     NO
DK/REF

1     ON ACTIVE DUTY IN THE ARMED FORCES
2     IN A RESERVES COMPONENT
3     NOW SEPARATED OR RETIRED FROM EITHER RESERVES OR ACTIVE DUTY
DK/REF

1     YES
2     NO
DK/REF

PRESS [ENTER] TO CONTINUE.
[ROUTE TO ENDAUDIO]

Please tell me the number from the card.

INCLUDE JUNIOR OR COMMUNITY COLLEGE ATTENDANCE; DO NOT INCLUDE TECHNICAL SCHOOLS (BEAUTICIAN, MECHANIC, ETC.).

0     NEVER ATTENDED SCHOOL
1     1^ST GRADE COMPLETED
2     2^ND GRADE COMPLETED
3     3^RD GRADE COMPLETED
4     4^TH GRADE COMPLETED
5     5^TH GRADE COMPLETED
6     6^TH GRADE COMPLETED
7     7^TH GRADE COMPLETED
8     8^TH GRADE COMPLETED
9     9^TH GRADE COMPLETED
10     10^TH GRADE COMPLETED
11     11^TH GRADE COMPLETED
12     12^TH GRADE COMPLETED
13     COLLEGE OR UNIVERSITY / 1^ST YEAR COMPLETED
14     COLLEGE OR UNIVERSITY / 2^ND YEAR COMPLETED
15     COLLEGE OR UNIVERSITY / 3^RD YEAR COMPLETED
16     COLLEGE OR UNIVERSITY / 4^TH YEAR COMPLETED
17     COLLEGE OR UNIVERSITY / 5^TH OR HIGHER YEAR COMPLETED
DK/REF

1     EXCELLENT
2     VERY GOOD
3     GOOD
4     FAIR
5     POOR
DK/REF

Throughout the rest of this questionnaire, I will be asking you to answer a number of questions about three specific time periods, namely the past 30 days, the past 12 months, and your lifetime. To help you remember the first two time periods, let's mark this calendar with the beginning dates for each one of them.

SHOW CALENDAR TO RESPONDENT.

Now let's think about the past 30 days. According to the calendar, DATEFILL was 30 days ago, so I will write DATEFILL here on the calendar. I'll call that your 30-day reference date.

WRITE 30-DAY REFERENCE DATE ON CALENDAR AND CIRCLE DAY; UNDERLINE ENTIRE 30-DAY PERIOD.

A number of questions will ask about the past 12 months, that is since this date last year. Let's look at the calendar and find that date — DATEFILL. I'll call that your 12-month reference date.

WRITE 12 MONTH REFERENCE DATE ON CALENDAR AND CIRCLE DAY ON CALENDAR.

Please use this calendar as we go through the interview to help you remember when different things happened. I will remind you to think about your 30-day reference date and your 12-month reference date when I ask you questions.

PRESS [ENTER] TO CONTINUE.

Press [ENTER] to continue.

1     YES
2     NO
DK/REF

To select more than one place, press the space bar between each number you type. When you have finished, press the [ENTER] key to go to the next question.

1     A private or public psychiatric hospital
2     A psychiatric unit of a general hospital
3     A medical unit of a general hospital
4     Another type of hospital
5     A residential treatment center
6     Some other type of facility
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

# OF NIGHTS:                      [RANGE: 1 – 365]
DK/REF

To select more than one answer, press the space bar between each number you type. When you have finished, press [ENTER].

1     Self or a family member living with you
2     A family member who does not live with you
3     Private health insurance
4     Medicare
5     Medicaid
6     Rehabilitation program
7     Employer
8     VA or other military program
9     Other public source
10     Other private source
11     No one paid because the treatment was free
DK/REF

Please select only one answer from those that are shown in blue below.
[NOTE TO PROGRAMMERS: RESPONSES CHOSEN IN ADMENT10 SHOULD BE SHOWN IN BLUE. HOWEVER DO NOT IMPLEMENT AN ERROR MESSAGE IF THE RESPONDENT SELECTS ONE OF THE OTHER RESPONSES.]

1     Self or a family member living with you
2     A family member who does not live with you
3     Private health insurance
4     Medicare
5     Medicaid
6     Rehabilitation program
7     Employer
8     VA or other military program
9     Other public source
10     Other private source
11     No one paid because the treatment was free
DK/REF

[IF ADMENT10 = 2 AND NE 1 AND ADMENT02 NE DK/REF] How much did your family pay for the inpatient mental health care you received during the past 12 months? Do not count any money that has been or will be reimbursed by insurance or any other source.

1     Less than $100
2     $100 to $200
3     $201 to $500
4     $501 to $900
5     $901 to $1,500
6     $1,501 to $2,000
7     $2,001 to $5,000
8     More than $5,000
DK/REF

During the past 12 months, did you receive any outpatient treatment or counseling for any problem you were having with your emotions, nerves, or mental health at any of the places listed below? [IF TX01 = 1 OR DK/REF] Please do not include treatment for alcohol or drug use.

• An outpatient mental health clinic or center
• The office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic
• A doctor's office that was not part of a clinic
• An outpatient medical clinic
• A partial day hospital or day treatment program
• Some other place

1     YES
2     NO
DK/REF

To select more than one place, press the space bar between each number you type. When you have finished, press the [ENTER] key to go to the next question.

1     An outpatient mental health clinic or center
2     The office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic
3     A doctor's office that was not part of a clinic
4     An outpatient medical clinic
5     A partial day hospital or day treatment program
6     Some other place
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

# OF VISITS:                      [RANGE: 1 – 365]
DK/REF

To select more than one answer, press the space bar between each number you type. When you have finished, press the [ENTER] key to go to the next question.

1     Self or a family member living with you
2     A family member who does not live with you
3     Private health insurance
4     Medicare
5     Medicaid
6     Rehabilitation program
7     Employer
8     VA or other military program
9     Other public source
10     Other private source
11     No one paid because the treatment was free
DK/REF

Please select only one answer from those that are shown in blue below.

[NOTE TO PROGRAMMERS: RESPONSES CHOSEN IN ADMENT22 SHOULD BE SHOWN IN BLUE. HOWEVER DO NOT IMPLEMENT AN ERROR MESSAGE IF THE RESPONDENT SELECTS ONE OF THE OTHER RESPONSES.]

1     Self or a family member living with you
2     A family member who does not live with you
3     Private health insurance
4     Medicare
5     Medicaid
6     Rehabilitation program
7     Employer
8     VA or other military program
9     Other public source
10     Other private source
11     No one paid because the treatment was free
DK/REF

[IF ADMENT22 = 2 AND NE 1 AND ADMENT14 NE DK/REF] How much did your family pay for the outpatient mental health care you received during the past 12 months? Do not count any money that has been or will be reimbursed by insurance or any other source.

1     Less than $100
2     $100 to $200
3     $201 to $500
4     $501 to $900
5     $901 to $1,500
6     $1,501 to $2,000
7     $2,001 to $5,000
8     More than $5,000
DK/REF

1     YES
2     NO
DK/REF

1     YES
2     NO
DK/REF

1     Couldn't afford it
2     Some other reason
DK/REF

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