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

1. Introduction

1.1 Purpose of the Report

Results from an array of clinical and population-based studies conclude that there are a variety of effective treatments for mental health problems, with most falling into the categories of psychosocial (counseling, both outpatient and inpatient) and pharmacological (prescription medication). When combined, these therapies can be even more effective than when used alone (U.S. Department of Health and Human Services [DHHS], 1999). Current data on mental health service utilization patterns and the characteristics of persons receiving treatment are critical for policy-makers and service providers in the mental health service delivery system. Given evidence that individuals with a substance use disorder are less likely to obtain treatment from the mental and addictive disorders service system (Regier et al., 1993), the influence of substance use and abuse on the receipt of mental health treatment is of particular interest.

This report presents estimates of the prevalence of mental health treatment among adults and describes the types of treatment received and the characteristics of persons receiving treatment based on data from the 2000 and 2001 National Household Survey on Drug Abuse (NHSDA). The NHSDA, which was renamed the National Survey on Drug Use and Health (NSDUH) in 2002, is a nationally representative survey of the civilian, noninstitutionalized population aged 12 or older and is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA). Summary results from the 2002 NSDUH were released in September 2003 (Office of Applied Studies [OAS], 2003). The more extensive analysis of the 2000–2001 data presented in this report is not comparable with the analysis of data from the 2002 survey because of methodological improvements made in the survey in 2002 that affected prevalence estimates.

To ensure adequate sample sizes for analyses of the smallest treatment group (i.e., persons receiving inpatient treatment), the analysis is based on combined data from the 2000 and 2001 NHSDA. Weights were adjusted to reflect a simple average over the 2 years. Estimates of the prevalence and selected demographic characteristics of persons receiving mental health treatment in 2000 and in 2001 were published earlier (OAS, 2001, 2002a, 2002b). The purpose of this report is to present an in-depth analysis of the prevalence of mental health treatment and types of treatment among population subgroups and to examine perceived unmet need for treatment. Specifically, the report has five objectives:

• estimate prevalence rates and characteristics of adults receiving mental health treatment;



• identify the types and combinations of treatments received;



• identify the types of facilities, number of visits (stays), and payers for outpatient and inpatient treatment received;



• examine the associations between receipt of mental health treatment and substance use, dependence/abuse, and substance abuse treatment; and



• describe the characteristics of persons reporting perceived unmet need for mental health treatment among the treated and untreated populations.

Subsequent reports will examine other topics, such as the relationship between serious mental illness (SMI) and the receipt of mental health treatment.

1.2 Prior Studies

Estimates of the numbers and characteristics of persons needing and receiving mental health treatment have been produced from various surveys conducted over the past two decades (Kessler et al., 1994; McKusick, Mark, King, Coffey, & Genuardi, 2002; OAS, 2001, 2002a, 2002b; Olfson, Pincus, & Sabashin, 1994; Regier et al., 1993; Sturm & Sherbourne, 2000). Direct comparison of estimates from these surveys is not possible because of differing definitions of treatment, survey methods, and sample composition. However, secondary analysis was performed on combined data from the two most often cited surveys, the Epidemiologic Catchment Area (ECA) study and the National Cormorbidity Survey (NCS), and a 1-year estimate of mental health treatment produced. That analysis estimated that 11 percent of the adult population received services for mental health or addictive disorders in the specialty mental health sector or the general medical sector in the year prior to interview (DHHS, 1999; Kessler et al., 1996). Despite differences in methods, instruments, and procedures among these surveys, these estimates are remarkably similar to the overall estimate of mental health and substance use treatment produced from the 2000–2001 NHSDA (11.1 percent).

1.3 Summary of NHSDA Methodology

The NHSDA is the primary source of statistical information on the use of licit and illicit drugs by the civilian, noninstitutionalized population of the United States aged 12 or older. Conducted by the Federal Government since 1971, the survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their places of residence. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). Data collection in 2000 and 2001 was carried out by RTI International of Research Triangle Park, North Carolina,¹ under a contract with SAMHSA's Office of Applied Studies (OAS). The survey is conducted from January through December each year. In addition to extensive questions about the use of substances, the 2000 and 2001 versions of the survey included questions on mental health treatment. A measure of serious mental illness (SMI) was included in the 2001 survey. An earlier report presents the 2001 findings on SMI and treatment (OAS, 2002a, 2002b). In 2002, the name of the survey was changed to the National Survey on Drug Use and Health (NSDUH), and several improvements and modifications were made. Respondents were offered a $30 incentive payment for participation in the survey, and quality control procedures were enhanced. Because of these improvements, estimates from the 2002 NSDUH should not be compared with estimates from the 2001 NHSDA or earlier versions. A discussion of survey methodology and results from the 2002 NSDUH are presented in OAS (2003).

The NHSDA is administered using computer-assisted interviewing (CAI) methodology. The demographic questions are administered by interviewers using computer-assisted personal interviewing (CAPI); the drug use, mental health, and other sensitive questions are administered using audio computer-assisted self-interviewing (ACASI). The CAI method has many advantages over the previously used paper-and-pencil interviewing (PAPI) method, including more efficient processing and collection of the data and improved data quality.

Use of ACASI is designed to provide the respondent with a highly private and confidential means of responding to questions and should increase the level of honest reporting of sensitive behaviors. The interview averages about an hour. In brief, the interview begins in CAPI mode with the interviewer reading the questions from the computer screen and entering the respondent's replies into the computer. The interviewer then turns the computer over to the respondent to answer the sensitive questions using ACASI. In this mode, the respondent can read the questions silently from the computer screen or listen to the questions read through headphones while entering his or her responses directly into the computer. The interviewer is responsible for ensuring that no other person in the household can see the computer screen during the self-administered portion. At the conclusion of the ACASI section, the interview returns to the CAPI mode with the interviewer completing the questionnaire. No personal identifying information is captured in the CAI record for the respondent. Additional details regarding the survey methodology are given in Appendix B.

SUrvey DAta ANalysis (SUDAAN) software (RTI, 2001) was used for the statistical analyses to take into account the NHSDA's complex survey design. Tests of significance, such as t tests and chi-square tests, were conducted using DESCRIPT and CROSSTAB procedures, and logistic regressions were conducted using the LOGISTIC procedure. Only significant differences between groups were reported. Missing data were excluded in all analyses.

1.4 Limitations of the Data

All data from the NHSDA are based on retrospective reports by survey respondents and are subject to recall and reporting biases. Some degree of underreporting on drug use and mental health treatment measures might occur because of the social unacceptability of drug use and the stigma of mental health treatment.

The survey represents the civilian, noninstitutionalized U.S. population aged 12 or older. Active military personnel, homeless persons not living in identifiable shelters, and persons who resided in long-term psychiatric or other institutions at the time of interview are excluded from the sample and from the estimates presented in this report.

See Appendix C for additional discussion of data limitations, including the effect of nonresponse on analyses presented in this report.

1.5 Sample Sizes

A total of 46,047 adults aged 18 or older completed the 2000 survey, and a total of 45,796 adults completed the 2001 survey. Analyses presented in this report are based on combined 2000 and 2001 NHSDA data. Therefore, weights are adjusted to reflect a simple average over the 2 years. Table  1.1 presents survey sample sizes for 2000 and 2001 by selected demographic and socioeconomic characteristics. The weighted interview response rate for adults aged 18 or older was 72.9 percent in 2000 and 72.3 percent in 2001 (OAS, 2001, 2002a).

1.6 Definitions of Certain Terms Used in the Report

This section describes the treatment, demographic, socioeconomic, and health variables examined in this report. Definitions of the types of mental health treatment and substance use measures also are given in the sections where those data are presented.

Estimated numbers and prevalence rates of interest are presented for major demographic, socioeconomic, and health variables in several groupings based on the level of detail the sample will allow. Questionnaire items used in the 2000 NHSDA to identify respondents' age, gender, race and Hispanic origin, education, marital status, and overall health are reproduced in Appendix A. Definitions of certain variables, or categories of variables, that are not evident from the labels are given in the chapter in which the data are discussed or presented in tables in this report. Following are explanations of other descriptive variables used in this report.

1.6.1 Mental Health Treatment

Based on annual averages of combined data from the 2000 and 2001 NHSDA, an estimated 21.1 million adults aged 18 or older, or 10.5 percent of the adult population, received mental health treatment in the 12 months prior to the interview. The NHSDA asks whether adults received "treatment or counseling for problems with emotions, nerves, or mental health" in an inpatient setting, an outpatient setting (both specialty mental health and general medical), or used prescription medication "to treat a mental or emotional condition."² In these questions, respondents were asked not to include treatment for alcohol or drug use (which was asked about elsewhere in the questionnaire). In addition to the 21.1 million adults receiving mental health treatment, an estimated 1.3 million adults, or 0.6 percent of the adult population, received treatment only for substance use.

1.6.2 Unmet Need for Mental Health Treatment

Unmet need is defined as a perceived need for mental health treatment during the past 12 months that was not received, based on respondents' self-report. Estimates include persons who did not receive any mental health treatment in the past 12 months, as well as persons who received some mental health treatment. Unmet need among those who received treatment may be interpreted as delayed or insufficient treatment in the past 12 months.

1.6.3 Demographic and Socioeconomic Variables

A range of social and demographic variables was included in the 2000 and 2001 NHSDA. Age of the respondent was defined as "age at time of interview." Race/ethnicity was coded into the following categories: (a) non-Hispanic whites (referred to as "whites"); (b) non-Hispanic blacks (referred to as "blacks"); (c) Hispanics; (d) non-Hispanic American Indians/Alaska Natives; (e) non-Hispanic Hawaiian or other Pacific Islanders; (f) non-Hispanic Asians; and (g) non-Hispanic persons reporting more than one race. Current employment was based on the following definitions: full-time employed persons have a job or business and worked 35 or more hours in the week prior to interview, or usually work 35 or more hours per week; part-time employed persons work fewer than 35 hours per week; unemployed persons do not have a job or business and have made specific efforts to find work in the past 30 days; and "not in the labor force" includes persons who are retired, homemakers, students, and others not looking for work. Family income was elicited in three steps: First, respondents were asked a series of "yes/no" questions about specific sources of income for family members; second, they were asked if last calendar year's total combined family income was $20,000 or more, or less than $20,000; and third, they were presented with a card from which they were asked to choose a range that included their income.

A series of questions was asked to identify whether respondents were currently covered by Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), military health care (TRICARE, CHAMPUS, CHAMPVA), private health insurance, or any kind of health insurance (if none of the above was reported). NOTE: For youths and those respondents who were unable to respond to the insurance questions, proxy responses were accepted. Respondents were asked to indicate all the health insurance they had in the past year. Therefore, individual categories were not mutually exclusive.

County type was grouped into three categories: large metropolitan, small metropolitan, and nonmetropolitan. Large metropolitan areas had a population of 1 million or more; small metropolitan areas had a population of fewer than 1 million (this category was broken into the subcategories 250,000 to 1,000,000 and <250,000); and nonmetropolitan areas were areas outside metropolitan statistical areas (MSAs). States were categorized into four regions (Northeast, Midwest, South, and West) and nine geographic divisions within these regions. These regions and divisions consist of the following groups of States:

Northeast Region – New England Division: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic Division: New Jersey, New York, Pennsylvania.

Midwest Region – East North Central Division: Illinois, Indiana, Michigan, Ohio, Wisconsin; West North Central Division: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota.

South Region – South Atlantic Division: Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia; East South Central Division: Alabama, Kentucky, Mississippi, Tennessee; West South Central Division: Arkansas, Louisiana, Oklahoma, Texas.

West Region – Mountain Division: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming; Pacific Division: Alaska, California, Hawaii, Oregon, Washington.

1.6.4 Use of Cigarettes, Alcohol, and Illicit Drugs

The variables measuring the use of cigarettes, alcohol, and other drugs include lifetime use and past year use. Lifetime use referred to a respondent reporting any use of the substance at least once in his or her lifetime. Past year use referred to a respondent reporting any use of the substance at least once during the 12 months preceding the interview date. For cigarettes, daily use referred to a respondent reporting smoking cigarettes every day during the 30 days preceding the interview date. Illicit drugs include marijuana, cocaine (including crack), inhalants, hallucinogens, heroin, and prescription-type drugs used nonmedically. Respondants are asked about nonmedical use of pain relievers, tranquilizers, sedatives, and stimulants. Nonmedical use of prescription-type drugs is defined as using the drug when it was not prescribed for the respondent, or used only for the experience or feeling it caused.

1.6.5 Heavy Use of Alcohol and Illicit Drugs

Heavy alcohol use was defined as drinking five or more drinks on the same occasion on 5 or more days in the past 30 days. Heavy marijuana use was defined as using marijuana on at least 300 days during the 12 months preceding the interview date. Heavy use of other illicit drugs referred to using one or more of the following drugs on at least 50 days in the past 12 months: cocaine, hallucinogens, heroin, inhalants, or the nonmedical use of prescription-type pain relievers, sedatives, tranquilizers, or stimulants, regardless of heavy marijuana use.

1.6.6 Substance Dependence or Abuse

The 2000 and 2001 NHSDA included a series of questions to assess substance dependence and abuse based on criteria in the 4^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association [APA], 1994). The seven dependence criteria are (1) tolerance; (2) withdrawal or avoidance of withdrawal; (3) persistent desire or unsuccessful attempts to cut down or stop substance use; (4) spending a lot of time using the substance, obtaining the substance, or recovering from its effects; (5) reducing or giving up occupational, social, or recreational activities in favor of substance use; (6) impaired control over substance use; and (7) continuing to use the substance despite physical or psychological problems. A respondent was considered to be dependent on a substance when he or she reported having at least three of the dependence criteria. According to the DSM-IV, a person is defined as dependent if he or she meets three out of seven dependence criteria (for substances with a withdrawal criterion) or three out of six criteria (for substances without a withdrawal criterion). An additional criterion imposed on NHSDA data is that a person must have used alcohol on 5 or more days in the past year to be asked the items that measure alcohol dependence or abuse. An additional criterion for marijuana is that a person must have used marijuana on 6 or more days to be asked the items that measure marijuana dependence or abuse.

The four substance abuse criteria are (1) having serious problems due to substance use at home, work, or school; (2) the use of that substance putting the respondent in physical danger; (3) substance use causing the respondent to be in trouble with the law; and (4) continuing to use the substance despite having substance use-related problems with family and friends. A respondent was classified with abuse when he or she reported having at least one of the four abuse criteria and did not meet the definition for dependence.

1.7 Organization of This Report

This report is divided into seven chapters. The demographic and socioeconomic characteristics of persons receiving mental health treatment are discussed in Chapter 2. Chapter 3 compares the characteristics of adults receiving each type of mental health treatment. Chapter 4 examines the characteristics of persons receiving outpatient treatment, as well as the location, number of visits, and payers, while Chapter 5 provides similar data on inpatient treatment. Rates of mental health treatment among substance users and nonusers and the co-occurrence of mental health treatment and substance abuse treatment are covered in Chapter 6. Data on perceived unmet need for mental health treatment are discussed in Chapter 7. Appendices provide technical details on the survey methodology, selected detailed tables with standard errors for population estimates in the report, and selected questionnaire pages from the 2000 NHSDA with demographic and mental health treatment questions.

Table 1.1 Survey Sample Sizes for Respondents Aged 18 or Older, by Selected Characteristics: 2000 and 2001

End Notes

This page was last updated on June 16, 2008.

SAMHSA, an agency in the Department of Health and Human Services, is the Federal Government's lead agency for improving the quality and availability of substance abuse prevention, addiction treatment, and mental health services in the United States.