Mental Health, Drug Use, Co-Occurring Disorders and Dual Diagnosis

Looking for a referral to, or more information about, mental health or substance use treatment services? The American Board of Preventive Medicine provides this service to locate physicians who are certified as specialists in Addiction Medicine

The federal Substance Abuse and Mental Health Services Administration has a free, confidential National Helpline at 1-800-662-HELP (4357).
"SAMHSA’s National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information."
SAMHSA's website also offers a free, confidential Behavioral Health Treatment Services Locator.

1. Mental Illness Among Adults in the US

"In 2016, an estimated 44.7 million adults aged 18 or older had AMI [Any Mental Illness] in the past year (Figure 54). This number represents 18.3 percent of adults in the United States. An estimated 10.4 million adults in the nation had SMI [Serious Mental Illness] in the past year, and 34.3 million adults had AMI excluding SMI in the past year. The number of adults with SMI represents 4.2 percent of adults in 2016, and the number of adults with AMI excluding SMI represents 14.0 percent of adults. Among adults with AMI in the past year, 23.2 percent had SMI, and 76.8 percent did not have SMI.41,42
"In 2016, the percentages of adults with AMI and adults who had AMI excluding SMI were similar to the percentages from 2008 to 2015 (Figures 55 and 57). The percentage of adults in 2016 with SMI was similar to the percentages from 2010 to 2015 but higher than the percentages in 2008 and 2009 (Figure 56)."

(Note: According to SAMHSA, "Adults with AMI were defined as having any mental, behavioral, or emotional disorder in the past year that met DSM-IV criteria (excluding developmental disorders and SUDs).30 Adults with AMI were defined as having SMI if they had any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities. AMI and SMI are not mutually exclusive categories; adults with SMI are included in estimates of adults with AMI. Adults with AMI who do not meet the criteria for having SMI are categorized as having AMI excluding SMI. This section includes past year estimates of adults with AMI, SMI, and AMI excluding SMI.40")

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, p. 36. Retrieved from https://www.samhsa.gov/data/
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2. Receipt of Services among Adults in the US with Co-Occurring Mental Illness and a Substance Use Disorder

"An estimated 8.2 million adults aged 18 or older in 2016 had co‑occurring AMI [Any Mental Illness] and an SUD [Substance Use Disorder] in the past year, corresponding to 3.4 percent of all adults. In addition, about 2.6 million adults had SMI and an SUD in the past year, representing 1.1 percent of all adults.1

"Among the 8.2 million adults with co‑occurring AMI and an SUD in the past year, 48.1 percent received either mental health care or substance use treatment at a specialty facility32 in the past year (Figure 30). In other words, about half of the adults with co‑occurring AMI and an SUD in the past year did not receive either type of service.33 An estimated 6.9 percent of adults with these co‑occurring disorders received both mental health care and specialty substance use treatment, 38.2 percent received only mental health care, and 2.9 percent received only specialty substance use treatment.

"In 2016, an estimated 2.1 million young adults aged 18 to 25, 4.5 million adults aged 26 to 49, and 1.7 million adults aged 50 or older had co‑occurring AMI and an SUD in the past year. These numbers represent 6.1 percent of young adults, 4.5 percent of adults aged 26 to 49, and 1.5 percent of adults aged 50 or older who had AMI and an SUD in the past year.1

"Among adults in 2016 who had co‑occurring AMI and an SUD in the past year, 42.0 percent of young adults aged 18 to 25, 47.9 percent of adults aged 26 to 49, and 56.3 percent of those aged 50 or older received mental health care or substance use treatment at a specialty facility in the past year (Table A.15B in Appendix A). Among adults in all three age groups in 2016 who had co‑occurring AMI and an SUD in the past year, the most common type of service was receipt of only mental health care. Specifically, 35.1 percent of young adults, 37.0 percent of those aged 26 to 49, and 45.1 percent of those aged 50 or older who had co‑occurring AMI and an SUD received only mental health care. In addition, 3.8 percent of young adults, 8.0 percent of adults aged 26 to 49, and 8.1 percent of adults aged 50 or older who had co‑occurring AMI and an SUD received both mental health care and specialty substance use treatment. About 3.1 percent of young adults, 2.8 percent of adults aged 26 to 49, and 3.0 percent of those aged 50 or older with co‑occurring AMI and an SUD received only specialty substance use treatment in the past year."

Park‑Lee, E., Lipari, R. N., Hedden, S. L., Kroutil, L. A., & Porter, J. D. (2017, September). Receipt of services for substance use and mental health issues among adults: Results from the 2016 National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from https://www.samhsa.gov/data/
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3. Receipt of Services among Adults in the US with Co-Occurring Serious Mental Illness and a Substance Use Disorder

"Among the 2.6 million adults who had co‑occurring SMI [Serious Mental Illness] and an SUD [Substance Use Disorder] in the past year, 65.6 percent received either substance use treatment at a specialty facility or mental health care in the past year (Figure 31). Stated another way, about 1 in 3 adults with co‑occurring SMI and an SUD did not receive either type of care in the past year. Among adults with co‑occurring SMI and an SUD, 12.0 percent received both mental health care and specialty substance use treatment, 51.2 percent received only mental health care, and 2.3 percent received only specialty substance use treatment.

"In 2016, about 711,000 young adults, 1.4 million adults aged 26 to 49, and 496,000 adults aged 50 or older had SMI and an SUD in the past year. These numbers correspond to 2.1 percent of young adults, 1.4 percent of adults aged 26 to 49, and 0.4 percent of adults aged 50 or older who had co‑occurring SMI and an SUD in the past year.1

"Among adults with co‑occurring SMI and an SUD in 2016, 55.7 percent of young adults aged 18 to 25 and 69.0 percent of those aged 26 to 49 received either mental health care or specialty substance treatment in the past year (Table A.15B in Appendix A). In addition, 3.8 percent of young adults and 12.7 percent of adults aged 26 to 49 who had co‑occurring SMI and an SUD received both mental health care and specialty substance use treatment. An estimated 49.6 percent of young adults aged 18 to 25 with co‑occurring SMI and an SUD and 54.1 percent of adults aged 26 to 49 received only mental health care. (Estimates for the receipt of services among adults aged 50 or older with co‑occurring SMI and an SUD were not reported because of low precision.9)"

Park‑Lee, E., Lipari, R. N., Hedden, S. L., Kroutil, L. A., & Porter, J. D. (2017, September). Receipt of services for substance use and mental health issues among adults: Results from the 2016 National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from https://www.samhsa.gov/data/
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4. Estimated Prevalence of Drug Use Disorder in the United States

"In 2012–2013, the NESARC-III [National Epidemiologic Survey on Alcohol and Related Conditions–III], a large national survey of US adults, assessed 12-month and lifetime disorders, including DUDs, diagnosed according to the new DSM-5. The NESARC-III used rigorous survey and field methods and incorporated measures of functioning and detailed assessments of treatment use. The NESARC-III results indicate that the prevalence rates of 12-month and lifetime DSM-5 DUD were 3.9% and 9.9%, respectively, representing approximately 9,131,250 and 23,310,135 US adults, respectively. Thus, a large number of US adults were affected by DUDs, as were an unmeasured additional number of individuals in the families and social networks of those with the disorder. Further, DSM-5 DUD was characterized by considerable psychiatric comorbidity and disability, thus indicating a serious condition. Associations with comorbidity and disability increased as the severity of DSM-5 DUD increased, indicating validity and utility for the DSM-5 DUD severity metric. Moreover, consistent with previous studies, DUDs largely went untreated, even among those with severe disorders, indicating that lack of treatment use continues to be a substantial problem."

Grant BF, Saha TD, Ruan WJ, et al. Epidemiology of DSM-5 Drug Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA psychiatry. 2016;73(1):39-47. doi:10.1001/jamapsychiatry.2015.2132.
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5. People Receiving Mental Health Services in the United States

"For the 2012 reporting period, 32 states and jurisdictions reported that a total of 3,126,234 individuals had received mental health services; for the 2015 reporting period, 45 states and jurisdictions reported that a total of 5,235,883 individuals had received mental health services [Table 1.1].

"• More than 50 percent of the total individuals served were female in every reporting period between 2012 and 2015 [Table 1.2a].

"&#149: For the 2012 to 2015 reporting periods, Whites represented between 67 and 71 percent of the individuals served; Blacks or African Americans represented between 20 and 21 percent; andAmerican Indians or Alaska Natives, Asians, Native Hawaiians or other Pacific Islanders, and other groups combined represented between 8 and 12 percent [Table 1.3].

"• In every reporting period, depressive disorders were the most frequently reported any-mention1 mental health diagnoses, regardless of gender or ethnicity, and for every race except Blacks orAfrican Americans and Asians in the 2012 reporting period. For these two exceptions, schizophrenia and other psychotic disorders were the most frequently reported any-mention diagnoses[Tables 1.11c, 1.12c, 1.13c, and 1.14c]."

"1 ‘Any-mention’ diagnoses include first, second, or third mental health diagnoses, not just the first-mentioned one"

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2015. Use of Mental Health Services: National Client Level Data. BHSIS Series S-92, HHS Publication No. (SMA) 17-5038. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.
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6. People with Co-occurring Mental Health and Substance Use Disorders Receiving Mental Health Services

"A total of 720,987 individuals aged 12 and older with co-occurring mental health and substance use disorders were served in 2015 [Table 6.1a].

"• Among males who had co-occurring mental health and substance use disorders served in the 2015 reporting period, the most frequently reported diagnoses were depressive disorders and schizophrenia and other psychotic disorders (25 percent each); for females, they were depressive disorders (33 percent) [Table 6.1c].

"• Depressive disorders were the most frequently reported diagnoses for individuals served who had co-occurring alcohol dependence (36 percent), opioid dependence and non-dependent opioid use (35 percent each), or cocaine dependence (30 percent) [Table 6.3c]."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2015. Use of Mental Health Services: National Client Level Data. BHSIS Series S-92, HHS Publication No. (SMA) 17-5038. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.
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7. Mental Health Medications: Antidepressants

"Antidepressants are medications commonly used to treat depression. Antidepressants are also used for other health conditions, such as anxiety, pain and insomnia. Although antidepressants are not FDA-approved specifically to treat ADHD, antidepressants are sometimes used to treat ADHD in adults.

"The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Examples of SSRIs include:

"Fluoxetine
"Citalopram
"Sertraline
"Paroxetine
"Escitalopram
"Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine and duloxetine.

"Another antidepressant that is commonly used is bupropion. Bupropion is a third type of antidepressant which works differently than either SSRIs or SNRIs. Bupropion is also used to treat seasonal affective disorder and to help people stop smoking.

"SSRIs, SNRIs, and bupropion are popular because they do not cause as many side effects as older classes of antidepressants, and seem to help a broader group of depressive and anxiety disorders. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications."

National Institute of Mental Health. Mental Health Information: Mental Health Medications. Last revised October 2016. Last accessed June 15, 2018.
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8. Antidepressant Side Effects

"The most common side effects listed by the FDA include:

"Nausea and vomiting
"Weight gain
"Diarrhea
"Sleepiness
"Sexual problems

"Call your doctor right away if you have any of the following symptoms, especially if they are new, worsening, or worry you(U.S. Food and Drug Administration, 2011):

"Thoughts about suicide or dying
"Attempts to commit suicide
"New or worsening depression
"New or worsening anxiety
"Feeling very agitated or restless
"Panic attacks
"Trouble sleeping (insomnia)
"New or worsening irritability
"Acting aggressively, being angry, or violent
"Acting on dangerous impulses
"An extreme increase in activity and talking (mania)
"Other unusual changes in behavior or mood

"Combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications. For more information, please see the FDA Medication Guide on Antidepressant Medicines

"Antidepressants may cause other side effects that were not included in this list. To report any serious adverse effects associated with the use of antidepressant medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

National Institute of Mental Health. Mental Health Information: Mental Health Medications. Last revised October 2016. Last accessed June 15, 2018.
https://www.nimh.nih.gov/healt...

9. Mental Health Medications: Anti-Anxiety Medications

"Anti-anxiety medications help reduce the symptoms of anxiety, such as panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Benzodiazepines can treat generalized anxiety disorder. In the case of panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments, behind SSRIs or other antidepressants.

"Benzodiazepines used to treat anxiety disorders include:
"Clonazepam
"Alprazolam
"Lorazepam

"Short half-life (or short-acting) benzodiazepines (such as Lorazepam) and beta-blockers are used to treat the short-term symptoms of anxiety. Beta-blockers help manage physical symptoms of anxiety, such as trembling, rapid heartbeat, and sweating that people with phobias (an overwhelming and unreasonable fear of an object or situation, such as public speaking) experience in difficult situations. Taking these medications for a short period of time can help the person keep physical symptoms under control and can be used “as needed” to reduce acute anxiety.

"Buspirone (which is unrelated to the benzodiazepines) is sometimes used for the long-term treatment of chronic anxiety. In contrast to the benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect. It is not useful on an “as-needed” basis."

National Institute of Mental Health. Mental Health Information: Mental Health Medications. Last revised October 2016. Last accessed June 15, 2018.
https://www.nimh.nih.gov/healt...

10. Anti-Anxiety Medication Side Effects

"Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:
"Nausea
"Blurred vision
"Headache
"Confusion
"Tiredness
"Nightmares

"Tell your doctor if any of these symptoms are severe or do not go away:
"Drowsiness
"Dizziness
"Unsteadiness
"Problems with coordination
"Difficulty thinking or remembering
"Increased saliva
"Muscle or joint pain
"Frequent urination
"Blurred vision
"Changes in sex drive or ability (The American Society of Health-System Pharmacists, Inc, 2010)

"If you experience any of the symptoms below, call your doctor immediately:
"Rash
"Hives
"Swelling of the eyes, face, lips, tongue, or throat
"Difficulty breathing or swallowing
"Hoarseness
"Seizures
"Yellowing of the skin or eyes
"Depression
"Difficulty speaking
"Yellowing of the skin or eyes
"Thoughts of suicide or harming yourself
"Difficulty breathing

"Common side effects of beta-blockers include:
"Fatigue
"Cold hands
"Dizziness or light-headedness
"Weakness
"Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms related to both.

"Possible side effects from buspirone include:
"Dizziness
"Headaches
"Nausea
"Nervousness
"Lightheadedness
"Excitement
"Trouble sleeping

"Anti-anxiety medications may cause other side effects that are not included in the lists above. To report any serious adverse effects associated with the use of these medicines, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects for each medication, please see Drugs@FDA."

National Institute of Mental Health. Mental Health Information: Mental Health Medications. Last revised October 2016. Last accessed June 15, 2018.
https://www.nimh.nih.gov/healt...

11. People in the US Receiving Mental Health Services Who Have a Co-Occurring Substance Use Disorder, by Age and Gender

"For the 2015 reporting period, states reported a total of 720,987 individuals served aged 12 and older (14 percent of all individuals served) had co-occurring mental health and substance use disorders.

"During this period, the data show that mental health diagnoses differed somewhat across categories for several variables, including gender, age group, race, ethnicity, living arrangements, employment and detailed “not in labor force,” service setting, and timing of admission. Mental health diagnoses were largely similar across SMI/SED status and level of functioning.

"Gender
"• Tables 6.1a-c. During the 2015 reporting period, for males served who had co-occurring mental health and substance use disorders, the most frequently reported diagnoses were schizophrenia and other psychotic disorders and depressive disorders (25 percent each).

"• For their female counterparts, the most frequently reported diagnoses were depressive disorders (33 percent) and bipolar disorders (29 percent).

"Age
"• Tables 6.1a-c. The most frequently reported diagnoses for individuals served aged 30 to 44 who had co-occurring mental health and substance use disorders were bipolar disorders (from 28 percent to 29 percent).

"• The most frequently reported diagnoses for individuals served aged 45 and older with co-occurring substance use and mental health disorders were depressive disorders (from 31 percent of those aged 45 to 49 to 35 percent of those aged 55 to 64)."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2015. Use of Mental Health Services: National Client Level Data. BHSIS Series S-92, HHS Publication No. (SMA) 17-5038. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.
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12. People in the US Receiving Mental Health Services Who Have a Co-Occurring Substance Use Disorder, by Diagnosis

"In the 2015 reporting period, mental health diagnoses among individuals served who had co-occurring mental health and substance use disorders differed very little by substance use diagnosis. (Unlike mental health diagnoses, where up to three diagnoses are recorded per client record, each client record contains only one substance use diagnosis. See the final section of Appendix E for definitions of substance abuse codes.)

"• Bipolar disorders were the most frequently reported mental health diagnoses for individuals served who had co-occurring marijuana dependence (29 percent).

"• Depressive disorders were the most frequently reported diagnoses for individuals served who had co-occurring alcohol dependence (36 percent), opioid dependence and non-dependent opioid use (35 percent each), or cocaine dependence (30 percent).

"• Bipolar disorders were the most frequently reported mental health diagnoses for individuals served who had co-occurring non-dependent cocaine use (29 percent), non-dependent marijuana use (26 percent), or other non-dependent substance use (26 percent).

"• Depressive disorders and bipolar disorders were the most frequently reported diagnoses for individuals served who had co-occurring non-dependent alcohol use (31 and 25 percent, respectively)."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2015. Use of Mental Health Services: National Client Level Data. BHSIS Series S-92, HHS Publication No. (SMA) 17-5038. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.
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13. Demographic Characteristics of People in the US Receiving 24-Hour Hospital Inpatient Mental Health Treatment Services

"Of the 105,860 clients who received inpatient mental health treatment services on April 29, 2016, 32 percent were in general hospitals, 29 percent were in public psychiatric hospitals, and 28 percent were in private psychiatric hospitals."

"Gender"
"Despite some variation across facility type, 58 percent of clients who received inpatient mental health treatment services were male. Veterans Administration medical centers and public psychiatric hospitals accounted for the highest percentages of males who received inpatient services (83 and 69 percent, respectively).

"Age"
"• Sixteen percent of clients who received inpatient mental health treatment services were aged 17 or younger, while 68 percent were aged 18 to 64, and 16 percent were aged 65 and older.
"• Ninety-eight percent of clients who received inpatient services in RTCs for children were aged 17 or younger, and 2 percent were aged 18 to 64. (RTCs for children varied in how they defined children; some facilities included youth up to age 21. Reports of clients aged 65 and older who received inpatient mental health treatment services in RTCs for children likely constitute reporting errors.)
"• Private psychiatric hospitals served a greater proportion of children aged 17 and younger (25 percent) than general hospitals or public psychiatric hospitals (9 and 5 percent, respectively).
"• Eighty-five percent of clients served in public psychiatric hospitals were aged 18 to 64.
"• General hospitals and VA medical centers reported the largest proportions (24 percent each) of clients aged 65 and older who received inpatient mental health treatment services.

"Race"
"Race information was missing or reported as unknown for 51 percent of clients who received inpatient mental health treatment services on April 29, 2016. Of the clients for whom race information was reported, 31 percent of all those who received inpatient mental health treatment services were white;; 15 percent were Black or African American, and 1 percent each were Asian or two or more races.
"All types of facilities that provided inpatient mental health treatment services served a greater proportion of White clients than clients of any other racial group.
Of clients who received inpatient services in residential treatment centers (RTCs) for children, , 29 percent were Black or African American [Figure 3.2].

"Ethnicity"
"Ethnicity information was missing or reported as unknown for 49 percent of clients who received inpatient mental health treatment services. Forty-five percent were not Hispanic or Latino and 6 percent were Hispanic or Latino."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, pp. 23-24.
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14. Legal Status of People in the US Receiving 24-Hour Hospital Inpatient Mental Health Treatment Services

"Across all facility types, half of all clients who received inpatient mental health treatment services on April 29, 2016, were involuntarily admitted for care: 38 percent of clients were admitted with an involuntary non-forensic (non-criminal) legal status and 15 percent were admitted with an involuntary forensic (criminal) legal status.
Involuntary admissions were highest (91 percent) for clients who received inpatient mental health treatment services in RTCs for children and lowest (19 percent) for clients who received inpatient mental health treatment services in another type of residential treatment facility."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, p. 25.
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15. Demographic Characteristics of People in the US Receiving 24-Hour Residential Mental Health Treatment Services

"Of the 65,324 clients who received residential mental health treatment services on April 29, 2016, 35 percent received services in RTCs for children and 27 percent received services in RTCs for adults.

"Gender"
"A greater proportion of clients who received residential mental health treatment services on April 29, 2016, were male (61 percent) than female. This finding is consistent with the gender composition of clients who received inpatient mental health treatment services.
"VA medical centers and public psychiatric hospitals had the highest proportions of males who received residential mental health treatment services (87 and 69 percent, respectively).

"Age"
"As shown in Table 3.2a-b, clients between 18 and 64 years old accounted for 49 percent of all clients who received residential mental health treatment services on April 29, 2016, while 45 percent were age 17 or younger, and 5 percent were 65 years or older.

"Race"
"Race information was missing or reported as unknown for 40 percent of clients who received residential mental health treatment services on April 29, 2016. White clients accounted for 37 percent of all those who received residential mental health treatment services, while 17 percent were Black or African American, 3 percent were two or more races, and clients who identified as Asian or as American Indian/Alaska Native comprised 1 percent each.
"As shown in Figure 3.4, all types of facilities provided residential mental health treatment services to higher percentages of White clients than Black or African American clients, except for partial hospitalization/day treatment facilities.

"Ethnicity"
Ethnicity information was missing or reported as unknown for 36 percent of clients who received residential mental health treatment services. Clients who identified as Hispanic or Latino accounted for 8 percent of clients, while 56 percent did not identify as Hispanic or Latino."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, pp. 26-28.
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16. Legal Status of People in the US Receiving 24-Hour Residential Mental Health Treatment Services

"Overall, 71 percent of all clients who received residential mental health treatment services on April 29, 2016, were voluntarily admitted for care, and the remaining 29 percent were admitted with an involuntary legal status."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, p. 28.
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17. Demographic Characteristics of People in the US Receiving Less Than 24-Hour Outpatient Mental Health Treatment Services

"Of the 4,161,697 clients who received outpatient mental health treatment services at least once in April 2016 and were still enrolled in treatment on April 29, 2016, 46 percent received services in outpatient mental health facilities and 32 percent received services in community mental health centers. VA medical centers accounted for 9 percent of clients served in less than 24-hour outpatient settings, while multi-setting mental health facilities and general hospitals accounted for 4 percent each.

"Gender"
"Unlike the gender distribution of clients who received inpatient and residential mental health treatment services, the proportion of males and females receiving outpatient mental health treatment services was similar: 51 percent were male and 49 percent were female. A notable exception was VA medical centers, which predominantly served males (77 percent).

"Age"
"Children aged 17 or younger accounted for 27 percent of clients who received outpatient mental health treatment services; 60 percent of clients were adults aged 18 to 64, and 13 percent were seniors aged 65 and older.
"As shown in Figure 3.5, RTCs for children served children in higher proportions than all other facility types. Adults aged 18 to 64 received outpatient services in higher proportion than other age groups in other types of residential treatment facilities (76 percent), VA medical centers (68 percent), and public psychiatric hospitals (67 percent). Clients aged 65 and older accounted for about a quarter of those who received outpatient services in both private psychiatric hospitals and VA medical centers (28 and 23 percent, respectively).

"Race"
"Race information was missing or reported as unknown for 46 percent of clients who received outpatient mental health treatment services. According to the reported race information, 35 percent of clients who received outpatient services were White, 12 percent were Black or African American, 5 percent were two or more races, and 1 percent each were Asian or American Indian/Alaska Native.
"Figure 3.6 compares the proportions of White and Black or African American clients receiving outpatient mental health treatment services by facility type. As with residential settings, all facilities served a greater proportion of White than Black or African American clients.

"Ethnicity"
"Ethnicity information was missing or reported as unknown for 41 percent of clients who received outpatient services. Clients who identified as Hispanic or Latino accounted for 11 percent of those served as outpatients, while 48 percent did not identify as Hispanic or Latino."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, pp. 28-29.
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18. Legal Status of People in the US Receiving Less Than 24-Hour Outpatient Mental Health Treatment Services

"Overall, 92 percent of clients who received outpatient services received care voluntarily, while the other 8 percent received care involuntarily."

Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2016. Data on Mental Health Treatment Facilities. BHSIS Series S-98, HHS Publication No. (SMA) 17-5049. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017, p. 29.
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19. Association Between Post-Traumatic Stress Disorder (PTSD) and Lifetime DSM-5 Psychiatric Disorders among Veterans

"Overall, the prevalence of 6.3% for lifetime DSM-5 PTSD in U.S. veterans is lower than that reported in previous studies of era-specific (18.7% and 52%) (Dohrenwend et al., 2007; Ikin et al., 2010; Jakupcak et al., 2010) veteran cohorts but similar to a national sample of veterans (7.95%; Wisco et al., 2014) using previous diagnostic classifications. In part this may reflect the narrow definition used in the study. However, the lifetime prevalence of PTSD among veterans in this study was very similar to the prevalences of 6.4% and 7.8% reported for DSM-IV PTSD in the general U.S. populations (Kessler et al., 1995; Pietrzak et al., 2011b). Similar to prior studies of veteran and general population samples, prevalence of PTSD was higher among women, and those with PTSD were more likely to be younger, non-white, and have lower income, in addition to reporting more traumatic events (Wisco, et al., 2014; Pietrzak et al., 2011b; Kessler et al., 1995).

"With adjustment for sociodemographic characteristics, PTSD was highly comorbid with all lifetime substance use and aggregate psychiatric disorders assessed in the NESARC-III. These estimates were lower for mood, alcohol use and drug use disorder, higher for nicotine use disorder and similar for anxiety disorders compared to the other recent nationally representative estimates among U.S. veterans (Wisco et al., 2014). Despite changes in diagnostic criteria for PTSD and many other disorders from DSM-IV to DSM-5, they were consistent with previous studies of the general U.S. population (Pietrzak et al., 2011b; Kessler et al., 1995). In models adjusting for only sociodemographic characteristics, PTSD was associated with substance use disorders (AOR=2.1–3.4) and especially mood, anxiety, and personality disorders (AOR=9.6–11.1). After further adjustment for other psychiatric disorders, associations between PTSD and substance use disorders were no longer significant, whereas associations between PTSD and mood, anxiety, and PDs were attenuated. These weaker associations, when adjusting models for psychiatric disorders, suggests shared factors underlying these associations. That the associations between PTSD and mood, anxiety, and PD remained significant, points to possible unique factors contributing to these associations (Agrawal and Lynskey, 2008; Awofala, 2013; Ball, 2008)."

Smith, Sharon M., Rise B. Goldstein, and Bridget F. Grant. “The Association Between Post-Traumatic Stress Disorder and Lifetime DSM-5 Psychiatric Disorders among Veterans: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III).” Journal of psychiatric research 82 (2016): 16–22.
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20. Post-Traumatic Stress Disorder (PTSD) and Lifetime DSM-5 Psychiatric Disorders among Veterans

"In this study, the highest levels of comorbidity (six or more comorbid conditions) among veterans were observed among treatment seekers. However, only those with comorbid DUD [Drug Use Disorders] were significantly more likely to seek treatment for PTSD once potentially confounding factors were accounted for. It is of concern that, in the present sample, 32% of veterans with PTSD who did not seek treatment had 6+ comorbid conditions. The 14.8% increase in completion of at least one PTSD treatment visit between 2005 and 2010, compared with 12.6% from 1997–2005 among veterans seen in the VA healthcare system (Hermes et al., 2012), is encouraging. Similarly, Mott et al., (Mott et al., 2014) recently reported an increase in psychotherapy utilization among veterans across three time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Although most of these increases were seen in those with anxiety and depression, those with PTSD had the highest rate of initiation and number of psychotherapy sessions. Nevertheless, the persistently low rates of help seeking, despite the availability of empirically supported psychotherapies and pharmacotherapies that can prevent psychiatric disorders, including PTSD, from becoming chronic (Bryant et al., 2003; Katon et al. 1996; Simon et al., 2004) is cause for concern. Although treatment may be available, it may not be accessible to all veterans who need it due to lack of proximity to these services (Lazar, 2014). Taken together these results call for efforts to understand low rates of help seeking and use the knowledge gained to increase uptake by veterans with PTSD who could benefit from these interventions wherever they present."

Smith, Sharon M., Rise B. Goldstein, and Bridget F. Grant. “The Association Between Post-Traumatic Stress Disorder and Lifetime DSM-5 Psychiatric Disorders among Veterans: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III).” Journal of psychiatric research 82 (2016): 16–22.
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21. Drug Use Disorder and Comorbidity / Co-Occurring Conditions

"Drug use disorder was highly associated with alcohol and nicotine use disorders, with ORs (95% CIs) ranging from 2.5 (2.00–3.06) to 4.4 (3.80–5.19) across time frames and severity levels (Table 3). Twelve-month DUD was also positively associated with major depressive disorder, bipolar I, posttraumatic stress disorder, and antisocial PD (any and moderate to severe); dysthymia (any and mild); and borderline and schizotypal PDs across severity levels. Lifetime DUD was associated with major depressive disorder and generalized anxiety disorder (any and mild); bipolar I, dysthymia, posttraumatic stress disorder, and borderline and schizotypal PDs (except mild); and panic disorder, social phobia, and antisocial PD across severity levels."

Grant BF, Saha TD, Ruan WJ, et al. Epidemiology of DSM-5 Drug Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA psychiatry. 2016;73(1):39-47. doi:10.1001/jamapsychiatry.2015.2132.
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22. Prevalence of Alcohol Use Disorder in the United States

"In 2012 through 2013, US prevalences of DSM-5 12-month and lifetime AUD [Alcohol Use Disorder] among adults 18 years and older were 13.9% and 29.1%, respectively, representing approximately 32 648 000 and 68 485 000 individuals, respectively, in the United States. Corresponding DSM-IV rates, 12.7% and 43.6%, respectively, increased substantially since 2001 through 2002 (8.5% and 30.3%, respectively).6 Increases in DSM-IV AUD during the past decade may partly reflect increases in heavy alcohol consumption during that period: past-year drinking of at least 5, at least 8, and at least 10 drinks/d increased from 31.0%, 15.6%, and 11.5%, respectively, in the 2001-2002 NESARC to 39.6%, 20.8%, and 15.5%, respectively, in the 2012-2013 NESARC-III (R.B.G., unpublished data, February 2015). In contrast, rates of 12-month AUD remained stable from 2002 and 2013 (about 7.5%) in the National Survey on Drug Use and Health.15 More research on reasons for increasing prevalence of AUD during the past decade and discrepancies in the rates between national surveys is warranted."

Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use DisorderResults From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757–766. doi:10.1001/jamapsychiatry.2015.0584
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23. Demographics of Alcohol Use Disorder in the United States

"Consistent with previous research, rates of AUD [Alcohol Use Disorder] were greater among men than women.1,2,5,14 Age was inversely related to 12-month AUD, a finding also observed in earlier epidemiologic studies.1-5,14 Whether this result is owing to cohort effects, differential mortality, or recall bias merits further investigation. The 12-month rate of 7.1% for severe AUD among 18- to 29-year-old respondents is especially striking. The rate is consistent with the earlier age at onset of severe relative to mild or moderate AUD (23.9 vs 25.9 or 30.1 years, respectively) and increasing rates of heavy drinking in this age group. For example, among men, past-year drinking of at least 5, at least 8, and at least 10 drinks/d increased from 60.7%, 41.0%, and 33.9%, respectively, in the NESARC [National Epidemiologic Survey on Alcohol and Related Conditions III] to 68.2%, 46.3%, and 38.0%, respectively, in the NESARC-III. In women, the increase was from 33.5%, 14.7%, and 8.7%, respectively, in the NESARC to 47.7%, 22.1%, and 14.2%, respectively, in the NESARC-III (R.B.G, unpublished data, February 2015). Thus, emerging adulthood is becoming an increasingly vulnerable period for AUD onset. Given the potential effect of young-adult AUD on long-term employment prospects in a changing economy and the risk for young-adult alcohol-related mortality, the increases suggest an urgent need to develop and implement more effective prevention and intervention efforts.

"Study findings indicate a lower risk for AUD among black, Asian or Pacific Islander, and Hispanic than white respondents. Although genetic factors affecting alcohol metabolism likely influence lower rates among Asian respondents,42,43 understanding risk factors among white respondents and protective factors among black and Hispanic respondents will be important to elucidate the etiology of AUD and design better prevention and intervention programs. In contrast, Native American respondents had high rates of 12-month and lifetime severe AUD. These results are consistent with regional studies of Native Americans showing high rates of alcohol-related morbidity and mortality44-46 and underscore the need for more extensive prevention and intervention efforts in this group."

Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use DisorderResults From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757–766. doi:10.1001/jamapsychiatry.2015.0584
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24. Alcohol Use Disorder, Comorbidity/Co-Occurring Disorders, and Treatment

"We generally found significant associations between 12-month and lifetime AUD and other substance use disorders, major depressive disorder, bipolar I disorder, specific phobia, and antisocial and borderline PDs when we controlled for sociodemographic characteristics and other disorders. Significant associations between persistent depressive disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety disorder with lifetime AUD were also observed. That these associations were weaker than those when we only controlled for sociodemographic variables suggests common causal factors underlying the pairwise comorbid associations. Moreover, that these associations remained significant after additional control for comorbid disorders indicates the possibility of unique underlying factors contributing to the disorder-specific associations.47-49 These findings, consistent with genetic studies, highlight the need for further investigation of the unique and common factors underlying AUD comorbidity. Within this framework, special emphasis should be given to sociodemographic risk factors identified herein (education and income) that may interact with genetic vulnerability to influence phenotypic expression of AUD.

"Despite increased AUD prevalence during the past decade, this study showed that AUD largely goes untreated. Rather than lack of insurance, fears of stigmatization and beliefs that treatment is ineffective explain the lack of AUD treatment in the United States.50-54 Nonetheless, a large body of literature supports the effectiveness of treatment of AUD. Prior NESARC findings55 show that participation in 12-step groups increases the likelihood of recovery, consistent with randomized clinical trials testing the efficacy of 12-step facilitation administered by health care practitioners.56 Reviews and meta-analyses of randomized trials involving thousands of patients have demonstrated the efficacy of brief screening and intervention in primary care settings among individuals whose alcohol problems are not yet severe.57-60 For more severe problems, effective medications include oral and extended-release naltrexone hydrochloride, acamprosate calcium, and disulfiram61-65; evidence-based behavioral treatments include 12-step facilitation,56 motivational interviewing,66-68 and cognitive-behavioral therapy.68-70 Effective treatment might be more widely accessed if public and professional education programs targeted mistaken attitudes about treatment efficacy and provided information about where to obtain treatment.

"All measures of current disability were strongly related to 12-month AUD, increasing with AUD severity. These findings highlight the seriousness of AUD, particularly among never-treated individuals. Prior research has shown significantly less disability among those treated for an AUD than those never treated.71,72 When untreated, AUD-related functional impairment also has been associated with diminished life chances, increased stressful life conditions, and increased risk for and severity of other psychiatric disorders, even after AUD remission.73 These findings suggest that AUD treatment should aim to remediate impaired functioning in addition to targeting alcohol consumption."

Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use DisorderResults From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757–766. doi:10.1001/jamapsychiatry.2015.0584
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25. Prevalence of DMS-5 Post-Traumatic Stress Disorder in the United States

"Past-year (4.7%) and lifetime (6.1%) prevalences of DSM-5 PTSD represent 10,972,986 and 14,411,005 affected U.S. adults, respectively. Broadly consistent with previous findings [3, 4, 42, 43], prevalences were higher among women and respondents aged <65 years, previously married, and with <high school education and household income <$70,000. Rates were also higher among Native American, but lower among Asian and Pacific Islander and Hispanic, versus non-Hispanic white, respondents, and lower among urban than rural residents. Past-year PTSD was less likely among Midwestern than Western residents. Taken together, these results indicate the need to characterize risk and protective factors, and underlying mechanisms, related to sociodemographic characteristics to improve understanding of the etiologies of both exposure to PTEs and PTSD and tailor prevention and intervention appropriately to subgroups at risk [3, 43].

"In the total NESARC-III sample, lifetime prevalence of PTE exposure (68.6%) was higher than reported by Kessler et al. [42] based on DSM-III-R criteria, but lower than those in recent studies [3, 22, 44, 45] based on DSM-IV, including Wave 2 of the NESARC. These differences likely reflect the broader range of qualifying events in DSM-IV than DSM-III-R or DSM-5. Nevertheless, rank-orderings of the most common exposures, particularly among respondents with PTSD, and differences by sex, were generally similar to those reported previously [4, 42–44]."

Goldstein RB, Smith SM, Chou SP, et al. The Epidemiology of DSM-5 Posttraumatic Stress Disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social psychiatry and psychiatric epidemiology. 2016;51(8):1137-1148. doi:10.1007/s00127-016-1208-5.
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26. Mental Health Treatment Admissions, Discharges, and Client Outcomes

"In the 2015 reporting period, six states and jurisdictions (Connecticut [adults only], the District of Columbia, Louisiana, Mississippi, Oklahoma, and Puerto Rico) reported a total of 417,443 admissions to MH-TEDS [Mental Health Treatment Episode Data Set]. [Table 7.1]:

"• Of admissions who began treatment prior to the 2015 reporting period, 69 percent of admissions received treatment in community programs, 57 percent in residential treatment centers, 43 percent in state psychiatric hospitals, and 31 percent in institutions under the justice system [Table 7.1].

"• More than half (66 percent) of admissions for individuals in treatment during the 2015 reporting period occurred prior to the reporting period [Table 7.2b].

"• There were more male than female admissions for ADD/ADHD, conduct disorder, and oppositional defiant disorder. There were more female than male admissions for adjustment disorders, anxiety disorders, bipolar disorders, and depressive disorders [Table 7.3a,Table 7.10a].

"Client Outcomes Among Individuals Receiving Mental Health Services: 2012 and 2015
"States reported a total of 701,355 individuals served in 2012 that were also reported to have received services in the 2015 reporting period and had known living arrangements in 2012 [Table 8.1a].

"• Among individuals served in both the 2012 and 2015 reporting periods overall, less than one-third of those who were homeless in 2012 also reported being homeless in 2015 (29 percent) [Figure 2].

"States reported a total of 497,340 individuals served in 2012 that were also reported to have received services in the 2015 reporting period and had known employment status in 2012 [Table 8.3a].

"• A higher percentage of individuals served in both periods reported being unemployed among those with alcohol and drug related disorders (69 percent) compared with all individuals served in both periods that reported being unemployed in 2012 and 2015 (51 percent) [Figure 5]."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Mental Health Annual Report: 2015. Use of Mental Health Services: National Client Level Data. BHSIS Series S-92, HHS Publication No. (SMA) 17-5038. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.
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27. Likelihood That Young People with Diagnosed Mental Health Conditions Will be Put on Long Term Opioid Therapy

"In this nationwide study of commercially insured adolescents, LTOT [Long Term Opioid Therapy] was relatively uncommon. The estimated incidence of LTOT receipt was 3.0 per 1000 adolescents within 3 years of filling an initial opioid prescription. Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT. Associations were strongest for OUD [Opioid Use Disorder], OUD medications, nonbenzodiazepine hypnotics, and other SUDs. The associations were stronger sooner after first opioid receipt for OUD, as well as for anxiety and sleep disorders and their treatments, suggesting that adolescents with these conditions and treatments were more likely to quickly transition into LTOT."

Quinn PD, Hur K, Chang Z, et al. Association of Mental Health Conditions and Treatments With Long-term Opioid Analgesic Receipt Among Adolescents. JAMA Pediatr. 2018;172(5):423–430. doi:10.1001/jamapediatrics.2017.5641
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28. Likelihood That Young People with Diagnosed Mental Health Conditions Will be Put on Long Term Opioid Therapy

"Of the 1,000,453 opioid recipients (81.7%) with at least 6 months of follow-up, 51.1% were female, and the median age was 17 years (interquartile range, 16-18 years). Among these adolescents, the estimated cumulative incidence of LTOT [Long Term Opioid Therapy] after first opioid receipt was 1.1 (95% CI, 1.1-1.2) per 1000 recipients within 1 year, 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years, 8.2 (95% CI, 7.8-8.6) per 1000 recipients within 6 years, and 16.1 (95% CI, 14.2-18.0) per 1000 recipients within 10 years. The prevalence of mental health conditions and treatments in this sample is shown in eTable 3 in the Supplement.

"All mental health conditions and treatments were associated with higher rates of transitioning from a first opioid prescription to long-term therapy. Table 2 provides the estimated incidence of LTOT among those with and without mental health conditions and treatments.Adjusted relative increases in the rate of LTOT ranged from a factor of 1.73 for ADHD [Attention-Deficit/Hyperactivity Disorder] (hazard ratio [HR], 1.73; 95% CI, 1.54-1.95) to approximately 4-fold for benzodiazepines (HR, 3.88; 95%CI, 3.39-4.45) and nonopioid SUDs [Substance Use Disorders] (HR, 4.02;95%CI, 3.48-4.65) to 6-fold for non benzodiazepine hypnotics (HR, 6.15; 95%CI, 5.01-7.55) and to nearly 9-fold for OUD [Opioid Use Disorder] (HR, 8.90; 95%CI, 5.85-13.54). In addition, relative to no condition, the number of condition types was also associated with higher LTOT rates (1 condition: HR, 2.21; 95% CI, 2.01-2.43; 2 or more conditions: HR, 4.01; 95% CI, 3.62-4.46).

"Given the strong associations for OUD, we explored other mental health factors and opioid receipt among those with preexisting OUD. These adolescents were more likely than
adolescents without OUD to have other mental health conditions and treatments (eTable 4 in the Supplement). For example, 76.1% of adolescents with OUD had other SUDs, 61.0% had depressive disorders, and 52.6% had received an SSRI [Selective Serotonin Reuptake Inhibitor]. During follow-up, those with preexisting OUD received opioid drugs similar to those received by adolescents without OUD, although the former were more likely to receive certain opioids (eg, oxycodone and tramadol; eTable 5 in the Supplement). Of those with preexisting OUD, 15.5% filled a prescription for OUD medication treatment during follow-up."

Quinn PD, Hur K, Chang Z, et al. Association of Mental Health Conditions and Treatments With Long-term Opioid Analgesic Receipt Among Adolescents. JAMA Pediatr. 2018;172(5):423–430. doi:10.1001/jamapediatrics.2017.5641
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29. Psychosocial Interventions and Chronic Pain Outcomes in Older Adults

"Mean treatment results demonstrated in the present study obscure variations at the individual patient level. Some older patients with chronic pain may receive substantial benefit through psychological therapy, while others may not benefit. There is no evidence that the beneficial results identified at the completion of treatment persisted up to 6 months for outcomes other than pain reduction. There were too few studies reporting long-term outcomes to determine completely whether this finding was due to decreased power or to a tapering of treatment benefits over time.

"The observed benefits were strongest when delivered using group-based approaches. Potential mechanisms that could account for this finding include access to peer support, social facilitation of target behaviors, and public commitment to therapy goals.52 No other results of participant, intervention, or study characteristics were found. Treatment benefits were equally likely to occur in older men and women irrespective of age and duration of chronic pain."

Niknejad B, Bolier R, Henderson CR, et al. Association Between Psychological Interventions and Chronic Pain Outcomes in Older AdultsA Systematic Review and Meta-analysis. JAMA Intern Med. Published online May 07, 2018. doi:10.1001/jamainternmed.2018.0756
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