1. The Epidemiology of Co-Occurring Disorders H. Westley Clark, MD, JD, MPH Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

2. There is no single road to Recovery. No absolute path. Each person must identify that which works. Some roads are paved, some are rough, and others are ill defined. No matter. Recovery works, but the burden rests on the individual, the family and the community.

3. Two Major Contemporary Surveys of Co-Occurring Disorders General –National Survey of Drug Use and Health (NSDUH) Specific –National Epidemiologic Survey of Alcohol Related Conditions (NESARC)

4. National Survey on Drug Use and Health Representative nationally and in each State Civilian, non-institutionalized population Aged 12 or older Face-to-face interview Computer-assisted, self-administered 67,784 respondents in 2003 2003 data comparable with 2002 data, but not with data prior to 2002

5. NATIONAL EPIDEMIOLOGIC SURVEY ON ALCOHOL AND RELATED CONDITIONS (NESARC) Nationally representative face-to-face survey of 43,093 respondents, 18 years and older. Conducted by NIAAA in 2001-2002 Civilian, non-institutionalized population in United States in housing, including group quarters. –Includes Alaska and Hawaii –Hospitals, jails and prisons not among the group quarters sampled Oversampling of: –Blacks –Hispanics –Young Adults aged 18-24

6. NSDUH vs. NESARC NSDUH 2003 like it’s predecessors is symptom driven NESARC is diagnosis driven

7. NSDUH: Serious Mental Illness (SMI) Definition: DSM-IV mental disorder and impairment in past year Measurement: K-6 distress scale Prevalence in 2003: 19.6 million adults with SMI (9.2%)

8. Rates of SMI among Adults Aged 18 or Older, by Age: 2002 and 2003 Percent with Past Year SMI  ,  = Significant change 2002 to 2003  Age in Years

9. Substance Use among Adults Aged 18 or Older, by SMI: 2003 Percent Using

10. Treatment for Mental Health Problems among Adults Aged 18 or Older, by Type of Treatment and Past Year SMI: 2003 Percent Receiving Treatment in the Past Year Type of Treatment 13.2 0.8 7.2 10.9

11. Reasons for Not Receiving Treatment in the Past Year among Persons Aged 18 or Older with SMI Who Did Not Receive Treatment but Perceived an Unmet Need for Treatment in the Past Year: 2003 Percent Did Not Feel Need for Treatment/ Could Handle the Problem without Treatment Fear of Being Committed/ Have to Take Medicine Did Not Know Where to Go for Services

12. Substance Dependence or Abuse among Adults Aged 18 or Older, by SMI: 2003 Percent Dependent or Abusing in Past Year

13. Co-Occurrence of SMI and Substance Use Disorders among Adults Aged 18 or Older: 2003 15.2 Million 15.4 Million Co-Occurring Disorders Substance Use Disorder Only SMI Only 4.2 Million

14. Past Year Treatment among Adults Aged 18 or Older with Co-Occurring SMI and a Substance Use Disorder: 2003 Substance Use Treatment Only 4.2 Million Adults with Co-Occurring SMI and Substance Use Disorder Treatment for Both Mental Health and Substance Use Problems No Treatment 39.8% 49.0% 7.5% 3.7% Treatment Only for Mental Health Problems

15. Most Adults Who Needed Treatment for Substance Use Problems Did Not Feel A Need for Treatment Illicit Drugs Alcohol Felt Need for TX, but untreated 2003 NSDUH Felt No Need for TX Received TX

16. Past Year Receipt of and Perceived Need for Treatment for Mental Health Problems among Persons Aged 18 or Older with SMI: 2003 Not Treated, No Perceived Unmet Need (7.8 Million) Treated (9.2 Million) Not Treated, Perceived Unmet Need (2.5 Million) 19.6 Million with SMI 47% 13% 40%

17. NESARC Diagnosis Specific Used DSM-IV Criteria to Establish Diagnosis Addressed specific diagnostic conditions and subsets of those conditions –Mood Disorder From Depression to Dysthymia –Anxiety Disorder From Panic to GAD

18. Prevalence of Mood & Anxiety Disorders “Of the approximately 19.3 million adults who had a current mood disorder, only 202,211 experienced episodes that were classified exclusively substance induced.” Of the approximately 23 million adults with a “current anxiety disorder”, only 50,980 experienced episodes that were exclusively substance induced. Of those respondents who were classified as having at least one current independent mood or anxiety disorder, only 7.35% and 2.95%, respectively, experienced independent and substance induced episodes in the year preceding the survey

19. Twelve Month Prevalence of Independent Mood Disorders Among Those with Substance Use Disorders Percentage

20. Twelve Month Prevalence of DSM-IV Substance Use Disorders Among Those with Independent Mood Disorders Percentage

21. Twelve Month Prevalence of Independent Anxiety Disorders Among Those with Substance Use Disorders Percentage

22. Twelve Month Prevalence of DSM-IV Substance Use Disorders Among Those with Independent Anxiety Disorders Percentage

23. TREATMENT SEEKING INDIVIDUALS

24. Locations Where Past Year Substance Treatment Was Received among Persons Aged 12 or Older: 2002 and 2003 Numbers (in Thousands) Receiving Treatment ,  = Significant change 2002 to 2003     Outpatient Rehabilitation Inpatient Rehabilitation Mental Health Center Hospital Inpatient

25. Those with Independent Mood Disorders Who Seek Treatment For that Disorder Who Also Have: A Substance Use Disorder, An Alcohol Use Disorder or A Drug Use Disorder, by Percentage Percentage

26. Those with Any Independent Anxiety Disorder Who Seek Treatment For That Disorder Who Also Have: A Substance Use Disorder, An Alcohol Use Disorder or A Drug Use Disorder, by Percentage Percentage

27. Independent Mood or Anxiety Disorders Among Those with Drug Use Disorders who Sought Treatment Percentage

28. 21. 3 % (4.2 million people) Mental Health Disorder Substance Use Disorder Co-Occurring Disorders General Population Survey (NSDUH) Drug Use Disorder Treatment Seeking Population (NESARC Study) Mood Disorders 60% 19.4 million people 19. 6 million people (6 million people need care for illicit drug use) (16.7 million people )

29. Significance of NESARC for SAMHSA Mood and anxiety disorders are more common among persons who have substance abuse disorders than among those who do not. This increase appears to be independent of the substance of abuse Consistent with NSDUH, only a minority of people with substance use disorders seek treatment---5.81% alcohol use disorder, 13.1% drug use disorder –However, of those who do seek treatment Of those with alcohol use disorder, 40.69% have a mood disorder and 33.38% have an anxiety disorder Of those with a drug use disorder, 60.31% have a mood disorder and 42.63 % have an anxiety disorder

30. Significance of NESARC to SAMHSA Of particularly note for SAMHSA is that while only 25.81% of those with a mood disorder seek treatment, those who also have a substance abuse disorder are even less likely to seek treatment: –20.78% for any substance use disorder –17.45% for any alcohol use disorder –7.96% for any drug use disorder –In other words, the presence of a co-occurring substance use disorder militates against treatment seeking behavior among persons with mood disorders, and the service systems are not adequately responsive to persons with co- occurring mood and substance use disorders.

31. Significance of NESARC to SAMHSA Only 5.81% of those with an alcohol use and 13.10% of those with drug use disorders seek treatment. Those who seek treatment with substance use disorders increase when there is a co-occurring mood or anxiety disorder.

32. Significance of NESARC to SAMHSA Key Policy Questions How treatment seeking behavior can be increased among those with substance use disorders? What can be done to accommodate greater systems strain from increased demand? While 13.1% of those with drug use disorders seek treatment, 86.9% do not

33. Substance Abuse Prevention and Treatment in Light of NESARC The substance abuse prevention and treatment system needs to improve the accessibility and quality of services for those with co-occurring disorders. The demand for illicit drugs undoubtedly comes from those who consume such drugs to the point of abuse or dependence. Hence the social consequences from drug use and excessive alcohol use cannot be adequately addressed unless new strategies evolve to reach the very large population supporting the illicit drug market and excessively consuming alcohol to the detriment of themselves and society.

34. Other Implications for the Substance Abuse Treatment Community Given the high prevalence of co-occurring mood and anxiety disorders among treatment seeking clients, it is clear that the substance abuse treatment community must be able to assess, diagnose and treat those conditions. –Treatment strategies must be developed to accommodate different modalities of intervention such as medications, cognitive behavioral strategies and other strategies –Without a clear entry assessment of co-occurring conditions proper care and treatment cannot be rendered

35. Implications for the Mental Health Treatment Community People with Mood Disorders or Anxiety Disorders with co-occurring Drug Use Disorders are not likely to present for treatment in a mental health clinic Apparently, people with Drug Use Disorders do not feel welcome in programs that are primarily mental health treatment oriented.

36. Where do we go from here?

37. Reaching the Untreated Patient Suffering from Substance Use Disorders Addressing State laws that translate “serious emotional illness” into “serious and persistent emotional illness” –Thus, limiting access for those with milder forms of mental illness Promoting screening and brief intervention for those suffering from substance use disorders –Thus, reaching those with both mild mental illness and substance use disorders BEFORE conditions grow more severe

38. Community Outreach Enlisting the vectors of values in a community to promote interventions and to facilitate Recovery –Community Based Organizations –Faith Based Organizations –Self Help Groups –Families –Employers/Business/Labor –Recovery Community/Peer Support –Law Enforcement –Child Welfare

40.  People in Recovery  Substance Abuse Treatment Capacity  Strategic Prevention Framework  Mental Health System Transformation  Primary healthcare  Child welfare  Criminal & Juvenile justice system  Housing  Education  Business  Labor  Community & Faith-based organizations

41. Many Pathways to