Identifying Need for Mental Health Services in Substance Abuse Clients

Abstract

Objective: Counselor detection of co-occurring disorders is critical to ensuring that clients with mental disorders entering substance abuse treatment receive appropriate care. This study sought to (a) examine correspondence between client-reported psychiatric symptoms and client and counselor ratings of need for mental health treatment and (b) explore client- and program-level characteristics associated with client and counselor underrating. Methods: Psychiatric symptoms and client and counselor ratings of need for mental health services were collected using the Addiction Severity Index (ASI) among 3,972 clients entering outpatient substance abuse treatment at 30 treatment programs across the U.S. Kappa statistics were used to determine level of agreement between client-reported symptoms and client and counselor ratings of need for mental health treatment. Multilevel modeling was used to examine characteristics associated with underrating. Results: While agreement between symptoms and ratings of need for mental health treatment was fairly high (kappas = .62–.73), there was a substantial amount of underrating. Approximately 54% (n = 2,128) of clients had at least some psychiatric problems based on symptoms reported in the ASI, and 30% (n = 630) of these clients underrated their need for mental health services. Counselors also underrated need for mental health services in 32% (n = 691) of clients who reported psychiatric problems, even though 36% of them (250 of 691) indicated that obtaining treatment for mental health problems was important to them. Two factors emerged from the multivariate model for both client and counselor underrating of need for mental health services. Clients with psychiatric problems and a drug disorder were more likely than clients without a drug disorder (OR = 1.30, p < .05) to underrate their need for mental health services (as were counselors), and clients with psychiatric problems who were assessed at programs that were licensed by an outside agency were less likely (OR = 0.59, p < .01) to underrate their need for mental health services (as were counselors). Conclusions: Many clients entering substance abuse treatment also need mental health services, but this need may go unrecognized. It is imperative that counselors receive the training, supervision, and support necessary to appropriately identify mental disorders and help their clients access needed care.

Keywords:

• substance abuse treatment
• co-occurring disorders
• mental health services
• counselor assessment
• ASI
• multilevel modeling

ACKNOWLEDGMENTS

This work was supported by funding from the White House Office of National Drug Control Policy (Contract #N66001–1143-8700). Dr. Martin helped develop this manuscript during an internship at the Treatment Research Institute (TRI). Dr. Carise was the principal investigator on the Drug Evaluation Network System study and conducted it while she was a senior research scientist at TRI. In addition to our funders, we would also like to acknowledge Drs. Kevin Lynch, Anna Pecarraro, John Cacciola, Adam Brooks, Amelia Arria, and Cathie E. Alderks for comments on drafts of this manuscript. Dr. Alderks, statistician for the Center for Behavioral Health Statistics and Quality in the Substance Abuse and Mental Health Services Administration, was also instrumental in assisting us in obtaining permission to use the National Survey of Substance Abuse Treatment Services 2000 data for this study. An earlier version of this article was presented at the Conference on Integrating Services for Co-Occurring Conditions held in Bethesda, Maryland, in March 2009.