It is known, however, that the specialty substance-use treatment workforce includes individuals from all of the above mental health professions (IOM, 1997) but is predominantly composed of counselors (McLellan et al., 2003). In 1998 approximately half of the staff delivering substance-use treatment services in about 13,000 outpatient clinics was licensed as substance-abuse counselors. The remainder were about equally composed of unlicensed counselors and “other” professionals who were predominantly master’s-level social workers, mental health counselors, marriage and family therapists, and psychologists with no certification or licensure as substance-use treatment providers; these “other” professionals also included psychiatrists and specialty-certified primary care physicians and nurses (Harwood, 2002). A more recent 2003 survey of 175 directors of inpatient/residential, outpatient, and methadone maintenance programs across the nation also found that apart from counselors, very few professional disciplines were represented among the treatment staff of these programs. With respect to program directors, 15 percent had no college degree; 58 percent had a bachelor’s degree, and 20 percent had a master’s degree. One program was under the direction of a physician (McLellan et al., 2003).
M/SU problems and illnesses are also treated by general internists, family medicine physicians, pediatricians, other medical specialists, and advanced practice nurses who have not been certified as mental health or substance-use treatment specialists and are delivering primary or specialty health care in office-based practices, clinics, acute general hospitals, and nursing homes. These providers are often the first point of contact for many adults with mental problems or illnesses. There is also some evidence that they are consumers’ preferred point of first contact for care: the majority of consumers initially turn to their primary care providers for mental health services (Mickus et al., 2000), and use of general medical providers for treatment of M/SU problems and illnesses increased more than 150 percent between 1990–1992 and 2001–2003—a significant shift away from other sectors of care (Kessler et al., 2005). An equal (DHHS, 1999) or greater (Wang et al., 2000) number of adults with M/SU problems and illnesses receive care from general medical providers relative to specialty mental health providers in a given year. Primary care physicians and physician specialists other than psychiatrists also prescribe the majority of psychotropic medications (Pincus et al., 1998). However, there also is evidence that the care provided by general, primary care physicians is less often consistent with clinical practice guidelines than that provided by psychiatrists (Friedmann et al., 2000; Young et al., 2001).