The Quality Chasm in Health Care for Mental and Substance-Use1 Conditions
Each year more than 33 million Americans use mental health services or services to treat their problems and illnesses resulting from alcohol, inappropriate use of prescription medications, or illegal drugs. Together, mental and substance-use illnesses are the leading cause of combined death and disability for women of all ages and for men aged 15–44, and the second highest for all men. When appropriately treated, individuals with these conditions can recover and lead satisfying and productive lives. Conversely, when treatment is not provided or is of poor quality, these conditions can have serious consequences for individuals, their loved ones, their workplaces, and the nation as a whole.
Although science continues to advance our knowledge about the etiology of mental and substance-use problems and illnesses and how to treat them effectively, health care for these conditions—like general health care—frequently is not delivered in ways that are consistent with science, ways that enable improvement and recovery. Moreover, care is sometimes unsafe; more often, it is not delivered at all. This gap between what can and should be and what exists is so large that, as with general health care, it constitutes a “chasm” as defined in the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century. Using that report as its template, this report puts forth an agenda for improving the quality of health care for mental and substance-use conditions.
MORE THAN 33 MILLION AMERICANS ANNUALLY RECEIVE CARE
Each year more than 33 million Americans use mental health services or services to treat their problems and illnesses2 resulting from alcohol, inappropriate use of prescription medications, or illegal drugs. Approximately 28 million Americans aged 18 or older (13 percent of this population) received mental health treatment in an inpatient or outpatient setting in 20033 (SAMHSA, 2004a), and more than 6 percent of American children and adolescents aged 5–17 had contact with a mental health professional in a 2-month period according to the 1998–1999 National Health Interview Survey (Simpson et al., 2004). The rates are higher still for adolescents: 20.6 percent of those aged 12–17 (5 million youths) received treatment or counseling for emotional or behavioral problems in 2003 (SAMHSA, 2004a); in addition, more than 3 million Americans aged 12 or older (1.4 percent of this group) reported receiving some kind of treatment during 2003 for a problem related to alcohol or other drug use (SAMHSA,
2004a). Combining mental and substance-use problems and illnesses, more than 20 percent of U.S. adults aged 18–54 received care for these conditions during a 12-month period between 2001 and 2003 (Kessler et al., 2005). Millions more reported that they needed treatment for their mental and/or substance-use (M/SU)4 problems or illnesses but did not receive it (Mechanic and Bilder, 2004; SAMHSA, 2004a; Wu et al., 2003). Fewer than half of adults aged 18–54 who met a definition of severe mental illness received treatment for the condition during a 12-month period between 2001 and 2003 (Kessler et al., 2005). And in contrast to the more than 3 million Americans aged 12 or older who received treatment during 2003 for a problem related to alcohol or other drug use, more than six times that number (approximately 21.6 million, or 9.1 percent of this age group) reported abusing or being physiologically dependent upon alcohol; illicit drugs such as marijuana, cocaine, heroin, hallucinogens, or stimulants; prescription drugs used for nonmedical purposes; or a combination of these (SAMHSA, 2004a).
Many individuals using services to address their mental or substance-use problems require only a short-term intervention to address their condition (Bernstein et al., 2005; Fleming et al., 1997; Ockene et al., 1999). They may be experiencing, for example, anxiety or other distress over the loss of a loved one or a job or some other life-changing event. They may be engaging in occasional heavy drinking or be teenagers experimenting with drugs. These and other less severe problems that many individuals encounter at some point in their lives are not considered mental illnesses or drug dependence but are occasions during which an individual might need assistance to cope with a stressful situation, change unhealthy behaviors, and prevent the condition from worsening. Mental illnesses and substance dependence, in contrast, involve significantly more distress, disability, chronicity, and physical risk and interfere with performing routine activities such as working, attending school, or participating fully in relationships.
Individuals with M/SU problems and illnesses represent a wide range of diagnoses, severity of illness, and disability. What they all have in common, however, is the hope that when they seek help for their condition, they will receive care that is safe, effective, and of good overall quality. They expect that such care will enable them either to recover completely from an acute mental or substance-use illness or manage the illness successfully so they can live happy, productive, and satisfying lives. As articulated in the 1999 Surgeon General’s report on mental health (Anthony, 1993 as cited in DHHS, 1999:98):
… a person with mental illness can recover even though the illness is not “cured”…. [Recovery] is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness.
Although a conceptual model of recovery from chronic M/SU illnesses is not yet fully developed (Onken et al., 2004), recovery as articulated in the Surgeon General’s report has been an accepted concept in use for over a century for individuals with alcohol-use problems and illnesses (White, 1998). More recently, recovery has become a widely accepted goal not just of mental health care (NAMI, 2005; New Freedom Commission on Mental Health, 2003), but of treatment for all individuals with M/SU problems and illnesses.
CONTINUING ADVANCES IN CARE AND TREATMENT ENABLE RECOVERY
The U.S. Surgeon General, the National Institutes of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Institute of Medicine (IOM), and many others (DHHS, 1999; IOM, 1997) continue to document ongoing advances in our understanding of M/SU problems and illnesses. These advances include the development of efficacious psychotherapies, drug therapies, and psychosocial services, as well as strategies for delivering these treatments effectively. Dissemination of information on brain functioning—the interplay of genetic, environmental, biological, and psychosocial factors in brain function and M/SU illnesses; our ability throughout our lives to influence the structure and functioning of our brains through environmental and behavioral factors (our brains’ “plasticity”); and improved treatments—has helped educate consumers,5 the health care community, and the public at large about M/SU problems and illnesses and the effectiveness of care for these conditions. Now that NIH has made translation of bench science to clinical applications a high priority in its strategic plans for the coming years (NIMH, 2005; Zerhouni, 2003), society is poised to reap even greater returns from developments in such basic science fields as genetics, proteomics, neuro-
imaging, and animal models of behavior (Gould and Manji, 2004; Sarver et al., 2002; Tecott, 2003).
The past decade also has seen rapid growth in the science of evaluating the costs and effectiveness of health interventions. These approaches increasingly demonstrate that care for many M/SU problems and illnesses can be both effective (i.e., it can work) and cost-effective (i.e., it can represent a good value). Recent studies have used these approaches to evaluate a variety of mental health interventions, ranging from use of a specific medication (clozapine) in populations with schizophrenia (Essock et al., 2000; Rosenheck et al., 1999), to using specific models for treating depression in primary care (Pirraglia et al., 2004), to providing supported housing for homeless persons with mental illness (Rosenheck et al., 2003). These and other mental health interventions have been found to be as or more cost-effective than many treatments currently provided in general medical practice. Consistent with these findings, more than half of adults who received treatment for mental health problems in 2003 reported that their treatment improved their ability to manage daily activities “a great deal” or “a lot” (SAMHSA, 2004a).
A large body of research shows likewise that treatment for alcohol and other drug problems and illnesses is effective. Many people who enter treatment decrease their substance use and have fewer problems (Finney and Moos, 1991; McLellan et al., 2000; Miller et al., 2001). Recent years have seen many scientific advances in understanding the behavioral and social factors that lead to substance use and dependence, in identifying key neuropathways and chemical changes that create the cravings characteristic of alcohol or drug dependence, and in developing mechanisms to block these effects. These advances have resulted in a spectrum of evidence-based pharmacological and psychosocial treatments for individuals who misuse or are dependent on substances—treatments that produce results similar to or better than those obtained with treatments for other chronic illnesses (McLellan et al., 2000). New medications, such as buprenorphine, are effective in significantly reducing opioid use (Johnson et al., 2000). In contrast to the first medication for opiate dependence (methadone), buprenorphine can be prescribed routinely in physicians’ offices. Naltrexone and acamprosate also show efficacy in treating alcohol dependence (Kranzler and Van Kirk, 2001; O’Malley et al., 2003) and may be more acceptable to patients than disulfiram, the first medication approved for treating that condition.6
Nonpharmacological treatments for drug dependence, such as cognitive behavioral therapy and motivational enhancement treatment, have also
demonstrated efficacy. Twelve-step mutual support groups such as Alcoholics Anonymous are effective as well, particularly as an adjunct to treatment and as a form of long-term aftercare (Emrick et al., 1993; Tonigan et al., 2003; Weisner et al., 2003). Contingency management, a treatment modality that employs positive reinforcement for desired behaviors and withholding of reinforcement or punitive measures for undesired behaviors has shown efficacy for treatment of the use of alcohol, cocaine, and other psychostimulants (Higgins and Petry, 1999). Brief advice from a physician and office-based alcohol counseling interventions have been shown to reduce episodes of binge drinking as well as alcohol use in problem drinkers (Fleming et al., 1997; Ockene et al., 1999). Organizing care to address co-occurring conditions, such as by integrating alcohol and drug treatment with medical services (Weisner et al., 2001) and combining substance-use and mental health services, also optimizes outcomes (Moggi et al., 1999), as well as cost (Parthasarathy et al., 2003). The latter approach is particularly effective for adolescents, in whom co-occurring substance-use and mental health problems are very common (Clark et al., 1997; Sterling and Weisner, 2005). As a result of these advances, patients who enter and remain in treatment for use of alcohol, opioids, or cocaine are less likely to relapse or resume use (Gossop et al., 1999; Miller and Wilbourne, 2002; Prendergast et al., 2002).
Additional good news is found in recent studies showing some improvements in access to and receipt of care. Over the past decade, although the prevalence of M/SU problems and illnesses has remained the same, a greater proportion of adults aged 18–54 with these conditions has received treatment (Kessler et al., 2005). This has been especially true of those with the most severe mental illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004). The rate of treatment for depression appears to have more than tripled between 1987 and 1997 (Olfson et al., 2002), and improvements have been seen in access to care and treatment for children (Glied and Cuellar, 2003).
On the other hand, the same reports showing improved access to care for people with the most severe mental illnesses show declining access for those with less severe mental illnesses (Mechanic and Bilder, 2004) and ethnic minorities (Kessler et al., 2005), and many people who need treatment for M/SU illnesses still do not receive it (Kessler et al., 2005; Mechanic and Bilder, 2004; SAMHSA, 2004a). Moreover, M/SU health care, like general health care, is frequently delivered in ways that are not consistent with scientific evidence. Sometimes care also is unsafe. When untreated or poorly treated, M/SU problems and illnesses can have serious consequences for the afflicted individuals, their loved ones, and society as a whole.
POOR CARE HINDERS IMPROVEMENT AND RECOVERY FOR MANY
Numerous studies document the discrepancy between the M/SU care that is known to be effective and the care that is actually delivered. A review of all peer-reviewed studies published from 1992 through 2000 assessing the quality of care for many different M/SU clinical conditions (including alcohol withdrawal, bipolar illness, depression, panic disorder, psychosis, schizophrenia, and substance abuse) found that only 27 percent of the studies reported adequate rates of adherence to established clinical practice guidelines (Bauer, 2002). Subsequent studies have continued to document clinicians’ departures from evidence-based practice guidelines for conditions as varied as attention deficit hyperactivity disorder (ADHD) (Rushton et al., 2004), anxiety disorders (Stein et al., 2004), comorbid mental and substance-use illnesses (Watkins et al., 2001), depression in adults (Simon et al., 2001a) and children (Richardson et al., 2004), opioid dependence (D’Aunno and Pollack, 2002), and schizophrenia (Buchanan et al., 2002). In a landmark study of the quality of a wide variety of health care received by U.S. citizens, individuals with alcohol dependence were found to receive care consistent with scientific knowledge only about 10.5 percent of the time (McGlynn et al., 2003).
In other clinical care situations, the absence of clinical practice guidelines further contributes to worrisome variation in the care individuals receive. One 1999–2000 study of the care received by children and adolescents at residential treatment centers in four states found that 42.9 percent were receiving antipsychotic medications without having any history of or current psychosis and were thus receiving such medications for “off-label” purposes (Rawal et al., 2004). Seclusion and restraints continue to be used in inpatient mental health facilities despite their resulting in substantial psychological and physical harm to patients (GAO, 1999), including an estimated 150 deaths in the United States annually (SAMHSA, 2004b), and despite a Cochrane Collaboration finding that “few other forms of treatment which are applied to patients with various psychiatric diagnoses are so lacking in basic information about their proper use and efficacy” (Sailas and Fenton, 2005).
Moreover, recent studies reaffirm that the health care system sometimes fails to provide any treatment for M/SU illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004), even when afflicted individuals are receiving other types of health care and have financial and geographic access to care. A 1997–1998 national survey found that among persons with probable co-occurring M/SU conditions who received treatment for one condition, fewer than a third (28.6 percent) received treatment for the other (Watkins et al.,
2001). A later longitudinal study of 1,088 youths in residential or outpatient treatment for drug use showed that although 67 percent reported having severe mental health problems upon admission, only 24 percent reported receiving mental health services within the 3 months following their admission (Jaycox et al., 2003). The 2003 National Survey on Drug Use and Health documents similar failure to treat adults (SAMHSA, 2004a). And despite the very frequent co-occurrence of M/SU and general health care problems and illnesses, coordination among providers of M/SU care and the other sectors of care delivery is highly inadequate (New Freedom Commission on Mental Health, 2003).
Departures from known standards of care, variations in care in the absence of care standards, failure to treat M/SU problems and illnesses, and lack of coordination are of concern for many reasons. While they may often represent ineffective care, there is evidence that they can also threaten patient safety. In addition to the substantial psychological and physical harm to patients caused by the use of seclusion and restraints noted above, injuries from drug errors are common. A retrospective, multidisciplinary review of the charts of 31 randomly selected patients in a state psychiatric hospital discharged during a 4 1/2-month study period detected 2,194 medication errors during these patients’ collective 1,448 inpatient days.7 Of these errors, 19 percent were rated as having the potential to cause minor harm, 23 percent the potential to cause moderate harm, and 58 percent the potential to cause severe harm (Grasso et al., 2003). Moreover, because M/SU illnesses are leading risk factors for suicide (Maris, 2002), failures to diagnose and treat them effectively can be lethal.
The receipt of ineffective and unsafe care by large numbers of people with M/SU illnesses is of particular concern because some of the unique features of these illnesses—such as the symptoms of major depression or schizophrenia—and their treatments could render patients less able to detect and avoid errors and more vulnerable to the consequences of errors that occur. The residual stigma attached to some M/SU illnesses also may make individuals with these diagnoses less willing to report errors and adverse events, and less likely to be believed when they do so. Most significant, the delivery of ineffective or unsafe care, or the failure to deliver any care, has serious consequences for individuals, their loved ones, and the nation as a whole.
FAILURE TO PROVIDE EFFECTIVE CARE HAS SERIOUS PERSONAL AND SOCIETAL CONSEQUENCES
A Leading Cause of Disability and Death in the United States
A 1996 study of the global burden of diseases, injuries, and risk factors conducted by the World Health Organization and the World Bank assessed for the first time the relative burden of 107 of the world’s most common diseases as of 1990. Using the metric of disability-adjusted life years (DALYs), representing the combined effect of years of life lost to premature death and years of life lived with a disability, the study assessed fatal and nonfatal health outcomes and objectively calculated the relative burden of major diseases and injuries. The results documented for the first time the profound effect of M/SU illnesses on death and disability worldwide and in the United States. In developed regions of the world, unipolar major depression was the second leading cause of death and disability (next to heart disease) for all ages,8 and the leading cause for individuals aged 15–44. Alcohol use ranked highest for males aged 15–44 and fifth across all ages. Alcohol use also was an underlying factor in a substantial portion of traffic accidents (which were ranked fourth for all ages and sexes and second only to alcohol for males aged 15–44). Schizophrenia and bipolar disorder ranked thirteenth and fifteenth for all ages in developed regions. Other drug use ranked twenty-second. In developed regions of the world and in countries with established market economies such as the United States, when all neuropsychiatric conditions were combined, they were responsible for more death and disability than any other category of health conditions, outranking cardiovascular diseases; cancers; and a combined category of communicable, maternal, perinatal, and nutritional illnesses (Murray and Lopez, 1996).
The major causes of DALYs differ somewhat for the United States, but M/SU illnesses remain prominent. In 1996, unipolar major depression was second only to ischemic heart disease for American women as the cause of DALYs. For men, traffic accidents ranked second; alcohol abuse and dependence ranked fifth; and depression and drug use ranked tenth and eleventh, respectively. Combined, unipolar major depression, drug use, and alcohol abuse and dependence are the leading cause of death and disability for American women and the second highest for men (behind heart disease) (Michaud et al., 2001). If mental illness diagnoses other than unipolar major depression were included, the DALYs would be even higher.
Moreover, mental or substance-use problems and illnesses seldom occur in isolation; approximately 15–43 percent of the time they co-occur
(Kessler et al., 1996; Kessler, 2004).9 They also accompany a substantial number of general medical illnesses, such as diabetes, heart disease, neurological illnesses, and cancers (Katon, 2003); sometimes masquerade as separate somatic problems (Katon, 2003); and often go undetected (Kroenke et al., 2000; Saitz et al., 1997). M/SU illnesses significantly compromise the treatment outcomes for general health conditions, increase the use and cost of general health care (Katon, 2003), and have adverse consequences for workplace productivity and costs (as discussed below). Mental illness also is a major risk factor for the development of adverse health behaviors such as smoking, overeating, and a sedentary lifestyle (Katon, 2003).
Great Cost to the Nation
The disabilities and other adverse effects resulting from M/SU illnesses impose a sizable cost on the nation (Frank and McGuire, 2000). Considering health care spending alone, M/SU problems and illnesses represent the fifth most expensive category of health care conditions10 in the United States among individuals not residing in nursing homes or other institutions (Thorpe et al., 2004). Direct spending11 for M/SU health care by all health care purchasers in the United States totaled an estimated $104 billion in 2001 (82 percent for mental and 18 percent for substance-use illnesses), representing 7.6 percent of all health care spending (Mark et al., 2005). Additional costs attributable to M/SU illnesses (e.g., secondary health problems, loss of productivity in the workplace, and social problems requiring the involvement of the welfare and criminal and juvenile justice systems) are even higher. Nationally, the estimated direct and indirect costs for alcohol-related illnesses, injuries, and other consequences, excluding those associated with the use of other drugs, were estimated at $185 billion in 1998. More than 70 percent of these costs were due to lost productivity resulting from alcohol-related illness and premature death (NIAAA, 2000). These direct and indirect costs affect employers, the child welfare system, the juvenile and criminal justice systems, education systems, and other sectors of society.
Decreased Productivity in the Workplace
Evidence is mounting that M/SU illnesses result in a considerable burden on the workplace and cost to employers due to absenteeism, “presenteeism” (i.e., attending work with symptoms that impair performance), days of disability, and “critical incidents” such as significant task failures and accidents. All cause a decrease in workplace productivity. Depression is the most frequently studied M/SU illness with respect to the workplace because it is highly prevalent among working-age adults and associated with substantial work impairment (Burton et al., 2004; Kessler et al., 2001a; Stewart et al., 2003); however, substance dependence and generalized anxiety disorders also are very common and associated with high levels of work impairment (Kessler et al., 2001a).
As part of a 2001–2002 national survey of American workers designed to better understand the relationship between health and productivity, interviews were conducted to determine the effect of depression on worker productivity. “Lost productive time” (LPT) was measured by summing employee self-reports of the hours per week absent from work for health-related reasons and hours of health-related reduced performance on workdays. Workers with depression reported significantly more total health-related LPT than workers without depression—on average, a loss of 5.6 hours per week compared with 1.5 hours per week for those without depression. Fully 81 percent of LPT was attributable not to absenteeism, but to reduced performance while at work—the component of reduced performance often invisible to employers because it is not captured in routine administrative data as are absenteeism, use of leave, and disability (Stewart et al., 2003). Indeed, there is evidence that improving care for depression can increase worker productivity and decrease absenteeism (Rost et al., 2004).
The accuracy of retrospective data self-reported by individuals with depression has been questioned (because the symptoms of depression may predispose individuals to appraise their productivity negatively). Yet when worker performance is measured by other valid and reliable means (Kessler et al., 2004), major depression continues to be associated with poor work performance more consistently than is the case for other high-prevalence conditions (allergies, arthritis, back pain, headaches, high blood pressure, and asthma) (Wang et al., 2004).
Decreased Achievement by Children in School
Emotional and behavioral problems of children and the M/SU problems and illnesses of their parents also are important predictors of poor school outcomes. Risk factors for early school failure include maternal
depression; parental substance-use problems and illnesses; early behavior problems, particularly aggression; and maltreatment. Several M/SU-related risk factors, including parental trauma, maternal depression, maternal alcoholism, and other substance-use problems and illnesses also are associated with disorganized attachment behaviors in infants (i.e., insecure and inconsistent patterns of attachment to key caregivers) (Ainsworth and Eichberg, 1992; Carlson et al., 1989; Green and Goldwyn, 2002; O’Connor et al., 1987; Teti et al., 1995; van Ijzendoorn et al., 1999). Those behaviors in turn lead to lower IQ and poorer school performance (van Izjendoorn and van Vliet-Vissers, 1988; Zeanah et al., 2003). Children of untreated depressed mothers, for example, have significantly more behavior and school achievement problems than children of nondepressed mothers (Greenberg et al., 1999; Gross et al., 1995; Sinclair and Murray, 1998). Children who experience trauma also have higher rates of school problems than children who are not maltreated, including lower IQ scores, lower test scores in math and English, less social acceptance as perceived by the child, increased absence from class, and more grade repetitions (Eckenrode et al., 1995; Wodarski et al., 1990).
Although risk factors often associated with substance-use problems and illnesses (such as poor maternal nutrition, health, and prenatal care) make it difficult to attribute school problems solely to in utero drug exposure, it is clear that maternal substance-use problems and illnesses are strongly associated with adverse effects on children’s cognitive, physical, and social development. Maternal alcohol consumption during pregnancy is associated with intrauterine growth retardation and low birth weight, which affect later cognitive and social development (Streissguth et al., 1994). Children exposed to alcohol in utero also have been found to have behavioral and social difficulties, such as trouble cooperating and paying attention and problems with impulsivity (Spohr et al., 1994). Findings of studies of prenatal exposure to other drugs, such as cocaine, heroin, and amphetamines, suggest that such exposure results in lower general intelligence and impairs school functioning (Eriksson and Zeterstrom, 1994; van Baar and de Graaff, 1994; van Baar et al., 1994). Other studies have found that although prenatal exposure to cocaine does not affect intellectual ability or academic achievement, it does affect the ability to sustain attention (Richardson et al., 1996).
These risks that place children on a dangerous trajectory toward school failure are compounded by the fact that academic failure itself breeds emotional and behavioral problems. Repeating a grade in school is associated with several specific behavioral problems and illnesses, such as ADHD, obsessive-compulsive disorder and other specific anxiety disorders, and major depressive disorder (Velez et al., 1989). Grade retention also predicts
school dropout and rapid, repeated adolescent pregnancies (Linares et al., 1991). This is not a minor problem. According to one national study, 7.6 percent of children repeat kindergarten or first grade (Byrd and Weitzman, 1994). Children who are unable to achieve mastery on standard measures of school achievement also are at risk for delinquent and antisocial behavior (Yoshikawa, 1995), and children with early reading difficulties have increased rates of conduct problems up to the age of 16 (Fergusson et al., 1997).
Increased Burden on the Child Welfare System
The nation’s child welfare system also is greatly affected by the high prevalence of and disability associated with M/SU illnesses. Foremost, children who are reported to and investigated by the child welfare system for maltreatment typically have experienced a number of known risk factors for the development of emotional and behavioral problems, including abuse, neglect, poverty, parental substance-use problems and illnesses, and domestic violence. As a result, almost half (47.9 percent) of a nationally representative, random sample of children aged 2–14 who were investigated by child welfare services in 1999–2000 had a clinically significant need for mental health care (Burns et al., 2004).
In addition, the U.S. Government Accountability Office (GAO) has found that, because of limitations on insurance coverage, some families resort to placing their children (most often adolescents with severe mental illness) in the child welfare system even though the family is not neglectful or abusive of the child. Because the child welfare system often is able to secure mental health services otherwise unavailable to them, parents use the system for this purpose even though they are placing their children in systems not designed to care for children who have not been abused or neglected (GAO, 2003). Doing so sometimes requires parents to give up legal custody of their children and place them in an out-of-home residential or foster care setting (Giliberti and Schulzinger, 2000). In Virginia, for example, a 2004 study of the use of the state’s foster care program for mental health services found that 2,008 children in foster care as of June 1, 2004—approximately 1 of every 4 children in the system at that time—were there either because their parents wanted them to have mental health care not fully covered by their insurance or because the family did not have access to any insurance (Jenkins, 2004).
Finally, the stresses involved with child protective services investigation and judicial decision making, and for those who are placed in foster care the stress of removal from home, also constitute risk factors for maladaptive outcomes, including emotional, social, behavioral, and psychiatric problems warranting mental health treatment (Landsverk, 2005).
Demands on the Juvenile and Criminal Justice Systems
Juvenile justice Between 60 and 75 percent of youth in the juvenile justice system have a diagnosable mental disorder (Otto et al., 1992; Teplin et al., 2002; Wierson et al., 1992), and it is conservatively estimated, although the evidence is less clear, that approximately 20 percent have a severe mental illness (Cocozza and Skowyra, 2000; Grisso, 2004). Many youths in the juvenile justice system with mental illness also have a co-occurring substance-use problem or illness. Although the research on this issue is limited, a recent study of juvenile detainees in Cook County, Illinois, found that nearly 30 percent of females and more than 20 percent of males with substance-use disorders had major mental disorders as well (Abram et al., 2003).
Moreover, like youths who are not abused or neglected but are placed in child welfare solely to obtain mental health services, many children who are not guilty of any offence are placed in local juvenile justice systems and incarcerated solely to obtain such services not otherwise available. Although no formal counting and tracking of such children takes place, juvenile justice officials in 33 counties in the 17 states with the largest populations of children under age 18 estimated that approximately 9,000 such children entered their systems under these circumstances in 2001; county estimates ranged from 0 to 1,750, with a median of 140. Nationwide the number of children placed in juvenile justice systems is likely to be higher; 11 states reported to GAO that they could not provide estimates even though they were aware that such placements occur (GAO, 2003).
In a subsequent 2003 survey of all (698) secure juvenile detention facilities in the United States,12 two-thirds of such facilities reported holding youths (prior to, after, or absent any pending adjudication) because they were awaiting community mental health services. In addition, seventy-one facilities in 33 states reported holding youths with mental problems or illnesses who had charges against them. As one detention facility administrator explained, “We are receiving juveniles that five years ago would have been in an inpatient mental health facility…we have had a number of juveniles who should no more be in our institution than I should be able to fly” (U.S. House of Representatives, 2004:8). A majority of detention facilities reported holding children under age 13; 117 reported holding children aged 10 and under; and 1 facility reported holding a 7-year-old child. Moreover, 27 percent of facilities holding children awaiting services rated the mental health treatment in their facility as “poor,” “very poor,” or “none.” The emotional toll on these children is high. Fully 48 percent of facilities that hold juveniles waiting for community mental health services report suicide attempts among these youths (U.S. House of Representatives, 2004).
Criminal justice In mid-2003, the nation’s prisons and jails held 2,078,570 persons—1 in every 140 U.S. residents13—and this rate has been increasing annually, from 601 persons in custody per 100,000 U.S. residents in 1995 to 715 persons in custody per 100,000 residents in 2003 (Harrison and Karberg, 2004). Although a rigorous epidemiological study of the prevalence of M/SU illnesses in correctional settings has not taken place,14 the U.S. Bureau of Justice estimates that approximately 16 percent of all persons in jails and state prisons report either having a mental disorder or staying overnight in a psychiatric facility, as do 7 percent of those in federal prisons (Ditton, 1999). Substance-use problems and illnesses play a larger role in incarceration. Approximately two-thirds of incarcerated individuals were under the influence of alcohol or drugs at the time of their offense, and nearly 60 percent of all state prisoners report using substances other than alcohol in the month prior to offending (Mumola, 1999). Moreover, in an average year, approximately one-third of new admissions to prisons result from parole violations, nearly 16 percent of which are drug-related (Hughes et al., 2001).
Because prisons and jails are legally required to provide medical treatment to inmates with medical needs (Haney and Specter, 2003; Metzner, 2002), approximately 95 percent of state correctional facilities report providing some form of mental health treatment to prisoners. The treatment provided includes screening for mental illness at intake (78 percent), assessing psychiatric problems (79 percent), delivering round-the-clock mental health care (63 percent), providing therapy or counseling (84 percent), prescribing psychotropic medications (83 percent), and providing reentry assistance (72 percent). On average, 1 in 8 prisoners in state prisons is engaged in structured counseling, and 1 in 10 is receiving psychotropic medication (Beck and Maruschak, 2001). The majority of jails also report providing some type of mental health treatment—most often screening at intake (78 percent), followed by psychotropic medication (66 percent), 24-hour care (47 percent), routine therapy or counseling (46 percent), and psychiatric evaluation (38 percent) (Stephan, 2001). Yet on average, mental health services are being provided at a level that is roughly half the estimated need (Wolff, 2004).
Although substance-use problems and illnesses play a larger role in incarceration than do mental illnesses, they receive less treatment (Wolff,
2004). One study found that roughly one in four state prisoners received any treatment for substance-use problems, with a higher percentage (40 percent) receiving such treatment if they reported drug use at the time of their offense. The most common treatment received was self-help group/peer counseling (Mumola, 1999). Similarly, although substance-use treatment or other programs, such as education or self-help, were provided by the majority of jails (73 percent) in 1998, only 20 percent of convicted jail inmates who were actively involved with drugs prior to their admission to jail had participated in substance-use treatment or program subsequent to their incarceration. Treatment (i.e., detoxification units, group/individual counseling, and residential programs) was provided by approximately 43 percent of jail facilities. Nearly two-thirds of jails reported providing access to drug or alcohol education or self-help groups (Wilson, 2000).
How These Adverse Consequences Can Be Mitigated
The delivery of effective treatment for M/SU problems and illnesses could mitigate many of the serious individual and societal consequences discussed above. Findings of observational studies and some controlled trials indicate that effective treatment for depression, for example, can result in improved productivity in the workplace, and this might substantially offset the cost of the treatment (Goetzel et al., 2002; Simon et al., 2001b; Wang et al., 2003). Treatment for this and other M/SU illnesses also might help ameliorate the adverse effects of emotional or behavioral problems and illnesses on children’s educational achievement, as well as reduce the burden on the child welfare and juvenile justice systems. At a minimum, provision of effective treatment ensures that funds spent for treatment will not be wasted.
A CHARGE TO CROSS THE QUALITY CHASM
The high prevalence and adverse consequences of M/SU problems and illnesses, the availability of many efficacious treatments, and the widespread delivery of poor-quality care are increasingly being recognized by consumers, purchasers, care providers, and policy makers. Similar concerns about the safety, ineffectiveness, and poor quality of U.S. health care overall have previously received substantial attention among the health care community, the lay press, and the public at large as a result of two IOM reports—To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). These reports have played a key role in focusing national attention on problems in the quality of the nation’s health care, while garnering consensus on strategies for achieving significant quality improve-
ments. Both reports underscore that the vast majority of problems in the quality of health care are not the result of poorly motivated, uncaring, or unintelligent health care personnel but instead result from numerous barriers to high-quality health care imposed by the delivery systems in which clinicians work. Some of these barriers occur at the level of the patient’s interaction with the clinician (e.g., not having sufficient time during the patient visit to talk with the clinician); some at the level of interactions among different clinicians serving the patient (e.g., poor communication, collaboration, and coordination of care); some within the organization in which care is delivered (e.g., poor decision support for clinicians); and some in the environment external to the delivery of care (e.g., the arenas of policy, payment, and regulation) (Berwick, 2002).
Crossing the Quality Chasm speaks to all of these barriers to quality health care15 and has gained considerable traction in the health care community since its publication. As the subject of more than 50 peer-reviewed articles in the medical literature and hundreds of lay publications and coverage in other media, it has attracted the attention of many health care leaders. In the M/SU sector, the American College of Mental Health Administration (ACMHA), for example, focused on the report at its 2002 summit meeting of leaders from public and private behavioral health care systems. Summit meeting participants reached strong consensus that the Quality Chasm framework is immediately relevant and applicable to the concerns of behavioral health systems of care and policy. Attendees also endorsed the IOM paradigm as a strategic planning blueprint for the redesign of the behavioral health care system. However, because the Quality Chasm report did not separately address the unique characteristics of health care for mental and substance-use conditions (e.g., the use of coercion into treatment; the delivery of care through non-health care sectors, such as schools), attendees also agreed on the need to develop a strategy for applying the framework and recommendations of the Quality Chasm to address the unique characteristics of M/SU health care (ACMHA, undated).
As a result of ACMHA leadership, there was a convergence of support from many sectors for adapting the Quality Chasm framework to M/SU health care. With support from the Annie E. Casey Foundation, the CIGNA Foundation, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, The Robert Wood Johnson Foundation, SAMHSA within the U.S. Department of Health and Human Services, and the Veterans Health Administration of the U.S. Department of Veterans Affairs, the IOM was given the following charge:
Crossing the Quality Chasm: A New Health System for the 21st Century identified six dimensions in which the United States health system functions at far lower levels than it should (i.e., safety, effectiveness, patient-centeredness, timeliness, efficiency and equity) and concluded that the current health care system in is in need of fundamental change. The IOM is to explore the implications of that conclusion for the field of mental health and addictive disorders, and identify the barriers and facilitators to achieving significant improvements along all six of these dimensions. The committee will examine both environmental factors such as payment, benefits coverage and regulatory issues, as well as health care organization and delivery issues. Based on a review of the evidence, the committee will develop an “agenda for change.”
To carry out this charge, in 2004 the IOM convened a multidisciplinary committee of experts in mental, substance-use, and general health care; public- and private-sector M/SU health care delivery; primary care; consumer issues; integration of service; ethics; economics; Medicaid; racial and ethnic disparities in care; veterans’ health and health care; child M/SU health care; geriatrics; informatics; and systems engineering (see Appendix A for the biographical sketches of committee members). This report is the result of their efforts.
As the committee’s charge and expertise indicate, the scope of this study was large, encompassing both public and private sectors, children and adults, and health care for mental and substance-use problems and illnesses. In particular, addressing health care for both mental and substance-use conditions in a single report was challenging; major public-and private-sector initiatives and reports have nearly always addressed only one or the other (DHHS, 1999; New Freedom Commission on Mental Health, 2003). Nonetheless, the committee found this dual focus to be appropriate and invaluable to its analysis of the evidence and formulation of policy recommendations, given the interconnected nature of these conditions and the resulting need for coordinated policy and care delivery. Indeed, the committee believes that in future initiatives to improve the quality of M/SU health care, expertise in health care for both mental and substance-use conditions should always be at the table.
SCOPE OF THE STUDY
At the beginning of its deliberations, the committee identified several issues that it decided should be excluded from this study to best focus its efforts. The special considerations involved in delivering care in rural areas consistent with the Quality Chasm recommendations are addressed in a separate IOM report (IOM, 2005), and thus are not addressed here. Similarly, a separate study on emergency care was under way at the same time as this study. Readers are directed to the reports of the IOM Committee on the Future of Emergency Care in the U.S. Health System, which will include discussion of the impact of M/SU illnesses on emergency departments and the quality of M/SU health care these facilities provide. Moreover, although touched on briefly in this report, difficulties in achieving diversity in the health care workforce and addressing disparities in health care likewise have been the subject two recent IOM reports (IOM, 2003, 2004). Also, because of the committee’s expansive charge, it was not able to attend to the unique issues related to dementia and the mental health care needs of older adults in long-term care facilities; the committee calls attention to the need for further study and resources focused on this population. Finally, Crossing the Quality Chasm sets forth a “patient-centered, treatment-focused” approach to improving individual health care, as opposed to a “population-centered, prevention-focused” approach to improving public health. The committee recognizes that much work is needed to apply public health interventions to M/SU problems and illnesses and briefly touches on a few of these issues in this report. However, resource limitations and the scope of the committee’s charge and expertise made it infeasible to address more fully this very important aspect of improving M/SU health care.
ORGANIZATION OF THE REPORT
In carrying out its charge, the committee focused on those characteristics of M/SU health care that distinguish it from non-M/SU health care (what is referred to throughout this report as “general” health care). These characteristics are briefly described in Chapter 2, along with the Quality Chasm framework. The report then examines how the Quality Chasm framework can be applied to achieve high-quality M/SU care, focusing first on patient-centered care (Chapter 3) and then on safe and effective care (Chapter 4). Approaches to implementing the Quality Chasm rule of coordinating health care across general, mental, and substance-use health conditions are discussed in Chapter 5. Chapter 6 mirrors the original Quality Chasm report by addressing the application of information technology to facilitate changes needed to improve the quality of care. This report also parallels the Quality Chasm report by reviewing in a separate chapter
(Chapter 7) changes needed in the M/SU health care workforce to implement the committee’s recommendations. New approaches to purchasing M/SU health care to create incentives for these changes are discussed in Chapter 8. Finally, Chapter 9 identifies areas in need of additional research. Appendix A contains further discussion of the Quality Chasm aims and rules and the organization of this report.
The report also contains overarching recommendations (in Chapter 2) as well as more specific recommendations for quality improvement. These latter recommendations, organized topically in Chapters 3–9, are collected and grouped according to the entities charged with their implementation in a series of tables at the end of Chapter 9.
Abram K, Teplin L, McClelland G, Dulcan M. 2003. Comorbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry 60(11):1097–1108.
ACMHA (American College of Mental Health Administration), undated. Summit 2002. Crossing the Quality Chasm: Translating the Institute of Medicine Report for Behavioral Health. March 13-16, 2002. Santa Fe, New Mexico [Online] Available: http://www.acmha.org/summit/summit_2002.cfm [accessed November 29, 2005].
Ainsworth M, Eichberg C. 1992. Effects on infant-mother attachment of unresolved loss of an attachment figure or other traumatic experience. In: Parkes C, Stevenson-Hinde J, Marris P, eds. Attachment across the Life-Cycle. New York: Routledge. Pp. 160–183.
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision, DSM-IV-TR ed. Washington, DC: American Psychiatric Association.
Anthony WA. 1993. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychological Rehabilitation Journal 16(4):11–24.
Bauer MS. 2002. A review of quantitative studies of adherence to mental health clinical practice guidelines. Harvard Review of Psychiatry 10(3):138–153.
Beck AJ, Maruschak LM. 2001. Mental Health Treatment in State Prisons, 2000. NCJ 188215. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. 2005. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence 77(1):49–59.
Berwick D. 2002. A user’s manual for the IOM’s “Quality Chasm” report. Health Affairs 21(3):80–90.
Buchanan RW, Kreyenbuhl J, Zito JM, Lehman A. 2002. The schizophrenia PORT pharmacological treatment recommendations: Conformance and implications for symptoms and functional outcome. Schizophrenia Bulletin 28(1):63–73.
Burns BJ, Phillips SD, Wagner R, Barth RP, Kolko DJ, Campbel Y, Landsverk J. 2004. Mental health need and access to mental health services by youths involved with child welfare: A national survey. Journal of the American Academy of Child and Adolescent Psychiatry 43(8):960–970.
Burton WN, Pransky G, Conti DJ, Chen C-Y, Edington DW. 2004. The association of medical conditions and presenteeism. Journal of Occupational and Environmental Medicine 46(6):S38–S45.
Byrd RS, Weitzman ML. 1994. Predictors of early grade retention among children in the United States. Pediatrics 93(3):481–487.
Carlson V, Cicchettti D, Barnett D, Braunwald K. 1989. Finding order in disorganization: Lessons from maltreated infant’s attachments to their caregivers. In: Cicchetti D, Carlson V, eds. Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. New York: Cambridge University Press. Pp. 494–528.
Clark DB, Pollock N, Bukstein OG, Mezzich AC, Bromberger JT, Donovan JE. 1997. Gender and comorbid psychopathology in adolescents with alcohol dependence. Journal of the American Academy of Child and Adolescent Psychiatry 36(9):1195–1203.
Cocozza J, Skowyra K. 2000. Youth with mental disorders: Issues and emerging responses. Juvenile Justice VII(1) [Online]. Available: http://www.ncjrs.org/html/ojjnl_2000_4/contents.html [accessed January 19, 2006].
D’Aunno T, Pollack HA. 2002. Changes in methadone treatment practices: Results from a national panel study, 1988–2000. Journal of the American Medical Association 288(7):850–856.
DHHS (U.S. Department of Health and Human Services). 1999. Mental Health: A Report of the Surgeon General. Rockville, MD: DHHS.
Ditton P. 1999. Mental Health and Treatment of Inmates and Probationers. NCJ 174463. Washington DC: Bureau of Justice Statistics, Department of Justice.
Eckenrode J, Rowe E, Laird M, Brathwaite J. 1995. Mobility as a mediator of the effects of child maltreatment on academic performance. Child Development 66(4):1130–1142.
Emrick CD, Tonigan JS, Montgomery H, Little L. 1993. Alcoholics Anonymous: What is currently known? In: McCrady BS, Miller WR, eds. Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, NJ: Rutgers Center of Alcohol Studies. Pp. 41–78.
Eriksson M, Zeterstrom R. 1994. Amphetamine addiction during pregnancy: 10-year follow-up. Acta Pediatrica, Supplement 404:27–31.
Essock SM, Frisman LK, Covell NH, Hargreaves WA. 2000. Cost-effectiveness of clozapine compared with conventional antipsychotic medication for patients in state hospitals. Archives of General Psychiatry 57(10):987–994.
Fergusson DM, Horwood LJ, Lynskey MT. 1997. Attentional difficulties in middle childhood and psychosocial outcomes in young adulthood. Journal of Child Psychology and Psychiatry 38(6):633–644.
Finney JW, Moos RH. 1991. The long-term course of treated alcoholism: I. Mortality, relapse, and remission rates and comparisons with community controls. Journal of Studies on Alcohol 52(1):44–54.
Fleming M, Barry K, Manwell L, Johnson K, London R. 1997. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary care practices. Journal of the American Medical Association 277(13):1039–1045.
Frank RG, McGuire TG. 2000. Economics and mental health. In: Cuyler AJ, Newhouse JP, eds. Handbook of Health Economics. Vol. 1B, No. 17. Amsterdam, The Netherlands: Elsevier Science B.V. Pp. 893–954.
GAO (Government Accountability Office). 1999. Mental Health: Improper Restraint or Seclusion Use Places People at Risk. GAO/HEHS-99-176. Washington, DC: GAO. [Online]. Available: http://www.gao.gov/archive/1999/he99176.pdf [accessed September 2, 2005].
GAO. 2003. Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services. GAO-03-397. Washington, DC: GAO. [Online]. Available: http://www.gao.gov/new.items/d03397.pdf [accessed October 25, 2004].
Giliberti M, Schulzinger R. 2000. Relinquishing Custody: The Tragic Result of Failure to Meet Children’s Mental Health Needs. Washington, DC: Bazelon Center for Mental Health Law.
Glied S, Cuellar AE. 2003. Trends and issues in child and adolescent mental health. Health Affairs 22(5):39–50.
Goetzel RZ, Ozminkowski RJ, Sederer LI, Mark TL. 2002. The business case for quality mental health services: Why employers should care about the mental health and well-being of their employees. Journal of Occupational and Environmental Medicine 44(4): 320–330.
Gossop M, Marsden J, Stewart D, Rolfe A. 1999. Treatment retention and one year outcomes for residential programmes in England. Drug and Alcohol Dependence 57(2):89–98.
Gould TD, Manji HK. 2004. The molecular medicine revolution and psychiatry: Bridging the gap between basic neuroscience research and clinical psychiatry. Journal of Clinical Psychiatry 65(5):598–604.
Grant BF, Stinson FS, Dawson DA, Chou P, Dufour MC, Compton W, Pickering RP, Kaplan K. 2004a. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 61(8):807–816.
Grant BF, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP. 2004b. Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 61(4):361–368.
Grasso BC, Genest R, Jordan CW, Bates DW. 2003. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatric Services 54(5):677–681.
Green J, Goldwyn R. 2002. Annotation: attachment disorganization and psychopathology: New findings in attachment research and their potential implications for developmental psychopathology in childhood. Journal of Child Psychology and Psychiatry 43(7): 835–846.
Greenberg M, Lengua L, Coie J, Pinderhughes E. 1999. Predicting developmental outcomes at school entry using a multiple-risk model: Four American communities. The Conduct Problems Prevention Research Group. Developmental Psychology 35(2):403–417.
Grisso T. 2004. Double Jeopardy: Adolescent Offenders with Mental Disorders. Chicago, IL: University of Chicago Press.
Gross D, Conrad B, Fogg L, Willis L, Garvey C. 1995. A longitudinal study of maternal depression and preschool children’s mental health. Nursing Research 44(2):96–101.
Haney C, Specter D. 2003. Treatment rights in uncertain legal times. In: Ashford JB, Sales BD, Reid WH, eds. Treating Adult and Juvenile Offenders with Special Needs. Washington, DC: American Psychological Association. Pp. 51–80.
Harrison PM, Karberg JC. 2004. Prison and Jail Inmates at Midyear 2003. Bureau of Justice Statistics Bulletin, Office of Justice Programs, NCJ 203947. Washington, DC: U.S. Department of Justice. [Online]. Available: http://www.ojp.usdoj.gov/bjs/pub/pdf/pjim03.pdf [accessed August 4, 2004].
Higgins S, Petry N. 1999. Contingency management. Incentives for sobriety. Alcohol Research and Health 23(2):122–127.
Hughes TA, Wilson DJ, Beck AJ. 2001. Trends in State Parole, 1990–2000. Bureau of Justice Statistics, NCJ 184735. Washington, DC: U.S. Department of Justice. [Online]. Available: http://www.Ojp.Usdoj.Gov/Bjs/Pub/Pdf/Tsp00.Pdf [accessed July 31, 2005].
IOM (Institute of Medicine). 1997. Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research. Washington, DC: National Academy Press.
IOM. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press.
IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.
IOM. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press.
IOM. 2004. In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press.
IOM. 2005. Quality through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press.
Jaycox LH, Morral AR, Juvonen J. 2003. Mental health and medical problems and service use among adolescent substance users. Journal of the American Academy of Child & Adolescent Psychiatry 42(6):701–709.
Jenkins CL. 2004, November 29. Mental illness sends many to foster care. The Washington Post. Metro Section. Pp. B1 and B4, Column 1.
Johnson R, Chatuape M, Strain E, Walsh S, Stitzer M, Bigelow G. 2000. A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence. New England Journal of Medicine 343(18):1290–1297.
Katon W. 2003. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry 54(3):216–226.
Kessler RC. 2004. Impact of substance abuse on the diagnosis, course, and treatment of mood disorders. The epidemiology of dual diagnosis. Biological Psychiatry 56(10):730–737.
Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank, RG, Leaf PJ. 1996. The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry 66(1):17–31.
Kessler RC, Greenberg PE, Mickelson KD, Meneades LM, Wang PS. 2001a. The effects of chronic medical conditions on work loss and work cutback. Journal of Occupational and Environmental Medicine 43(3):218–225.
Kessler RC, Costello EJ, Merikangas KR, Ustun TB. 2001b. Psychiatric epidemiology: Recent advances and future directions. In: Manderscheid RW, Henderson MJ, eds. Mental Health, United States, 2000. DHHS Publication Number: (SMA) 01-3537. Washington, DC: U.S. Government Printing Office. Pp. 29–42.
Kessler RC, Ames M, Hymel PA, Loeppke R, McKenas DK, Richling DE, Stang PE, Ustun TB. 2004. Using the World Health Organization Health and Work Performance Questionnaire (HPQ) to evaluate the indirect workplace costs of illness. Journal of Occupational and Environmental Medicine 46(Supplement 6):S23–S37.
Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, Wang P, Wells KB, Zaslavsky AM. 2005. Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine 352(24):2515–2523.
Kranzler H, Van Kirk J. 2001. Efficacy of naltrexone and acamprosate for alcoholism treatment: A meta-analysis. Alcoholism: Clinical and Experimental Research 25(9):1335–1341.
Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. 2000. Interventions to improve provider diagnosis and treatment of mental disorders in primary care: A critical review of the literature. Psychosomatics 41(1):39–52.
Landsverk J. 2005. Improving the Quality of Mental Health and Substance Use Treatment Services for Children Involved in Child Welfare. Notes: Paper commissioned by the Institute of Medicine Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.
Linares LO, Leadbetter BJ, Kato PM, Jaffe L. 1991. Predicting school outcomes for minority group adolescent mothers: Can subgroups be identified? Journal of Research on Adolescence 1(4):379–400.
Maris RW. 2002. Suicide. The Lancet 360(9329):319–326.
Mark TL, Coffey RM, Vandivort-Warren R, Harwood HJ, King EC, the MHSA Spending Estimates Team. 2005. U.S. spending for mental health and substance abuse treatment, 1991–2001. Health Affairs, Web Exclusive W5-133–W5-142.
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348(26):2635–2645.
McLellan AT, Lewis DC, O’Brien CP, Kleber HD. 2000. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association 284(13): 1689–1695.
Mechanic D, Bilder S. 2004. Treatment of people with mental illness: A decade-long perspective. Health Affairs 23(4):84–95.
Metzner JL. 2002. Class action litigation in correctional psychiatry. Journal of the American Academy of Psychiatry and the Law 30(1):19–29.
Michaud CM, Murray CJL, Bloom BR. 2001. Burden of disease: Implications for future research. Journal of the American Medical Association 285(5):535–539.
Miller WR, Walters ST, Bennett ME. 2001. How effective is alcoholism treatment? Journal of Studies on Alcohol 62:211–220.
Miller W, Wilbourne P. 2002. Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 97(3):265–277.
Moggi F, Hirsbrunner HP, Brodbeck J, Bachmann KM. 1999. One-year outcome of an integrative inpatient treatment for dual diagnosis patients. Addictive Behaviors 24(4): 589–592.
Mumola CJ. 1999. Substance Abuse and Treatment, State and Federal Prisoners, 1997. NCJ 172871. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
Murray CJL, Lopez AD. 1996. The global burden of disease in 1990: Final results and their sensitivity to alternative epidemiological perspectives, discount rates, age-weights and disability weights. In: Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: The Harvard School of Public Health on behalf of the World Health Organization and the World Bank. Pp. 247–293.
NAMI (National Alliance for the Mentally Ill). 2005. Consumer Support: Recovery. [Online]. Available: http://www.nami.org/Content/NabigationMenuFind_Support/Consumer_Support/Recovery.htm [accessed May 3, 2005].
New Freedom Commission on Mental Health. 2003. Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Publication Number SMA-03-3832. Rockville, MD: U.S. Department of Health and Human Services.
NIAAA (National Institute on Alcohol Abuse and Alcoholism). 2000. 10th Special Report to the U.S. Congress on Alcohol and Health. [Online]. Available: http://www.niaaa.nih.gov/publications/10report [accessed May 6, 2005].
NIMH (National Institute of Mental Health). 2005. NIMH Strategic Plans and Priorities. [Online]. Available: www.nimh.nih.gov/strategic/strategicplanmenu.cfm [accessed September 1, 2005].
Ockene J, Adams A, Hurley T, Wheler E, Hebert J. 1999. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: Does it work? Archives of Internal Medicine 159(18):2198–2205.
O’Connor M, Sigman M, Brill N. 1987. Disorganization of attachment in relation to maternal alcohol consumption. Journal of Consulting and Clinical Psychology 55(6):831–836.
Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. 2002. National trends in the outpatient treatment of depression. Journal of the American Medical Association 287(2):203–209.
O’Malley S, Rounsaville B, Farren C, Namkoong K, Wu R, Robinson J, O’Connor P. 2003. Initial and maintenance naltrexone treatment for alcohol dependence using primary care vs. specialty care: A nested sequence of three randomized trials. Archives of Internal Medicine 163(14):1695–1704.
Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. 2004. An Analysis of the Definitions and Elements of Recovery: A Review of the Literature. Paper Prepared for the National Consensus Conference on Mental Health Recovery and Systems Transformation. Held in Rockville, MD on December 16, 2004: U.S. Department of Health and Human Services.
ONS (Office of National Statistics). 1998. Psychiatric Morbidity among Prisoners in England and Wales. London, UK: The Stationery Office.
Otto R, Greenstein J, Johnson M, Friedman K. 1992. Prevalence of mental disorders among youth in the juvenile justice system. In: Cocozza J, ed. Responding to the Mental Health Needs of Youth in the Juvenile Justice System. Seattle, WA: National Coalition for the Mentally Ill in the Criminal Justice System.
Parthasarathy S, Mertens J, Moore C, Weisner C. 2003. Utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care 41(3):357–367.
Pirraglia PA, Rosen AB, Hermann RC, Olchanski NV, Neumann P. 2004. Cost-utility analysis studies of depression management: A systematic review. American Journal of Psychiatry 161(12):2155–2162.
Prendergast M, Podus D, Chang E, Urada D. 2002. The effectiveness of drug abuse treatment: A meta-analysis of comparison group studies. Drug and Alcohol Dependence 67(1): 53–72.
Rawal PH, Lyons JS, MacIntyre II JC, Hunter JC. 2004. Regional variation and clinical indicators of antipsychotic use in residential treatment: A four state comparison. Journal of Behavioral Health Services and Research 31(2):178–188.
Richardson GA, Conroy ML, Day NL. 1996. Prenatal cocaine exposure: Effects on the development of school-age children. Neurotoxicology Teratology 18(6):627–634.
Richardson LP, Di Giuseppe D, Christakis DA, McCauley E, Katon W. 2004. Quality of care for Medicaid-covered youth treated with antidepressant therapy. Archives of General Psychiatry 61(5):475–480.
Rosenheck R, Cramer J, Allen E, Erdos J, Frisman LK, Xu W, Thomas J, Henderson W, Charney D. 1999. Cost-effectiveness of clozapine in patients with high and low levels of hospital use. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia. Archives of General Psychiatry 56(6):565–572.
Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. 2003. Cost-effectiveness of supported housing for homeless persons with mental illness. Archives of General Psychiatry 60(9): 940–951.
Rost K, Smith JL, Dickinson M. 2004. The effect of improving primary care depression management on employee absenteeism and productivity: A randomized trial. Medical Care 42(12):1202–1210.
Rushton JL, Fant K, Clark SJ. 2004. Use of practice guidelines in the primary care of children with Attention-Deficit Hyperactivity Disorder. Pediatrics 114(1):e23–e28. [Online]. Available: http://www.pediatrics.aappublications.org.cgi/reprint/114/1/e23 [accessed September 1, 2005].
Sailas E, Fenton M. 2005. Seclusion and restraint for people with serious mental illness. The Cochrane Database of Systematic Reviews (2):CD001163. Date of most recent update: September 24, 2005. Date of most recent substantive update: October 26, 1999.
Saitz R, Mulvey KP, Plough A, Samet JH. 1997. Physician unawareness of serious substance abuse. American Journal of Drug and Alcohol Abuse 23(3):343–354.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2004a. Results from the 2003 National Survey on Drug Use and Health: National Findings. DHHS Publication Number SMA 04-3964. NSDUH Series H-25. Rockville, MD: U.S. Department of Health and Human Services.
SAMHSA. 2004b. SAMHSA Action Plan: Seclusion and Restraint—Fiscal Years 2004 and 2005. [Online]. Available: http://www.samhsa.gov/Matrix/SAP_seclusion.aspx [accessed February 20, 2005].
Sarver JH, Cydulka RK, Baker DW. 2002. Magnetic resonance spectroscopy and its applications in psychiatry. Australian and New Zealand Journal of Psychiatry 36(1):31–43.
Simon GE, Von Korff M, Rutter CM, Peterson DA. 2001a. Treatment processes and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry 58(4):395–401.
Simon GE, Barber C, Birnbaum HG, Frank RG, Greenberg PE, Rose RM, Wang PS, Kessler RC. 2001b. Depression and work productivity: The comparative costs of treatment versus nontreatment. Journal of Occupational and Environmental Medicine 43(1):2–9.
Simpson GA, Scott G, Henderson MJ, Manderscheid RW. 2004. Estimates of attention, cognitive, and emotional problems, and health services use by U.S. school-age children. In: Manderscheid RW, Henderson MJ, eds. Mental Health, United States, 2002. DHHS Publication number: (SMA) 3938. Rockville, MD: SAMHSA. Pp. 105–119.
Sinclair D, Murray L. 1998. Effects of postnatal depression on children’s adjustment to school. Teacher’s Reports. British Journal of Psychiatry 172(1):58–63.
Spohr HL, Willms J, Steinhausen HC. 1994. The fetal alcohol syndrome in adolescence. Acta Paediatricia (Supplement 404):19–26.
Stein MB, Sherbourne CD, Craske MG, Means-Christensen A, Bystritsky A, Katon W, Sullivan G, Roy-Byrne PP. 2004. Quality of care for primary care patients with anxiety disorders. American Journal of Psychiatry 161(12):2230–2237.
Stephan JJ. 2001. Census of Jails, 1999. NCJ 196633. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. Available: http://www.ojp.usdoj.gov/bjs/pub/pdf/cj99.pdf [accessed September 2, 2004].
Sterling S, Weisner C. 2005. Chemical dependency and psychiatric services for adolescents in private managed care: Implications for outcomes. Alcoholism: Clinical and Experimental Research 25(5):801–809.
Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. 2003. Cost of lost productive work time among U.S. workers with depression. Journal of the American Medical Association 289(23):3135–3144.
Streissguth AP, Barr HM, Sampson PD, Bookstein FL. 1994. Prenatal alcohol and offspring development: The first fourteen years. Drug and Alcohol Dependence 36(2):89–99.
Tecott LH. 2003. The genes and brains of mice and men. American Journal of Psychiatry 160(4):646–656.
Teplin L, Abram K, McClelland G, Dulcan M, Mericle A. 2002. Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry 59(12):1133–1143.
Teti D, Gelfand D, Messinger D, Isabella R. 1995. Maternal depression and the quality of early attachment. Developmental Psychology 31(3):364–376.
Thorpe KE, Florence CS, Joski P. 2004. Which medical conditions account for the rise in health care spending? Health Affairs Web exclusive (W4):437–445.
Tonigan JS, Connors GJ, Miller WR. 2003. Participation and involvement in Alcoholics Anonymous. In: Babor TF, Del Boca FK, eds. Treatment Matching in Alcoholism. Cambridge, UK, and New York: Cambridge University Press. Pp 184–204.
U.S. House of Representatives. 2004. Incarceration of Youth Who Are Waiting for Community Mental Health Services in the United States. [Online]. Available: http://www.house.gov/reform/min/pdfs_108_2/pdfs_inves/pdf_health_mental_health_youth_incarceration_july_2004_rep.pdf [accessed September 1, 2005].
van Baar A, de Graaff BM. 1994. Cognitive development at preschool-age of infants of drug-dependant mothers. Developmental Medicine and Child Neurology 36(12):1063–1075.
van Baar AL, Soepatmi S, Gunning WB, Akkerhuis GW. 1994. Development after prenatal exposure to cocaine, heroin, and methadone. Acta Paediatrica, Supplement 404:40–46.
van Ijzendoorn MH, Schuengel C, Bakermans-Karenenburg. 1999. Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Developmental Pscyhopathology 11:225–249.
van Izjendoorn M, van Vliet-Vissers M. 1988. The relationship between quality of attachment in infancy and IQ in kindergarten. Journal of Genetics and Psychology 149(1): 23–28.
Velez CN, Johnson J, Cohen P. 1989. A longitudinal analysis of selected risk factors for childhood psychopathology. Journal of the American Academy of Child & Adolescent Psychiatry 28(6):861–864.
Wang P, Simon G, Kessler R. 2003. The economic burden of depression and the cost-effectiveness of treatment. International Journal of Methods in Psychiatric Research 12(1):22–33.
Wang PS, Beck AL, Berglund P, McKenas DK, Pronk NP, Simon GE, Kessler RC. 2004. Effects of major depression on moment-in-time work performance. American Journal of Psychiatry 161(10):1885–1891.
Watkins KE, Burnam A, Kung F-Y, Paddock S. 2001. A national survey of care for persons with co-occurring mental and substance use disorders. Psychiatric Services 52(8):1062–1068.
Weisner C, Mertens J, Parthsarathy S, Moore C. 2001. Integrating primary medical care with addiction treatment: A randomized controlled trial. Journal of the American Medical Association 286(14):1715–1723.
Weisner C, Ray GT, Mertens J, Satre D, Moore C. 2003. Short-term alcohol and drug treatment outcomes predict long-term outcome. Drug and Alcohol Dependence 71(3): 281–294.
White WL. 1998. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems/Lighthouse Institute.
Wierson M, Forehand R, Frame C. 1992. Epidemiology and treatment of mental health problems in juvenile delinquents. Advances in Behavior Research and Therapy 14, 93–120.
Wilson DJ. 2000. Drug Use, Testing and Treatment in Jails. NCJ 179999. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. [Online]. Available: http://www.ojp.usdoj.gov/bjs/pub/pdf/duttj.pdf [accessed August 11, 2005].
Wodarski JS, Kurtz PD, Gaudin JM, Howing PT. 1990. Maltreatment and the school-age child: Major academic, socioemotional, and adaptive outcomes. Social Work 35(6): 506–513.
Wolff NP. 2004. Law and Disorder: The Case against Diminished Responsibility. Notes: Paper commissioned by the Institute of Medicine Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.
Wu L-T, Ringwalt CL, Williams CE. 2003. Use of substance abuse treatment services by persons with mental health and substance use problems. Psychiatric Services 54(3): 363–369.
Yoshikawa H. 1995. Long-term effects of early childhood programs on social outcomes and delinquency. The Future of Children 5(3):51–75.
Zeanah CH, Keyes A, Settles L. 2003. Attachment relationship experiences and childhood psychopathology. Annals of the New York Academy of Sciences 1008:22–30.
Zerhouni E. 2003. Medicine: The NIH roadmap. Science 302(5642):63–72.