The Household Survey reports that 106 million persons, 53.4 percent of the household population, were current drinkers of alcohol in 1988, down from 113 million in 1985. The household population age 35 and over is the largest group of current alcohol users, at nearly 57 million (51.3 percent of the group), but 25.2 percent of those in the 12-17 age group (5 million persons) report drinking alcohol beverages in the 30 days prior to the survey.1 In addition to the information on alcohol use contained in the Household Survey, the National Institute on Alcohol Abuse and Alcoholism of ADAMHA estimates that 18 million adults 18 years old and older currently experience problems as a result of alcohol use. The problems may include such symptoms of dependence as loss of memory, inability to stop drinking until intoxication, inability to cut down on drinking, binge drinking, and withdrawal symptoms. ADAMHA also sponsors a nationwide survey of young people entitled Monitoring the Future: A Continuing Study of the Lifestyles and Values of Youth. Better known as the High School Senior Survey, it has reported, annually since 1975, on the drug use and related attitudes of a representative national sample of high school seniors. The 1988 High School Senior Survey shows decreases in alcohol and drug use similar to those reported by the Household Survey. Use of marijuana, the illicit drug most frequently used by high school seniors, has declined markedly over the past decade. In 1979, half of all seniors reported some marijuana use in the year prior to the survey; in 1988, only one-third reported such use. In 1979, 36.5 percent of all high school seniors reported marijuana use in the prior 30 days; by 1988, only 18 percent reported marijuana use in the previous month. Similar trends were reported for other drug use-use of cocaine in the 30 days prior to the survey fell from a peak of 6.7 percent in 1985 to 3.4 percent in 1988. Use of alcohol also declined among this population, although alcohol use remains high. Nearly 64 percent of the class of 1988 reported using alcohol in the previous 30 days; 34.7 percent reported having five drinks or more in a row in the last 2 weeks before the survey. 2 These surveys have certain limitations in measuring national alcohol and drug use in that they leave out populations some of whom could represent extensive drug and alcohol use. The National Household 1 U.S. Department of Health and Human Services, National Institute on Drug Abuse, of the Alcohol, Drug Abuse, and Mental Health Administration. National Household Survey on Drug Abuse: 1988 Population Estimates, 1989. 2U.S. Department of Health and Human Services, Alcohol, Drug Abuse, and Mental Health Administration, Drug Use, Drinking, and Smoking: National Survey Results from High School, College, and Young Adults Populations, 1975-1988, 1989. Survey, for instance, includes no information on alcohol and drug use by persons not living in households, such as the homeless, military personnel living on base, and those in dormitories, hospitals, and jails. The High School Senior Survey includes no information on the alcohol and drug use of the dropout population of the high school senior age group. Despite these limitations, the various national surveys of alcohol and drug use are helpful in examining current trends in such use. Mentally Ill Population-The chronically mentally ill population encompasses persons both in institutions and in the community who suffer certain mental or emotional disorders (organic brain syndrome, schizophrenia, recurrent depressive and manic-depressive disorders, paranoid and other psychoses, plus other disorders that may become chronic) that erode or prevent the development of their functional capacities in relation to such primary aspects of daily life as personal hygiene and self-care, self-direction, interpersonal relationships, social transactions, learning, and recreation, and that erode or prevent the development of their economic self-sufficiency. In addition to the severely or chronically mentally ill, there is a substantial population of persons who, from time to time during their lives, suffer from less severe mental disorders or upsets in their everyday lives. While the diagnosis for such disorders may not qualify as clinical mental illnesses, they may cause sufficient upset in the life of the individual to require some short-term treatment from some facet of the health care sector, whether in the form of psychiatric or psychological care, marital counseling, or other counseling. Opinions vary on the number of mentally ill persons in the U.S., with estimates ranging from 1 percent to 5 percent of the general population with severe mental disorders. National Institute of Mental Health (NIMH) estimates that the number of chronically mentally ill in the United States ranges from 1.7 million to 2.2 million, including 900,000 who are receiving residential services in a variety of institutional settings, including nursing homes, public and private mental or psychiatric hospitals, Department of Veteran Affairs facilities, residential treatment centers, or community mental health centers. Less information is available on the prevalence of less severe mental disorders. ADAMHA estimated in 1980 that 10 to 15 percent of the adult population of the U.S. suffered from all types of mental disorders, including severe U.S. Department of Health and Human Services, National Institute of Mental Health, Alcohol, Drug Abuse, and Mental Health Administration, Mental Health, United States, 1987. [Hereafter cited as Mental Health, United States, 1987.] and chronic disorders such as depression and affective disorders, schizophrenia, alcohol and drug problems, and anxiety, phobia, and other neuroses. The Cost to Society of Substance Abuse and Mental Illness In 1981, the Research Triangle Institute prepared a report for ADAMHA on the costs to U.S. society in 1977 of alcoholism, drug abuse, and mental illness. The report divided total costs to society between "core costs" and "other related costs." "Core costs" were costs that are borne by the health care system or are indirectly related through reduced productivity as a result of premature mortality or excessive morbidity. "Other related costs" include the costs of social programs other than health programs, in addition to accident costs, and costs of incarceration. The 1981 report estimated that the combined economic costs of alcohol, drug abuse, and mental illness in 1977 was $106 billion-$49.4 billion for alcoholism, $16.4 billion for drug abuse, and $40.3 billion for mental illness. These cost estimates were updated for 1980 at a total of $190.7 billion-$89.5 billion for alcohol abuse, $46.9 billion for drug abuse, and $54.2 for mental illness, and again in 1983 at a total of $249 billion-$116.7 billion for drug abuse, $59.7 billion for drug abuse, and $72.8 billion for mental illness. ADAMHA has contracted with the University of California, San Francisco to prepare new estimates of the economic costs to society from substance abuse and mental illness; the results are expected momentarily. TREATMENT FOR SUBSTANCE ABUSE AND MENTAL ILLNESS Substance Abuse Treatment Treatment services for alcohol and drug abuse are provided in a variety of settings and modalities. Some forms of treatment are aimed at drug abusers only, such as in the case of methadone maintenance for heroin addicts, others for alcohol abuse only, such as treatment involving the use of the sensitizing drug disulfiram (Antabuse). Aside from such exceptions, however, similar modalities of treatment are used for both alcohol or drug abuse, and often in the same setting. Such treatment often starts with a short-term program of detoxification, which can be provided on an inpatient basis in a hospital or other residential facility or in an outpatient program. Although many substance abusers do not receive any treatment services beyond it, detoxification is not a treatment for the substance abuse dependence as such, but is used, most often with alcohol abuse and heroin addiction, to clear the client's system of the physical remnants of the drug or alcohol. For those who choose to proceed to further care following detoxification, a variety of program modalities are available to prevent relapse and help clients remain alcohol- or drug-free. Treatment can be provided on an inpatient basis, in such settings as detoxification and rehabilitation units in general hospitals, treatment units in public and private psychiatric hospitals, and free-standing treatment facilities. Substance abuse treatment can also be provided in an outpatient setting, in the office of a private physician or other treatment professional, in treatment units of community facilities such as community mental health center or hospital, or in freestanding outpatient substance abuse treatment facilities. Treatment modalities in inpatient and outpatient settings include medical approaches, psychological approaches, and social-cultural approaches, or a combination of them, in providing care. The medical approach uses medications such as antidepressants, sensitizing agents such as disulfiram, and other medications to assist the patient in remaining drug-free. Psychological approaches to treatment use aversion therapy and other behavioral and nonbehavioral techniques. Social-cultural approaches to treatment focus on changing the social environment in which the drug or alcohol abuser functions. An example of this is the approach used by such groups as Alcoholics Anonymous and Narcotics Anonymous, which try to establish a whole new culture for the alcoholic or drug addict. It is not at all unusual for a drug or alcohol abuser to go through many different types and settings of treatment before achieving long-term success in becoming alcohol- or drug-free. Most treatment for drug abuse in recent years has focused on three different modalities of treatmentmethadone maintenance for opiate addiction, and therapeutic communities and outpatient drug-free programs for all types of drug abuse. Methadone maintenance is a treatment, usually outpatient, designed to help persons addicted to heroin and other opium-derivative drugs. It combines the daily administration of methadone, a synthetic opiate product that is administered orally and controls the craving for heroin in the addict, with intensive counseling and other social and medical services. The residential drug-free program approach, includes the therapeutic community approach, the model for which was the Synanon program in California in the late 1950s. Therapeutic communities are full-time, drug-free residential programs which provide a highly-structured, nonpermissive program of treatment. Therapy in a therapeutic community is generally a long-term proposition, often extending beyond a year in duration. Treatment features peer support and confrontation, individual and group counseling, and educational and job training when appropriate. Outpatient drug-free programs vary widely in duration, goals, and content, but have in common that they do not use medication in treatment, they use counseling as the major form of therapy, and as outpatient programs they allow clients to live at home during the course of treatment. These outpatient programs began as a response to a need for communitybased crisis centers for addicts. Many outpatient programs operate largely as drop-in "crisis" centers, while others are more structured. As with the therapeutic community, outpatient drug-free programs make extensive use of former addicts as staff counselors and therapists. The National Association of State Alcohol and Drug Abuse Directors (NASADAD) has for the past 3 years, under contract to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) of ADAMHA, compiled and published fiscal, client, and other service data related to substance abuse treatment activities in the States. These data apply to only those treatment units and programs in the States "that received at least some funds administered by the State Alcohol/Drug Agency." In FY 1988, the most recent year for which data are published, the NASADAD study reported on 6,926 alcohol and/or drug treatment units which received funds administered by State alcohol and drug abuse agencies. Of the total, 1,806 were identified as alcohol units, 1,614 as drug units, and the remaining 3,506 as combined alcohol/drug units. These units in FY 1988 reported 1.2 million admissions for alcoholism and alcohol abuse treatment and 518,000 for drug abuse and dependency treatment. Of the admissions for alcoholism and alcohol abuse treatment, 392,000 were for detoxification (79,000 in a hospital setting and 313,000 in a nonhospital setting), 182,000 were for longer term rehabilitation or residential care (19,000 in a hospital setting and 163,000 in nonhospital setting), and 549,000 were for outpatient care (33,000 in a hospital setting and 516,000 in a nonhospital setting). Of the more than half million admissions for drug treatment, nearly 96 thousand were for detoxification (13,000 in a hospital setting, 47,000 in other residential settings, and 36,000 in an outpatient setting), 47,600 for methadone maintenance (nearly 46,000 in an outpatient program and 1,600 in a residential facility), and 357,000 in drug-free programs (7,800 in a hospital setting, 72,700 in a residential program, and 276,700 in an outpatient program).* Mental Health Treatment Treatment for mental illness is also provided in a variety of settings, both inpatient and outpatient, including the following: A psychiatric hospital is a hospital (public or private) that is primarily concerned with providing inpatient care to mentally ill persons. A general hospital with separate psychiatric service is a licensed hospital that has established organizationally separate psychiatric units with assigned staff for inpatient care and/or outpatient care and/ or partial hospitalization to provide diagnosis, evaluation, and/or treatment to persons admitted with known or suspected psychiatric diagnoses. If inpatient care is provided in the separate psychiatric service, beds are set up and staffed specifically for psychiatric patients in a separate ward or unit. These beds may be located in a separate building, wing, ward, or floor, or they may be a specific group of beds physically separated from regular or surgical beds. A residential treatment center (RTC) for emotionally disturbed children is a facility that is designed and operated primarily to provide mental health treatment to children and youth. An outpatient mental health clinic is a facility that provides only ambulatory mental health services. The medical responsibility for all patients/clients and/or direction of the mental health program is generally assumed by a psychiatrist. A mental health partial care organization is a freestanding organization offering primarily day or night partial care. A multiservice mental health care organization is an organization that provides outpatient care and inpatient/residential treatment care in settings that are under the organization's direct administrative con * National Association of State Alcohol and Drug Abuse Directors, Inc., State Resources and Services Related to Alcohol and Drug Abuse Problems. Fiscal Year 1988 (August 1989). trol. A community mental health center (CMHC) may qualify as multiservice mental health organizations for the purpose of this survey, if not part of a general or psychiatric hospital. Mental health treatment services are also provided in the private office practices of psychiatrists, psychologists, and other providers, and general hospitals that have no separate psychiatric services, but admit psychiatric patients to nonpsychiatric units. Clinical social workers, family therapists, marriage counselors, and other counselors also provide a substantial amount of what must be described as mental health care, particularly to those suffering from less severe mental illnesses or the everyday problems of life. In addition, a substantial number of persons, receive care for such disorders from primary care physicians. Some estimates, in fact, indicate that a majority of individuals seeking care for a mental health disorder go to primary care physicians rather than to mental health specialists. The prevalence of mental illness among those seeking care in primary medical care settings has been estimated to range from 20 to 50 percent. In any case, it is estimated "that millions of individuals depend for their emotional well-being upon the primary care physician's sensitivity to emotional distress and willingness to accord it the same clinical significance as physical symptomatology." 5 The third edition of Mental Health, United States, published in 1987 by NIMH provides statistical data on mental health organizations providing care in the U.S. and the numbers of patients they serve. In 1984, according to this survey, there were 280 State and county mental hospitals, 221 private psychiatric hospitals, 1,347 general hospitals with psychiatric services, 140 VA medical centers providing psychiatric care, 325 RTCs for emotionally disturbed children, 798 freestanding psychiatric outpatient clinics, 90 freestanding psychiatric partial care organizations, and 1,263 multiservice mental health organizations. The average daily inpatient and residential treatment census for these facilities in the U.S. excluding territories for 1983 was 224,169 patients. Of this total, 116,236 were in State and county mental hospitals, 16,467 were in private psychiatric hospitals, 34,328 were in general hospital psychiatric services, 20,342 were in VA medical centers, 15,826 were in RTCs for children, and 20,970 were in multiservice mental health organizations. The survey does not include average daily census for outpatient and partial care organizations, but does Herbert C. Schulberg, and Ronald W. Manderscheid, "The Changing Network of Mental Health Service Delivery," [In] The Future of Mental Health Services Research, NIMH, 1989, 20. include information on additions to such programs. Additions refer to patients admitted or readmitted to such settings or transferred from one such settings to another during a year. Each time a person is admitted or readmitted is counted separately, so there is some duplication of numbers, but the information is helpful in noting where outpatient services are provided. In 1983, in the U.S. excluding the territories, there were nearly 2.7 million outpatient additions for treatment.6 Existing Knowledge on Effectiveness and Findings of research into the effectiveness of substance abuse and mental health treatment can be described as inconclusive at best. Treatment research carried out over the past two decades on various treatment settings and modalities has found at least limited effectiveness for most if not all types and settings of treatment for alcohol and drug abuse and for mental illness. Most treatments, apparently, can be shown to be effective in detoxifying and preventing relapses in some alcohol and drug abusers some of the time. Similarly, research on the various types of treatment of mental illness has demonstrated limited success with many patients in reducing symptoms and returning the patient to productive life in the community. What treatment research thus far has been unable to do is to prove that any particular form of treatment is more effective than another, or to enable us to predict the most appropriate treatment for a specific patient at any particular time. Effectiveness of Alcoholism Treatment-In 1983, the U.S. Office of Technology Assessment (OTA) published a report, The Effectiveness and Costs of Alcoholism Treatment (prepared under contract by Saxe et al, Boston University) which focused on the costs of alcoholism and alcohol abuse to the health care system and to society in general. The OTA report, in assessing the effectiveness and cost-effectiveness of the various treatment settings and modalities for alcoholism based on a review of available treatment research, concluded that "treatment is better than no treatment, but that methodological problems render it difficult to conclude that any specific treatment is more effective than any other." The report found consensus that inpatient treatment is far more expensive than other treatment options, but found no evidence to demonstrate that inpatient care for alcoholism treatment offered greater likelihood of suc 6 Mental Health, United States, 1987. cessful treatment than outpatient care. In assessing cost-effectiveness, the OTA review found "some evidence to support the hypothesis that alcoholism treatment is cost-beneficial" in that the benefits "seem to be in excess of the costs of providing such treatment.” The review, however, concluded that it was difficult from the evidence available at the time "to determine the relative effectiveness or cost-effectiveness of inpatient v. outpatient treatment.” 7 The 1983 OTA report suggested that treatment reimbursement strategies that encouraged early outpatient treatment and continuing aftercare services on a outpatient basis would lead to better use of resources. The report, however, did not recommend curtailing the use of hospital programs because it was felt that there was not a sufficient supply of non-hospital based treatment programs available at that time. In a 1988 study updating OTA's 1983 review and findings, the principal author states that in not making such a recommendation, the "hope was that encouragement of such alternatives would lead, over time, to a reduced utilization of hospitals." The 1988 study concluded that the hoped-for reduction in the use of hospital-based treatment programs had not occurred; that, in fact, there had been an increase in the use of such treatment. (Between 1980 and 1986, the number of hospital-based inpatient addiction treatment programs more than doubled, from 506 to 1,039, while outpatient programs increased only 13 percent, from 1,182 to 1,342.8) Further, the 1988 review confirmed the findings of the earlier report-that both inpatient and outpatient treatment have demonstrable effectiveness, but that there is "no evidence to suggest that inpatient treatment is better than outpatient treatment" and that there is a growing body of evidence to indicate that "relapse rates and other outcomes are no different as a result of inpatient v. outpatient." It concludes that "these findings have remained consistent across a variety of different approaches to treatment and across a diversity of populations. There remains little convincing evidence in favor of inpatient treatment or lengthy and intensive treatment." And because inpatient treatment programs are consistently more expensive than outpatient programs, the 1988 study further concludes is that "the clear implication of currently available data is that outpatient care is not only effective, but far more cost-effective than inpatient care." 9 7 Office of Technology Assessment, The Effectiveness and Costs of Alcoholism Treatment, March 1983. 8 Paul Cotton, "Detox Programs Called 'Wasteful'." Medical World News, (December 26, 1988), 53. • Leonard Saxe and Lisa Goodman, The Effectiveness of Outpatient v. Inpatient Treatment: Updating the OTA Report, Working Paper, Bigel Institute for Health Policy, Brandeis University, 5. The preceding paragraphs use this paper as source. Effectiveness of Drug Abuse Treatment-Most research on drug abuse treatment until recently has focused on treatment for heroin addiction. Much of this research, on methadone maintenance programs and early therapeutic community programs such as Synanon, reported success in helping addicts to achieve abstinence from heroin. There was skepticism about such reports of success, due to flaws in much of the research, such as the lack of control groups. In 1969, the first national comprehensive study of drug abuse treatment effectiveness was initiated as the Drug Abuse Reporting Program (DARP). This study looked at four major treatment modalities-methadone maintenance, therapeutic communities, outpatient drug-free programs, and detoxification. The major conclusion of the DARP research was that the most favorable results in terms of abstinence or reduced drug use and reductions in criminal activity were produced by treatment in the three major modalities, but not by detoxification only. All three produced similar positive outcomes. The DARP study appeared to show that length of treatment was the most effective predictor of success in treatment, whatever the modality-the clients who remained longer in treatment had the most favorable outcomes in terms of reduced drug use and criminal activity. The data suggested that treatments which lasted less than 90 days appeared to be of limited benefit, regardless of the type of treatment involved. Beyond 90 days, treatment outcomes improved in direct proportion to the length of time spent in treatment. 10 A second national study of drug abuse treatment effectiveness called the Treatment Outcome Prospective Study (TOPS) was initiated in the mid-1970s. A multi-year study financed by NIDA, the project studied 10,000 drug users who entered treatment in 1979, 1980, or 1981 in 37 selected U.S. drug abuse treatment programs representing three major treatment modalities-methadone maintenance, therapeutic communities, and outpatient drug-free programs. Patients who served as study subjects were followed from the time they entered treatment, through five years after they left treatment. The TOPS study addressed the impact of drug abuse treatment across the range of settings and for clients with varying degrees of dependence and associated programs. 11 The study measured the actual re 10 D. Wayne Simpson, "National Treatment System Evaluation Based on the Drug Abuse Reporting Program (DARP) Followup Research,” [In] Drug Abuse Treatment Evaluation: Strategies, Progress, and Prospects, Frank M. Tims and Jacqueline P. Ludford, eds. Research Monograph 51, National Institute on Drug Abuse, DHHS Publication No. 84-1329. 11 Robert L. Hubbard, et al., Drug Abuse Treatment: A National Study of Effectiveness, 1989. This section of the paper uses this book as source. |