Elsevier

Drug and Alcohol Dependence

Volume 175, 1 June 2017, Pages 157-163
Drug and Alcohol Dependence

Full length article
The association of psychiatric comorbidity with treatment completion among clients admitted to substance use treatment programs in a U.S. national sample

https://doi.org/10.1016/j.drugalcdep.2017.02.006Get rights and content

Highlights

  • In the US, clients with psychiatric comorbidity have lower substance use disorder (SUD) treatment retention.

  • Comorbidity is most strongly associated with treatment (tx) non-completion for alcohol users.

  • Comorbidity does not impact retention of opioid users in programs that utilize medication assisted treatment (MAT).

Abstract

Background

Psychiatric disorders are highly comorbid with substance use disorders and play an important role in their course and recovery. However, the impact of comorbidity on treatment outcomes has not been examined in a U.S. national sample. This study explores the impact of psychiatric comorbidity on treatment completion among individuals admitted to publicly funded substance use treatment facilities across the United States.

Methods

Using data on first-time treatment episodes in the U.S. from the Treatment Episode Dataset-Discharges (TEDS-D) for the years 2009–2011, logistic regression was used to assess the association between psychiatric comorbidity and treatment non-completion, and Cox proportional hazards regression was used to assess the association between comorbidity and rate of attrition. Analyses were performed for all substances together and then stratified by primary substance of abuse (alcohol, cannabis, stimulants, or opioids).

Results

Of 856,385 client treatment episodes included in our analysis, 28% had a psychiatric comorbidity and 38% did not complete treatment. After adjusting for socio-demographic and treatment characteristics, clients with psychiatric comorbidity had higher odds of not completing treatment relative to those without comorbidity [OR = 1.28 (1.27–1.29)], and had an earlier time to attrition [HR = 1.14 (1.13–1.15)]. Psychiatric comorbidity was most strongly associated with treatment non-completion and rate of attrition in those admitted primarily for alcohol [OR = 1.37 (1.34–1.39); HR = 1.19 (1.17–1.21), respectively].

Conclusions

Individuals with psychiatric comorbidities receiving treatment for substance use disorders face unique challenges that impact their ability to complete treatment. The findings call for further efforts to integrate treatment for psychiatric comorbidities in substance use treatment settings.

Introduction

The successful retention of individuals who suffer from substance use disorders (SUDs) in treatment and long-term recovery remains a persistent challenge. Indeed, many authors have pointed to the need to improve the quality and effectiveness of existing treatment programs and systems to address the varied needs of patients (Pating et al., 2012, Watkins et al., 2015, Saloner and Sharfstein, 2016). A particularly relevant factor in addressing the needs of this patient population is the high prevalence of comorbid psychiatric conditions. Epidemiological studies have repeatedly pointed to comorbidities between substance use disorders and mood, anxiety, and personality disorders, in particular (Lai et al., 2015). Comorbidity of substance use and mental health disorders have also been found to be highly prevalent among treatment-seeking populations, (McGovern et al., 2006) with adults more often experiencing co-occurring internalizing disorders and adolescents more often experiencing externalizing disorders (Chan et al., 2008).

Individuals with SUDs who have psychiatric comorbidities not only experience barriers that impact access to care (Mojtabai et al., 2014), but also have more difficulty integrating into existing treatment and recovery programs (Torrens et al., 2012, Urbanoski et al., 2007). Clients with co-occurring psychiatric comorbidities are likely to experience more severe clinical, social, and legal problems than the general population, and may thus require more specialized care than what is typically available in substance use treatment programs (Cacciola et al., 2001, McGovern et al., 2006, Torrens et al., 2012). Studies that explore the relationship between psychiatric comorbidity and treatment outcomes among drug and alcohol users often find that psychiatric disorders are associated with lower treatment retention and poorer outcomes (Bradizza et al., 2006, Compton et al., 2003, Ouimette et al., 1999). Similar findings have been reported for substance using adolescents with comorbid psychiatric disorders (Tomlinson et al., 2004). Nevertheless, the impact of psychiatric comorbidity on substance use outcomes is not always consistent and may vary by sex, the type and severity of comorbidity, substance use type, and treatment setting (Choi et al., 2015, Compton et al., 2003, Mertens and Weisner, 2000, Polcin et al., 2015). Past research on the association of psychiatric comorbidities with substance use treatment outcomes has been mainly limited to small samples and select treatment programs. Studies have yet to examine these associations at a national level in the United States and explore variations in this association by the type of substance of use. Greater understanding of the impact of psychiatric comorbidities on treatment completion in the U.S. as a whole, and variations in these associations may have implications for national policies and design of services.

The current study addresses this need by exploring differences in treatment completion patterns among individuals with and without psychiatric problems using three years of U.S. national data on substance use treatment episodes from the Treatment Episode Dataset (TEDS). The study further examines whether comorbidity has a differential effect on treatment completion for different classes of substances, specifically alcohol, cannabis, stimulants, and opioids.

Section snippets

Source of data

Data on treatment episodes were obtained for the years 2009, 2010, and 2011 from the Treatment Episode Dataset-Discharges (TEDS-D), a database of substance use treatment episodes in the United States. The TEDS is managed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and includes information regarding admissions and discharges from treatment programs that receive public funding throughout the 50 U.S. States, the District of Columbia and Puerto Rico. This dataset

Sample characteristics

Of the clients whose treatment episodes were included in the complete case analysis, 28% were registered as having a psychiatric problem in addition to a substance use problem. The prevalence of psychiatric comorbidity in individual states ranged between 8% and 62%, indicating substantial reporting and coding variation depending on the state. Overall, 38% of the sample did not complete treatment. Frequency of reasons for non-completion included leaving against professional advice (72%), being

Discussion

In this study based on data from substance use treatment facilities across the United States, we observed a modest but significant association between psychiatric comorbidity and treatment non-completion. This remained true after controlling for a multitude of potential demographic and treatment-related confounders. Clients with psychiatric comorbidity also had an earlier time to treatment attrition with shorter lengths of treatment. As staying in treatment for longer has been associated with

Conclusion

This research is relevant in highlighting the need for appropriate and integrated care to address the needs of patients with co-occurring mental health and substance use disorders. Treatment services need to include methods to properly diagnose and address the unique needs of patients with mental disorders, while also providing resources to improve retention in care and ultimately treatment success in this group of clients. Recent healthcare reforms have motivated the integration of substance

Conflict of interest

No conflict declared

Role of funding source

This work was conducted with the support of grants by the National institute of Drug Abuse (1R01-DA039863-01A1, PI: Rosa M. Crum and Ramin Mojtabai and T32-DA007293, PI: Renee Johnson). In addition, Kenneth A. Feder was supported as a predoctoral Department of Mental Health Scholar, Johns Hopkins Bloomberg School of Public Health.

Contributors

NK and KAF formulated the primary research question, carried out the analyses of the data and drafted the manuscript. BS, RMC, MK and RM assisted in the formulation of the research question, participated in the design of the methodology for analyses, and contributed to several revisions and editions of the manuscript. All authors contributed to and have approved the final manuscript.

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