JBHSR Recent Issues

The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.

Volume 36, 2009

Number 1 / January 2009

Changes in How Health Plans Provide Behavioral Health Services …11-24
Constance M. Horgan, Deborah W. Garnick, Elizabeth Levy Merrick, Dominic Hodgkin Abstract: Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans’ delivery of these services. This study examined plans’ behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N=434, 92% response) and 2003 (N=368, 83% response). Findings indicate health plans’ behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients’ needs.

Individual and Program Predictors of Attrition from VA Substance Use Treatment …25-34 Geoffrey M. Curran, Tracy Stecker, Xiaotong Han and Brenda M. Booth
Abstract: The study investigated patient- and program-level variables associated with attrition from intensive outpatient (IOP) substance use treatment in a national VA sample. National databases were used to identify a recent cohort of veterans receiving intensive IOP substance use treatment. Attrition was defined as receiving less than five visits of IOP treatment. Patient-level variables examined included age, gender, race, and psychiatric and medical comorbidities. Program-level variables examined included the number of hours of treatment offered, the percentage of patients living on-campus, and extent of staff cuts in the past year. Twenty-seven percent of veterans left treatment early. Being older, female, and having a psychotic disorder was associated with attrition. Program-level factors associated with attrition were the number of hours the program offered treatment, in that more treatment offered was associated with higher attrition. Focus on individual and program level factors associated with attrition is crucial to retaining individuals in treatment.

Utilization of Mental Health Services Among Adolescents in Community-Based Substance Abuse Outpatient Clinics …35-51
Ya-Fen Chan, Mark D. Godley, Susan H. Godley and Michael L. Dennis
Abstract:This study examined the rates and correlates of self-reported receipt for mental health services among 1,190 adolescents, aged 12–19, who were admitted to community-based substance abuse outpatient clinics and had a co-occurring mental health problem. Utilization of mental health service was ascertained 3 months post-intake. About one third (35%) of adolescents with a co-occurring mental health problem identified at intake received mental health service in the 3 months after treatment entry. After holding other correlates constant, history of mental health treatment, suicidal behavior, family history of mental disorder and insurance coverage at intake were associated with mental health service utilization at the 3-month follow up. Predictors of service utilization varied by gender and racial/ethnic status. Implications for integrated substance use and mental health services are discussed.

Improving Care for the Treatment of Alcohol and Drug Disorders …52-60
Dennis McCarty, David Gustafson, Victor A. Capoccia and Frances Cotter
Abstract:The Network for the Improvement of Addiction Treatment (NIATx) teaches alcohol and drug treatment programs to apply process improvement strategies and make organizational changes that improve quality of care. Participating programs reduce days to admission, increase retention in care, and spread the application of process improvement within their treatment centers. More generally, NIATx provides a framework for addressing the Institute of Medicine’s six dimensions of quality care (i.e., safe, effective, patient-centered, efficient, timely, and equitable) in treatments for alcohol, drug, and mental health disorders. NIATx and its extensions illustrate how the behavioral health field can respond to the demand for higher quality treatment services.

Assessing Culturally Competent Chemical Dependence Treatment Services for Mexican Americans …61-74
Clayton Shorkey, Liliane Cambraia Windsor and Richard Spence
Abstract:Mexican Americans struggling with chemical dependence are greatly underserved. Barriers to treatment include language, lack of culturally relevant services, lack of trust in programs, uninviting environments, and limited use and linkage with cultural resources in the community. This project aimed to develop a tool for assessing and planning culturally competent/relevant chemical dependence treatment services for Mexican Americans. Focus groups were conducted with experts in Mexican-American culture and chemical dependence from six substance abuse programs serving adult and adolescent Mexican Americans and their families. Sixty-two statements were developed describing characteristics of culturally competent/relevant organizations. Concept mapping was used to produce a conceptual map displaying dimensions of culturally competent/relevant organizations and Cronbach’s alpha was calculated to assess the internal consistency of each dimension. Analysis resulted in seven reliable subscales: Spanish language, counselor characteristics, environment, family, linkage, community, and culture. The resulting instrument based on these items and dimensions enable agencies to evaluate culturally competent/relevant services, set goals, and identify resources needed to implement desired services for both individual organizations and networks of regional services.

Substance Use, Education, Employment, and Criminal Activity Outcomes of Adolescents in Outpatient Chemical Dependency Programs …75-95
Ana I. Balsa, Jenny F. Homer, Michael T. French and Constance M. Weisner
Although the primary outcome of interest in clinical evaluations of addiction treatment programs is usually abstinence, participation in these programs can have a wide range of consequences. This study evaluated the effects of treatment initiation on substance use, school attendance, employment, and involvement in criminal activity at 12 months post-admission for 419 adolescents (aged 12 to 18) enrolled in chemical dependency recovery programs in a large managed care health plan. Instrumental variables estimation methods were used to account for unobserved selection into treatment by jointly modeling the likelihood of participation in treatment and the odds of attaining a certain outcome or level of an outcome. Treatment initiation significantly increased the likelihood of attending school, promoted abstinence, and decreased the probability of adolescent employment, but it did not significantly affect participation in criminal activity at the 12-month follow-up. These findings highlight the need to address selection in a non-experimental study and demonstrate the importance of considering multiple outcomes when assessing the effectiveness of adolescent treatment.

The Mental Health Benefits of Work: Do They Apply to Welfare Mothers with a Drinking Problem? …96-110
Denise Zabkiewicz and Laura A. Schmidt
Abstract: A longstanding tradition of employment-related research has shown the mental health advantages of employment. However, given welfare reform mandates for employment and a welfare population with disproportionately high rates of depression and co-occurring substance abuse problems, it is unclear if women on welfare reap this advantage. This analysis draws on 4 years of data from the Welfare Client Longitudinal Study to examine the mental health benefits of employment among women on welfare (N=419) and to assess whether drinking problems alter the relationship. Repeated measures analyses suggest that women who enter welfare with a drinking problem may not experience the same decline in depression symptoms following employment. Improving the connections between welfare and treatment services for women with alcohol problems may, however, have important implications for their mental health.

Estimating the Differential Costs of Criminal Activity for Juvenile Drug Court Participants: Challenges and Recommendations … 111-126
Kathryn E. McCollister, Michael T. French, Ashli J. Sheidow, Scott W. Henggeler and Colleen A. Halliday-Boykins
Abstract:Juvenile drug court (JDC) programs have expanded rapidly over the past 20 years and are an increasingly popular option for rehabilitating juvenile offenders with substance use problems. Given the high cost of crime to society, an important economic question is whether and to what extent JDC programs reduce criminal activity among juvenile offenders. To address this question, the present study added an economic cost analysis to an ongoing randomized trial of JDC conducted in Charleston, South Carolina. Four treatment conditions were included in the parent study: Family Court with usual community-based treatment (FC, the comparison group), Drug Court with usual community-based treatment (DC), DC with Multisystemic Therapy (DC/MST), and DC/MST enhanced with Contingency Management (DC/MST/CM). The economic study estimated the cost of criminal activity for nine specific crimes at baseline (pretreatment) and 4 and 12 months thereafter. A number of methodological challenges were encountered, suggesting that it may be more difficult to economically quantify frequency and type of criminal activity for adolescents than for adults. The present paper addresses methodological approaches and challenges, and proposes guidelines for future economic evaluations of adolescent substance abuse and crime prevention programs.

Number 2 / April 2009

Examining Self-Control as a Multidimensional Predictor of Crime and Drug Use in Adolescents with Criminal Histories … 137-149
Bradley T. Conner, Judith A. Stein and Douglas Longshore
Abstract:The general theory of crime posits that variability in propensities to engage in crime and deviance is partly a function of individual differences in low self-control (LSC). LSC is hypothesized to comprise of six subdomains: impulsiveness, preference for physical activities, risk seeking, self-centeredness, preference for simple tasks, and volatile temper. Using structural equation modeling, LSC was examined to determine if a global self-control measure or a multidimensional measure of its subdomains was a more salient predictor of violent and property crimes and drug use among adolescent male offenders (n=317). Only the multidimensional model adequately fit the data. Risk seeking predicted violent and property crimes, whereas volatile temper predicted violent crimes and drug use. The general theory of crime may obscure differences in the explanatory power of self-control subfactors for specific types of crime, especially within at-risk youth. Findings have implications for effective interventions among adolescent males with criminal histories.

Modeling Attitude towards Drug Treament: The Role of Internal Motivation, External Pressure, and Dramatic Relief … 150-158
Bradley T. Conner, Douglas Longshore and M. Douglas Anglin
Abstract:Motivation for change has historically been viewed as the crucial element affecting responsiveness to drug treatment. Various external pressures, such as legal coercion, may engender motivation in an individual previously resistant to change. Dramatic relief may be the change process that is most salient as individuals internalize such external pressures. Results of structural equation modeling on data from 465 drug users (58.9% male; 21.3% Black, 34.2% Hispanic/Latino, and 35.1% White) entering drug treatment indicated that internal motivation and external pressure significantly and positively predicted dramatic relief and that dramatic relief significantly predicted attitudes towards drug treatment: 2=142.20, df=100, p<0.01; Robust Comparative Fit Index=0.97, Root Mean Squared Error of Approximation=0.03. These results indicate that when external pressure and internal motivation are high, dramatic relief is also likely to be high. When dramatic relief is high, attitudes towards drug treatment are likely to be positive. The findings indicate that interventions to get individuals into drug treatment should include processes that promote Dramatic Relief. Implications for addictions health services are discussed.

Influence of Perceived Coercion and Motivation on Treatment Completion and Re-Arrest among Substance-Abusing Offenders … 159-176
Michael Prendergast, Lisa Greenwell, David Farabee and Yih-Ing Hser
Abstract:The effects of perceived coercion and motivation on treatment completion and subsequent re-arrest were examined in a sample of substance-abusing offenders assessed for California’s Substance Abuse and Crime Prevention Act (SACPA) program. Perceived coercion was measured with the McArthur Perceived Coercion Scale; motivation was measured with the subscales of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). At treatment entry, clients were more likely to believe that they had exercised their choice in entering treatment than that they had been coerced into treatment. SACPA clients scored relatively low on Recognition and Ambivalence regarding their drug use but relatively high on Taking Steps to address their drug problem. Correlations between perceived coercion and motivation measures at treatment entry indicated that these are separate constructs. In logistic regression models, the Recognition subscale of the SOCRATES significantly predicted “any re-arrest,” and Ambivalence and Taking Steps predicted “any drug arrest.”

Are Religiosity and Spirituality Useful Constructs in Drug Treatment Research? … 177-188 Douglas Longshore, M. Douglas Anglin and Bradley T. Conner
Abstract: Religiosity and spirituality (R/S) have been shown to be related to better outcomes in many health service areas, including drug abuse treatment. The latter area, however, lacks a fully emergent empirical framework to guide further study. Moreover, although scientists have tested isolated hypotheses, no comprehensive process model has been designed and validated, limiting conceptual development as well. This paper reviews the relevant R/S and health research literature with a primary focus on drug treatment processes. Then a conceptual model is suggested to guide future incremental study of R/S assessment and intervention development. Implications for addiction health services include increased efforts to empirically validate R/S interventions, to increase practitioner competencies in this area, and to disseminate relevant research findings.

Effect of Religiosity and Spirituality on Drug Treatment Outcomes … 189-198
Bradley T. Conner, M. Douglas Anglin, Jeffery Annon and Douglas Longshore
Abstract: This study empirically tested one component of a comprehensive model of the role of religiosity and spirituality (R/S) in drug treatment that is presented as a companion article in this special issue. Data collected from individuals dependent on heroin receiving narcotic replacement therapy were used to assess the effects of R/S on drug treatment outcomes. Based on their R and S scores, participants were assigned to one of four groups: those whose scores remained consistently high across the 12-month study period were compared to those whose scores were consistently low, increased, or decreased across the same period. Results indicated that at both study completion (12 months after admission) and 6 months after that participants in the consistently high and increasing spirituality groups self-reported significantly fewer days of heroin and cocaine/crack use than those in the consistently low group (p<0.05). There were no significant differences among the religiosity groups on self-reported heroin or cocaine/crack use. Results from 2 analyses indicated that at 12 months the results of urinalysis for the presence of opiates, but not cocaine/crack, were dependent on spirituality group membership (p<0.01) but not religiosity group membership. Results also indicated that at the 6-month follow-up, there were significantly more participants in the decreasing group who were not in maintenance treatment who had a positive urinalysis and fewer in the increasing group than would be expected if the two variables were independent (p<0.05). Implications for addictions health services are discussed.

Substance Use and Intimate Partner Violence: Clarifying the Relevance of Women’s Use and Partners’ Use … 199-211
Daniela Golinelli, Douglas Longshore and Suzanne L. Wenzel Abstract:
Abstract: Research has shown that, when women and/or their partners are involved in substance use, women’s risk for intimate partner violence (IPV) is higher. Prior research has not examined whether substance use by both women and their partners contributes independently or interactively to women’s risk of victimization and has not identified factors moderating the effect of substance use by victim or partner. Mental health and social support are explored as moderators of the association between women’s victimization and substance use by victim or partner in a study of 590 impoverished women residing in the Los Angeles area. This study found that substance use by both the woman and her partner independently predicted IPV and that social support moderated the effect of women’s substance use. These findings clarify the relevance of substance use in the context of intimate relationships and that of social support as a buffer against IPV among impoverished women.

Hospitalizations Among Homeless Women: Are There Ethnic and Drug Abuse Disparities? … 212-232
Lillian Gelberg, Ronald Andersen, Douglas Longshore, Barbara Leake, Adeline Nyamathi, Cheryl Teruya and Lisa Arangua
Abstract:This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women’s hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15–44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9–17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Trauma and Psychosocial Predictors of Substance Abuse in Women Impacted by HIV/AIDS … 233-246
Hector F. Myers, Lekeisha A. Sumner, Jodie B. Ullman, Tamara B. Loeb, Jennifer Vargas Carmona and Gail E. Wyatt
Abstract:The purpose of this study was to estimate the relative contributions of trauma, chronic stress burden, depression, anxiety, social support, and social undermining in predicting alcohol and drug abuse, and whether ethnicity moderated these relationships. A multi-ethnic sample of 288 HIV-positive and HIV-negative women was recruited. Multiple group path analysis indicated that greater drug dependence was associated with being HIV+, more depression, and higher chronic burden. Trauma was related only to anxiety. Also, greater alcohol dependence was associated with more depression and more social undermining, and these effects were moderated by ethnicity. African American and Latina women evidenced different relationships between depression, social support and social undermining. Depression, social support and social undermining served as intervening variables in influencing the relationships between the other psychosocial variables and drug and alcohol dependence. The implications of these findings for alcohol and drug abuse research and services are discussed.

Longitudinal Effects of LAAM and Methadone Maintenance on Heroin Addict Behavior … 267-282
M. Douglas Anglin, Bradley T. Conner, Jeffrey J. Annon and Douglas Longshore
Abstract: Levo-alpha-acetylmethadol maintenance (LAAM) was compared to methadone maintenance (MM) on the behavioral performance of 315 heroin addicts before, during, and after 12 months of fully subsidized treatment. Assessments of drug use, criminal behavior, HIV risk behaviors, and employment and residential status were obtained at treatment intake and at 6, 12, and 18 months after admission. Treatment retention and in-treatment suppression of heroin use were significantly better for the LAAM group than for the MM group. Improvements were also noted during treatment in criminal behavior, criminal justice involvement, and employment status, and there were reductions in injection HIV risk and number of sexual partners. Most significant effects were primarily related to active participation in maintenance treatment. Under subsidized treatment, retention rates were two to four times that of similar clients in local community programs during the same period. LAAM was a useful and a potentially important addition to treatment options for opiate addiction, conferring greater retention and opiate suppression benefits. Its removal from application provides a historical lesson concerning the introduction of new medications into addiction health services. type of criminal activity for adolescents than for adults. The present paper addresses methodological approaches and challenges, and proposes guidelines for future economic evaluations of adolescent substance abuse and crime prevention programs.

Number 3 / July 2009

Perceived Norms and Mental Health Help Seeking among African American College Students … 285-299
Crystal L. Barksdale and Sherry D. Molock
Abstract: In general, African Americans do not seek mental health treatment from formal sources at the same rates as Caucasians. The present study examined whether culturally relevant factors (i.e., perceived negative peer and family norms about help seeking) influence help-seeking intentions in a late adolescent African-American sample (n=219) and whether there is a gender difference in the predictive strength between peer and family norms. Participants were primarily female (n=144). Multiple regressions were implemented to explore the relationship between perceived norms and help-seeking intentions. Analyses revealed that males had higher perceived peer norms, and family norms were a stronger predictor of intentions than peer norms for females. Individually, peer norms and family norms were related to help-seeking intentions. When perceived norms were analyzed together, only negative family norms were related to intentions. Findings suggest that incorporating family norms is critical when developing interventions to increase formal service utilization among African Americans.

Factors Associated with Extended Length of Stay for Patients Presenting to an Urban Psychiatric Emergency Service: A Case-Control Study … 300-308
Jennifer M. Park, Lawrence T. Park, Caleb J. Siefert, Melissa E. Abraham, Christine R. Fry and Mark S. Silvert
Abstract: This study assessed factors associated with extended length of stay (ELOS) for patients presenting to a psychiatric emergency service (PES). Two hundred six subjects with a length of stay of 24 h or longer were compared with time-matched controls (patients that presented directly after the ELOS patient). Binary logistic regression was used to identify risk factors for ELOS. ELOS was associated with suicidal ideation, disposition to an inpatient unit, homicidal ideation, lack of insurance, homelessness, male gender, past history of psychiatric hospitalization, diagnosis of substance abuse, significant psychiatric co-morbidity (represented by three or more Axis I diagnoses), and diagnosis of a psychotic disorder. Lack of insurance, suicidal ideation, disposition to inpatient unit, and homicidal ideation all made nonredundant contributions to predicting stays of 24 h or longer.

System-Wide Implementation of ACT in Ontario: An Ongoing Improvement Effort … 309-319
Lindsey George, Janet Durbin and Christopher J. Koegl
Abstract: In the late 1990s, the government of Ontario undertook a province-wide implementation of Assertive Community Treatment (ACT). Capacity grew to 59 teams within 6 years. This paper describes the implementation process, focusing on three phases—start-up, or the enabling phase; feedback, or the reinforcement phase; and response, or the corrective action phase. Key implementation supports include an active oversight committee with representation from both the ministry and the field and the availability of the planning data on ACT performance. Three areas of underperformance were identified: lower than expected team caseloads, drift from the target client group, and significant under-staffing in the teams. Likely causes were suggested, and corrective actions developed, which centered on clarifying the ACT standards, especially related to intake criteria, rate of intake and staffing, increasing team funding, and establishing expectations for reporting and accountability. While these corrective responses are promising, implementation of infrastructure and mechanisms for providing systematic practice feedback is still underdeveloped.

Social Support, Activities, and Recovery from Serious Mental Illness: STARS Study Findings … 320-329
Michael Hendryx, Carla A. Green and Nancy A. Perrin
Abstract: Research on the role of social support in recovery from severe mental illness is limited and even more limited is research on the potential effects of participating in various activities. This study explores these relationships by analyzing baseline data from a 153-participant subsample in the Study of Transitions and Recovery Strategies. Higher scores on the recovery assessment scale were related to both social support/network size and engagement in more activities. The particular nature of the activities (more/less social, more/less physically active, inside/outside the home) was not important, rather, activities of any type were related to recovery. Furthermore, engagement in activities was more important as levels of social support declined. The results suggest that both social support and activities may promote recovery, and that for persons with poor social support, engagement in a variety of individualized activities may be particularly beneficial.

Program Characteristics and the Length of Time Clients are in Substance Abuse Treatment … 330-343
Melissa A. Walker
Abstract: Is there a relationship between the characteristics of drug addiction treatment programs and an important correlate of better outcomes, the length of time clients are in treatment? Previous research has consistently shown longer periods in treatment and a range of services each have a salutary effect on client outcomes after treatment. Much of this research has examined the characteristics of clients. Program attributes are another important consideration. Multivariate analysis of data collected from a national survey of outpatient drug addiction treatment programs shows offering a range of services along with several other program characteristics are relevant to the duration of treatment. When a range of services are available, this has a positive association with both the number of months programs report clients are in treatment and with the number of counseling sessions programs report clients receive over the course of treatment. Ultimately, this should lead to better outcomes for clients.

A Naturalistic Study of MST Dissemination in 13 Ohio Communities … 344-360
Carol A. Carstens, Phyllis C. Panzano, Rick Massatti, Dee Roth and Helen Anne Sweeney Abstract: The diffusion of evidence-based practices (EBPs) to child-serving human service organizations often occurs within the context of a comprehensive system-of-care in which a coordinated network of service providers collaborate to meet the needs of children and adolescents with serious behavioral and emotional disturbances. To the extent that inter-organizational networks influence the choices of organizational decision makers, it is necessary to understand interactions among participating organizations within the system when studying diffusion processes associated with EBP adoption and implementation. The present study analyzes decision making about the adoption and implementation of an EBP within the ecological context of system-of-care collaboration. Findings suggest that several factors impact the adoption decision, including system-of-care infrastructure planning and development activities before the decision process, the perception of adequate start-up and ongoing implementation resources among key players in the system-of-care, the range of motivations to participate in collaborative decision making, and the presence of entrepreneurial leadership.

Characteristics of Users of Consumer-Run Drop-In Centers Versus Clubhouses … 361-371
Carol T. Mowbray, Amanda Toler Woodward, Mark C. Holter, Peter MacFarlane and Deborah Bybee
Abstract: Clubhouses and consumer-run drop-in centers (CRDIs) are two of the most widely implemented models of consumer-centered services for persons with serious mental illness. Differences in structure and goals suggest that they may be useful to different types of consumers. Information on what types of consumers use which programs would be useful in service planning. This study analyzes data from the authors’ NIMH-funded research on 31 geographically matched pairs of clubhouses and CRDIs involving more than 1,800 consumers to address the following question: are there significant differences in the characteristics and outcomes of members of clubhouses versus CRDIs? Results from multilevel analyses indicated that clubhouse members were more likely to be female, to receive SSI/SSDI, to report having a diagnosis of schizophrenia, and to live in dependent care; and they reported both a greater number of lifetime hospitalizations and current receipt of higher intensity traditional MH services. Controlling for differences in demographic characteristics, psychiatric history, and mental health service receipt, clubhouse members also reported higher quality of life and were more likely to report being in recovery. CRDI consumers were more likely to have substance abuse histories. Possible reasons for the differences are discussed. The results suggest that CRDIs are a viable alternative to more traditional mental health services for individuals who might not otherwise receive mental health services.

The Influence of Social Anchorage on the Gender Difference in the Use of Mental Health Services … 372-384
Aline Drapeau, Richard Boyer and Alain Lesage
Abstract: Overall, women are more likely than men to seek professional care when they face light or moderate mental health problems. This difference is usually attributed to culture-related factors, but neither women nor men form a homogeneous cultural group. The help-seeking behavior may reflect not only the cultural values and expectations associated with a specific gender but also those associated with specific social roles endorsed by women and men. In addition, the influence of these culture-related factors on the help-seeking behavior is constrained by barriers to care, which apply similarly to women and men. In consequence, the gender difference in the use of mental health services should vary across social roles and types of service. This hypothesis was tested on data from the cycle 1.2 of the Canadian Community Health Survey. Logistic regression analyses show that, although women are more likely than men to use mental health services, this gender difference is larger for general services than for psychiatric and psychological services whose access in Canada is constrained, respectively, by systemic and financial barriers to care. They also suggest that holding the role of worker tends to foster the use of psychological services in women, especially in married women, and to a lesser degree in men, whereas it tends to hinder the use of general and psychiatric services in men but to exert no or less influence in women. Thus, professional anchorage seems to be an important source of the societal norms that influence the decision of women and men to seek or not to seek medical care for mental health problems.

Adolescent Satisfaction with Brief Motivational Enhancement for Alcohol Abuse … 385-395
Maryam Kia-Keating, Sandra A. Brown, Marya T. Schulte and Teresa K. Monreal
Abstract: Although many investigations point to the importance of treatment satisfaction and working alliance as predictors of treatment engagement and outcome, few studies have closely examined these issues among adolescents. This study investigates satisfaction among a nonclinical adolescent sample participating in a school-based alcohol-prevention program. Adolescents self-selected to one of three formats: individual, group, and website. Three hundred nineteen satisfaction measures completed at the time of each participant’s final session were used for analyses. Hierarchical regression analyses examined predictors of consumer satisfaction. In general, greater participation in the program was significantly related to satisfaction. Students who participated in the group and individual formats reported greater satisfaction than students who participated in the website format. Current alcohol users were less satisfied with the session focusing on how experimental use can lead to problem use; lifetime abstainers were more satisfied with the session focusing on stress and coping. These analyses have implications for informing future adolescent school-based interventions for alcohol problems.

Patient Outcome after Treatment in a Community-Based Crisis Stabilization Unit … 396-399
Charlotte L. Adams and Rif S. El-Mallakh
Abstract: Community-based residential treatment for acute psychiatric crisis has been proposed as an alternative to inpatient hospitalization, but there is a dearth of adequate outcome studies. We examined naturalistic symptomatic and treatment outcomes in patients admitted to a residential crisis treatment program. The 24-item Brief Psychiatric Rating Scale score dropped from moderately ill (40.5±SD 8.25 points) on admission to mildly ill at discharge (28.7±11.37 points, t=10.02, P<0.0001). Beck’s Depression Inventory also improved greatly, from a significant level of depression of 29.5±11.41 points on admission, to a nearly euthymic level of 10.1±8.60 points at discharge (a difference of 19.4±12.10 points, t=12.5, P<0.0001). The current study is limited by the lack of a matched comparison group of hospitalized patients. Nonetheless, community-based crisis stabilization units appear to be cost-effective alternatives to inpatient hospitalization for selected patients.

Number 4 / October 2009

Implementation of Evidence-Based Practices for Treatment of Alcohol and Drug Disorders: The Role of the State Authority …407-419
Traci R. Rieckmann, Anne E. Kovas, Holly E. Fussell, Nicole M. Stettler
Abstract: The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.

Accessing Specialty Behavioral Health Treatment in Private Health Plans …420-435
Elizabeth L. Merrick, Constance M. Horgan, Deborah W. Garnick, Sharon Reif, Maureen T. Stewart
Abstract: Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N=368 plans with 767 managed care products; 83%response rate).Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment. Service Use Patterns for Adolescents with ADHD and Comorbid Conduct Disorder …436-449 Damon E. Jones, E. Michael Foster, Conduct Problems Prevention Research Group Abstract: Service use patterns and costs of youth diagnosed with attention-deficit/hyperactivity disorder (ADHD) and comorbid conduct disorder (CD) were assessed across adolescence (ages 12 through 17). Featured service sectors include mental health, school services, and the juvenile justice system. Data are provided by three cohorts from the Fast Track evaluation and are based on parent report. Diagnostic groups are identified through a structured assessment. Results show that public costs for youth with ADHD exceed $40,000 per child on average over a 6-year period, more than doubling service expenditures for a non-ADHD group. Public costs for children with comorbid ADHD and CD double the costs of those with ADHD alone. Varying patterns by service sector, diagnosis, and across time indicate different needs for youth with different conditions and at different ages and can provide important information for prevention and treatment researchers.

Program and Client Characteristics as Predictors of the Availability of Social Support Services in Community-Based Substance Abuse Treatment Programs …450-464
Peter J. Delany, Joseph J. Shields, Dana L. Roberts
Abstract: Recent emphases on increasing accountability, using less intensive settings, and implementing evidence-based services helped to focus the research community on the structure, processes, and outcomes of services delivered to substance abuse clients. Considerably less attention has been given to understanding how to structure services to enhance engagement and retention leading to treatment continuity. This study examined structural characteristics of community-based treatment facilities in relationship to the availability of supportive services within a sample of 1,332 substance abuse treatment programs surveyed through the Alcohol and Drug Services Study in 1996 and 1997. Structural and client characteristics are important predictors of added supportive services. Furthermore, a program with a broader and established set of core services is more likely to have expanded supportive services. These findings have implications for public health professionals, both in terms of ensuring sustainable service programming for these chronic clients and in identifying services to adopt or discard to meet a population with multiple needs.

Substance Use, Mental Illness and Violence: The Co-Occurrence of Problem Behaviors Among Young Adults …465-477
Richard A. Van Dorn, James Herbert Williams, Melissa Del-Colle, J. David Hawkins
Abstract: A paucity of research exists in which the co-occurrence of substance use, mental illness, and violence in young adults is examined. Concurrently, there is also a lack of research explicating the contribution of theoretically based risk factors for these problematic outcomes in this population. This lack of both outcome and explanatory research equally affects the utility of theories and interventions for this population. This article utilizes a sample of N=633 21-year-olds to examine the prevalence of (1) violence and substance use, (2) mental illness (i.e., mood and anxiety disorders) and substance use, and (3) the use of multiple substances and investigates the relationship between various social determinants and said outcomes. Overall, the prevalence rates for the comorbid conditions were low; although on average males had higher rates than did females. Individual attitudes, perceived opportunities, and recent stressful life events were associated with the co-occurrence of outcomes. Implications for behavioral health are explored.

The BMC ACCESS Project: The Development of a Medically Enhanced Safe Haven Shelter …478-491
Alisa Lincoln, Peggy Johnson, Dennis Espejo, Sara Plachta-Elliott, Peggy Lester, Christopher Shanahan, Susan Abbott, Howard Cabral, Amber Jamanka, Jonathan Delman, Patty Kenny
Abstract: This paper describes the development and implementation of the Boston Medical Center (BMC) Advanced Clinical Capacity for Engagement, Safety, and Services Project. In October 2002, the BMC Division of Psychiatry became the first such entity to open a Safe Haven shelter for people who are chronically homeless, struggling with severe mental illness, and actively substance abusing. The low-demand Safe Haven model targets the most difficult to reach population and serves as a “portal of entry” to the mental health and addiction service systems. In this paper, the process by which this blended funded, multi-level collaboration, consisting of a medical center, state, city, local, and community-based consumer organizations, was created and is maintained, as well as the clinical model of care is described. Lessons learned from creating the Safe Haven Shelter and the development and implementation of the consumer-informed evaluation are discussed as well as implications for future work with this population.

Child Anxiety Disorders in Public Systems of Care: Comorbidity and Service Utilization …492-504
Denise A. Chavira, Ann Garland, May Yeh, Kristen McCabe, Richard L. Hough
Abstract: Little is known about mental health service use among children with anxiety disorders, and even less is known about these children in public sectors of care. In this study, 1,715 children were randomly sampled from one of five public service systems. Psychiatric diagnoses were assessed with a structured interview, and standardized measures were used to assess mental health service utilization. Data from a subsample (n=779) of youth with psychiatric disorders were analyzed. Analyses revealed that comorbidity among children with anxiety disorders was substantially higher than general population estimates. Approximately 26% of children with anxiety had a comorbid mood disorder, and 62% had a disruptive behavior disorder. Among children with anxiety disorders, those who had comorbid conditions were more likely to receive inpatient services than those without comorbidity. Comorbidity, caregiver strain, and service sector were associated with inpatient and nonspecialty service use in this group. Findings underscore the substantial comorbidity among children with anxiety disorders in public sectors of care and the potential need to adapt evidence-based interventions to meet the complex and multiple needs of these children.

Impact of Court-Mandated Substance Abuse Treatment on Clinical Decision Making …505-516
Noosha Niv, Alison Hamilton, Yih-Ing Hser
Abstract: California’s Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. The study objective was to examine how substance abuse treatment providers perceive the impact of Proposition 36 on their clinical decision making. Program surveys were completed by 115 treatment programs in five California counties to assess the impact of the law on clinical decision making, and five focus groups were conducted with 37 treatment providers to better understand their perspectives. Compared to residential programs, outpatient programs reported that the policy impacted them to a greater extent in terms of drug testing, reporting to criminal justice personnel, and determining client discharge. Providers in the focus groups particularly highlighted their changing roles in assessing clients’ treatment needs and determining the best routes of care for them. The findings indicate that alternate strategies for determining treatment placement and continuing care should be developed.