Service Use and Barriers to Mental Health Care Among Adults With Major Depression and Comorbid Substance Dependence
Abstract
Objective
Methods
Results
Conclusions
Methods
Sample
Assessment
Data analysis
Results
Characteristics of groups
Characteristic | No comorbidity (N=15,089) | Alcohol dependence (N=1,932) | Nonalcohol drug dependence (N=1,266) | Alcohol and nonalcohol drug dependence (N=685) | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N | % | N | % | OR | 95% CI | N | % | OR | 95% CI | N | % | OR | 95% CI | |
Gender | ||||||||||||||
Male | 4,376 | 32.2 | 827 | 50.4 | 1.00 | — | 463 | 41.9 | 1.00 | — | 318 | 57.5 | 1.00 | — |
Female | 10,713 | 67.9 | 1,105 | 49.7 | .47 | .41–.53*** | 803 | 58.1 | .66 | .55–.78*** | 367 | 42.6 | .35 | .27–.45*** |
Age | ||||||||||||||
18–25 | 7,477 | 16.3 | 1,161 | 25.8 | 1.00 | — | 866 | 33.5 | 1.00 | — | 506 | 42.4 | 1.00 | — |
26–34 | 2,406 | 17.6 | 307 | 22.8 | .82 | .69–.98* | 169 | 21.4 | .59 | .45–.78*** | 85 | 22.7 | .50 | .36–.68*** |
35–50 | 3,513 | 33.0 | 365 | 32.9 | .63 | .53–.74*** | 194 | 31.2 | .46 | .38–.57*** | 80 | 25.7 | .30 | .22–.42*** |
>50 | 1,693 | 33.1 | 99 | 18.5 | .35 | .26–.48*** | 37 | 13.9 | .20 | .13–.32*** | 14 | 9.3 | .11 | .06–.20*** |
Race-ethnicity | ||||||||||||||
White | 10,467 | 74.6 | 1,301 | 71.9 | 1.00 | — | 880 | 74.2 | 1.00 | — | 461 | 68.6 | 1.00 | — |
Black | 1,545 | 9.4 | 178 | 11.3 | 1.24 | .92–1.66 | 154 | 13.5 | 1.44 | 1.04–2.00* | 84 | 17.2 | 1.98 | 1.35–2.91** |
Hispanic | 1,864 | 11.0 | 288 | 12.4 | 1.17 | .88–1.57 | 129 | 9.2 | .84 | .55–1.29 | 90 | 11.4 | 1.13 | .76–1.68 |
Other | 1,213 | 5.0 | 165 | 4.4 | .90 | .63–1.29 | 103 | 3.1 | .62 | .41–.92* | 50 | 2.8 | .60 | .33–1.08 |
Marital status | ||||||||||||||
Married | 4,648 | 43.4 | 308 | 25.6 | 1.00 | — | 180 | 20.9 | 1.00 | — | 58 | 13.8 | 1.00 | — |
Divorced, separated, or widowed | 2,596 | 27.1 | 325 | 28.5 | 1.78 | 1.39–2.27*** | 161 | 2.6 | 1.97 | 1.39–2.79*** | 89 | 23.2 | 2.69 | 1.59–4.56*** |
Never married | 7,845 | 29.5 | 1,299 | 45.9 | 2.64 | 2.14–3.25*** | 925 | 53.4 | 3.76 | 2.85–4.96*** | 538 | 63.1 | 6.74 | 4.59–9.90*** |
Education | ||||||||||||||
Less than high school | 2,513 | 15.1 | 323 | 16.4 | 1.00 | — | 286 | 20.2 | 1.00 | — | 186 | 24.8 | 1.00 | — |
High school | 4,773 | 30.1 | 629 | 31.9 | .98 | .75–1.28 | 446 | 36.1 | .90 | .68–1.17 | 259 | 39.6 | .80 | .58–1.10 |
College and above | 7,803 | 54.8 | 980 | 51.8 | .87 | .69–1.10 | 534 | 43.7 | .60 | .45–.79*** | 240 | 35.6 | .39 | .29–.54*** |
Household income | ||||||||||||||
≤$19,999 | 4,632 | 24.6 | 695 | 32.2 | 1.00 | — | 508 | 37.1 | 1.00 | — | 253 | 37.3 | 1.00 | — |
$20,000–$34,999 | 5,429 | 35.3 | 651 | 31.5 | .68 | .54–.85** | 425 | 36.9 | .69 | .55–.87** | 239 | 35.9 | .67 | .50–.90* |
$35,000–$69,999 | 2,274 | 17.4 | 240 | 13.7 | .60 | .45–.79** | 161 | 12.4 | .47 | .34–.65*** | 78 | 10.2 | .39 | .25–.59*** |
≥$70,000 | 2,754 | 22.7 | 346 | 22.6 | .76 | .59–.97* | 172 | 13.7 | .40 | .28–.57*** | 115 | 16.7 | .48 | .34–.68*** |
Health insurance | ||||||||||||||
None | 3,332 | 17.8 | 538 | 25.5 | 1.00 | — | 368 | 29.3 | 1.00 | — | 255 | 37.2 | 1.00 | — |
Private | 7,620 | 51.4 | 929 | 47.2 | .64 | .53–.77*** | 491 | 34.3 | .41 | .31–.53*** | 254 | 33.1 | .31 | .23–.41*** |
Medicare | 602 | 9.5 | 28 | 3.4 | .25 | .15–.42*** | 20 | 3.2 | .20 | .12–.34*** | 8 | 2.0 | .10 | .04–.26*** |
Medicaid or state | 2,540 | 14.4 | 274 | 14.0 | .68 | .53–.87** | 303 | 24.6 | 1.04 | .76–1.42 | 117 | 18.8 | .63 | .44–.89** |
CHAMPUS or military | 576 | 5.1 | 83 | 6.8 | .93 | .60–1.40 | 32 | 4.8 | .57 | .29–1.12* | 24 | 6.6 | .62 | .32–1.22 |
Other | 391 | 1.9 | 74 | 3.1 | 1.17 | .78–1.75 | 47 | 3.9 | 1.27 | .76–2.13 | 25 | 2.2 | .57 | .28–1.16 |
Employment | ||||||||||||||
Part- or full-time | 9,579 | 60.3 | 1,316 | 66.2 | 1.00 | — | 729 | 50.8 | 1.00 | — | 411 | 56.4 | 1.00 | — |
Unemployed | 1,318 | 6.7 | 211 | 9.9 | 1.36 | 1.02–1.81* | 173 | 12.8 | 2.27 | 1.65–.14*** | 118 | 15.2 | 2.43 | 1.78–3.32*** |
Not in labor force | 4,192 | 33.0 | 405 | 23.9 | .66 | .54–.81*** | 364 | 36.4 | 1.31 | 1.07–.60* | 156 | 28.5 | .92 | .70–1.22 |
Disabilityb | ||||||||||||||
None | 92 | .7 | 6 | .4 | 1.00 | — | 2 | .1 | 1.00 | — | 1 | .1 | 1.00 | — |
Mild | 1,048 | 7.5 | 88 | 4.5 | .99 | .24–4.13 | 49 | 4.2 | 5.41 | 1.08–6.97* | 15 | 2.2 | 1.73 | .20–15.27 |
Moderate | 4,492 | 30.5 | 533 | 28.4 | 1.52 | .39–5.96 | 258 | 16.2 | 5.16 | 1.11–23.89* | 137 | 20.6 | 4.05 | .52–31.54 |
Severe | 6,682 | 42.3 | 950 | 48.2 | 1.87 | .47–7.41*** | 625 | 50.6 | 11.60 | 2.45–54.82** | 365 | 58.4 | 8.29 | 1.09–62.84* |
Very severe | 2,701 | 19.1 | 336 | 18.5 | 1.59 | .39–6.53*** | 325 | 29.0 | 14.77 | 3.09–70.59** | 163 | 18.8 | 5.93 | .76–46.49 |
Population density of area of residence | ||||||||||||||
Metropolitan | 5,964 | 49.1 | 774 | 53.4 | 1.00 | — | 552 | 49.7 | 1.00 | — | 300 | 53.9 | 1.00 | — |
Suburban | 7,798 | 43.9 | 1,001 | 40.1 | .84 | .70–1.00 | 623 | 44.2 | .99 | .81–1.22 | 340 | 42.4 | .88 | .65–1.19 |
Rural | 1327 | 7.0 | 157 | 6.5 | .85 | .60–1.21 | 91 | 6.2 | .87 | .56–1.35 | 45 | 3.8 | .49 | .27–.89* |
Use of services and unmet treatment need
Service | No comorbidity (N=15,089) | Alcohol dependence (N=1,932) | Nonalcohol drug dependence (N=1,266) | Alcohol and nonalcohol drug dependence (N=685) | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N | % | N | % | ARRa | 95% CI | N | % | ARRa | 95% CI | N | % | ARRa | 95% CI | |
Any mental health treatment | 7,151 | 53.4 | 888 | 53.6 | 1.32 | 1.08–1.62** | 675 | 60.5 | 1.54 | 1.22–1.93*** | 370 | 55.4 | 1.77 | 1.29–2.43*** |
Inpatient care | 575 | 4.1 | 105 | 5.8 | 1.28 | .88–1.85 | 125 | 10.7 | 1.91 | 1.40–2.60*** | 96 | 13.9 | 2.96 | 1.86–4.71*** |
Outpatient care | 4,681 | 34.4 | 576 | 30.8 | .95 | .79–1.14 | 420 | 38.8 | 1.20 | .93–1.54 | 239 | 36.1 | 1.46 | 1.10–1.93** |
Medication | 6,136 | 47.7 | 732 | 46.8 | 1.31 | 1.06–1.61* | 598 | 56.1 | 1.70 | 1.38–2.08*** | 309 | 45.6 | 1.55 | 1.14–2.10** |
Outpatient care setting | ||||||||||||||
Mental health clinic or center | 1,311 | 9.0 | 200 | 9.6 | 1.07 | .78–1.45 | 174 | 16.9 | 1.53 | 1.14–2.05** | 112 | 19.3 | 2.37 | 1.67–3.36*** |
Private office of a mental health professional | 2,613 | 19.0 | 319 | 17.2 | 1.00 | .78–1.29 | 224 | 19.0 | 1.11 | .82–1.50 | 104 | 13.5 | .93 | .69–1.27 |
Doctor's office | 983 | 8.7 | 107 | 6.0 | .82 | .60–1.13 | 62 | 6.1 | .79 | .45–1.38 | 31 | 5.8 | 1.06 | .54–2.07 |
Outpatient general medical clinic | 404 | 3.1 | 58 | 3.9 | 1.24 | .81–1.90 | 32 | 4.1 | 1.17 | .73–1.91 | 23 | 2.5 | .79 | .42–1.47 |
Partial-day hospital or day treatment program | 117 | .7 | 19 | 1.3 | 1.48 | .74–2.95 | 19 | 2.4 | 2.39 | 1.18–4.85* | 14 | 3.0 | 3.30 | 1.20–9.04* |
Perceived unmet need for mental health treatment | 4,850 | 28.6 | 847 | 43.0 | 1.83 | 1.51–2.22*** | 661 | 53.6 | 2.31 | 1.88–2.85*** | 398 | 54.8 | 2.71 | 2.04–3.60*** |
Treatment barriers
Barrier | No comorbidity (N=4,850) | Alcohol dependence (N=847) | Nonalcohol drug dependence (N=661) | Alcohol and nonalcohol drug dependence (N=398) | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N | % | N | % | ARRa | 95% CI | N | % | ARRa | 95% CI | N | % | ARRa | 95% CI | |
Financial | 2,576 | 54.8 | 426 | 51.0 | .85 | .64–1.13 | 357 | 59.6 | 1.15 | .85–1.56 | 206 | 56.9 | 1.05 | .73–1.51 |
Cost | 2,338 | 48.8 | 393 | 46.0 | .85 | .65–1.10 | 328 | 52.5 | 1.03 | .77–1.38 | 185 | 51.8 | 1.00 | .68–1.46 |
No insurance coverage | 326 | 7.5 | 48 | 4.1 | .51 | .31–.82** | 54 | 7.9 | 1.11 | .64–1.91 | 24 | 6.6 | .97 | .52–1.76 |
Insufficient insurance contribution | 567 | 15.0 | 78 | 12.4 | .97 | .59–1.60 | 89 | 10.0 | 1.08 | .69–1.69 | 24 | 6.3 | .67 | .35–1.26 |
Stigma | 1,299 | 23.6 | 275 | 29.0 | 1.24 | .95–1.62 | 193 | 23.0 | 1.00 | .71–1.43 | 112 | 28.8 | 1.23 | .75–2.01 |
Fear of neighbors' opinion | 524 | 8.6 | 108 | 12.1 | 1.32 | .84–2.07 | 84 | 9.3 | 1.09 | .68–1.75 | 51 | 9.4 | .97 | .58–1.61 |
Fear of negative effect on job | 371 | 8.5 | 86 | 12.9 | 1.45 | .94–2.25 | 48 | 6.0 | 1.09 | .46–1.36 | 34 | 10.9 | 1.23 | .69–2.18 |
Confidentiality concerns | 514 | 9.9 | 99 | 10.5 | .99 | .66–1.48 | 92 | 11.7 | 1.21 | .75–1.93 | 52 | 15.5 | 1.59 | .87–2.89 |
Did not want others to find out | 467 | 7.1 | 94 | 7.3 | .91 | .65–1.29 | 58 | 5.7 | .76 | .47–1.22 | 27 | 4.9 | .64 | .28–1.44 |
Attitudinal | 2,157 | 39.8 | 380 | 40.6 | .94 | .67–1.30 | 273 | 34.8 | .79 | .57–1.08 | 158 | 36.1 | .77 | .55–1.09 |
Fear of being committed or forced to use medication | 746 | 12.7 | 162 | 15.9 | 1.10 | .79–1.53 | 136 | 16.8 | 1.11 | .75–1.63 | 74 | 15.8 | .96 | .59–1.57 |
Treatment not necessary | 418 | 6.7 | 83 | 6.8 | .92 | .58–1.47 | 46 | 6.6 | .94 | .48–1.85 | 35 | 9.1 | 1.22 | .62–2.39 |
Treatment won’t help | 640 | 10.5 | 104 | 10.5 | .93 | .54–1.62 | 62 | 6.3 | .57 | .35–.92 | 38 | 10.1 | .85 | .46–1.57 |
Can handle the problem without treatment | 1,350 | 25.9 | 218 | 23.6 | .87 | .58–1.30 | 134 | 16.1 | .61 | .42–.89* | 70 | 15.2 | .53 | .37–.78** |
Structural | 1,630 | 31.1 | 260 | 28.2 | .86 | .65–1.14 | 188 | 23.2 | .68 | .51–.91* | 86 | 20.4 | .59 | .41–.87** |
Did not know where to go | 908 | 16.9 | 162 | 17.1 | .96 | .69–1.32 | 121 | 14.5 | .75 | .52–1.07 | 57 | 14.2 | .73 | .45–1.21 |
Lack of time | 785 | 14.8 | 111 | 10.0 | .67 | .46–.96* | 66 | 8.5 | .63 | .40–.98* | 32 | 4.8 | .35 | .21–.58*** |
Lack of transportation or other inconvenience | 242 | 4.4 | 27 | 3.4 | .78 | .34–1.82 | 37 | 5.1 | 1.05 | .61–1.81 | 23 | 6.4 | 1.54 | .75–3.16 |
Other | 438 | 9.3 | 62 | 6.5 | .69 | .44–1.09 | 62 | 10.4 | 1.17 | .74–1.84 | 29 | 7.5 | .85 | .48–1.48 |
Discussion
Conclusions
Acknowledgments and disclosures
Supplementary Material
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