CHAPTER I

INTRODUCTION

Mental illness and substance use disorders (SUD) are often linked together.

Individuals who struggle with a mental illness often struggle with a substance addiction

simultaneously and vice versa. This descriptive study will discuss and highlight the

barriers associated with co-occurring disorders, as well as identify the research used to

discover preventative measures, strategies for successful treatment outcomes and

challenge policies that add weight to the existing barriers.

Statement of the Study Issue

Since the 1980’s, increasing recognition has been given to the issue of comorbid

psychiatric and substance use disorders (SUDs), otherwise known as dual disorders.

Historically, dually diagnosed patience did not receive adequate treatment for their

condition. According to researcher Kathryn Hryb, in the 1980s, dually diagnosed patients

received treatment for either the mental health or substance related disorder, instead of

necessary simultaneous treatment. The low success rates of this particular population

made it apparent to researchers that new methods should be investigated and

implemented. Subsequently, the National Institute of Mental Health (NIMH), National

Institute of Drug Abuse (NIDA) and National Institute on Alcohol Abuse (NIAA),

recommended the integration of treatment for mental health and substance-related

disorders for this population. Kathryn Hryb states that, “this recommended integrated

treatment approach has produced conflicting empirical evidence to substantiate the

effectiveness of this type of treatment for dually diagnosed individuals” (Hryb, 2007).

The methodological problems that arise for researchers investigating the effectiveness of

integrative treatment approaches for dually diagnosed patients, begins with the

inconsistent diagnostic criteria that clinicians use to refer patients to appropriate

treatment programs. This problem indicates further need for standardized diagnostic

criteria for dual diagnosis in order for clinicians to identify individuals appropriate for

integrated treatment and also to develop an effective modality to treat this complex

population with a diverse range of mental disorders. Hryb concludes that by

standardizing this definition of dual diagnosis, dually diagnosed individuals will be

identified universally by clinicians rather than by individual professional opinion.

Purpose of the Study

This purpose of this study is to identify barriers associated with co-

occurring disorders on a micro and macro scale, as well as examine implications for

practice. According to the National Survey on Drug Use (NSDUH), in 2002, more than

half of adults with co-occurring serious mental illness (SMI) and a substance use disorder

received neither specialty substance use treatment nor mental health treatment during that

year (NSDUH, 2004).

Significance of the Study

The following statistical report by, The National Survey on Drug Use and Health

includes information concerning to the prevalence of co-occurring mental illness and

substance use disorders. The National Survey on Drug Use and Health (NSDUH)

includes questions for adults aged 18 or older to assess serious mental illness (SMI)

during the year prior to the survey interview. NSDUH also includes a series of questions

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to assess dependence on or abuse of alcohol or an illicit drug. These questions are

designed to measure dependence and abuse based on criteria specified in the DSM-IV.

For the purpose of this report, individuals with either alcohol or drug dependence or

abuse are said to have a substance use disorder, and individuals with both SMI and a

substance use disorder are said to have co-occurring SMI and a substance use disorder

(NDSU, 2004).

The findings of the 2002 NSDUH survey concluded that, 17.5 million adults aged

18 or older were estimated to have SMI in the past year. This represents about 8 percent

of all adults. About 23 percent (4 million) of adults with SMI in 2002 had a co-occurring

substance use disorder. Among adults without SMI, the rate of dependence or abuse was

only about 8 percent. More than half of adults (a total of 2 million persons) with co-

occur- ring SMI and a substance use disorder received neither mental health nor specialty

substance use treatment during the past year. Among adults with co-occurring dis-

orders, 34 percent received mental health treatment only, 2 percent received specialty

substance use treatment only, and 12 percent received both mental health and specialty

substance use treatment during the past year.

The Substance Abuse and Mental Health Services Administration, Office

of Applied Studies conducted a health services analyses on a variety of behavioral health

care issues. The research traces recent trends in access to treatment for substance use and

mental disorders. Then results from analyses based on large, representative datasets and

economic modeling approaches provide new insights into access, treatment choice,

retention in treatment, and costs associated with treatment for substance use and mental

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disorders The in-depth review of current research findings on access to treatment for

substance use and mental disorders encompasses the wider area of health care utilization

and places special emphasis on financial factors impacting access to care. This analysis

also gives insight to financing, management, and delivery of behavioral health services

for substance use and mental disorders by exploring such issues as utilization, quality,

cost, cost-effectiveness, and outcomes. The authors examine how the demographic

characteristics of an individual affect how, when, where, and if a person will seek care,

what types of care are chosen or provided, and what happens during the delivery of care

(Council, 2004).

There is a growing awareness of the effects of financing and costs on access to

treatment. Managed care and financing issues appear to be as important as nonfinancial

barriers, such as the severity of the substance use disorder, in influencing access to care.

Homeless people with substance use and mental disorders may have the most difficulty in

accessing treatment, even if they have public health insurance (Council, 2004).

Managed care for substance abuse treatment not only has shifted treatment from

inpatient care to outpatient care, but also has shifted the risk to providers, thus

constraining provider treatment options (Council, 2004).

Those with more serious behavioral illnesses may encounter more barriers to

access because successful treatment for them may be more expensive and because

redundant and bureaucratic procedures may pose insurmountable obstacles. However,

changes in government-sponsored systems can promote access for clients with more

serious disorders (Council, 2004).

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CHAPTER II

REVIEW OF LITERATURE

The following literary review will provide an extensive overview of research

related to substance use and mental health co-occurring disorders. This review will

particularly highlight the historical perspective of co-occurring disorders as well as

current implications. Much of the overview will…

Historical Perspective

According to Paige Ouimette—author of the article, Co-occurring Mental Health

and Substance Abuse Disorders—community and clinical studies show that dual

disorders are very prevalent nation wide. In the National Comorbidity Study, a nationally

representative population study, about 41-65% of participants with any lifetime substance

use disorder also had a lifetime history of at least one mental health disorder. Among

those with a lifetime history of any mental disorder, 51% had a co-occurring addictive

disorder.

As confirmed by the National Alliance on Mental Illness (NAMI, 2013), it is now

essentially agreed that as much as 50 percent of the mentally ill population also has a

substance abuse problem. The drug most commonly used is alcohol, followed by

marijuana and cocaine. In further discovery, the rate of abuse is greater among males and

those between the age of 18 and 44.

The most common mental illnesses seen in combination with substance abuse

among young adults are Clinical Depression, Anxiety Disorder and Post Traumatic Stress

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Disorder (CCSA, 2013). Clinical depression intensifies and prolongs sadness in such a

way that impairs the ability to function at home, at school or in the community. Anxiety

disorder causes panic, shyness, worry or compulsion in a way that makes it hard for

youth to function in everyday activities. Furthermore, patients who are diagnosed with

Post-traumatic stress disorder, which is commonly caused from witnessing a traumatic

event, might experience severe and prolonged distress and anxiety that interferes with

daily functioning (CCSA, 2013).

According to the National Expenditures report prepared by Thomson Reuters,

mental illness and substance use disorders have a significant impact on the productivity,

morbidity, and mortality of the United States population. Mental and substance use

conditions are a leading cause of disability in the U.S. and in 2005, mental health and

substance abuse treatment spending from all public and private sources totaled 135

billion dollars (Reuters, 2010).

The SAMHSA Spending Estimates (SSE) initiative was created to provide policy

makers with essential information on expenditures for mental health (MH) and substance

abuse (SA) treatment services. To strengthen their ties to other all-health accounts, the

SSE was designed to mirror the National Health Expenditure Accounts (NHEA)

produced annually by the Centers for Medicare and Medicaid Services (CMS).

Therefore, the SSE relies heavily upon the definitions and concepts used in the NHEA

(Reuters, 2010).

The estimates presented in this report are a baseline from which the impacts of the

MHPAEA and the PPACA can be measured in the future. The six policy questions for

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which this report presents a 1986 through 2005 baseline include: How much was spent in

the U.S. for mental health (MH) and substance abuse (SA) treatment; Who paid for MH

and SA services and how much did they spend? How much was spent by provider type?

How much was spent by type of setting on MH and SA services? How has spending

changed over time? How did MHSA expenditures compare with those for all health care

spending (Reuters, 2010)?

MHSA spending estimates in this report focus on expenditures for treatment and

not disease burden; they include only spending for the direct treatment of MHSA

disorders and exclude other substantial comorbid health costs that can result from MHSA

conditions (such as trauma and liver cirrhosis). Other costs of client care (such as job

training and subsidized housing) are also excluded, as are indirect costs, such as lost

wages and productivity (Reuters, 2010).

Average cost per admission declined as facilities became larger, which suggests

that larger facilities may be able to provide care at a lower price than smaller facilities.

Facilities with a greater proportion of clients who received Supplemental Security

Income (SSI) or Social Security Disability Insurance (SSDI) had higher costs (Council,

2004).

Barriers

There are a wide range of barriers associated with those who suffer from co-

occurring mental illness and substance use disorders. Preliminary for the diagnosed

population can be especially difficult in that it is difficult to assess “which” came first.

The dually diagnosed population might have developed a substance use disorder prior to

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any psychiatric break, or may have already had a pre-existing condition before the

development of an SUD. Examiners find it nearly impossible to determine which of the

two co-existing conditions occurred first. Those who struggle both with serious mental

illness and substance abuse face problems of enormous proportions.

The National Alliance on Mental Illness (NAMI) recognizes that, mental health

services are often not well prepared to deal with patients undergoing both afflictions. It is

very common that only one of the two quandaries is identified. For instance, treatment

programs designed specifically for substance abusers tend to be aggressive for the dually

diagnosed population. The NAMI study reveals that if both mental illness and SUD are

present, the afflicted individual may likely bounce back and forth between services

intended for mental illness and those for substance abuse, and they may be refused

treatment all together.

The NAIM also states that, people with mental illnesses may abuse drugs covertly

without their families knowing it. It is now reported that both families of mentally ill

relatives and mental health professionals underestimate the amount of drug dependency

among people in their care. Researchers suppose and acknowledge the apparent

difficulties in separating the behaviors of dually diagnosed patients. There may be a

degree of denial concerning the problem because of the past and current treatment

failures. The NAMI disclaims that caregivers might prefer not to acknowledge such a

frightening problem when so little hope has been offered.

No single factor causes substance abuse, mental health problems or their co-

occurrence, but the connection is clear. Mental health problems are often associated with

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later substance abuse that occurred as self-medication. Even so, substance abuse can and

often does trigger mental health problems (When Mental Health and Substance Abuse

Problems Collide, 2013).

According to the National Expenditures report prepared by Thomson Reuters,

other barriers for the dually diagnosed population include limited insurance coverage for

mental and substance use conditions as well as accessible treatment. Historically,

financing challenges faced by providers included insurance coverage limitations for

MHSA treatment and a heavy reliance on public funding that became even more onerous

in the wake of economic recession.

Public Health Policies and Initiatives

The Substance Abuse and Mental Health Services Administration (SAMHSA) has

identified eight Strategic Initiatives to guide and support its work through 2014 to help

people with mental and substance use disorders and their families build strong and

supportive communities, prevent costly and painful behavioral health problems, and

promote better health for all Americans. The strategic initiatives identified by SAMHSA

include: prevention of substance abuse and mental illness, trauma and justice, military

families, recovery support, health reform, health information technology, and public

awareness and support. The above strategic plan will guide SAMHSA as it: sets budget

and policy priorities; Manages grants, contracts, technical assistance, agency staff, and

interagency efforts; Engages partners at every level; and Measures and communicates

progress (SAMHSA, 2011).

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The first SAMHSA initiative, “Prevention of Substance Abuse and Mental

Illness” aims to create communities where individuals, families, schools, faith-based

organizations, and workplaces take action to promote emotional health and reduce the

likelihood of mental illness, substance abuse including tobacco, and suicide. This

Initiative will include a focus on the Nation’s high-risk youth, youth in Tribal

communities, and military families (SAMHSA, 2011).

The second SAMHSA initiative, “Trauma and Justice” aims to reduce the

pervasive, harmful, and costly health impact of violence and trauma by integrating

trauma-informed approaches throughout health, behavioral health, and related systems

and addressing the behavioral health needs of people involved in or at risk of

involvement in the criminal and juvenile justice systems (SAMHSA, 2011).

Initiative number three, “Military Families” will support the service men and

women of America along with their families and communities by leading efforts to ensure

that needed behavioral health services are accessible and that outcomes are positive

(SAMHSA, 2011).

Initiative number four, “Recovery Support” will partner with people in recovery

from mental and substance use disorders and family members to guide the behavioral

health system and promote individual, program, and system-level approaches that foster

health and resilience; increase permanent housing, employment, education, and other

necessary supports; and reduce discriminatory barriers (SAMHSA, 2011).

Initiative number five, “Health Reform” aims to increase access to appropriate

high quality prevention, treatment, and recovery services; reducing disparities that

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currently exist between the availability of services for mental and substance use disorders

compared with the availability of services for other medical conditions; and supporting

integrated, coordinated care, especially for people with behavioral health and other co-

occurring health conditions such as HIV/AIDS (SAMHSA, 2011).

The sixth initiative, “Health Information Technology” aims to ensure that the

behavioral health system, including States, community providers, and peer and

prevention specialists, fully participates with the general health care delivery system in

the adoption of health information technology and interoperable electronic health records

(SAMHSA, 2011).

Initiative number seven, “Data, Outcomes, and Quality” will work towards

realizing an integrated data strategy and a national framework for quality improvement in

behavioral health care that will inform policy, measure program impact, and lead to

improved quality of services and outcomes for individuals, families, and communities

(SAMHSA, 2011).

The final initiative, “Public Awareness and Support” will focus on Increasing the

understanding of mental and substance use disorders and the many pathways to recovery

to achieve the full potential of prevention, help people recognize mental and substance

use disorders and seek assistance with the same urgency as any other health condition,

and make recovery the expectation (SAMHSA, 2011).

As preciously addressed, coverage providers face several financing challenges

such as coverage limitations for MHSA treatment and a heavy reliance on public funding.

However, these financing challenges are undergoing improvements as the provisions of

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the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of

2008, and the Patient Protection and Affordable Care Act of 2010 became effective,

causing MHSA insurance coverage benefits to improve and the ranks of the uninsured to

shrink (Reuters, 2010).

Afrocentric Perspective

The Afrocentric Model was born out of the need to address the challenge that

European models of human behavior and thought arose from the concepts and ideals of a

European society, which did not represent the cultures, paradigms, or worldview of

people of color. In addition, this paradigm addresses the effects of Eurocentric practices

and social constructs on people of color and incorporates acknowledged restrictions on

the understanding of human behavior and thought processes of minority peoples (Schiele,

1990).

In 2000, the National Treatment Plan Initiative Panel conducted focused on

identifying ways to close the “gap” in alcohol and drug treatment, defined as the

difference between individuals requiring treatment and those receiving treatment. This

report discusses a number of underlying issues surrounding the treatment gap and

proposed alternative recommendations for filling the gap (NTPI Panel, 2000).

Substance abuse and dependence is a “bio-psychosocial” disorder, which means

that the nature of the disorder is influenced by a combination of biological, medical,

psychological, emotional, social, and environmental factors. Often, substance abuse

dominates an individual’s life, with a profoundly negative impact on the individual and

those around him or her (NTPI Panel, 2000).

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According to the NTPI Panel discussion report, substance abuse disorders afflict

approximately 13 million individuals. Of those 13 million individuals, only about 3

million are receiving treatment, leaving approximately 10 million people stranded in the

treatment gap. To fill this gap, the Panel strongly recommends a “no wrong door”

strategy to assure effective and appropriate care for all individuals in need of treatment,

regardless of demographic or other factors that might impede their access to care.

Although it is now well established that treatment is effective to counter substance abuse,

the Panel identified significant barriers to treatment: societal, organizational, and

individual factors; access to appropriate treatment; the use and allocation of resources and

adequate financing of programs and services; and issues surrounding the quality of care

and treatment outcomes. To address these barriers, the panel developed

recommendations in three areas: Access and interstate linkages; resource allocation and

financing; and quality care and outcome measures (NTPI Panel, 2000).

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CHAPTER III

METHODS OF THE STUDY

Several methods of research were applied throughout this particular study.

Content Analysis, as a quantitative technique, is a way discovering patterns and meanings

from communications. As a qualitative technique, it involves transforming qualitative

data into quantitate data. Qualitative research methods were utilized in order to conduct

the study. The specific research methods utilized to conduct the study were observation,

content analysis. A database search through engines such as Google Scholar, Ebsco Host,

JSTOR, Galileo, and Social Work abstracts assisted in the research process. These

databases included peer-reviewed journals, book chapters, abstracts and case studies. A

literature review was conducted that included works from various researchers. The

literature was compared and contrasted to several examined hypothesis and theories. A

standardized, open-ended interview was also conducted during the investigation of this

particular study.

Limitations of the Study

During the latter portion of my research, there were various limitations that

occurred, which delayed the research process. For example, in the United States

Republican Party’s attempt to refute President Barak Obama’s political strategies, they

initiated a “government shutdown.” During this period, government databases such as

the Center of Disease and Control (CDC) became unavailable for use; thus, creating a

barrier for statistical data. Other limitations for research of this topic include slight

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ambiguity of the presented problem. For instance, researchers have not been able to

determine concrete and definite sources of the presented problem.

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CHAPTER IV

PRESENTATION OF FINDINGS

On January 1, 2010, the Paul Wellstone and Pete Domenici Mental Health Parity

and Addiction Equity Act of 2008 went into effect. This particular law was passed to end

discrimination against consumers of mental health and substance abuse treatment services

in many health insurance plans. In short, consumers will have better access to the care

they need. “The passage of this landmark legislation was the culmination of years of

work by consumers, providers, advocates, and others,” said SAMHSA Administrator

Pamela S. Hyde, J.D. “This historic occasion marks the beginning of improved coverage

for an estimated 113 million Americans” (Goodman, 2010).

In the past, health plans have often treated mental health and substance abuse

treatment services differently than they have medical and surgical benefits. Now plans

that offer both physical and mental health benefits must treat the two similarly, explained

Kevin D. Hennessy, Ph.D., the Science to Service (Goodman, 2010).

“Historically, access to care has been low,” said Dr. Hennessy, noting that

financial concerns are one of the primary obstacles to receiving care. SAMHSA’s 2008

National Survey on Drug Use and Health, for example, found that by far the biggest

barrier to people receiving the treatment they needed was lack of health coverage and

inability to pay. “Now those financial reasons should be less of a barrier,” said Dr.

Hennessy. The law focuses primarily on two areas: financial requirements and treatment

limitations. Financial requirements, such as copayments, deductibles, and out-of- pocket

limits, must be the same for both mental health and substance abuse services, and medical

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and surgical services. Similarly, the number of visits allowed, duration of treatment, and

other treatment limitations can’t be more restrictive for mental health and substance

abuse services (Goodman, 2010).

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CHAPTER V

DISCUSSION OF FINDINGS

Co-occurring mental illness and substance use disorders are prevalent among

young adults in the United Sates. There are several barriers, which include but are not

limited to, lack of access to health care and treatment services, lack of education and

denial of treatment, and treatment measures that have not been fully developed. To better

understand the issues of access to services, researchers should study the entire universe of

persons with substance use and mental disorders, not just those who seek treatment

(Council, 2004). Patients with substance use and mental disorder diagnoses were more

likely to receive uncompensated care or have Medicaid coverage than other community

hospital patients (Council, 2004).

Summary of the Study

Substance use disorders, which can result in health issues, problems at home, at

school or within the community, coupled with a serious mental illness, can severely

impact a person’s quality of life and even the quality of his or her entire family. In

addition, those who suffer from co-existing disorders have a higher risk of inflicting self-

harm than those who suffer from one of these disorders alone (When Mental Health and

Substance Abuse Problems Collide, 2013).

Discharges from community hospitals of those with substance use and mental

disorder diagnoses grew substantially between 1990 and 1995, a time of stability in

overall hospital discharges (Council, 2004). Although the complexity of substance use

and mental disorders increased over time, the length of stay (LOS) decreased in

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community hospitals. The decrease was most pronounced for those with disorders

related to substance use (Council, 2004).

The Federal Government's role in paying for the care of patients with substance

use and/or mental disorders in community hospitals increased between 1990 and 1995,

with Medicare and Medicaid paying for the treatment of more than half of discharges

with such diagnoses (Council, 2004). In fact, the criminal justice system was the most

common source of treatment referral for adult males with a substance use disorder

(Council, 2004).

Referral by an alcohol or drug treatment provider generally increased the

likelihood of inpatient admission, but in many of the states examined, co-occurring

mental disorders did not consistently increase the odds of inpatient admission. Clients

who were employed were less likely to have an inpatient admission; clients who paid for

their own care had a lower likelihood of entering inpatient treatment (Council, 2004).

An examination of the choice among five types of treatment (standard outpatient,

intensive outpatient, long-term residential, short-term residential, and inpatient hospital)

in two states revealed that those admitted to standard outpatient treatment appeared to

have less severe alcohol use disorders and were more likely to be employed than those

admitted to any other treatment setting. Furthermore, analyses that allowed for only two

choices, inpatient and outpatient, obscured the relationships between client characteristics

and treatment-setting choice (Council, 2004).

Implications for Social Work

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It is important to identify and treat mental health or substance abuse problems as

early as possible. Young adults who receive prompt treatment for mental disorders are

less likely to abuse substances later in life. Alternately, given that substance abuse can

trigger mental health problems, addressing substance abuse may help reduce distress and

the risk of concurrent disorder (When Mental Health and Substance Abuse Problems

Collide, 2013).

The article, When Mental Health and Substance Abuse Problems Collide, states

that the most effective and efficient way to address co-occurring mental health and

substance abuse disorders is to stop them before they start. Prevention of and early

intervention for mental health and substance use problems require less intensive services

than fully developed disorders When learning prevention methods, it is important to first

understand the risk factors associated with SUD’s and mental disorders. Risk factors are

characteristics that can increase the chance of a mental health disorder or substance abuse

problem occurring. Examples of risk factors include but are not limited to, problems in

the community, within the family or with peers, and even genetics.

NAMI affirms that, while the picture regarding dual diagnosis has not been very

positive or encouraging in the past, there are signs that the problem is being recognized

and there are an increasing number of programs trying to address it. Different approaches

to treatment need to be matched with the individual needs of young adults. For example,

treatment might involve medication, psychosocial treatment or a combination of both.

Family-based treatment approaches are effective for treating young adults with co-

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occurring disorders. Engaging family is a key success factor with any type of treatment

for young adults (When Mental Health and Substance Abuse Problems Collide, 2013).

Spreading Awareness of co-occurring disorders can help both mental health and

substance abuse professionals identify, prevent and treat the duel-diagnosed patients

(When Mental Health and Substance Abuse Problems Collide, 2013). Researcher Paige

Ouimette affirms that, “increasing recognition has been given to the issue of comorbid

psychiatric and substance use disorders (SUDs), otherwise known as dual disorders” (Co-

occurring mental health and substance abuse disorders, 2005).

To conclude, advocacy and early diagnosis are key practices for social workers

that work with dually diagnosed clients. The NAMI affirms that if no appropriate

programs exist in the community, families of dually diagnosed persons should advocate

for the proper facilities. When recognizing the problem in its early state, treatment may

be less extensive. In order identify a co-existing problem it is important to examine the

signs associated with each disorder. Finally, addressing the problem and developing a

plan of action are important steps to consider when the issue begins to arise.

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Reference

(2013). When Mental Health and Substance Abuse Collide: Understanding, Preventing, Identifying and Addressing Mental Health Disorders and Substance Abuse Issues in Youth. Canadian Centre On Substance Abuse, Retrieved From Www.Ccsa.Ca

(2013). Dual Diagnosis: Substance Abuse and Mental Illness. National Alliance on Mental Illness retrieved from WWW.Nami.Org

Council, Carol L. (2004). Health Services Utilization by Individuals with Substance Abuse and Mental Disorders. Department Of Health And Human Services: Substance Abuse and Mental Health Services Administration Office of Applied Studies

Goodman, D. (2010, January). Parity: Landmark legislation takes effect. What are the Implications for Millions of Americans? Substance Abuse and Mental Health Service Administration News. www.samhsa.gov

Hryb, Kathryn; Rob Kirkhart, and Rebecca Talbert (2007), A Call for Standardized Definition of Dual Diagnosis. Psychiatry (Edgmont)

Ouimette, P. (2005). Co-occurring Mental Health and Substance Abuse Disorders. The Washington Institute for Mental Illness Research & Training. www.dshs.wa.gov

Reuters, Thomson (2010). Substance Abuse and Health Administration, U.S Department of Human Services. National Expenditures for Mental Health Services & Substance Abuse Treatment 1986 – 2005

Schiele, J. (1990). Organizational Theory From An Afrocentric Perspective. Journal of Black Studies, 21(2), 145-161

Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014. HHS Publication No. (SMA) 11-4629. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

The National Survey on Drug Use and Health Report: NSDUH (2004), Adults with Co-Occurring Serious Mental Illness and a Substance Use Disorder

The National Survey on Drug Use and Health Report: NSDUH (2003), Reasons for Not Receiving Treatment among Adults with Serious Mental Illness

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Improving Substance Abuse Treatment: The National Treatment Plan Initiative Panel Reports, Public Hearings, and Participant Acknowledgements (2000). Changing the Conversation

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