Winter 2012 Vol. 12 Number 2
Mental Health and Substance Abuse Care in Key Populations
Substance abuse and mental health disorders have taken a backseat to physical illnesses and injuries when it comes to coverage and care. Even with the passage of federal parity legislation in 2008, many individuals and families have struggled to get and maintain services for these disorders. Less than half of the 45.6 million adults with mental illness received help in 2011, according to the latest government survey.
Two reports released by the Institute of Medicine in 2012 examine the scope of these conditions among particular segments of the population: older Americans and military service members.
Aging baby boomers who need help for problems such as mood disorders, hoarding, medication addiction, and alcoholism could have a hard time finding services, says one of the reports. There are too few geriatric specialists, and most primary care providers have little or no knowledge about diagnosing and caring for these problems in older patients.
Nearly one in five older Americans experience at least one mental health condition or problem with the misuse or abuse of drugs. Inattention to these conditions can contribute to higher costs and greater suffering. For example, older people with untreated depression are less likely to properly take medicines for other ailments, and they are more likely to require repeated hospital stays.
Making sure there are enough providers able to handle the needs of older patients will take a combination of incentives and requirements, the report concludes. Organizations that accredit health and social service schools and license professionals should require all providers who will work with older patients to demonstrate basic knowledge and skills in recognizing the signs of mental health and substance abuse problems and providing at least basic care. The report supports the use of loan forgiveness programs and scholarships for people who train in geriatric mental health and substance abuse to increase the number of specialists.
Moreover, patients' ability to get care is too often hindered by Medicare and Medicaid payment restrictions. For example, Medicare does not pay for care provided by nurses working without physician oversight and does not pay psychiatrists for supervisory services. These limitations need to be removed.
Similar restrictions and work-force shortages hamper care for military service members dealing with problems related to misuse or abuse of alcohol and drugs, another IOM report notes. TRICARE, the military's health insurance program, does not cover several therapies that are now standard practice. It also does not permit long-term use of certain medications for the treatment of addiction and covers care delivered only in specialized rehabilitation facilities, even though care in outpatient settings more effectively helps patients avoid relapses.
Prescription drug misuse is a growing concern among service members. Just 2 percent of active duty personnel reported misusing medication in 2002 compared with 11 percent in 2008. In addition, binge drinking increased from 35 percent in 1998 to 47 percent in 2008. Substance abuse frequently occurs along with conditions such as post-traumatic stress disorder, depression, and suicidal thoughts, which likewise are occurring more often among this population.
Military health care professionals at all levels need training to recognize patterns of substance abuse and misuse and clear guidelines for referring patients to specialists, the report says. The U.S. Department of Defense should promote team care by a range of providers, which is the most effective approach and would help alleviate the provider shortage created by the military's sole reliance on specialty clinics.
While the armed forces should move away from a permissive attitude toward alcohol by enforcing regulations on underage drinking and reducing the availability of alcohol on bases, they should also work to ease the stigma that deters service members from seeking care. Making screening and intervention services part of primary care would help achieve this goal and increase the number of places where service members and families can get basic care for these problems. -- Christine Stencel
The committee was chaired by Dan G. Blazer, J.P. Gibbons Professor of Psychiatry and Behavioral Sciences and vice chair for faculty development, Duke University Medical Center, Durham, N.C. The study was funded by the U.S. Department of Health and Human Services.
Substance Use Disorders in the U.S. Armed Forces . Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces, Board on the Health of Select Populations, Institute of Medicine (2012, 410 pp.; ISBN 0-309- 26055-8).
Charles P. O'Brien, Kenneth Appel Professor and vice chair, department of psychiatry, and director, Center for Studies of Addiction, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. The study was funded by the U.S. Department of Defense.
Both reports are available from the National Academies Press, tel. 1-800-624-6242, and free to download on the Internet.