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Behavioral Health Services Influence Medical Treatment Utilization Among Primary Care Patients with Comorbid Substance Use and Depression

  • Benjamin I. FellemanEmail author
  • Dylan R. Athenour
  • Minhdan T. Ta
  • David G. Stewart
Article

Abstract

Although research has shown benefits of integrating psychological care in primary care settings, it is unclear how this form of treatment impacts individuals with comorbid substance use and depression. The findings are also mixed concerning how frequently this comorbid population seeks primary care services. This study examined the associations between substance use, depression, and medical treatment utilization among 224 primary care patients. The aim of the investigation was twofold. First, to determine if depression increases medical treatment utilization among patients with substance use disorders; second, to evaluate if behavioral health treatment reduces medical service utilization. A moderated mediation model with bootstrapping analyses revealed that depression strengthened the relationship between substance use and primary care treatment utilization (both medical and behavioral health). The model also indicated that behavioral health services were associated with fewer primary care visits for individuals with comorbid substance use and depression. Clinical and social implications are discussed.

Keywords

Behavioral health Substance use Depression Primary-care 

Notes

Acknowledgments

The authors wish to thank Melissa Baker for her assistance with this research.

References

  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.Google Scholar
  2. Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, 57–87. doi: 10.1111/1469-7610.00424.PubMedCrossRefGoogle Scholar
  3. Auxier, A., Runyan, C., Mullin, D., & Kessler, R. (2012). Behavioral health referrals and treatment initiation rates in integrated primary care: A Collaborative Care Research Network study. Translational Behavioral Medicine, 3, 337–344. doi: 10.1007/s13142-012-0141-8.CrossRefGoogle Scholar
  4. Beck, A. T. (2001). Collaborative behavioral health in primary care. Group Practice Journal, 50, 22–26.Google Scholar
  5. Bijl, R., & Ravelli, A. (2000). Psychiatric morbidity, service use, and need for care in the general population: Results of the Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health, 90, 602–607. Retrieved from EBSCOhost.Google Scholar
  6. Blow, F. C., Walton, M. A., Barry, K. L., Murray, R. L., Cunningham, R. M., Massey, L. S., & Booth, B. M. (2011). Alcohol and drug use among patients presenting to an inner-city emergency department: A latent class analysis. Addictive Behaviors, 36, 793–800. doi: 10.1016/j.addbeh.2010.12.028 Google Scholar
  7. Borowsky, S., Rubenstein, L., Meredith, L., Camp, P., Jackson-triche, M., & Wells, K. (2000). Who is at risk of nondetection of mental health problems in primary care? Journal of General Internal Medicine, 15, 381–388. doi: 10.1046/j.1525-1497.2000.12088.x.PubMedCrossRefGoogle Scholar
  8. Butler, M., Kane, R., McAlpine, D., Kathol, R., Fu, S., Hagedorn, H., & Wilt, T. (2008). Integration of mental health/substance abuse and primary care. Evidence Report/Technology Assessment, 173, 1–362. Retrieved from PubMed.Google Scholar
  9. Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/correlation analysis for the behavioral sciences. Mahwah, NY: Lawrence Erlbaum Associates.Google Scholar
  10. Collins, C. (2009). Integrating behavioral and mental health services into the primary care setting. North Carolina Medical Journal, 70, 248–252. Retrieved from http://www.ncmedicaljournal.com.Google Scholar
  11. Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625. doi: 10.1037/0003-066X.59.7.614.PubMedCrossRefGoogle Scholar
  12. Cummings, N., O’Dononhue, W., & Cummings, J. (2009). The financial dimension of integrating behavioral/primary care. Journal of Clinical Medicine, 16, 31–39. doi: 10.1007/s10880-008-9139-2.Google Scholar
  13. Dennis, M. L., Chan, F., & Funk, R. R. (2006). Development and validation of the GAIN SS (GSS) for internalizing, externalizing, and SUDs and crime/violence problems among adolescents and youth. American Journal on Addiction, 15, 80–91. doi: 10.1080/10550490601006055.CrossRefGoogle Scholar
  14. Druss, B. G., & Rosenheck, R. A. (1999). Patterns of health care costs associated with depression and substance abuse in a national sample. Psychiatric Services, 50, 214–218. Retrieved from EBSCOhost.Google Scholar
  15. Edwards, T. M., Stern, A., Clarke, D. D., Ivbijaro, G., & Kasney, L. (2010). The treatment of patients with medically unexplained symptoms in primary care: A review of the literature. Mental Health in Family Medicine, 7, 209–221.PubMedGoogle Scholar
  16. French, M. T., McGeary, K. A., Chitwood, D. D., & McCoy, C. B. (2000). Chronic illicit drug use, health services utilization and the cost of medical care. Social Science & Medicine, 50, 1703–1713. Retrieved from GoogleScholar.Google Scholar
  17. Gatchel, R. J., & Oordt, M. S. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association. doi: 10.1037/10592-000.CrossRefGoogle Scholar
  18. Grant, B., Peterson, A., Dawson, D., & Chou, P. (1992). Source and Accuracy statement for the National Longitudinal Alcohol Epidemiologic Survey (NLAES). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.Google Scholar
  19. Grant, B., Stinson, F., Dawson, D., Chou, A., Dufour, M., Compton, W., … Kaplan, K. (2006). Prevalence and co-occurrence of SUDs and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol Research & Health, 29, 107-120Google Scholar
  20. Harpole, L. H., Williams, J. R., Olsen, M. K., Stechuchak, K. M., Oddone, E., Callahan, C. M., … Unützer, J. (2005). Improving depression outcomes in older adults with comorbid medical illness. General Hospital Psychiatry, 27, 4–12. doi: 10.1016/j.genhosppsych.2004.09.004
  21. Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable moderation, mediation, and conditional process modeling. Retrieved from http://www.afhayes.com/public/process2012.pdf.
  22. Hedrick, S. C., Chaney, E. F., Felker, B., Liu, C., Hasenberg, N., Heagerty, P., … Katon, W. (2003). Effectiveness of collaborative care depression treatment in Veterans Affairs primary care. Journal of General Internal Medicine, 18, 9 16. doi: 10.1046/j.1525-1497.2003.11109.x
  23. Horgan, C. M., Garnick, D. W., Merrick, E. L., & Hodgkin, D. (2009). Changes in how health plans provide behavioral health services. Journal of Behavioral Health Services and Research, 36, 11–24. doi: 10.1007/s11414-007-9084-0.PubMedCrossRefGoogle Scholar
  24. Huag, T. T., Mykletun, A., & Dahl, A. A. (2004). The association between anxiety, depression, and somatic symptoms in a large population: The HUNT-II Study. Psychsomatic Medicine, 66, 845–851. doi: 10.1097/01.psy.0000145823.85658.0c.CrossRefGoogle Scholar
  25. Katon, W., Robinson, P., Von Korff, M., Lin, E., Bush, T., Ludman, E., et al. (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry, 53, 924–932.PubMedCrossRefGoogle Scholar
  26. Katon, W., Russo, J., Von Korff, M., Lin, E., Simon, G., Bush, T., … Walker, E. (2002). Long-term effects of a collaborative care intervention in persistently depressed primary care patients. Journal of General Internal Medicine, 17, 741–748. doi:  10.1046/j.1525-1497.2002.11051.x.
  27. Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142, 1259–1264.PubMedGoogle Scholar
  28. Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509–521.Google Scholar
  29. Kroenke, K., Spitzer, R. L., Williams, J. W., & Löwe, B. (2010). The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 32, 345–359. doi: 10.1016/j.genhosppsych.2010.03.006.PubMedCrossRefGoogle Scholar
  30. Lagoni, L., Crawford, E., & Huss, M. T. (2011). An examination of the self-medication hypothesis via treatment completion. Addiction Research & Theory, 19, 416–426. doi: 10.3109/16066359.2010.525332.CrossRefGoogle Scholar
  31. Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99, 280–295. doi: 10.1016/j.drugalcdep.2008.08.003.PubMedCrossRefGoogle Scholar
  32. Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief patient health questionnaire mood scale (PHQ-9) in the general population. General Hospital Psychiatry, 28, 71–77. doi: 10.1016/j.genhosppsych.2005.07.003.PubMedCrossRefGoogle Scholar
  33. McGovern, M. P., Clark, R. E., & Samnaliev, M. (2007). Co-occurring psychiatric and substance use disorders: A multistate feasibility study of the quadrant model. Psychiatric Services, 58, 949–954. doi: 10.1176/appi.ps.58.7.94.PubMedCrossRefGoogle Scholar
  34. Menchetti, M., Murri, M., Bertakis, K., Bortolotti, B., & Berardi, D. (2009). Recognition and treatment of depression in primary care: Effect of patients’ presentation and frequency of consultation. Journal of Psychosomatic Research, 66, 335–341. doi: 10.1016/j.jpsychores.2008.10.008.PubMedCrossRefGoogle Scholar
  35. Mertens, J. R., Weisner, C., Ray, G. T., Fireman, B., & Walsh, K. (2005), Hazardous drinkers and drug users in HMO primary care: Prevalence, medical conditions, and costs. Alcoholism: Clinical and Experimental Research, 29, 989–998. doi: 10.1097/01.ALC.0000167958.68586.3D.
  36. Minkoff, K., Zweben, J., Rosenthal, R., & Ries, R. (2003). Development of service intensity criteria and program categories for individuals with co-occurring disorders. Journal of Addictive Diseases, 22, 113–129.PubMedCrossRefGoogle Scholar
  37. Mynors-Wallace, L., Gath, D. H., Lloyd-Thomas, A. R., & Tomlinson, D. (1995). Randomized controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. British Medical Journal, 310, 441–446.CrossRefGoogle Scholar
  38. National Institute on Alcohol Abuse and Alcoholism (2000). Tenth special report to the U.S. Congress on alcohol and health. Retrieved from http://www.pubs.niaaa.nih.gov/publications/10report/intro.pdf.
  39. National Institute on Drug Abuse. (2011a). Drug abuse and addiction: One of America’s most challenging public health problems. Retrieved from http://archives.drugabuse.gov/about/welcome/aboutdrugabuse/magnitude/.
  40. National Institute on Drug Abuse. (2011b). NIDA infofacts: Comorbidity: Addiction and other mental disorders. Retrieved from http://www.nida.nih.gov/infofacts/comorbidity.html.
  41. Ouimette, P., Goodwin, E., & Brown, P. (2006). Health and well being of SUD populations with and without posttraumatic stress disorder. Addictive Behaviors, 31, 1415–1423. doi: 10.1016/j.addbeh.2005.11.010.PubMedCrossRefGoogle Scholar
  42. Preacher, K. J., Rucker, D. D., & Hayes, A. F. (2007). Addressing moderated mediation hypotheses: Theory, methods, and prescriptions. Multivariate Behavioral Research, 42, 185–227.CrossRefGoogle Scholar
  43. Rasmussen, N. H., Bernard, M. E., & Harmsen, W. S. (2008). Physical symptoms that predict psychiatric disorders in rural primary care adults. Journal of Evaluation in Clinical Practice, 14, 399–406. doi: 10.1111/j.1365-2753.2007.00879.x.PubMedCrossRefGoogle Scholar
  44. Robinson, P. J., & Reiter, J. T. (2007). Behavioral consultation and primary care: A guide to integrating services. New York, NY: Springer Science Business Media.CrossRefGoogle Scholar
  45. Schmitz, N., & Kruse, J. (2002). The relationship between mental disorders and medical service utilization in a representative community sample. Social Psychiatry and Psychiatric Epidemiology, 37, 380–386. doi: 10.1007/s00127-002-0567-2.PubMedCrossRefGoogle Scholar
  46. Schumaker, R. E., & Lomax, R. G. (2004). A beginner’s guide to structural equation modeling (2nd ed.). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  47. Simon, G., VonKorff, M., Piccinelli, M., Fullerton, C., & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. The New England Journal of Medicine, 341, 1329–1335. doi: 10.1056/NEJM199910283411801.PubMedCrossRefGoogle Scholar
  48. Spitzer, R., Kroenke, K., & Williams, J. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA: The Journal of the American Medical Association, 282, 1737–1744. Retrieved from EBSCOhost.Google Scholar
  49. Stewart, D. G., Welton, S., Arger, C, Effinger, J., Serafini, K., & Harris, J. (2011). The utility of a developmentally based quadrant model of co-occurring substance use and mood disorder classification in adolescents. Journal of Dual Diagnosis, 7, 130–140. Retrieved from EBSCOhost.Google Scholar
  50. Strosahl, K. (1998). Integrating behavioral health and primary care services: The primary mental health care model. In A. Blount (Ed.), Integrated primary care: The future of medical and mental health collaboration (pp. 139–166). New York, NY: W.W. Norton & Co.Google Scholar
  51. Strosahl, K., Baker, N. J., Braddick, M., Stuart, M. E., & Handley, M. R. (1997). Integration of behavioral health and primary care services: The Group Health Cooperative model. In N. A. Cummings, J. L. Cummings, & J. N. Johnson (Eds.), Behavioral health in primary care: A guide for clinical integration (pp. 61–86). Madison, CT: Psychosocial Press.Google Scholar
  52. Substance Abuse and Mental Health Services Administration. (2009). National survey on drug use and health. Retrieved from http://www.samhsa.gov/co-occurring/topics/data/disorders.aspx#2.
  53. Todd, J., Green, G., Pevalin, D. J., Ikuesan, B. A., Harrison, M., Self, C., & Baldacchino, A. (2005). Service uptake in a sample of substance misuse and community mental health service clients—A case control study. Journal of Mental Health, 2, 95–107. doi: 10.1080/09638230500060011.Google Scholar
  54. Unutzer, J., Schoenbaum, M., Druss, B., & Katon, W. (2006). Transforming mental healthcare at the interface with general medicine: Report of the President’s New Freedom Commission on Mental Health. Psychiatric Services, 57, 37–47. Retrieved from ProQuest.Google Scholar
  55. van Beljouw, I., Verhaak, P., Prins, M., Cuijpers, P., Penninx, B., & Bensing, J. (2010). Reasons and determinants for not receiving treatment for common mental disorders. Psychiatric Services, 61, 250–257. Retrieved from http://ps.psychiatryonline.org/article.aspx?articleID=101228.
  56. Von Korff, M., Moore, J., Lorig, K., Cherkin, D., Saunders, K., Gonzalez, V., … Comite, F. (1998). A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care. Spine, 23, 2608–2615.Google Scholar
  57. Walker, B. B., & Collins, C. A. (2009). Developing an integrated primary care practice: Strategies, techniques and a case illustration. Journal of Clinical Psychology, 65, 268–280.PubMedCrossRefGoogle Scholar
  58. Wu, L., Kouzis, A. C., & Leaf, P. J. (1999). Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey. The American Journal of Psychiatry, 156, 1230–1236. Retrieved from EBSCOhost.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Benjamin I. Felleman
    • 1
    Email author
  • Dylan R. Athenour
    • 1
  • Minhdan T. Ta
    • 1
  • David G. Stewart
    • 1
  1. 1.Department of Clinical PsychologySeattle Pacific UniversitySeattleUSA

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