Service Use Among
Adolescents with Comorbid Mental Health and Substance Use Disorders
Large numbers of adolescents with serious mental health
(MH) disorders also have a co-occurring substance use (SU) disorder.
Only recently, beginning with changes implemented in DSM-III that permitted
multiple diagnoses and subsequent results from large-scale epidemiological
field studies, has co-occurring MH and SU disorders been recognized
as more the rule than the exception among those with either type of
problem. For example, Greenbaum, Prange, Friedman, and Silver (1991)
found that among 547 adolescents aged 12-18 years who were identified
as having a DSM-III MH disorder, 22% had a co-occurring SU disorder.
Other estimates have reported higher prevalence of co-occurrence; ranging
from 45% to 71% (Groves, Batey, & Wright, 1986; Roehrich & Gold,
1986). Similar studies of adolescents, but among those initially identified
with an SU disorder, have found even higher rates of co-occurrence,
as high as 82-85% (Hovens, Cantwell, & Kiriakos, 1994; Stowell &
Estroff, 1992). Unfortunately, as in all studies of prevalence based
on clinical samples, completely unbiased estimates cannot be established
from these samples, and currently there have been no detailed general
population studies of co-occurrence among American adolescents.
Nevertheless, the few existing epidemiological studies
of psychiatric disorders in the general population also have supported
high co-occurrence of MH and SU, both among adults and adolescents.
Kessler et al. (1996), in the National Comorbidity Study, found that
co-occurring MH and SU disorders were widespread. For example, 52% of
respondents with lifetime alcohol abuse or dependence diagnosis also
had a lifetime mental disorder. Further, among those who had a history
of both an MH and SU disorder, the first onset was preponderantly for
the MH disorder. That is, 83.5% of those with co-occurrence had an initial
MH disorder, 3.7% had simultaneous onset, and only 12.8% had the SU
disorder occur first. When the course of these disorders was plotted
by age of onset for those with a primary MH disorder, median onset for
the MH disorder was 11 years of age, while median onset for the subsequent
SU disorder was 21 years of age. The median difference between these
onsets was 5-10 years. These results strongly support: (a) a clear temporal
sequence among most individuals who experienced co-occurrence, (b) the
characteristic start of the co-occurrence pattern was during adolescence,
and (c) the initial diagnosis was typically a MH disorder. A strong
implication of these findings has been that identification of children’s
MH disorders may be useful for both prevention and effective delivery
of services for treatment of SU disorders.
Current concepts of mental health treatment for children
and adolescents have called for integrated services from all of the
child-serving systems so as to maximize treatment impact on the multiple
problems that these children have (e.g., Stroul & Friedman, 1986).
Benefits to be derived from an integrated approach for children with
co-occurrence include a systematic perspective that provides an improved
ability to recognize, assess, and treat both types of disorders as they
interrelate with each other (Petrila, Foster-Johnson, & Greenbaum,
1996). Nevertheless, a number of barriers to integrated services have
existed. Historically, substance use treatment (i.e., drugs, alcohol)
and mental health systems have been discrete entities with minimal coordination
or collaboration between them. Little information exists as to the extent
that nonintegrated MH and SU services remain a barrier to receive needed
services for adolescents with co-occurring disorders.
The present study used an existing research database that
sampled multiple residential mental health and special education sites
(N = 121) to explore the extent that adolescents who had been
identified as having co-occurring MH and SU disorders received appropriate
services. During the 1985-1991 time period when the database was collected,
no integrated service systems were in operation; therefore, the data
reflect service delivery as provided by nonintegrated (i.e., either
separate or parallel) systems delivery models. The primary research
question addressed was: Do adolescents with a MH disorder who have been
served in the mental health or special education system and have a SU
disorder (i.e., alcohol, marijuana) receive differential rates of services
from the various child-serving agencies compared to those who have only
a MH disorder, particularly with regard to alcohol and drug counseling,
mental health, educational, and health services, and contact with law
enforcement? It was expected that those who were comorbid would have
received, at a minimum, the same levels of mental health, medical, educational,
and vocational services that their non-comorbid peers received. Any
reduction in services for the comorbid presumably would reflect barriers
that were experienced by children whose problems cross the traditional
MH or special education service provider systems. Additionally, based
on need, it was expected that the comorbid would receive higher rates
of alcohol and drug counseling. Finally, the data on alcohol and drug
counseling also would provide an objective measure of service penetration
(i.e., the difference between service need and use) for children with
co-occurring MH and SU disorders.
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