Unmet need for treatment for substance use disorders across race and ethnicity☆
Introduction
Planning for service provision for drug and alcohol treatment requires precise estimates of unmet need for such treatment (Rehm and Greenfield, 2008, Shepard et al., 2005) broken down by subgroups such as race and ethnicity (Alvarez et al., 2007, Reynoso-Vallejo et al., 2008). Generating such estimates is difficult. Few studies have large enough sample sizes to compare need for treatment for substance use only across racial and ethnic subgroups; hence, many studies combine mental health and substance diagnoses and treatment estimates across groups. Inconsistencies in how need for behavioral health treatment is defined are also evident (Aoun et al., 2004, Sareen et al., 2005), making it difficult to reconcile different findings across groups.
A comprehensive understanding of disparities in need for substance use treatment is necessary. To achieve this goal, researchers must agree on what constitutes need. Some evidence suggests that differential endorsements of symptoms in diagnostic assessments may occur across race/ethnicity and cultures (Alegría and McGuire, 2003, Breslau et al., 2008, Weiss et al., 2003). Hence, restricting need estimates for substance use treatment to those who fulfill the most restrictive diagnostic criteria may undercount need estimates for some subpopulations and bias estimates. Alternately, substance use treatment has a health system function and a criminal justice function, with evidence of disproportionate court-mandated substance use treatment services for Latinos and African Americans compared to non-Latino whites (Rounds-Bryant et al., 2003) which could reflect a social control element embedded in treatment for substance use disorders (Burman, 2004). If some groups are more vulnerable to such social influences, relaxing the diagnostic criteria could lead to artificially inflated and biased rates of treatment use for some groups. It is critical to take into account differences across need definitions when considering disparities estimates.
Two need definitions often used in psychiatric epidemiology are normative need and felt need (Aoun et al., 2004). Normative need is defined by diagnostic criteria determined by experts (e.g., the presence of a psychiatric diagnosis). Felt need (or perceived need) is defined by the subjective opinion that one needs treatment. These definitions are often combined differently across studies, yielding inconsistent conclusions about unmet need for treatment across racial/ethnic groups.
Inconsistencies in need definitions may contribute to contradictory disparities estimates. In the longitudinal household telephone survey, Health Care for Communities, need for treatment services was defined by whether a person thought they needed help (felt need) or probable clinical need (normative need), measured by screening positive for mental health problems and/or alcohol abuse or recent use of illicit drugs. Analyses based on these data showed greater unmet need for treatment among racial/ethnic minorities relative to Whites (Stockdale et al., 2007, Wells et al., 2001). In contrast, other studies using the National Survey of Drug Use and Health (NSDUH), calculated past year unmet need for substance use treatment using only diagnostic criteria from the DSM-IV-R (normative need; Epstein et al., 2004, Wu et al., 2003). These studies found no significant differences in unmet need across race/ethnicity. A third study using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) defined need according to lifetime diagnoses, and found Blacks were more likely to utilize non-specialty services for drug disorders compared to Whites (Hatzenbuehler et al., 2008). The differences in methodologies make drawing conclusions about disparities in unmet need for substance disorders difficult to disentangle across studies.
Even within normative diagnostic definitions of need, significant variability in criteria used to define need is often evident. Using DSM criteria, definitions of substance use disorders can differ according to whether a respondent meets one or more of six symptoms (Wu et al., 2003) or meets three or more of seven criteria (Harris and Edlund, 2005). However, current APA practice guidelines recommend treating individuals with substance “misuse” without progression to dependence or abuse (American Psychiatric Association, 2006). The critical question is whether variability in substance use treatment disparities across race/ethnicity exists depending upon the cut-off point in the normative definition of need.
The purpose of this analysis is to compare disparities in unmet need for substance use treatment restricted to substance use disorders only, using robust sample sizes to enable comparisons across groups. A related objective is to observe whether disparities estimates vary depending upon the definitions of need for treatment applied. We concentrate on substance use disorders without co-occurring mental health diagnoses because little information exists about treatment patterns for substance use services only across race/ethnicity. Such information is necessary to improve tracking across race/ethnicity and to design more targeted clinical and policy interventions that are culturally appropriate for these populations (Robles et al., 2006).
To provide a comprehensive picture of unmet need, we utilize data from two epidemiologic datasets – the 2002–2005 National Survey of Drug Use and Health (NSDUH) and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We match definitions for categories of need and treatment across the two surveys. By conducting parallel analyses with two different surveys, we accomplish two goals. First, we capitalize on the strengths of both datasets, as the NSDUH has a large enough sample size to allow comparisons across ethnic/racial groups in past year diagnoses, and the NESARC has more comprehensive treatment data. Secondly, we enable assessment of a broad range of need definitions, as the NSDUH collects data on perceived unmet need and past year substance diagnoses, while the NESARC includes lifetime substance diagnoses in addition to past year. We estimate disparities using the large samples available in the NSDUH, and check these findings against those in the NESARC as a sensitivity analysis.
Section snippets
Methods
The NSDUH is an annual survey administered to approximately 67,500 non-institutionalized civilians in the United States including Alaska and Hawaii. It measures substance and alcohol use, abuse and/or dependence, and treatment for these disorders. From 2002 to 2005 the measures for substance abuse and dependence and treatment, remained consistent, allowing us to combine these datasets. The NESARC is a US-Census Bureau conducted national survey focused on substance and/or alcohol use disorders
Results
Unadjusted rates of treatment, need and sociodemographic characteristics were consistent across studies (see Table 2) suggesting a high level of comparability. Bivariate analyses compared differences across race/ethnicity in use of specialty services stratified by varying definitions of need (see Table 3). In the NSDUH, Asians had significantly higher rates of unmet need for specialty care compared to Whites across many categories of need – perceived need (p < 0.01), past year alcohol abuse (p <
Discussion
Significant disparities in rates of substance use treatment were identified for Asians who were consistently more likely to have unmet need. Low rates of substance use treatment by Asians are consistent with other studies documenting underutilization of behavioral health services in general by Asians (Abe-Kim et al., 2007, Le Meyer et al., 2009, Ta et al., 2008). Increasing culturally and language appropriate substance use services may be one way to counter underutilization by Asians (Yu et
Role of funding source
This work was supported by NIH Research Grant # #P60 MD0 02261-01, funded by the National Institute for Minority Health and Health Disparities and Grant # 1P50 MHO 73469 funded by the National Institute of Mental Health.
These funding sources had no role whatsoever in the development of the manuscript, design of the study, data collection, analysis and interpretation of findings or writing of the paper.
Contributors
Drs. Mulvaney-Day and Alegria conceived the study and overall analytic design. Dr. Mulvaney-Day developed the data analysis plan, oversaw the data analyses and interpretation, and wrote the manuscript. Ms. DeAngelo conducted the literature review, drafted the introduction, and contributed to the interpretation of the data analysis. Dr. Chen conducted the analyses, drafted the results section, and provided input on the statistical methods utilized. Dr. Cook provided input on the design and
Conflict of interest
All authors declare that they have no conflicts of interest.
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Work completed while at the Center for Multicultural Mental Health Research, 120 Beacon Street, 4th floor, Somerville, MA 02143.