Alcohol treatment utilization: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions

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Abstract

Background

Epidemiological studies consistently show low rates of alcohol treatment utilization among individuals with an alcohol use disorder (AUD). However, there is not as great consistency in the characteristics that predict alcohol treatment utilization.

Methods

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we examined attributes associated with treatment utilization among individuals with an AUD. We used stepwise backward selection logistic regression analysis to examine demographic and clinical predictors of treatment utilization, in order to identify opportunities to improve the delivery of services to this population.

Results

Only 14.6% of individuals who met lifetime criteria for an AUD reported ever having received alcohol treatment (including self-help group participation). A greater proportion of respondents with both alcohol abuse and dependence (27.9%) reported having received treatment, compared with 7.5% of those with alcohol abuse only and 4.8% of those with alcohol dependence only. Older individuals, men, and those who were divorced, had less education or more lifetime comorbid mood, personality, and drug use disorders were also more likely to have received treatment.

Conclusions

The majority of individuals with an AUD never receive formal alcohol treatment, nor do they participate in self-help groups. Although natural recovery from an AUD is well documented, participation in alcohol treatment is associated with improved outcomes. The data presented here should be taken into account when efforts are made to enhance alcohol treatment utilization.

Introduction

Alcohol abuse and dependence are common psychiatric disorders, recently estimated in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to affect 17.8 million adult Americans (Grant et al., 2004a). A variety of adverse consequences are associated with AUDs, including medical, social, and legal problems (Caetano and Cunradi, 1997). The estimated annual cost of alcohol abuse in the US is nearly US$ 185 billion (Harwood, 2000).

Despite the high prevalence of these disorders and their negative impact on individuals, families, and society, community studies show that many people with an alcohol or other substance use disorder (SUD) never receive treatment (Regier et al., 1993, Rabinowitz et al., 1999, Wu et al., 2003b, Mojtabai et al., 2002). For example, the National Comorbidity Survey (NCS) showed that, overall, 13.3% of individuals with a psychiatric disorder received an outpatient treatment during the preceding 12-month period (Kessler et al., 1999). However, while 11.6% of individuals with a diagnosis of alcohol abuse and 24.4% of individuals with alcohol dependence received treatment, 36.4% of individuals with a mood disorder and 26.5% of individuals with an anxiety disorder (including simple phobia) received any treatment. The recent NCS Replication (NCS-R) showed a cumulative lifetime probability of treatment contact being 52.7% for individuals with alcohol abuse and 69.8% for individuals with alcohol dependence (Wang et al., 2005a).

NESARC data show that, among individuals with a past prior year (PPY) history of alcohol dependence, nearly two-thirds were still alcohol dependent, in partial remission, or asymptomatic risky drinkers at the time of assessment. The rate of natural recovery rate (i.e., recovery without treatment) among these individuals was 24.4% (Dawson et al., 2005). The estimated natural recovery rate from alcohol dependence was approximately 40% in a smaller German sample (Bischof et al., 2005). These estimates contrast sharply with the rate of natural recovery observed in the National Longitudinal Alcohol Epidemiologic Survey (NLAES), which exceeded 70% (Dawson, 1996). NLAES data also showed that, for individuals with onset of an AUD during the 5 years preceding the survey, the rate of untreated recovery from AUD was closer to 50% (Dawson, 1996). In the NESARC, as with most of the earlier studies, there was a greater likelihood of recovery among females and among older, married individuals, effects that were independent of treatment history (Dawson et al., 2005). In summary, although natural recovery from an AUD is well documented, many individuals do not recover spontaneously, and might benefit from alcohol treatment services. Further, the observation that the likelihood of natural recovery decreases with increasing age suggests that treatment early in the course of the disorder may be most beneficial (Hermos et al., 1988).

There are many factors that contribute to the decision to seek alcohol treatment. Hasin and colleagues, using national data from the 1980s, showed that a diagnosis of alcohol dependence, greater severity of alcohol dependence, a sense of a compulsion to drink, and social pressure to drink were associated with seeking alcohol treatment (Hasin and Glick, 1992, Hasin, 1994, Hasin and Grant, 1995). Several studies (Brennan and Moos, 1991, Ross et al., 1999, Weisner et al., 2002) have shown that individuals who report more life stressors, such as legal or work-related problems, are more likely to seek treatment. More recent data (Tucker et al., 2004) show that the decision to seek treatment is based on an interaction of social pressures, severity of illness and related impairments, access to services, and perceived costs and benefits. Other data show that individuals seek treatment only after they experience substantial difficulties in daily functioning (Simpson and Tucker, 2004, Weisner and Matzger, 2003), and the number of life areas that alcohol has negatively affected correlates with the probability of seeking help (Ogborne and DeWit, 1999).

Among individuals with a SUD, the presence of a comorbid psychiatric disorder may be a particularly important predictor of treatment utilization. In the NCS, for example, 16% of individuals with comorbid mood and SUDs and 18% of individuals with comorbid anxiety and SUDs received substance abuse treatment, a rate more than twice that of individuals with a SUD only (Mojtabai et al., 2002). Moreover, these effects were additive, such that 34% of individuals with comorbid mood, anxiety, and SUDs received treatment (Mojtabai et al., 2002). Often, the individual seeks treatment for a psychiatric disorder, at which time a SUD is detected (Agosti and Levin, 2004, Schadé et al., 2004, Wu et al., 1999, Wu et al., 2003b, Mojtabai et al., 2002, Salloum et al., 1998). This pattern of findings may reflect the fact that many people view a mood or anxiety disorder as less stigmatizing than a SUD (Wu et al., 2003b).

Efforts to identify which individuals are most likely to seek treatment have yielded variable findings. Most studies show men to be significantly more likely to seek treatment for a SUD (Schober and Annis, 1996, Kaskutas et al., 1997, Mojtabai et al., 2002), though some have shown the opposite (Salloum et al., 1998, Weisner et al., 2001). Schober and Annis (1996) found that women with an AUD are more likely to seek mental health treatment for a co-occurring problem, whereas men are more likely to seek an alcohol-specific intervention.

Most studies show adults aged 35–54 years as being most likely to seek alcohol treatment (Wu et al., 1999, Ogborne and DeWit, 1999, Proudfoot and Teesson, 2002, Weisner et al., 2002, Wu and Ringwalt, 2004), with the elderly being least likely to do so (Proudfoot and Teesson, 2002, Satre et al., 2003). Although some studies have shown that younger age is associated with treatment-seeking behavior (Kaskutas et al., 1997, Kessler et al., 1999), college-age problem drinkers are more likely to seek help from friends or school counselors than to receive substance abuse treatment per se (Yu et al., 2003).

Studies of the relationship between ethnicity and alcohol treatment utilization have also yielded variable findings. In some studies, Blacks and Hispanics were more likely than Whites to seek treatment (Kaskutas et al., 1997, Weisner et al., 2002). In one study, Blacks and Hispanics were least likely to seek alcohol-specific treatment; their alcohol problems were often identified only through other primary diagnoses (Booth et al., 1992). In addition, compared to Whites, Native Americans are much more likely to use substance abuse services, while Asians and Pacific Islanders are much less likely to do so (Wu et al., 2003b).

We examined demographic and clinical attributes of alcohol treatment utilization in the National Epidemiologic Survey on Alcohol and Related Conditions (Grant et al., 2003, Grant et al., 2004a), a large general population survey. In this report, we examine the specific alcohol treatment modalities utilized by individuals with an AUD, the characteristics of individuals who sought alcohol treatment, and reasons for not seeking alcohol treatment among survey respondents who considered seeking treatment, but did not.

Section snippets

Study sample

The NESARC, covering the period 2001–2002, is the largest study ever of alcohol use and alcohol-related disorders. It included a nationally representative sample of 43,093 participants recruited from a non-institutionalized household population, 18 years and older, living in the US, including the District of Columbia, Alaska, and Hawaii (Grant et al., 2004a). Face-to-face personal interviews were conducted by experienced interviewers from the US Census Bureau, with a response rate of 81.2%.

Diagnoses and assessments

The

Results

Of the 43,093 participants, 30.3% met criteria for a lifetime AUD. The mean age of individuals with an AUD was 42.2 (S.D. = 14.7) years [median = 41, interquartile range (IQR) = 31–52] and 66.5% were male, 79.8% were White, 7.5% were Black, and 8.0% were Hispanic, 3.0% were Native-American, and 1.7% were Asian. The majority of individuals with an AUD (61.9%) were married, 87.8% completed high school, 27.1% completed college, 64% were employed, and the median household income was US$ 45,000.

As has

Discussion

Alcohol use disorders are among the most costly and damaging public health problems in the US today (Harwood, 2000). During the period 2001–2002, although 17.8 million adult Americans were diagnosed with one or more current AUDs (Grant et al., 2004a), only about 1 in 7 individuals with an AUD reported ever having received any kind of alcohol treatment. Among those who received treatment, AA participation was the most common treatment option; about three-quarters of those who ever utilized

Acknowledgements

Supported by NIAAA grants P50 AA03510 and K24 AA13736 (to HRK). The authors thank Deborah Hasin, Ph.D. for helpful comments on the manuscript.

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