With Depression Without Depression 8.0% 1.8% Alcohol Disorder Drug Disorder Alcohol or Drug Disorder

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1 Minnesota Adults with Co-Occurring Substance Use and Mental Health Disorders By Eunkyung Park, Ph.D. Performance Measurement and Quality Improvement May 2006 In Brief Approximately 16% of Minnesota adults were found with either a substance use disorder or a mental health disorder: 7.7% with substance use disorder only, 7.0% with mental health disorder only, and 1.4% with both of the disorders. Minnesota adults with co-morbidity are more likely to be unemployed and tend to have lower levels of education than those with either single disorder. Multiple drug users and those with drug disorder compared to those with alcohol disorder have higher odds of having co-morbidity. Minnesota adults with more severe alcohol disorder and mental health disorder are more likely to have co-morbidity: The higher the number of symptoms, the higher the odds of having co-morbidity. The majority of Minnesota adults with co-morbidity don t receive the treatment they need: Only 11% received both mental and chemical health treatments and 62% received neither. The 2004/2005 Minnesota Survey on Adult Substance Use and Treatment Need (MNSASU) 1 found approximately 8.0% of the adult population met the criteria for alcohol abuse or dependence and 2.2% met the criteria for drug abuse or dependence. Overall, 9.1% of Minnesota adults reported symptoms for substance use disorder. 1 Detailed information about this statewide survey project can be found on DHS web site: 1

2 On the other hand, approximately 7.7% of Minnesota adults reported significant depressive symptoms and 2.3% reported symptoms of a serious psychological distress (SPD) 2,3. Overall, 8.4% of Minnesota adult population reported either depressive symptoms or SPD. Persons with a substance use disorder often have other mental health problems. Seven to 10 million adult Americans have at least one mental disorder as well as an alcohol or drug use disorder in any one year (U.S. DHHS, 1999; SAMHSA National Advisory Council, 1998). MNSASU found that Minnesota adults with depressive symptoms or SPD are significantly more likely to have an alcohol disorder or a drug disorder than are those who do not have those mental health symptoms (Figures 1 & 2). For example, those with significant depressive symptoms are almost twice as likely to have a substance use disorder compared to their counterparts who do not experience depressive symptoms. Similarly, Minnesota adults with SPD are more than three times as likely to have a substance use disorder compared to those without symptoms of SPD. 20.0% 11.6% With Depression Without Depression 15.6% 7.8% 8.0% 8.6% 1.8% 0.0% Alcohol Disorder Drug Disorder Alcohol or Drug Disorder Figure 1. Prevalence of Substance Disorders by Depression. 2 SPD was measured by K6 scale, which is designed to screen for nonspecific psychological distress. SAMHSA (Substance Abuse and Mental Health Services Administration) referred to the K6 scale as a measure of serious mental illness (SMI) in reports preceded its 2004 National Survey on Drug Use and Health (NSDUH). However, in the 2004 NSDUH, SAMHSA found that the K6 scale is more appropriate for measuring psychological distress than SMI, and decided to refer it as SPD. 3 The K6 scale in MNSASU asks about psychological symptoms during past month whereas NSDUH asks about the 1 month in the past 12 months when respondents were at their worst emotionally. In addition, the K6 items in NSDUH were preceded by a broad array of mental health questions. The differences in time reference and the context of items might have caused the lower SPD estimate in MNSASU than the estimate in NSDUH. 2

3 40.0% 20.0% With SPD Without SPD 20.0% 21.0% 31.3% 0.0% 7.8% 1.8% 8.6% Alcohol Disorder Drug Disorder Alcohol or Drug Disorder Figure 2. Prevalence of Substance Disorders by SPD. Individuals with co-occurring disorders are challenging to the mental health and drug treatment systems because such co-morbidity often times negatively affects treatment outcomes. In comparison to single-disorder clients, those with co-occurring disorders have higher rates of recidivism, criminal involvement, suicide, unemployment, homelessness, and lower rates of treatment and medication adherence, and often require higher cost services such as inpatient and emergency room care (SAMSHA, 2002; Burns et al., 2005). This report describes the prevalence of co-occurring disorders among adults in Minnesota, and compares the characteristics of those with and without co-occurring substance use and mental health disorders. Data The data came from a statewide survey of Minnesota adults on their substance use, a project funded by Minnesota Department of Human Services. A total of 16,891 telephone interviews were completed by University of Minnesota Survey Center between October 2004 and July 2005 in English (16,340 interviews) and Spanish (551 interviews). A stratified random sample design was employed to get more accurate estimates for minority populations as well as 7 prevention planning regions. The overall response rate was 55%. More detailed information on the survey can be found in its final report at Measures The survey instrument was based on the 2002 State Treatment Needs Assessment Program (STNAP) survey core protocol questionnaire designed by the Center for 3

4 Substance Abuse Treatment (CSAT). The core survey was designed to yield rates of substance use, abuse, dependence, and treatment need. Substance abuse or dependence was defined consistent with criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition (DSM-IV) (American Psychiatric Association, 1994). A diagnosis of dependence requires meeting three or more of the seven criteria that include symptoms such as tolerance, withdrawal, failed attempts to control substance use and impaired role performance. A diagnosis of substance abuse requires meeting at least one of the four criteria in the absence of a dependence diagnosis: continued use despite recurrent familial, social, and occupational disorders; recurrent use in physically hazardous situations; recurrent substance related legal problems; recurrent substance use resulting in a failure to fulfill major role obligations. Substance abuse and dependence were defined separately for alcohol and illicit drugs. Persons who meet the criteria for either an alcohol or a drug related disorder are defined as meeting the criteria for substance use disorder. Mental health disorder was measured by depression and serious psychological distress (SPD) screeners. For depression, a two-item Patient Health Questionnaire (PHQ-2) depression screener was used, asking about depressed mood and anhedonia during the past two weeks. SPD was measured by a 6-item K6 scale, asking about how often in the past month respondents felt nervous, hopeless, restless, depressed, worthless, or that everything was an effort. Following the guidelines, a score of 3 or above on the 0-6 possible scores of PHQ-2 scale was defined as depression and a score of 13 or above on the 0-24 possible scores of K6 scale was defined as SPD. Demographic variables examined in relation to the co-occurring disorders include age, gender, race/ethnicity, marital status, education, income, employment status, and residence in metro. Race/ethnicity variable was compiled with 5 categories of White only, Latino/Hispanic, Black, Asian/Pacific Islander, and American Indian based on the respondents answers to their racial/ethnicity background. If they answered yes to white and to one of the other racial ethnicity, they were coded as the nonwhite category. Those who picked multiple nonwhite categories (.2%) were excluded from the current analyses. Residence in metro is a dummy variable based on the respondent s residential county: Metro counties for current analyses included not only the 7 metro counties (Hennepin, Ramsey, Anoka Carver, Scott, Washington, Dakota), but also Olmsted, Stearns, and St. Louis counties which are categorized as metropolitan statistical areas by U.S. Census Bureau. Results Approximately 16% of Minnesota adults showed either substance use disorder or mental health disorders. Compared to Minnesota adults without any disorder, those with either a mental health disorder or a substance use disorder were more likely to be male, young adult, single, less educated, unemployed, and from a low income household (Table 1). 4

5 They also showed higher proportions of racial/ethnic minorities, with an exception of Asians/Pacific Islanders. Table 1. Demographic characteristics of Minnesota adults with a substance use disorder or a mental health disorder vs. those without a disorder. Gender*** Age*** With disorder (N=2,657) Without disorder (N=14,164) male Race/Ethnicity*** White only Latino/Hispanic Black API American Indian Immigration Status Immigrant Marital Status*** never been married married/cohabitating widowed/divorced/separated Education*** less than high school high school graduate some college or above Income*** <30, ,001-60, >60, Employment Status*** Full/Part time Currently unemployed Other/not in labor force Residency Living in metro Note. N is the unweighted sample size. * p<.05 ** p<.01 *** p<.001 5

6 The 16% of Minnesota adults with a substance use disorder or a mental health disorder are comprised of 7.7% with a substance use disorder only, 7.0% with a mental health disorder only, and 1.4% with co-occurring disorders (Figure 3). Without Disorder 83.9% With Disorder 16.1% 7.7% 7.0% Substance Use Mental Health 1.4% Co-morbidity Figure 3. Prevalence of substance use disorder, mental health disorder, and co-morbidity among Minnesota adults. To compare Minnesota adults with co-occurring disorders to those with a single disorder, further analyses were conducted using a subset of respondents with either of the two types of disorders. Minnesota adults with co-occurring disorders both with substance use disorder and mental health disorder (co-morbidity group) will be compared first to those with substance use disorder only, then to those with mental health disorder only. Co-morbidity group vs. substance use disorder only group Compared to those with a substance use disorder only, Minnesota adults with both substance use disorder and mental health disorder were more likely to be unemployed, have lower levels of education, and come from a lower income household (Table 2). 6

7 Table 2. Demographic characteristics of Minnesota adults with only a substance use disorder vs. those with both substance use and mental health disorders. Gender Age Substance Use (N=1054) Co-occurring disorders (N=219) male Race/Ethnicity* White only Latino/Hispanic Black API American Indian Immigration Status Immigrant Marital Status* never been married married/cohabitating widowed/divorced/separated Education*** less than high school high school graduate some college or above Income*** <30, ,001-60, >60, Employment Status*** Full/Part time Currently unemployed Other/not in labor force Residency Living in metro Note. N is the unweighted sample size. * p<.05 ** p<.01 *** p<.001 Table 3 shows drug and alcohol use patterns across the two sub-groups. Compared to those who have a substance use disorder only, significantly more people with cooccurring disorders reported both lifetime and past year drug use. In addition, Minnesota 7

8 adults with co-occurring disorders were more likely to have used more than one illicit drug past year and used it once a week or more often than their counterparts. However, there was no significant difference found in binge drinking between the two groups. Table 3. Substance Use by Co-morbidity Status Substance Use (%) Co-Occurring Disorders (%) Life Time Drug Use Marijuana** Crack/Cocaine*** Heroin*** Methamphetamine*** Hallucinogen*** Stimulants*** Pain Relievers/Opiates*** Tranquilizers*** Sedatives*** Past Year Drug Use Marijuana*** Prescription Drugs*** Other Drugs*** Heavy drug use a *** Multiple drug use*** Binge Drinking Past Month b ** p<.01 *** p<.001 a Used a drug once a week or more often during past year. b 5 or more drinks for male and 4 or more for female in one occasion. Substance use disorder was measured separately for alcohol and illicit drugs. The above analyses raised a possibility that people in the two groups might have different types of substance use disorder. Based on the findings in table 3, it can be hypothesized that there are more people with alcohol problem among the substance use disorder only group and more people with drug problem among the co-morbidity group. To see if this is the case, the type of substance an individual has a problem with (alcohol vs. drugs) was examined across the two groups. Table 4 shows that the co-morbidity group has significantly more people with drug problems and significantly less people with alcohol problem compared to the singledisorder group. Vast majority of Minnesota adults with a substance use disorder only (90.7%) had either alcohol problem. About 73% of those with co-occurring disorders reported alcohol problems: Although still a substantial majority, this percentage is significantly lower than the percentage among their single-disorder counterparts. On the other hand, those with co-occurring disorders were more than twice as likely to have a 8

9 drug problem compared to those with substance use disorder only. In addition, Minnesota adults with co-occurring disorders were more likely to have both alcohol and drug problems than those only with substance use disorder (25.2% vs. 10.2%) Table 4. Type of substance use disorder by co-morbidity status Substance Use (%) Co-Occurring Disorders (%) Alcohol Disorder *** Drug Disorder*** *** p<.001 The severity of the substance use disorder was measured separately for alcohol and drugs by counting positive answers to the DSM-IV criteria questions for each substance. The severity scores ranged from 0 through 10 for each substance. Table 5 compares the mean scores for the two severity scales between the two groups. For both alcohol and drugs, those with co-occurring disorders reported significantly more numbers of symptoms of abuse or dependence compared to those only with substance use disorder. Table 5. Mean number of substance use disorder symptoms by co-morbidity status Substance Use Co-occurring disorders Number of Symptoms for Alcohol Disorder** Number of Symptoms for Drug Disorder*** ** p<.01 *** p<.001 To see if the bivariate analyses findings will hold when we consider all the variables together, a multivariate logistic regression is conducted. Dependent variable is comorbidity status: Those with both mental health and substance use disorders are coded as 1 and others with only substance disorder are coded as 0. All of the demographic variables in the previous analyses were included as well as the substance use disorder severity variables number of symptoms for alcohol disorder and drug disorder. Type of substance use disorder variable was also included with three categories: Alcohol disorder only, drug disorder only, and both alcohol and drug disorders. 9

10 Table 6. Logistic regression analysis comparing co-morbidity group to substance use disorder only group. Factor (reference category) Gender (female) Dependent Variable Co-morbidity a (N=1,200) OR male.88 Age (45+) Race/Ethnicity (White only) Latino/Hispanic 1.21 Black 1.16 API.05* American Indian 1.23 Immigration Status (Immigrant) US born.31 Marital Status (never been married) married/cohabitating 1.22 widowed/divorced/separated 1.36 Education (some college or above) less than high school 2.15 high school graduate 2.61** Income (60,000+) <= 30, ,001-60, Employment Status (employed) Currently unemployed 5.87*** Other/not in labor force 1.44 Residency (metro) Non-metro.95 Multiple Drug Use (No) Yes 2.58* Substance Disorder (Alcohol only) Drug only 8.62*** Both alcohol and drug 1.21 Number of Symptoms for Alcohol Disorder 1.37*** Number of Symptoms for Drug Disorder.96 * p<.05 ** p<.01 *** p<.001 a Those with both mental health disorder and substance use disorder are coded as 1 and others with only substance disorder are coded as 0. 10

11 Among the three substance use pattern variables -- past month binge drinking, heavy drug use, and multiple drug use -- only the multiple drug use was included in the final regression model because the other two variables were considered to be redundant with the two symptom severity variables in the model. In addition, those two variables -- past month binge drinking and heavy drug use -- were found insignificant in the initial regression analysis. Table 6 reports the odds ratio for each variable in the analysis. As shown, education level and employment status were found significant in predicting co-morbidity status even after controlling for other factors: Compared to those with some college level education, people who graduated from a high school were more likely to have both mental health disorder and substance use disorder. Also, compared to those who worked full time or part time, the unemployed were more likely to have co-occurring disorders. In addition, Asians and Pacific Islanders had lower odds of having both of the substance use and mental health disorders compared to whites. Controlling for the demographic variables, both multiple drug use and the type of substance use disorder were found significant predictors for co-morbidity status. Minnesota adults who used more than one illicit drug past year showed higher odds of having both mental health disorder and substance use disorder compared to those who used only one drug past year. Also, those who had problem with illicit drugs were more likely to have co-morbidity than those who had a problem only with alcohol. Alcohol disorder severity was also found as a significant predictor for co-morbidity status: Even after controlling for all the other factors, the more symptoms of alcohol disorder one has, the higher the odds of having both the substance use disorder and mental health disorder. Drug disorder symptom severity variable, on the other hand, was not found significant. Co-morbidity group vs. mental health disorder only group This section compares Minnesota adults who have both mental health and substance use disorders to those who have a mental health disorder only. First, the demographic comparisons between the two groups are reported in Table 7. Minnesota adults who had both mental health and substance use disorders were more likely to be male, to be young adults, and to have never been married, compared to those only with a mental health disorder. Overall, minorities were overrepresented in both groups. There were significantly more American Indians in co-morbidity group than the mental health disorder only group. On the other hand, there were about twice more Hispanics and blacks in the mental health disorder only group than in the co-morbidity group. Also, those with mental health disorder only were more likely to be immigrants and to have some college education compared to those with co-occurring disorders. 11

12 Table 7. Demographic characteristics of Minnesota adults with a mental health disorder only vs. those with both substance use and mental health disorders. Gender*** Mental Health (N=1384) % Co-Occurring Disorders (N=219) % male Age*** Race/Ethnicity** White only Latino/Hispanic Black API American Indian Immigration Status* Immigrant Marital Status*** never been married married/cohabitating widowed/divorced/separated Education* less than high school high school graduate some college or above Income <30, ,001-60, >60, Employment Status*** Full/Part time Currently unemployed Other/not in labor force Residency Living in metro * p<.05 ** p<.01 *** p<

13 In addition to the demographics, the severity of mental health problem was examined across the two groups using the mean scores of the two mental health scales used in the survey. Table 8 compares mean scores across the two groups: Minnesota adults with both mental health disorder and substance use disorder reported significantly higher scores on K6 scale compared to those who only had a mental health disorder. However, no significant difference was found on the depression scale. Table 8. Mean scores of mental health symptom scales by Co-morbidity Status Mental Health Co-occurring disorders Serious Psychological Distress (K6) *** Depression (PHQ-2) *** p<.001 To consider the demographic variables and mental health disorder severity variables at the same time, a multivariate logistic regression was conducted. The dependent variable is co-morbidity status with those who have both mental health disorder and substance use disorder coded as 1 and those who have only mental health disorder coded as 0. All the demographic variables as well as the two variables of mental health scales (K6 and PHQ-2) were included in the regression. Table 9 reports the odds ratios from the multivariate analysis. Gender and age are significantly associated with having co-morbidity: Even after controlling for other factors, compared to females or older adults, males and younger adults are more likely to have co-occurring disorders than just a mental health disorder. Both American Indians and blacks, compared to whites, were more likely to have both of the disorders. Minnesota adults who graduated from high school compared to those who had some college education were more likely to report co-occurring disorders. Compared to those who worked full or part time, the unemployed were more likely to report comorbidity whereas those who were not in labor force, such as a homemaker, retired, disabled, or students, were less likely to have co-morbidity. Controlling for all the demographic variables, the score on the Serious Psychological Distress scale was found as a significant predictor for co-morbidity status with the higher a score on the scale, higher the odds to have co-occurring disorders. 13

14 Table 9. Logistic regression analysis comparing co-morbidity group to mental health disorder only group. Dependent Variable Factor (reference category) Gender (female) Co-morbidity (N=1,511) OR male 3.28*** Age (45+) *** ** Race/Ethnicity (White only) Latino/Hispanic.25 Black.20** API.03*** American Indian 1.70 Immigration Status (Immigrant) US born 1.13 Marital Status (never been married) married/cohabitating.73 widowed/divorced/separated.83 Education (some college or above) less than high school 1.42 high school graduate 2.35** Income (60,000+) <= 30, ,001-60, Employment Status (employed) Currently unemployed 1.99* Other/not in labor force.40** Residency (metro).75 Serious Psychological Distress 1.11*** (K6) score Depression (PHQ-2) score.87 * p<.05 ** p<.01 *** p<

15 Receipt of treatment by co-morbidity status This section examines how many Minnesota adults who have a substance use disorder or a mental health disorder received a relevant treatment and if there is any difference in the treatment receipt by the co-morbidity status. Table 10 shows that significantly more Minnesota adults who had co-occurring disorders received treatment for substance use disorder during past year compared to those with only substance use disorder. Approximately 21% of those with co-occurring disorders received treatment during past year, whereas only about 4% of those only with substance use disorder received such treatment. Table 10. Past year treatment receipt by co-morbidity status. Substance Use Co-Occurring Disorders Mental Health received chemical health treatment past year*** 4.3% 20.9% --- alcohol treatment among those in need*** 2.9% 20.4% --- drug treatment among those in need 13.5% 26.8% --- received mental health treatment past year % 19.8% *** p<.001 Since we found a significant relationship between substance type and co-morbidity status, further analysis was conducted for those in need of treatment for alcohol separately from those in need of treatment for illicit drugs. Among those in need for alcohol treatment, significantly more people with co-occurring disorders have received a treatment than those with substance use disorder only. On the other hand, among those in need for drug treatment, higher percentage of people with co-occurring disorders reported receiving a drug treatment, but the difference was not statistically significant (p=058). Similar comparison was conducted on the receipt of mental health treatment during past year between those with co-occurring disorders and those only with a mental health disorder. Although more of Minnesota adults with co-morbidity reported having received mental health treatment than those only with a mental health disorder, the difference was not statistically significant (p=.056). Overall, those who had both mental health and substance use disorders received a treatment more than those who had a single-disorder. However, as shown in figure 4, the majority of those with co-occurring disorders didn t receive any treatment, and only about 11% of those received both treatments for mental health and substance use disorders. 15

16 received mental health treatment only 16.9% 62.2% received neither treatment 9.7% 11.2% received chemical health treatment only received both treatment Figure 4. Past year treatment receipt among Minnesota adults who have co-morbidity. Conclusion Approximately 16% of Minnesota adults were found with either a substance use disorder or a mental health disorder: 7.7% with substance use disorder only, 7.0% with mental health disorder only, and 1.4% with both of the disorders. Minnesota adults with lower levels of education and who were unemployed have higher odds of having co-occurring disorders relative to having substance use disorder only. In addition, those who used multiple drugs in the past year as well as those who had a drug disorder rather than alcohol disorder are more likely to have co-morbidity. Also, even after controlling for other factors, alcohol disorder severity was found significant in predicting co-morbidity status: the more symptoms of alcohol disorder one has, the higher the odds of having co-morbidity relative to having just a substance use disorder. Same pattern of influence of education and employment status was found in predicting co-morbidity relative to having just a mental health disorder: People with low education and unemployment have higher odds of having co-morbidity. Controlling for the other factors, blacks and Asians/Pacific Islanders had lower odds of having co-morbidity relative to having just a mental health disorder. In addition, males and young adults compared to females and older adults had higher odds of having co-morbidity relative to having just a mental health disorder. Severity of mental health disorder was also found as a significant factor in predicting co-morbidity: the higher SPD score one has, the higher the odds of having co-morbidity relative to having just a mental health disorder. Minnesota adults who are in need for both alcohol treatment and mental health treatment received alcohol treatment significantly more than those who are in need just for the 16

17 alcohol treatment. Alcohol treatment receipt rate was more than 6 times among those who are in need for both alcohol treatment and mental health treatment compared to those who are in need only for alcohol treatment. This might be partially because those with cooccurring substance use disorder and mental health disorder tend to have more severe alcohol problem than those with just substance use disorder. On the other hand, Minnesota adults with co-occurring substance use disorder and mental health disorder did not receive mental health treatment significantly more than those with just a mental health disorder although the former had more severe mental health problem than the latter. Majority of people with co-morbidity, even though they tend to have more severe levels of disorders, don t receive the treatment they need. More than 60% of Minnesota adults with co-morbidity did not receive any treatment; 17% received only mental health treatment, 10% received only chemical health treatment, and only about 11% received both treatments they needed. The co-occurrence of substance use and mental health disorders continues to be a major challenge for public health researchers, health care providers and policy makers. It is now well recognized that the abuse of drugs and alcohol by persons with mental illnesses has a wide range of adverse impacts on the course of mental illness and psychosocial functioning, resulting in poor compliance with treatment, poor prognosis, and higher rates of utilization of acute services leading to more costly care (Muester et al, 1992; Owen et al, 1996; RachBeisel et al, 1999). This raises concerns even more about the lack of treatment among those with co-occurring disorders. Access to treatment starts with timely screening and assessment. More research is needed to learn more about the barriers to treatment among people with co-occurring disorders. However, a routine screening for use of illicit drugs among people with mental conditions and a routine screening for mental symptoms among substance abusers can be a good starting point. Even after being diagnosed, numerous barriers have limited the capacity of treatment systems to meet the needs of those with co-occurring disorders (SAMHSA, 2002). The traditional treatment system typically is not equipped to address the complexity of co-occurring disorders. In addition, the funding mechanisms do not encourage flexible, creative financing across the substance abuse and mental health systems. Lately, however, extensive efforts have been made to develop integrated models of care that bring together mental health and substance abuse treatment with a focus on integration, comprehensiveness and individualized treatment (Osher, 2001). More progressive policies would make the integrated treatment more widely available for those with co-occurring disorders. 17

18 Reference American Psychiatric Association, (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC. Burns L., Teesson M. & O Neill K. (2005). The impact of comorbid anxiety and depression on alcohol treatment outcomes. Addiction, 100 (6), Mueser KT, Bellack AS, Blanchard JJ (1992). Comorbidity of schizophrenia and substance abuse: Implications for treatment. Journal of Consulting and Clinical Psychology. 60, Osher, F.C. (2001). Co-occurring addictive and mental disorders. In Manderscheid, R.W., & Henderson, M.J. (Eds.). Mental health, United Staets, DHHS Publication No. (SMA) Rockville, MD: Center for Mental Health Services. SAMHSA (Substance Abuse and Mental Health Services Administration) (2002). Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. Rockville, MD: SAMHSA. SAMHSA National Advisory Council (1998). Improving services for individuals at risk or, or with, co-occurring substance-related and mental health disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration. Swartz, J. A., & Lurigio, A. J. (2005). Detecting serious mental illness among substance abusers: Use of the K-6 screening scale. Journal of Evidence-Based Social Work, 2, U. S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. 18