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Patterns and Predictors of Treatment Seeking After Onset of a Substance Use Disorder
Ronald C. Kessler, PhD;
Sergio Aguilar-Gaxiola, MD, PhD;
Patricia A. Berglund, MBA;
Jorge J. Caraveo-Anduaga, MD, MPH;
David J. DeWit, PhD;
Shelly F. Greenfield, MD, MPH;
Bohdan Kolody, PhD;
Mark Olfson, MD, MPH;
William A. Vega, PhD
Arch Gen Psychiatry. 2001;58:1065-1071.
ABSTRACT
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Background We studied survey respondents aged 18 through 54 years to determine
consistent predictors of treatment seeking after onset of a DSM-III-R substance use disorder.
Methods Survey populations included a regional sample in Ontario (n = 6261),
a national sample in the United States (n = 5388), and local samples in Fresno,
Calif (n = 2874) and Mexico City, Mexico (n = 1734). The analysis examined
the effects of demographics, symptoms, and types of substances on treatment
seeking.
Results Between 50% (Ontario) and 85% (Fresno) of people with substance use
disorders seek treatment but the time lag between onset and treatment seeking
averages a decade or more. Consistent predictors of treatment seeking include:
(1) late onset of disorder (odds ratio [OR], 3.8; 95% confidence interval
[CI], 2.6-5.6 for late [ 30 years] vs early [1-15 years] age at first symptom
of disorder); (2) recency of cohort (OR, 3.4; 95% CI, 2.3-5.0 for most recent
[aged 15-24 years at interview] vs earliest [aged 45 years] cohorts);
(3) 4 specific dependence symptoms (using larger amounts than intended, unsuccessful
attempts to cut down use, tolerance, and withdrawal symptoms), with ORs ranging
between 1.6 (95% CI, 1.3-2.0) and 2.7 (95% CI, 2.1-3.6) for people with vs
without these symptoms; and (4) use vs nonuse of cocaine (OR, 2.1; 95% CI,
1.6-2.7) and heroin (OR, 2.6; 95% CI, 1.1-6.0).
Conclusions Although most people with substance use disorders eventually seek treatment,
treatment seeking often occurs a decade or more after the onset of symptoms
of disorder. While treatment seeking has increased in recent years, it is
not clear whether this is because of increased access, increased demand, increased
societal pressures, or other factors.
INTRODUCTION
PREVIOUS RESEARCH on treatment seeking for substance use disorders has
demonstrated effects of clinical,1 demographic,2 attitudinal,3, 4
cultural,5 and social6, 7
factors. Several studies have also shown that the severity of substance dependence8, 9, 10 and the severity of
substance-related adverse consequences2, 6, 10
are associated with treatment seeking. However, these studies have generally
focused on a single substance of use and have followed up with prevalent cases
for short periods (typically 1 year or less). Much less is known about treatment
seeking among incident cases during longer periods using a wide range of substances.
Our report presents data based on 4 population surveys, including 1 from Canada,
2 from the United States, and 1 from Mexico. The 4 surveys were designed in
parallel to facilitate the search for consistent patterns and predictors.
The focus of our report is on the effects of age at onset, sex, cohort, severity
of disorder, and types of substances used on the odds of initial treatment
seeking among incident cases of substance abuse and dependence.
Three issues are considered. First, we examined the cumulative probabilities
of lifetime treatment seeking for substance use disorders in each survey.
Based on previous research,11, 12, 13
we hypothesized that most people with substance use disorders would eventually
seek treatment but that delays would be common. Second, we evaluated whether
treatment seeking is associated with age at onset, sex, and cohort. Consistent
with similar previous research, we hypothesized that treatment seeking would
be more likely among people with early-onset than with later-onset disorders
and among people in recent cohorts vs earlier cohorts. Because the literature
is inconsistent regarding the effect of sex on treatment seeking,14, 15 we had no hypothesis about whether
men and women would differ in treatment seeking. Third, previous studies have
shown that severity of dependence is related to treatment seeking.8, 9, 10 We consequently hypothesized
that treatment seeking would be more likely among people with dependence than
with abuse. We also evaluated whether the odds of treatment seeking are related
to the type of substance used.
METHODS
SAMPLES
All 4 surveys were carried out in multistage clustered area probability
household samples. Face-to-face interviews were administered to 1 randomly
selected respondent in each household. Respondents were aged 18 to 54 years.
The surveys included: (1) the Mental Health Supplement to the Ontario Health
Survey, a survey of 6261 respondents in Ontario, Canada, carried out in 1990-1991
(67% response rate)16; (2) the National Comorbidity
Survey (NCS), a national survey of 5388 respondents in the coterminous United
States, carried out in 1990-1992 (82% response rate)17;
(3) the Mexican-American Prevalence and Services Survey, a county-level survey
of 2875 respondents of Mexican origin in Fresno County, Calif, carried out
in 1995-1996 (90% conditional response rate in successfully screened households
known to contain Mexican-born residents)18;
and (4) the Epidemiology of Psychiatric Comorbidity Survey, a survey of 1734
residents of one catchment area in Mexico City, Mexico, carried out in 1995
(60% response rate).19 The data in all 4 surveys
were weighted to adjust for differences in within-household probabilities
of selection and to adjust the sample distributions to the census distributions
on a wide range of sociodemographic variables. More detailed discussions of
sample designs and sociodemographic distributions are presented elsewhere.20
INTERVIEWERS
The US and Ontario lay interviewers were experienced professionals who
worked for the Survey Research Center at the University of Michigan (Ann Arbor)
and for StatisticsCanada (Ottawa, Ontario) (the Canadian equivalent of the
US Census Bureau), respectively. The Mexico City and Fresno interviewers were
hired specifically for this survey. The interviewers in all 4 surveys completed
a 40-hour study-specific interviewer training course and successfully administered
a series of supervised test interviews before beginning work on the survey.
DIAGNOSTIC ASSESSMENT
The DSM-III-R21
diagnoses of alcohol and drug abuse and dependence were generated from a modified
version of the Composite International Diagnostic Interview22
developed for the NCS.23 The Composite International
Diagnostic Interview is a fully structured diagnostic interview designed to
be used by trained interviewers who are not clinicians. Both World Health
Organization field trials24 and an NCS clinical
reappraisal study25 documented acceptable reliability
and validity of these diagnoses.
Nine types of substances were assessed in the surveys: alcohol, prescription
sedatives, prescription stimulants, inhalants, marijuana, psychedelics, cocaine,
opiates, and heroin. Respondents were asked whether they had ever met each
of the DSM-III-R Criterion A symptoms of dependence
for each of the substances used (at least 5 times) and to retrospectively
report their ages at the onset of each of the 81 symptom-substance combinations
endorsed. These reports were used to estimate lifetime prevalences and ages
at onset. The analysis reported here is confined to the 3467 respondents of
the total 16 257 (the 4 surveys combined) who met lifetime criteria for
abuse or dependence. Age at onset is defined as the age at which the respondent
reported his or her first DSM-III-R Criterion A symptom
of abuse or dependence to have occurred. In most cases, this corresponds to
the age at onset of alcohol abuse. The mean (SD) and median amounts oftime
between retrospectively reported age at onset of symptoms and age at interview
were 12.5 (7.3) years and 12 years, respectively, with an age range of 0 to
52 years.
TREATMENT SEEKING
Respondents with lifetime abuse or dependence were asked whether they
had ever told a professional about their substance use problems or sought
help at a self-help group. Positive responses were followed with probes to
determine the age at which the respondent first told a professional or attended
a self-help group meeting. These responses were combined to define the age
at initial treatment seeking as the earliest age the respondent reported telling
a professional or attending a self-help group meeting. The mean (SD) and median
amounts of time between retrospectively reported age of first treatment seeking
and age at interview were 7.8 (5.9) years and 6 years, respectively, with
an age range of 0 to 37 years.
PREDICTOR VARIABLES
Discrete-time survival analysis, with person-year as the unit of analysis,
was used to study the predictors of treatment seeking. Two time-related sets
of variables that are constants for an individual older than the ages represented
in the survival analysis were included as predictors. The first set was a
series of dummy variables to define age at onset of symptoms (ages 1-15, 16-20,
21-29, and 30 years). In most cases this corresponded to the age at which
alcohol was first abused, although a small number of respondents reported
using drugs earlier than alcohol. Since no effect on treatment seeking was
found by distinguishing among types of substances first used, in the analysis
reported below we focused on age at first use and ignored the type of substance
first used. The second set of time-related predictors was a series of dummy
variables to distinguish age at interview (18-24, 25-34, 35-44, and 45-54
years).
In addition, 3 sets of predictors that take on different values for
an individual at different times during an analysis were included. The first
was the time since the onset of symptoms, created by subtracting age at symptom
onset from age in each subsequent person-year and coded as dummy variables
to distinguish 0 (age at onset), 1 through 4, 5 through 9, and 10 or more
years since onset. The second set of time-varying predictors was a series
of 9 dummy variables to describe which of the 9 substances the respondent
ever used as of each year of observation. The third set was a series of 9
dummy variables to describe which of the 9 DSM-III-R
Criterion A symptoms of dependence the respondent ever had as of each year
of observation. Preliminary investigation failed to find statistically significant
interactions between type of substance and type of symptom in predicting treatment
seeking. As a result, these effects were evaluated in an additive prediction
equation. Sex and country were also included as predictors.
ANALYSIS PROCEDURES
The Kaplan-Meier method26 was used to
generate a cumulative probability of a treatment seeking curve for respondents
with lifetime substance use disorders starting at the age of symptom onset.
Discrete-time survival analysis27 with person-year
as the unit of analysis was used to study the predictors of treatment seeking
within and across surveys. Standard errors of parameter estimates were generated
using the jackknife repeated replications procedure28
to adjust for the weighting and clustering of observations. An SAS (SAS Institute,
Cary, NC) macro29, 30, 31
was written to operationalize the jackknife repeated replications procedure.
Statistical significance was evaluated at the .05 level using 2-sided tests.
RESULTS
LIFETIME PREVALENCES OF SUBSTANCE USE DISORDERS AND TREATMENT SEEKING
The proportion (SE) of respondents in the surveys who met DSM-III-R criteria for lifetime substance abuse or dependence (Table 1) varied from a high of 28.2% (0.9%)
in the United States to a low of 10.6% (0.9%) in Mexico City. The proportion
(SE) who reported ever seeking treatment for their substance problems varied
from a high of 47.9% (3.8%) in Fresno to a low of 24.8% (3.4%) in Mexico City.
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Table 1. Lifetime Prevalence of DSM-III-R Substance Use and Lifetime
Treatment Seeking in the 4 Surveys*
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CUMULATIVE LIFETIME PROBABILITIES OF TREATMENT SEEKING
Kaplan-Meier curves (Figure 1)
show that most people with substance use disorders eventually seek treatment
(50% in Ontario, 60% in Mexico City, 72% in the United States, and 85% in
Fresno). These proportions are uniformly higher than the proportions of lifetime
treatment seeking reported in Table 1
because Table 1 reports treatment
seeking to date, while Figure 1
includes projections of anticipated future treatment seeking. The median time
between onset of symptoms and initiation of treatment seeking is 10 years
in Ontario, 13 in Fresno and Mexico City, and 16 in the United States.
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Time to initial treatment seeking after symptom onset in the
4 surveys.  23 = 26.2.
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THE EFFECTS OF AGE AT SYMPTOM ONSET, AGE AT INTERVIEW, SEX, AND TIME
SINCE SYMPTOM ONSET
Survival models were estimated to evaluate the effects of age at symptom
onset, age at interview, sex, and time since symptom onset to predict treatment
seeking. Preliminary analysis showed that none of the survival coefficients
differed significantly across surveys.32 Therefore,
only pooled results are reported here. The survival coefficients from the
additive model (Table 2) have
been reparametrized and can be interpreted as odds ratios (ORs).
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Table 2. Effects of Age at First Use, Age at Interview (Cohort), Sex,
and Time Since Onset of Disorder in Predicting Treatment Seeking for Substance
Use, 4 Surveys Combined*
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The first 4 rows of Table 2
show a significant inverse relationship between age at symptom onset and odds
of treatment seeking. The next 4 rows show that the odds of seeking treatment
in a given year are higher for the youngest respondents, controlling for age
at symptom onset. Given that the prediction equation controls for person-year,
the effect of age at interview is probably a cohort effect and will be referred
to as such for the remainder of the article. The next 2 rows show that there
is no meaningful sex difference. The next 4 rows follow the pattern seen in Figure 1: that the odds of treatment seeking
are somewhat greater in the year of onset of symptoms than in subsequent years.
Another aspect of this progression that can be seen in Table 2 but not in the unadjusted rates used to compute Figure 1 is that the odds of treatment-seeking
increase after the first decade of symptoms. The next 4 rows, finally, show
that there is a significant between-country difference in the treatment-seeking
net of the sociodemographic variables because of a lower odds in the Mexico
City sample than the other samples.
A number of interaction models were investigated to determine whether
the cohort effect observed in Table 2
varies systematically by the other predictors. A significant interaction between
cohort and age at symptom onset was found in the United States (29 = 18.7; P = .03) and Fresno (29 = 12.1; P = .21). This occurs
because treatment seeking is more likely among recent cohorts and more so
among respondents with the earliest ages at onset of symptoms. A significant
interaction between cohort and sex was found in Fresno (23 = 10.4; P = .02). This is owing to a stronger
cohort effect among women than men. A significant interaction between cohort
and time since symptom onset was found in the United States (29 = 18.4; P = .03). This is caused by a stronger
cohort effect in the first few years after symptom onset than in later years.
THE EFFECTS OF DSM-III-R SYMPTOMS AND TYPES
OF SUBSTANCES USED
The results in Table 3 show
that, after adjusting for the effects documented in Table 2, there is significant variation in the pooled association
between the 9 Criterion A symptoms of dependence and treatment seeking (29 = 334.5; P<.001). This variation
is also significant in each of the 4 individual surveys (with 29 in the range of 32.5-470.9; P<.001).
Four of the 9 criteria have significantly elevated ORs in the pooled data:
using larger amounts or for longer periods than intended (DSM-III-R Criterion A1), unsuccessful attempts to cut down use (A2),
tolerance (A7), and withdrawal symptoms (A8). Each of these symptoms is associated
with an average increase in the odds of treatment seeking compared with people
without the symptom (OR, 1.7-2.7). The ORs of these 4 significant symptoms
do not differ significantly across the surveys (23
range, 2.0-3.7; P = .23-.57). The residual between-country
difference in treatment seeking, presented in the last 4 rows of Table 3, is no longer significant after
adjusting for differences in symptom prevalences (23 = 5.3; P = .15).
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Table 3. Effects of DSM-III-R Substance Use
Disorder Symptoms in Predicting Initial Treatment Seeking, 4 Surveys Combined*
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After adjusting for the effects presented in Table 2 and Table 3, there is significant variation (Table 4) in the pooled associations between the 9 types of substances and
treatment seeking (29 = 65.3; P<.001). This variation is also significant in 3 of the 4 individual
surveys (29 range, 56.4-214.6; P<.001). The exception is Mexico City, where only 3 substances were
reported to be used by a large enough number of respondents to be included
in the analysis (alcohol, marijuana, and sedatives). No significant variation
in the ORs among these 3 substances was found in any of the surveys (22 range, 0.8-2.8; P = .25-.67).
Cocaine and heroin have significantly elevated ORs in the pooled data, each
associated with an OR of 2.2-2.7. These ORs do not differ significantly across
the surveys (22 range, 1.8-4.9; P = .07-.41). The residual between-country difference in treatment
seeking remains nonsignificant after adjusting for differences in types of
substances used (23 = 3.4; P = .37).
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Table 4. Effects of Type of Substance Used in Predicting Treatment
Seeking for Substance Use, 4 Surveys Combined*
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COMMENT
The results support all 3 initial hypotheses. (1) Most people with substance
use disorders eventually seek treatment but long lag times until such action
are the norm. (2) The odds of treatment seeking are positively related to
the age at onset of disorder and are higher in successively more recent cohorts.
(3) The rate of treatment seeking is higher among people with than without
certain symptoms of dependence and among users than nonusers of cocaine and
heroin. All of these results were confirmed in all 4 surveys.
As noted in the introduction, most research on barriers to treatment
seeking for substance use disorders focuses on recent use of services among
prevalent cases and finds low rates of service use.5, 6, 33
Our finding that most people with substance use disorders eventually seek
treatment puts these results into a broader context. Our finding is consistent
with data on more general patterns of lifetime treatment seeking for a wide
range of mental disorders in previous analyses of 2 of the 4 surveys considered
here11, 12 as well as in an 11-country
comparative analysis of first treatment seeking among incident cases in a
survey of members of mental health patient advocate groups.13
The seeming discrepancy between the low current treatment-seeking rates
in prevalence studies and the high lifetime treatment-seeking rates in our
study is largely explained by the long lag time between symptom onset and
first treatment seeking. Whether this long lag time should be a source of
concern is questionable since much of this time might be spent with only 1
or 2 symptoms of abuse that do not warrant treatment. To shed some light on
this issue, we replicated the survival analysis separately for respondents
with abuse and with dependence. Estimated lifetime rates of treatment seeking
were found to be higher for dependence (60%-92% across surveys) than abuse
without dependence (18%-40% across surveys), with estimated median time lags
between symptom onset and first treatment seeking shorter for dependence (5-8
years across surveys) than abuse without dependence (10-19 years across surveys).
Although it is unclear what the "right" time is to intervene in substance
problems, it is a matter of concern that lag times are a decade or longer
for individuals with dependence. The much longer lag times for abuse might
be less of a problem. However, these long lag times seem inconsistent with
the substance abuse treatment community's emphasis on early outreach and high-risk
preventive intervention.
The significant inverse relationship between age of symptom onset and
treatment seeking is also of concern. Early symptom onset is a powerful predictor
not only of substance abuse34 but also of the
transition from abuse to dependence,35 and
of adverse social consequences of substance use, such as truncated educational
attainment, teen childbearing, marital instability, and economic adversity.36, 37 The low treatment-seeking rates of
early-onset users presumably occurs because they hide their substance problems
from their parents and teachers and are dependent on these adults to initiate
treatment.38, 39 It is less clear
why early-onset users continue to have low rates of treatment seeking even
after they enter adulthood, a pattern that we observed in subsample analyses.
One possibility is that early-onset users develop adult lifestyles that allow
them to continue using drugs without disrupting established adult roles, thereby
reducing their chances of seeking treatment. Although we have no way of investigating
this interpretation in these surveys, the reasons for low rates of treatment
seeking among early-onset users warrant more serious investigation in future
studies.
On a more positive note, we found that treatment seeking has increased
significantly in recent cohorts. This is part of a broader pattern of similar
cohort effects in treatment seeking for a wide range of mental disorders in
several countries around the world.11, 12, 13
In the case of substance use disorders, this could be owing to the joint effects
of consolidation of drug and alcohol programs,40
changing attitudes,41 greater awareness about
treatment options,42 and expansion of treatment
options.43 Pressures for involuntary treatment
have also increased through the expansion of school-based programs, employee
assistance programs, mandatory treatment programs for drunk drivers, and substance
programs in the criminal justice system. Because the surveys included no questions
about site, the circumstances surrounding treatment, or whether treatment
was voluntary or mandated, it is impossible to evaluate the relative importance
of these various possibilities. Future research should include questions of
this sort.
The finding that 4 of the 9 symptoms of substance dependence are associated
with increased odds of treatment seeking is consistent with previous evidence
that treatment seekers have more symptoms of dependence than those who do
not seek treatment.6, 10 Why these
4 symptoms are important and the others are not is unclear. Previous studies
have generally found that the effects of symptoms are mediated by perceptions
of need for treatment and recognition of adverse social and health consequences.5, 9, 44 It is plausible, then,
to think that the effects of the dependence symptoms found in our report are
mediated by unmeasured cognitive factors, although it is also plausible to
speculate that these symptoms increase the probability of detection and involuntary
treatment.
The finding that users of cocaine and heroin are more likely to seek
treatment than users of other substances with comparable symptoms goes beyond
previous studies, which have largely focused on treatment seeking for problems
with one substance. One plausible interpretation of these results is that
cocaine and heroin are more likely than other substances to lead to impairments
or symptoms that promote treatment seeking. This possibility is consistent
with the finding, in studies of gateway drugs, that use of cocaine and heroin
typically occurs fairly late in the progression of drug use by an individual.45, 46
No hypotheses were advanced about differences across the surveys, since
our goal was to search for consistencies in patterns and predictors. However,
it is noteworthy that the higher rate of substance use disorder in the United
States than in Ontario or Mexico City is consistent with the findings in cross-national
substance-use prevalence studies.47, 48
The higher rate of treatment seeking in Fresno than the rest of the United
States is consistent with the findings of Kaskutas et al2
in a US national sample that Hispanics are more likely than non-Hispanics
to seek treatment for substance problems. However, the significant between-survey
differences in odds of treatment seeking disappeared when we controlled for
symptoms, implying that the lower gross treatment-seeking rate in Mexico City
is owing to substance use disorders being less severe than in the other samples.
An important methodological limitation is that recall errors might have
led to unreliability in retrospectively reported ages of symptom onset and
first treatment seeking. Validation studies show that recall errors of this
sort tend to be systematically "forward telescoped," that is, to recall dates
as being more recent than they are.49, 50
This means that the lag times reported here are likely to be lower bound estimates.
Variation in recall errors with age might at least partly explain the higher
reported rates of treatment seeking in more recent cohorts.
Another limitation is the absence of confirmatory evidence of treatment
from service records. In addition, it is important to note that we focused
on treatment "seeking" rather than receiving treatment. No data in the surveys
are available to estimate the proportion of treatment-seekers who eventually
obtained appropriate treatment or the typical lag time between initial treatment
seeking and eventually receiving appropriate care. We know from other studies
that the lag time between initial treatment seeking and receiving appropriate
care can be substantial.51 Future research
is consequently needed not only to elaborate our understanding of modifiable
determinants of initial treatment seeking, but also to study patterns and
determinants of obtaining appropriate treatment.
AUTHOR INFORMATION
Accepted for publication May 1, 2001.
The data reported here come from the International Consortium in Psychiatric
Epidemiology (ICPE). The ICPE is supported by grant R01- DA11121 from the
National Institutes of Health (NIH), Bethesda, Md. The Mental Health Supplement
to the Ontario Health survey was supported by funds from the Ontario Ministry
of Community and Social Services, Ottawa. The NCS was supported by grants
R01-MH46376, R01-MH49098, and K05-MH00507 from the NIH, and by grant 90135190
from the W.T. Grant Foundation, New York, NY. The Mexican-American Prevalence
and Services survey was supported by grants R01-MH51192 and R01-DA12167 from
the NIH. The Epidemiology of Psychiatric Comorbidity survey was funded by
grant 2077-H9302 from the Mexican National Council of Science and Technology,
Mexico City.
From the Departments of Health Care Policy (Dr Kessler), and Psychiatry
(Dr Greenfield), Harvard Medical School, Boston, Mass; the Department of Psychology,
School of Natural Sciences, California State University, Fresno (Dr Aguilar-Gaxiola);
the Institute for Social Research, University of Michigan, Ann Arbor (Ms Berglund);
Instituto Mexicano de Psiquiatria, Huipulco, Mexico (Caraveo-Anduaga); the
Addiction Research Foundation, Clinical, Social, and Evaluation Research Department,
London, Ontario (Dr DeWit); McLean Hospital, Belmont, Mass (Dr Greenfield);
Sociology Department, San Diego State University, San Diego, Calif (Dr Kolody);
Department of Psychiatry, College of Physicians and Surgeons, Columbia University,
New York, NY (Dr Olfson); and Robert Wood Johnson Medical School–UMDNJ,
Institute for Quality Research and Training, New Brunswick, NJ (Dr Vega).
Corresponding author and reprints: Ronald C. Kessler, PhD, Department
of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA
02115 (e-mail: kessler{at}hcp.med.harvard.edu).
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