Substance Abuse Treatment of American Indian Adolescents: Comorbid Symptomatology, Gender Differences, and Treatment Patterns

Substance Abuse Treatment of American Indian Adolescents: Comorbid Symptomatology, Gender Differences, and Treatment Patterns DOUGLAS K. NOVINS, M.D., JANETTE BEALS, PH.D., JAMES H. SHORE, M.D., AND SPERO M. MANSON, PH.D.

ABSTRACT Objective: To describe the patient population and use of mental health treatment at a residential substance abuse

treatment program for American Indian and Alaska Native adolescents. Specifically, this article (1) reports the level of psychiatric symptomatology among the patient population; (2) compares male and female patients in terms of demographics, symptomatology, and receipt of mental health treatment; and (3) examines the degree of association between patient psychiatric symptomatology and the receipt of mental health treatment. Method: Medical records were reviewed for all 64 patients admitted over a 1-year period. Data included patient characteristics such as substance use and psychiatric symptomatology as well as the receipt of mental health treatment. Results: Sixty-eight percent of patients screened positive for at least one psychiatric symptom type. Females reported greater substance use and were more likely to report that they were victims of abuse. Females also were more likely than males to receive mental health treatment even though males had at least equal need. Finally, there was no significant relationship between measures of psychopathology and subsequent receipt of mental health treatment. Conclusions: Reassessment of the methods for identifying and treating patients with comorbid psychopathology within programs of this nature is indicated. J. Am. Acad. Child Ado/esc. Psychiatry, 1996,35(12):1593-1601. Key Words: American Indian, adolescent, substance abuse,

substance abuse treatment.

The use and abuse of drugs and alcohol among American Indian youth has been a major concern at both the local (Porterfield, 1995) and national levels (US Congress, Office of Technology Assessment, 1990). In comparison with their non-Indian peers, American Indian youth are more likely to use a wide variety of substances, begin using drugs at a younger age, continue Accepted May 9, 1996. From the National Centerftr American Indian and Alaska Native Mental Health Research, Department of Psychiatry, University of Colorado Health Sciences Center, Denver. Presented at the 1995 Annual Meeting, American Academy of Child and Adolescent Psychiatry. This study was supported in part by the American Academy of Child and Adolescent Psychiatry's Eli Lilly Pilot Research Award, NIMH Institutional Training Grant MH15442 and NIMH Scientist Development Award [ar Cliniciam K20-MHOI253 (Dr. Nouins), NIMH Research Scientist Development Award K02-MH00833 (Dr. Manson), and NIMH grant R01MH42413. Reprint requests to Dr. Nouins, Campus BoxAO11-13, UniversityofColorado Health Sciences Center, 4455 East Twelfth Avenue, Denver, CO 80220.

0890-8567/96/3512-1593$03.00/0©1996 by the American Academy of Child and Adolescent Psychiatry.

using them after initial experimentation, move on to "heavier" drugs, and use alcohol and drugs in combination with one another (Beauvais, 1992; US Congress, Office of Technology Assessment, 1990), The comorbidity of substance abuse and dependence with other mental disorders among American Indian adolescents appears to be an equally serious problem. Depression, suicide, conduct disorder, school dropout, delinquency, and running away have been shown to be related to substance abuse among Indian youth (US Congress, Office of Technology Assessment, 1990). Despite the wide recognition of the severity of these problems, the delivery of substance abuse treatment to American Indian adolescents has been described as inadequate (May, 1986; US Congress, Office of Technology Assessment, 1990). There is a paucity of substance abuse treatment programs and a bias toward treating adults in these programs (US Congress, Office of Technology Assessment, 1990). Furthermore, there have been very few studies of the substance abuse treatment of American Indians, adolescents, or adults.

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Studies of the residential treatment of American Indian adults date to the 1970s. Shore and Von Fumetti (1972) reviewed three alcohol treatment programs for American Indian adults. They found that such programs primarily treated men who had a history of legal problems in addition to their substance use disorders. Wilson and Shore (1975) completed an 18-month postdischarge follow-up of 83 American Indian men after their discharge from a regional intertribal/interagency alcohol rehabilitation program. At follow-up, 44% of these patients were either abstinent or drinking sporadically and were maintaining vocational, home, and family responsibilities. These treatment efforts used then-innovative treatment approaches, which were thought to contribute to their success. These included involvement of American Indians in the planning and operation of the programs, respect for the special characteristics and needs ofAmerican Indian alcoholics, and coordination of services with the COutts and the Indian Health Service (IHS). A more recent study compared Indian and nonIndian adults who received inpatient or outpatient treatment at a university substance abuse treatment program (Westermeyer, 1993). American Indian patients were more likely than the non-Indians to be given a dual diagnosis (72% versus 45%, respectively). This difference was due mainly to a much higher prevalence of alcohol-related organic mental disorders among the former. To our knowledge, only two studies have examined the residential treatment of substance abuse among American Indian adolescents. Johnson and Stewart (1990) reviewed the treatment of 152 American Indian adolescents at commercial residential drug and alcohol treatment facilities in the Pacific Northwest in 1988 and 1989. Unlike earlier studies ofIndian adults, they found that almost half of these adolescents (47.4%) were female. They also reported a high prevalence of polysubstance use (41.4% used three or more substances) and psychiatric comorbidity (29.6%). The program completion rate was 72.4%. Males were more likely than females to complete treatment. Husted et al. (1995) followed 290 American Indian adolescents of the Sisseton-Wahpeton Sioux tribe who received treatment at their tribally-operated residential treatment program, O'Inazin. The treatment program combined modern psychotherapeutic techniques with tribal values and traditions. Fifty-four percent of the

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sample was female. Patients reported significant problems such as suicidal ideation, history of a previous suicide attempt, curfew violations, truancy, alcohol abuse, and antisocial behaviors. The program completion rate was 59%. Program completers were more likely to remain in school and were less likely to experience continued legal problems than those who did not complete treatment. These studies suggest that several factors should be considered in evaluating treatment programs for substance-abusing American Indian youth: (1) active participation of American Indians in the treatment program; (2) use of standard treatment approaches for substance use and related disorders along with traditional Indian healing and education; (3) coordination of services with local, tribal, and IHS providers; (4) the need for attention to potential gender differences in the problems presented for treatment as well as the response to treatment; and (5) the proper identification and treatment of psychiatric comorbidity. In considering this work it is most notable that, despite the recognition of substance use as a major health problem among Indian youth, there have been very few studies concerning their treatment. This review found only two studies that examined the residential treatment of Indian youth. Therefore, it is not surprising that while this work provides some insight into the treatment ofAmerican Indian youth with substance use disorders, many important issues are only partially explored, if at all. First, the importance of culturally competent treatment (Orlandi, 1992) is emphasized in the existing studies; however, only one (Husted et aI., 1995) describes this process in detail. Optimal methods for providing culturally competent treatment for Indian youth remain undefined. Moreover, the influence of such treatment methods on outcome has yet to be documented. Second, although Johnson and Stewart (1990) documented different treatment completion rates for male and female Indian adolescents, they did not identify the reasons for such a difference. Therefore, it is important to describe the patient and programmatic characteristics that might lead to gender differences in treatment outcome. Third, both of these studies raised the issue of psychiatric comorbidity among Indian youth (Husted et aI., 1995; Johnson and Stewart, 1990), but they

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did not examine whether comorbidity influenced treatment, program completion, or treatment outcome. This is of particular concern as a recent review of adult substance abuse treatment programs provided by the IHS found that these progr ams did not systematically evaluate incoming patients for comorbid psychiatric conditions (Walker et al., 1993). The comorbidity of mental and substance use disorders is common among diagno sed adolescents in the general population (Boyle and Offord, 1991; Cohen et al., 1993; Fergusson et aI., 1993; Greenbaum et aI., 1996 ; Rohde et aI., 1996). In clinical settings, comorbid substance use disorders are common among adolescents receiving inpatient psychiatric treatment (Caton et aI., 1989 ; Eisen et aI., 1992; Greenbaum et aI., 1991; Groves er aI., 1986; Roehrich and Gold, 1986). In addition , psychiatric comorbidity (particularly conduct and mood disorders) is common among substanceabus ing adolescents receiving addictions treatment (Brown et aI., 1990, 1992; Bukstein et aI., 1989, 1992; DeMilio, 1989; Kaminer, 1991; Stowell and Estroff, 1992). The significance of psychiatric comorbidity in the treatment of substance use and dependence has been established for non-American Indian patients. Kaminer et al. (1992) studied a group of dually diagnosed substance-abusing adolescents who received inpatient treatment. Comorbid affective and anxiety disorders were more prevalent among treatment completers, while conduct disorder was associated with noncompleters. A higher percentage of program completers than noncompleters received psychotropic medications. In studies of adults with substance use disorders, individuals with comorbid psychiatric symptomatology responded differently to standard treatments and were more likely to relapse (DeLeon et aI., 1973; Horton and Bryant, 1996 ; LaPorte er al., 1981 ; McLellan et al., 1983 ; Rounsaville et al., 1987; Schuckit, 1985). There are no similar studies among Ameri can Indians of any age. Thus, th ere are substantial gaps in our knowledge about the residential treatment of substance abuse among Indian youth . These gaps include limited information about patient characteristics, program design, and treatment outcome. In response to grave concerns about substance abu se among American Indian adol escents and lack of appropriate treatment programs, the 1986 Omnibus Drug

Act provided new program dollars to establish nine residential drug and alcohol treatment programs specifically intended to serve this population. To date, none of these programs have been examined in terms of patient population, treatments provided, or the effectiveness of treatment. The aim of this article, then, is to describe the patient population and use of mental health treatment at one of the first residential treatment programs designed specifically for American Indian adolescents. In describing these patients and their use of mental health treatment, this study has th ree major goals: (1) to describe the prevalence of psychiatric symptomatology; (2) to compare male and female patients in terms of demographic characteristics, substance use, psychiatric symptomatology, and receipt of mental health treatment; and (3) to examine the degree of association between psychiatric symptomatology and subsequent receipt of mental health treatment. METHOD

The Treatment Program Study participants were treated at a 24-bed, tribally operared resident ial substance abuse treatment program for male and female American Indi an adolescents located in the South Central United States. The clinical program is infused with a culturally sensitive approach to treatment, This is accomplished through the use of American Indian staff along with the culturally specific educational and therapeutic components described below. In using these methods, the program actively seeks to enhance patients' positive Ind ian identity and utilize traditional Indi an approaches toward healing. The program is designed to provide specialized treatment of patients with substance use disorder s, including those with cornorbid psychiatric disorders. The staff includ es male and female mental health professionals encompass ing the fields of clinical psychology, social work, education, and nursing . A large number of treatment techni cians, includ ing counselors, recreation therapists, and cultural experts, complement the professional staff. Outside consultants and ment al health services are used for patients with comorb id psychiatric conditions. Most of the professional and techn ical staff are themselves American Ind ian. The clinical program consisrs of thr ee major components: (1) a therapy and counseling component (described further below); (2) an educational (school) component, which include s a course in American Ind ian culture s and history; and (3) a nur sing comp onent, which provides linkages to the local IH S hospital for pediatric and ment al health services. All patients receive a ment al health evaluation at the local IH S hospital shortly after their admission to the resident ial treatment program . T he therapy and counseling compon ent of the clinical program util izes several different treatment mod alities: (1) substance abuse counseling, which includes individual and group treatment based on a l2-step treatment philosophy; (2) recreation therap y, which uses an " O utward Bound " model to build tru st, teamwork, and

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self-esteem; and (3) the Sweat Lodge (a traditional Indian healing ritual). Other treatment modalities ate available such as family therapy, art therapy, and two therapy groups, one aimed at developing social skills, the other aimed at helping individuals deal with emotional, physical, and sexual abuse. Outreach staff provide rhe local Indian communities with information about the treatment program and facilitate the referral process. Aftercare staff coordinate ongoing treatment and develop an aftercare plan with the patient's family, community, and related agencies (e.g., social services agencies, juvenile justice system). At the time of admission, each patient is assigned a primary therapist, who works with the patient throughout treatment. The patient is usually matched to a therapist of the same gender. The program uses a "point system" in which patients earn and lose points on the basis of their performance within the treatment program. Earning points to specified levels results in an increasing number of privileges and advancement within the treatment program. The program is completed when the necessary number of points has been earned.

behaviors listed in DSM-IV, only 4 were consistently available in the medical records, and (2) the presence of two antisocial behaviors in childhood and adolescence has been found to be a strong predictor of continued social difficulties, including antisocial behavior, as an adult (Zoccolillo et al., 1992). Suicide Attempts. An additional question from the intake questionnaire completed by the patient was used to identify previous suicide attempts.

Analytic Plan Data were analyzed using SPSS for Windows, version 6.1 (N orusis, 1994). Patients were excluded from individual analyses if the necessary information was missing from their records. Chi-square and t tests were used as appropriate to examine potential gender differences in patient characteristics, substance use, psychiatric symptomatology, and mental health treatment as well as the relationships between psychiatric symptomatology and mental health treatment.

Medical Record Review Medical records were reviewed for all patients admitred from] une 1, 1993, to May 31, 1994. Data collected included demographic characteristics, referral source, discharge type, family structure (e.g., two-parent home), school status, legal status, history of victimization, previous treatments, substances used, psychiatric symptomatology (described below), and use of family therapy and mental health treatment, To determine more accurately the use of family therapy and mental health treatment, information from the medical records was supplemented with information obtained through semistructured interviews of each patient's primary therapist and the program's family therapist. Dates of admission and discharge, tribal affiliation, and discharge type were gathered from the treatment program's patient log. All other information was obtained entirely from individual medical records, A concerted effort was made to obtain a complete set of data for each patient, but rhe incompleteness of some charts introduced gaps in the data. No patrern was identified for the missing information. However, female patients were more likely to have missing data for the antisocial behaviors screening instruments than males. Patients who did not complete the program were more likely than program completers to have missing data for the Beck Depression Inventory.

Measures All summary measures were extracted from the charts. Depression. Depression was measured by using the Beck Depression Inventory; a score of 16 or greater was considered significant for depressive symptoms (Beck et al., 1961; Kaplan et al., 1984; Strober et al., 1981). Antisocial Behavior. Antisocial behavior was operationalized in terms of four questions from the treatment program's intake questionnaires completed by both the patient and his or her guardian. These items identified the following antisocial behaviors: violence toward others, vandalism, fircsctting, and cruelty toward animals. Patients identified as having displayed an aggregate of two or more of these behaviors screened positive for antisocial behaviors. Although DSM-IV requires three behaviors for a diagnosis of conduct disorder (American Psychiatric Association, 1994), a cutoff of two behaviors was chosen for the purposes of this study. There were two reasons for this decision: (1) of the 15

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RESULTS

Patient Characteristics

Sixty-four admission records were reviewed. These American Indian young people reported membership in 33 different tribes and came from every region of the continental United States. Fifty-three percent of the sample was male. The mean age was 16.3 years, with a range from 11.7 to 19.7 years old. Males were significantly older than females, with mean ages of 16.9 and 15.7, respectively (t = 3.3, 62 df, P < .OI). The average length of stay was 98.6 days. The shortest length of stay was 1 day, the longest 201 days. Referrals came from three major sources: social services (34.4%), the legal system (29.7%), and the patient or his or her family (28.1 %). Forty-four percent of the sample earned enough points in the program to complete it. Twenty-two percent of patients were discharged before completing the program when the clinical staff determined that they would not benefit further by extending their stay. Twenty-five percent were discharged from the program for noncompliance or left against medical advice. Only 29.7% of patients were living in a two-parent household when admitted; 54.8% of school-age patients were actually attending school at the time of admission (one patient had already graduated); 79.2% had legal problems prior to admission, with 28% courtordered into treatment. Fifty-two percent of the sample reported previous residential substance abuse treatment. Sixty-eight percent of patients reported they were victims of emotional, physical, or sexual abuse. Females

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were significantly more likely than males to repo rt that th ey were victims of abu se, with prevalence rates of 82.6% and 55.6% , respectively (X 2 = 4.2; 1 df,P < .05).

Adjunctive Treatm ents

Two adjunc tive treatment modalities were examined. Thirty-nine percent of patient s received family th erapy. Two thirds of tho se individuals who received family therapy did so through face-to-face sessions; the remaining one thi rd received this treatment solely by teleconference. We were unable to determine definitively whether 18 patients (28.1%) had received family therapy treatment or not. Consequently, these patients were excluded from the above analyses. Only 20.3% of patients received mental health treatment. Females were significantly more likely to receive mental health treatment tha n males (33.3% versus 8.8%, respectively; (X 2 = 5.9, 1 df,P < .05). Also, there was no significant relationship between the presence of psychiatric symptomatology and mental health treatment. Of those patients who screened positive for depression, antisocial behavior, or a previous suicide attempt, only 17.6%, 25.0%, and 23.8% , respectively, actually received mental healt h treatment .

Substance Use

The types and number of subs tances used are summarized in Table 1. The most commonly used substances were alcohol and marij uana. Fema les were more likely than males to report the use of cocaine and amp hetamines. Polysubstance use was common. Females reported using more substances than males. Eigh ty percent of patient s reported increased tolerance toward alcohol's effects; 75.6% had experienced alcohol-related blackouts; 51.6 % reported tha t their alcoho l use had damaged a relationship; 40.9% had used alcoho l to ease withdrawal symptoms; and 18.2% had attempted suicide while un der the influe nce of alcohol. The mean age at first alcoho l intoxi cation was 11.9 years. Psychiatr ic Symptomatology

The types and nu mber of psychiatric symptoms are summarized in Table 2. Sixty-eight percent of patients screened positive for at least one of these psychiatric symptoms.

DISCUSSION

This study provides initial insight into the programmatic design and pat ient characteristics of a residential

TABLE 1 T ypes and Nu mber of Substances Used Females (n = 30)

Substances used Alcohol Marijuana Inh alant s Amphetamines H allucinogens Co caine O piates Sedat ive/hyp notics Phen cyclidine No . of substances used 1 2 3 4 or more

Males (n = 34)

Gender Comparis on a (t or X2 , df!

n

%

n

%

28 25 12 15 8 7 3 3 1

93.3 83.3 40.0 50.0 26.7 23.3 10.0 10.0 3.3

32 25 8 5 4 1 1 0 1

97 .0 75.8 24.2 15.2 12.1 3.1 3.0 0.0 3.1

0.5 , 0.6, 1.8, 8.8, 2.2, 5.6, 1.3, 3.5, 0.0,

3 6 10 10

10.3 20 .7 34.5 34.5

6 15 8 4

17.6 44.1 23 .5 11.7

3.0,6 1**

I

1 1

To tal Missing (n)

I

1

1

1 1 1 2 1 1

1

2

1"" I

1* 1

2 a Genders compared on each variable; significant differences as noted at * p < .05 or ** p < .0 1 by X (substances used) or t test (number of substances used). as ind icated. h One female did not answer these questions; one male repon ed no substance use.

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TABLE 2 Psychiatric Comorbidity: Types and Number of Psychiatric Symptoms

Types of psychiatric symptoms Depression Antisocial behavior Previous suicide attempt No. of psychiatric symptoms 0 1 2 or more

Females

Males

(n = 30)

(n = 34)

n

%

n

%

Gender Comparison" (r or X2 , dj)

10 10 12

45.5 52.6 57.1

7 14 9

25.0 46.7 33.3

2.3, 1 0.2, 1 2.7, 1

8 13 9

26.7 40.0 30.0

12 14 7

36.4 42.4 21.2

0.7, 61

Total Missing (n)

14 15 16

2 a Genders compared on each variable; significant differences as noted at * p < .05 or ** p < .01 by X (types of psychiatric symptoms) or t test (number of psychiatric symptoms), as indicated.

substance abuse treatment program for American Indian adolescents. Three major findings emerged: (1) a high prevalence of comorbid psychiatric symptomatology among this program's patient population; (2) important gender differences and similarities in terms of demographic characteristics, substance use, psychiatric symptomatology, and receipt of mental health treatment; and (3) the lack of a significant association between psychiatric symptomatology and subsequent mental health treatment. Before considering these findings, we first review specific characteristics of this treatment program in the context of the limited literature concerning the residential substance abuse treatment of American Indian youth. The program addresses many of the criteria for success established by previous studies regarding the substance abuse treatment of American Indian youth. The program displays a high level of cultural competence (Orlandi, 1992). It is tribally operated, employs mainly American Indian staff, teaches American Indian culture and history, and uses traditional Indian healing in combination with standard treatment approaches. Through the use of outreach and aftercare planning as well as family therapy, the program emphasizes coordination of care and aftercare planning together with patients' families, communities, social service agencies, the juvenile justice system, and outside treatment providers. This treatment program provides long-term treatment to both male and female Indian adolescents with significant substance use disorders, many of whom have received prior residential substance abuse treatment.

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Polysubstance use is the norm for this patient population, as are symptoms of physical dependence on alcohol (i.e., tolerance, blackouts, and withdrawal). Such dependence symptoms are typically less common among adolescents than adults with substance use disorders, highlighting the severity of these patients' substance use problems (Kaminer, 1994). The seriousness of these patients' problems is further underscored by the high prevalence of legal problems, poor school attendance, history of victimization, and significant psychiatric symptomatology. The program has developed a referral system that revolves mainly around tribal and nontribal social services departments, the legal system, as well as individuals and their families. Forty-four percent of these patients actually completed the program by earning enough points to "graduate." Approximately one fifth of patients were discharged when the staff determined that the patient had received "maximum benefit" from the program despite failure to earn enough points to graduate. This discharge pattern suggests the program is moderately successful in terms of enabling youth with severe substance use disorders and related pathology to complete a long and rigorous treatment regimen. The treatment completion rate is lower than those reported for other treatment programs for American Indian youth (58% to 72.4%). This lower completion rate may reflect the higher levels of psychiatric symptomatology reported here (68% compared with 30% reported by Johnson and Stewart, 1990). Furthermore, this program treats young people from 33 different American Indian tribes, many of whom travel great

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distances to receive treatment. The two other treatment systems previously studied provided care to either the youth of a single community or from a single region of the United States. The lower completion rate may reflect the difficulty in providing comprehensive, culturally appropriate treatment to such a diverse patient population. Also, other problems such as "homesickness" and difficulties in providing family therapy over great distances (only 26.1 % of patients received faceto-face family therapy) may result in many patients leaving the treatment program before completion. As noted above, this study found a high level of psychiatric symptomatology. Sixty-eight percent of patients had at least one of the three types of psychiatric symptoms examined. More than one third of patients screened positive for depressive symptoms and almost one half screened positive for antisocial behavior. This is consistent with the conclusions of investigators studying non-Indian youth. Psychiatric comorbidity is generally present among substance-abusing adolescents, particularly among those who receive treatment (Bukstein et al., 1989; Kaminer, 1991). In addition, mood and disruptive behavior disorders are probably the most common (and best studied) psychiatric disorders among substance-abusing adolescents (Bukstein et al., 1989; DeMilio, 1989; Greenbaum et al., 1996; Kaminer, 1991). It appears that, in terms of psychiatric cornorbidity, the Indian youth described here are comparable with non-Indian youth in similar clinical settings. The analyses of gender differences are striking for both the differences found and those that were not. Females did not differ from males in terms of referral source, family structure, school attendance, legal problems, previous substance abuse treatment, or the presence of comorbid psychiatric symptomatology. This suggests that the females admitted to the treatment program were at least as severely ill as the males. In fact, female patients reported using more substances than males (specifically cocaine and amphetamines) and were more likely to report they were victims of abuse, suggesting that in some ways they may actually have more severe problems than the male patients. A treatment bias also was observed. Females were more likely to receive mental health services than males. As there is no evidence from this study that female patients had a greater need for such services (in terms of psychiatric symptomatology), it appears that the treatment program is more sensitive to the mental

health needs of its female clients and is thus more aggressive in providing them with appropriate treatment. Alternatively, it is possible that the female clients were more open about their psychiatric symptoms than their male counterparts and thus were more likely to be referred for mental health treatment. Mental health treatment was received by a minority of patients. Furthermore, there was no significant relationship between the presence of psychiatric symptomatology and the actual receipt of mental health treatment. Although the measures used in this study were at best screeners for psychopathology, this result suggests that a significant number of patients who need mental health treatment are not receiving it. This may partially be the result of the evaluation process, which involves a brief mental health assessment at the local IHS hospital. It is possible that many of these patients minimize their symptoms during their mental health assessment, resulting in the underdiagnosis of psychiatric morbidity. Unfortunately, because of the small sample size and missing data, it is not possible to determine whether psychiatric symptomatology, or the failure to treat such symptoms, was associated with failure to complete the treatment program. Some caution is in order with respect to interpreting the results of these analyses. The quality of data collected was limited by patient medical records and, in the case of adjunctive treatments, the vagaries of recall by the program's professional staff. This resulted in 25% or more of patients with data missing for one or more key variables. Although there were no overall patterns in the missing information, this may have introduced an unmeasured bias into the analysis. This missing information most likely resulted in more type II errors than type I, resulting in a failure to define completely the gender differences for this population. In addition, many symptom types that would be of concern in a population such as this could not be assessed. Therefore, we were unable to determine levels of anxiety, posttraumatic symptomatology, attentional problems, hyperactivity, mania, psychosis, or cognitive difficulties. Finally, the measures of substance use and psychopathology were not diagnostic in nature. Thus, it was not possible to ascertain the exact nature of the substance use disorders in these patients, nor the percentage who were suffering from a major depression or conduct disorder.

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Clinical Implications

REFERENCES

For substance abuse treatment programs treating similar patient populations, this study has several implications. First, these programs should review their methods of identifying and treating comorbid psychopathology. This study found that while the majority of patients screened positive for comorbid psychiatric symptomatology, only a minority of these patients received mental health treatment. While we were not able to determine whether psychiatric symptomatology, or the failure to treat such symptoms, was associated with failure to complete the treatment program, studies of adults (DeLeon et al., 1973; Horton and Bryant, 1996; LaPorte et al., 1981; McLellan et al., 1983; Rounsaville et al., 1987; Schuckit, 1985) and adolescents (Kaminer et al., 1992) in substance abuse treatment settings suggest that comorbidity does influence treatment outcome. Second, programs should carefully consider the potential for important gender differences among their patients. This study found that females were more likely to report being victims of abuse and used different types and numbers of substances than males. Such differences may have important implications for treatment design and implementation. For example, interventions developed primarily for males may not easily be applied to females because of differences in the problems males and females bring to treatment. Third, program administrators need to monitor potential gender biases in the use of specific treatment modalities, particularly mental health treatment. This study demonstrates that such biases can develop, and they may prevent some youth from receiving needed treatment. Indeed, these results suggest that males may be at greater risk for such biases, at least with respect to mental health treatment. This study provides preliminary information regarding the level of comorbid psychiatric symptomatology, gender comparisons, and the receipt of concurrent mental health treatment among patients at a residential substance abuse treatment program for American Indian adolescents. Future reports issuing from this line of inquiry will describe the prevalence and patterns of psychiatric comorbidity at a diagnostic level and the impact of such comorbid psychopathology on the treatment these patients receive as well as their eventual treatment outcome.

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