Girls Entering Substance Abuse Treatment

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Psychology of Addictive Behaviors 2012, Vol. 26, No. 2, 345–350

© 2011 American Psychological Association 0893-164X/11/$12.00 DOI: 10.1037/a0025355

BRIEF REPORT

Mental Health Treatment Need Among Pregnant and Postpartum Women/ Girls Entering Substance Abuse Treatment Victoria H. Coleman-Cowger Chestnut Health Systems Substance use during pregnancy is widely acknowledged as a major public health concern with detrimental effects on both mother and unborn child. Mental health issues often co-occur with substance use and may trigger continued use during pregnancy or relapse to use postpartum, though little is known about the extent of these issues in pregnant and postpartum women entering substance abuse treatment. The purpose of this study is: (a) to examine self-reported mental health in a population of women and girls who were pregnant in the past year and are entering substance abuse treatment, and (b) to determine whether disparity exists in mental health treatment received across groups by race and age if a treatment need is present. Secondary data analysis was conducted with Global Appraisal of Individual Needs (GAIN) data from 502 female adolescents and adults who reported having been pregnant in the past year and who completed the GAIN upon entry into substance abuse treatment. Participants were compared on demographic, diagnostic, and problem severity variables by race and age. Results indicate that mental health treatment need is high among the whole pregnant and postpartum sample, but African American and Hispanic women and girls are receiving less mental health treatment than other groups despite having a need for it. No mental health treatment acquisition disparity was found by age. Keywords: mental health, substance use, pregnancy, racial/ethnic disparity

drug use during pregnancy is mental distress (Allen, Prince, & Dietz, 2009; Havens, Simmons, Shannon, & Hansen, 2009). There is a need to focus more intently on mental health issues specific to a pregnant population entering substance abuse treatment, given that: (a) mental health disorders are often comorbid with substance use (e.g., Compton, Thomas, Stinson, & Grant, 2007; Merikangas et al., 1998; Regier et al., 1990); (b) psychiatric disorders in these groups of women have been linked to poor maternal health, inadequate prenatal care, and adverse outcomes for their children including abnormal growth and development, poor behavior during childhood and adolescence, and negative nutritional and health effects (Vesga-Lopez et al., 2008); and (c) psychiatric treatment rates among pregnant women with psychiatric disorders are very low (Vesga-Lopez et al., 2008). Specific groups within this population may particularly benefit from integrated mental health/substance abuse treatment. A comprehensive report by the U.S. Surgeon General on mental health stated that certain racial/ethnic groups experience tremendous mental health treatment disparities (USDHHS, 2001). Wells, Klap, Koike, and Sherbourne (2001) found that African Americans (20.1%) and Hispanics (16.6%) had higher rates of probable mental disorders than Whites (13.4%), and among those with perceived or clinical need, Whites were more likely to be receiving active treatment (37.6%) than either African Americans (25.0%) or Hispanics (22.4%). Several researchers have replicated these findings (e.g., Abrams, Dornig, & Curran, 2009; Kataoka, Zhang, & Wells, 2002; Lasser, Himmelstein, Woolhandler, McCormick, & Bor, 2002), suggesting a need for improved access to mental health treatment among African Americans and Hispanics.

Substance use among pregnant women is a major public health issue in the United States (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009), and the associated perinatal complications and poor neonatal outcomes have been well-documented (El Marroun et al., 2009; Huizink & Mulder, 2006; Kelly et al., 2002; Shankaran et al., 2007). Typically, substance use decreases during pregnancy (Muhuri & Gfroerer, 2009; SAMHSA, 2008), but a substantial percentage of women continue to use tobacco, alcohol, and/or illicit drugs throughout pregnancy and many relapse postpartum (SAMHSA, 2009). A common predictor of greater resumption postpartum and/or greater level of

This article was published Online First September 5, 2011. Data (from 2007 CSAT dataset) was presented at the NIH Summit: The Science of Eliminating Health Disparities, National Harbor, Maryland, December 16-18, 2008. The development of this article was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) contract 270-07-0191 using data provided by the following grants and contracts from CSAT (Contract 207-98-7047, Contract 277-00-6500, Contract 270-2003-00006), Grant 1 HS4 TI00567 and State of Illinois Department of Alcohol and Substance Abuse, and NIDA grant R37 DA11323. The author is also the recipient of an NIH LRP award #1L60MD002957 from the National Institute on Minority Health and Health Disparities (NIMHD). The opinions are those of the author and do not reflect official positions of the contributing project directors or government. Correspondence concerning this article should be addressed to Victoria H. Coleman-Cowger, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761. E-mail: [email protected] 345

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Pregnant adolescents (aged 15–17) may also be a high-risk group, because they report a higher rate of current illicit drug use (15.8%) than nonpregnant adolescents (13.0%)—a disturbing trend that is reversed for women aged 18 – 44 (SAMHSA, 2010). The high rates of substance use during pregnancy may be indicative of underlying primary mental health issues, because psychiatric disorders seem to play an important role in the etiology of and vulnerability to substance use problems in adolescents (Swendsen et al., 2010). Indeed, the rates of mood and disruptive behavior disorders are much higher among adolescents with current substance use disorders than among adolescents without a substance use disorder (Chan, Dennis, & Funk, 2007; Kandel et al., 1999), indicating a need to examine mental health trends among pregnant and postpartum adolescents entering substance abuse treatment. Taken together, previous research findings highlight a need for comprehensive study of mental health issues among pregnant women who are racially/ethnically diverse and/or of a younger age who are entering substance abuse treatment. Despite recent advances in mental health treatment and considerable efforts to improve quality of and access to treatment, there appears to be a significant mismatch between need and treatment (Blanco et al., 2007). The purpose of this study is to examine Global Appraisal of Individual Needs (GAIN; Dennis, Titus, White, Unsicker, Hodgkins, & Webber, 2003) data collected from a diverse sample of pregnant and postpartum adults and adolescents upon entry into substance abuse treatment facilities across the United States, in an effort to identify severity of mental health issues and any disparity in mental health treatment received, given need, that exists across groups by race/ethnicity and age. This study will add significantly to extant literature by determining unmet mental health needs associated with past-year pregnancy and potential areas for improving treatment within substance treatment facilities.

Materials and Methods Data Source Data utilized for the secondary data analysis are from three sources: the Mothers at the Crossroads (MAC) project (Godley et al., 2004), which was part of the Pregnant and Postpartum Women Program funded by the Center for Substance Abuse Treatment (CSAT) of SAMHSA, and primarily an urban population; CSAT data from 8 adolescent and adult substance treatment studies with cohorts in various urban, suburban, and rural cities across the United States; and data from the Early Re-Intervention (ERI) project, an urban population (Scott & Dennis, 2003). Each site sent their data to a central data management system at Chestnut Health Systems (CHS), where it was subsequently cleaned and permission was obtained for its use. Participants in this study were 5,241 female adolescents and adults who completed the GAIN at intake for substance abuse treatment in 2008 as part of general clinical practice. Of these, 502 (9.6%) made up our study sample of those who reported having been pregnant in the past year, with ages ranging from 12 to 43 (M ⫽ 18.93, SD ⫽ 6.39). Participants were enrolled in the following levels of care: outpatient (41.8%), postresidential continuing care (15.7%), corrections (9.6%), long-term residential (9.9%), intensive outpatient (8.2%), early intervention (8.2%), or short/

moderate-term residential (4.6%). They were from small (⬍250,000 people; 21%), moderate (250,000 to 1 million; 32.2%), or large (46.8%) metropolitan areas. The largest race/ethnic groups identified in the pregnant and postpartum sample were examined: White (41.3%), African American (19.2%), Hispanic (17.8%), and Mixed (18.4%). The Mixed group consisted of individuals who self-identified as being of two or more races. All data was collected by GAIN administrators in one-on-one interviews with clients. Prior to data collection, all interviewers received intensive GAIN training by CHS staff and passed a certification process that requires proficiency in GAIN administration.

Measures The GAIN is a comprehensive biopsychosocial assessment and treatment planning instrument that consists of over 100 scales, subscales, and indices directed at understanding drug abuse treatment and all of its attendant complications and exacerbating factors, and service utilization (Dennis, Titus, White, Unsicker, Hodgkins, & Webber, 2003). The GAIN has eight core sections (Background, Substance Use, Physical Health, Risk Behaviors and Disease Prevention, Mental and Emotional Health, Environment and Living Situation, Legal, and Vocational) containing questions on the recency of problems, breadth of symptoms, and recent prevalence as well as lifetime service utilization, recency of utilization, and frequency of recent utilization. The GAIN has been demonstrated to be sensitive to change and has been validated with adult, adolescent, and pregnant and postpartum populations (Dennis, Titus, White, Unsicker, Hodgkins, & Webber, 2003; Dennis, Scott, & Funk, 2003; Dennis, Scott, Godley, & Funk, 1999, 2000). It is currently one of the most widely used measures in adolescent treatment studies in the United States (Dennis, Dawud-Noursi, Muck, & McDermeit, 2003). For this study, the following GAIN scales were examined, with associated alphas for adolescent girls (ages 12–17) noted in parentheses: Substance Problems Scale (SPSy, ␣ ⫽ .85), Internal Mental Distress Scale (IMDS, ␣ ⫽ .96), Behavioral Complexity Scale (BCS, ␣ ⫽ .94), General Crime Scale (GCS, ␣ ⫽ .86), and General Victimization Scale (GVS, ␣ ⫽ .87; Modisette, Hunter, Ives, Funk, & Dennis, 2010). Studies with adolescents have found good reliability in test/retest situations on days of use and symptom counts (r ⫽ .7 to .8), as well as diagnosis (kappa of .5 to .7; Chestnut Health Systems, 2010). SPSy, composed of 16 recency items (e.g., “When was the last time you . . .”), is a count of the number of various types of problems related to substance use that a client endorses having in the past year, including Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) symptoms of substance use disorders (abuse, dependence) and substance induced disorders (health, psychological). IMDS, composed of 43 items, is a count of past-year symptoms including somatic, anxiety, depression, traumatic stress, and suicide/homicide. BCS, composed of 33 items, is a count of past-year external behavioral problems, such as fidgeting, being forgetful, being disorganized, avoiding things that took too much effort, starting fights, setting fires, vandalism, running away, and so forth. GCS, composed of 19 items, is a count of the number of different types of illegal activities in the past year endorsed by the respondent. GVS, composed of 15 items, is a

MENTAL HEALTH TREATMENT NEED AMONG PPW

count of types of victimization experienced by the respondent (including physical, emotional, and sexual victimization) in the past year and the number of traumagenic factors involved in the victimization (including origination and duration, type and relation of perpetrator, etc.). Using discriminant analysis, the GAIN scales have been found to reliably predict independent and blind staff psychiatric diagnoses of co-occurring psychiatric disorders in an adolescent population including attention-deficit/hyperactivity disorder (ADHD; ␬ ⫽ 1.00), mood disorders (␬ ⫽ .85), conduct disorder/ oppositional defiant disorder (␬ ⫽ .82), adjustment disorder (␬ ⫽ .69), or the lack of a non-substance use diagnosis (␬ ⫽ .91) and to discriminate the primary other disorders across these conditions (␬ ⫽ .65; Shane, Jasiukaitis, & Green, 2003).

Definitions “Treatment acquisition disparity” was defined as not having received treatment in the past year, given need for mental health treatment. “Need for mental health treatment” was defined as having a moderate to high scale score on the IMDS (⬎8), moderate to high scale score on the BCS (⬎5), or endorsing suicidal thoughts. Low/moderate/high cutoffs are listed in the GAIN manual for each scale (Dennis, Titus, White, Unsicker, Hodgkins, & Webber, 2003). “Treatment received” was determined by the following question: “When was the last time, if ever, you were treated for a mental, emotional, behavioral or psychological problem by a mental health specialist or in an emergency room, hospital or outpatient mental health facility, or with prescribed medication?” Responses that indicated having received any treatment in the past year were considered “treatment received.”

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Data Analysis Data were collected as part of general clinical practice, which allows it to be used for research when de-identified or for specific research studies under their respective voluntary consent procedures. The data was pooled and de-identified for secondary analysis here under the terms of data sharing agreements and the supervision of CHS’ Institutional Review Board. All analyses were conducted with SPSS version 19.0 (Chicago, 2009). Demographic/intake profiles were created to determine group differences (Tables 1 and Tables 2). Differences in these characteristics by race and age were examined by ␹2 analysis for categorical variables or one-way analysis of variance (ANOVA) for continuous variables. Analysis to examine mental health treatment disparity (i.e., treatment received given treatment need) utilized ␹2 analysis, and separate analyses were conducted by race and by age.

Results The entire sample (N ⫽ 5,241) was assessed for mental health treatment need and treatment received to determine disparity. Over two-thirds (77%) qualified as having past-year mental health treatment need, yet only 37.6% had received mental health treatment in the past year. The sample who reported past-year pregnancy (N ⫽ 502) did not differ significantly from the no past-year pregnancy group in treatment need (78.3%) or treatment received (38.3%). Subsequent analyses focused on the sample reporting past-year pregnancy. Participants were compared on demographic, diagnostic, and problem severity variables as reported on entry into substance abuse treatment. This sample (N ⫽ 502) ranged in age from 12 to 43 years (M ⫽ 18.93, SD ⫽ 6.39), was primarily White

Table 1 Intake Characteristics by Race (N ⫽ 484)

Age, mean years (SD)ⴱⴱ Pregnancy status (all past year)ⴱⴱ Current (1, 2, or 3 trimester) Miscarried Aborted Live birth Current criminal justice system involvementⴱⴱ High severity victimization (past year)ⴱⴱ Weekly drug use Weekly alcohol use Weekly tobacco useⴱⴱ Any past year substance dependencea Any past year alcohol dependence Any past year marijuana dependence Any past year tobacco dependence Any past year substance abuse Any co-occurring mental health disorderbⴱⴱ a

White (n ⫽ 207)

African American (n ⫽ 96)

Hispanic (n ⫽ 89)

Mixed (n ⫽ 92)

18.7 (5.8)

23.6 (9.1)

17.5 (4.6)

16.3 (2.7)

27.7% 36.6% 19.8% 15.8% 63.3% 72.0% 52.9% 14.6% 73.7% 63.9% 6.0% 15.5% 25.6% 20.6% 75.4%

33.0% 20.2% 11.7% 35.1% 50.0% 49.0% 59.4% 16.7% 67.4% 57.3% 10.1% 14.6% 26.8% 21.1% 61.5%

28.4% 28.4% 19.3% 23.9% 76.1% 57.3% 46.5% 16.9% 42.7% 56.2% 4.6% 10.3% 11.6% 20.5% 77.5%

20.2% 39.3% 30.3% 10.1% 72.8% 78.3% 60.4% 14.1% 63.7% 70.3% 9.2% 16.1% 25.0% 21.1% 91.3%

␹2 or F F(3, 480) ⫽ 27.33 ␹2(9) ⫽ 35.34

␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3) ␹2(3)

⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽

16.98 24.85 4.63, p 0.49, p 26.43 5.17, p 2.99, p 1.55, p 4.12, p 0.02, p 24.02

⫽ .2 ⫽ .9 ⫽ ⫽ ⫽ ⫽ ⫽

.2 .4 .7 .2 1

Any past year dependence and any past year abuse may not add up to 100% because some individuals in the sample are in early intervention and may not qualify for a diagnosis. Twelve substances are included in these categories: alcohol, amphetamine, cannabis, cocaine, hallucinogen, inhalant, opioid, PCP, sed./Hyp./Anx., tobacco, polysubstance [i.e., across substances], other. b Any co-occurring mental health disorder includes suggested diagnoses for conduct disorder, attention-deficit/hyperactivity disorder, major depressive disorder, generalized anxiety disorder, and traumatic stress disorder. ⴱ Significant difference at p ⬍ .05. ⴱⴱ Significant difference at p ⬍ .001.

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Table 2 Intake Characteristics by Age (N ⫽ 501)

Pregnancy status (all past year)ⴱⴱⴱ Current (1, 2, or 3 trimester) Miscarried Aborted Live birth Current criminal justice system involvementⴱⴱ High severity victimization (past year) Weekly drug use Weekly alcohol use Weekly tobacco useⴱⴱⴱ Any past year substance dependenceaⴱⴱ Any past year alcohol dependence Any past year marijuana dependenceⴱ Any past year tobacco dependenceⴱ Any past year substance abuse Any co-occurring mental health disorderbⴱⴱ

Adolescents (12–17 years, n ⫽ 361)

Adults (18 years⫹, n ⫽ 140)

23.5% 41.1% 24.9% 10.5% 68.7% 65.7% 52.4% 14.4% 58.7% 57.5% 5.6% 16.2% 18.1% 22.3% 80.3%

35.5% 10.9% 6.6% 47.4% 54.7% 67.9% 57.6% 15.8% 77.7% 72.9% 10.1% 8.6% 30.2% 16.4% 64.4%

␹2 or F ␹2(3) ⫽ 113.92

␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1) ␹2(1)

⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽

8.65 0.22, p 1.07, p 0.16, p 15.75 10.00 3.09, p 4.67 5.42 2.12, p 7.45

⫽ .6 ⫽ .3 ⫽ .7 ⫽ .08 ⫽ .1

a

Any past year dependence and any past year abuse may not add up to 100% because some individuals in the sample are in early intervention and may not qualify for a diagnosis. Twelve substances are included in these categories: alcohol, amphetamine, cannabis, cocaine, hallucinogen, inhalant, opioid, PCP, sed./hyp./anx., tobacco, polysubstance [i.e., across substances], other. b Any co-occurring mental health disorder includes suggested diagnoses for conduct disorder, attention-deficit/hyperactivity disorder, major depressive disorder, generalized anxiety disorder, and traumatic stress disorder. ⴱ Significant difference between groups at p ⬍ .05. ⴱⴱ Significant difference between groups at p ⬍ .01. ⴱⴱⴱ Significant difference between groups at p ⬍ .001.

(41.3%), and over half reported high-severity victimization in the past year (66.1%), criminal justice system involvement (64.7%), weekly tobacco use (64.1%), past year substance dependence (61.9%), weekly drug use (53.9%), and having a co-occurring mental health disorder (78.0%). Significant differences between race/ethnic groups were observed by age, pregnancy status, criminal justice system involvement, high-severity victimization, tobacco use, and presence of a co-occurring mental disorder (Table 1). Specifically, African Americans were typically older, more likely to have had a live birth, and least likely to report highseverity victimization in the past year or current criminal justice system involvement. Tobacco use was highest in the White sample. Of note, over 91% of Mixed participants acknowledged having a co-occurring mental health disorder. The same variables were examined by age (i.e., adolescents compared with adults), and significant difference emerged between the two age groups in report of pregnancy status, current criminal justice system involvement, weekly tobacco use, pastyear substance dependence, and the presence of any co-occurring mental health disorder (Table 2). Adolescents were significantly more likely than adults to have miscarried in the past year, have current involvement with the criminal justice system, and report a co-occurring mental health disorder, and less likely than adults to smoke or have past-year substance dependence.

received treatment despite treatment need) between race/ethnic groups was observed. Specifically, within individuals with treatment need, Hispanic (69.1%) and African American (65.1%) groups reported significantly higher percentages of no treatment received than the Mixed (48.8%) or White (45%) groups, ␹2(3) ⫽ 15.46, p ⫽ .001.

Mental Health Treatment Need and Acquisition by Age The need for mental health treatment also differed significantly by age, ␹2(1) ⫽ 15.93, p ⬍ .001, with adolescents (82.8%) needing more treatment than adults (66.4%). However, an analysis of treatment acquisition by age among those who reported having a treatment need (N ⫽ 389) revealed no significant differences between the groups, ␹2(1) ⫽ 0.36, p ⫽ .5, with 55.9% of adults and 53.5% of adolescents receiving no past-year treatment.

95%

100%

86%

81%

80%

78% 68%

67%

70%

64%

60% 40%

Mental Health Treatment Need and Acquisition by Race/Ethnicity Mental health treatment need was calculated by age and race and is presented graphically in Figure 1. Mixed adolescents were most in need of mental health treatment (95%; p ⬍ .001). Among all those in need of mental health treatment (N ⫽ 393), a significant difference in treatment disparity (i.e., not having

20% 0%

White

Afr Amer Adolescent (N=347)

Mixed-Race

Hispanic

Adult (N=136)

Figure 1. Mental health treatment need. Adults: ␹2(3) ⫽ 1.4, p ⫽ .7 Adolescents: ␹2(3) ⫽ 18.19, p ⬍ .001.

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Mental Health Treatment Need and Acquisition by Pregnancy Status Given the significant difference noted in the pregnancy status of the sample, additional analysis was conducted to determine mental health treatment disparity by pregnancy status. Mental health treatment need was found to vary by pregnancy status, ␹2(5) ⫽ 32.8, p ⬍ .001, with greatest need among those who miscarried (90%) or had an abortion (84.5%). Treatment need ranged from 65% to 71% for those currently pregnant and postpartum (with live birth). Despite a range in treatment need, no disparity was observed in treatment received by pregnancy status. All groups were equally likely to have received no past-year treatment (ranging from 50 – 75%), with those in greater need acquiring nonsignificantly more treatment, ␹2(5) ⫽ 8.9, p ⫽ .1.

Discussion There has been limited study of large samples of pregnant and postpartum, substance-using women and girls, and researchers have acknowledged an urgent need for information on the mental health of this population (Vesga-Lopez et al., 2008). This study contributes to the literature by highlighting the mental health and other needs of this population while examining treatment disparity by race/ethnicity and age. Mental health treatment need is staggeringly high within the overall sample entering substance abuse treatment and in the past-year pregnant sample, and co-occurring mental health disorders are more common than not. In addition to mental health concerns, over half of the past-year pregnant sample have been severely victimized in the past year, have current involvement with the criminal justice system, report weekly drug and tobacco use, and qualify for diagnoses of substance dependence. The results of this study support previous findings that African American and Hispanic women have mental health treatment needs that are not being met (Abrams, Dornig, & Curran, 2009; Kataoka, Zhang, & Wells, 2002; Wells et al., 2001), and past-year pregnancy does not appear to change this. It is interesting to note that mental health need was lower in these populations but those in need were less likely to receive treatment. Though the reason for these disparities is unclear, the awareness of their existence should compel additional research in this area to connect pregnant minority women to treatment once a need is determined. Unlike previous studies (e.g., Kataoka, Zhang, & Wells, 2002), no disparity in mental health treatment acquisition by age was found. It is important to note that though treatment disparity by age may not have been present, disparity still exists in that mental health treatment received is far less than mental health treatment needed by both adults and adolescents. It is noteworthy that such a high percentage of Mixed adolescents are in need of mental health treatment, as well as individuals who miscarried or had an abortion in the past year. These populations should also be targeted for mental health intervention tailored specifically for them. There has been an acknowledgment of the need to integrate mental health into substance abuse treatment centers, specifically for pregnant and postpartum women (e.g., Grella, 1996), and mental health programming is especially beneficial for women (Ashley, Marsden, & Brady, 2003). Findings from this study lend

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further support for the need for more widespread mental health integration into substance abuse treatment, specifically with at-risk populations.

Strengths and Limitations Strengths of this study include the large sample of pregnant and postpartum women/girls, and the use of a comprehensive interview. A limitation is that the majority of the sample consist of adolescents, thus results may not be generalizable to the pregnant and postpartum population at large. Also, socioeconomic status (SES) was not measured in this study but may be a factor in the results found, as previous studies have found greater mental health need among those with lower SES (Neugebauer, Dohrenwend, & Dohrenwend, 1980). Though perhaps not a limitation, it should be noted that the definition of “treatment received” utilized in this study is quite inclusive such that one treatment episode in the past year would be considered treatment received.

Conclusions Despite these limitations, results suggest that targeted mental health treatment for African American and Hispanic women and girls may be appropriate given observed treatment disparity. Addressing disparity in health care remains a national priority (Fiscella, Franks, Gold, & Clancy, 2000), and though there is a tremendous need for mental health intervention among all women and girls presenting to substance abuse treatment during pregnancy and postpartum, it is particularly important to address the needs of those who may not have the resources or opportunity to obtain it outside of substance treatment.

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Received January 5, 2011 Revision received July 25, 2011 Accepted August 4, 2011 䡲