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Article Excerpt
Possession of a large amount of money is a well-recognized relapse trigger (O'Brien et al. 1990; Wallace 1992), and several highly publicized reports have suggested that Social Security Administration (SSA) benefit payments to patients disabled by psychiatric illness result in greater use of alcohol and drugs of abuse (Satel 1995; Shaner et al. 1995). Other studies have specifically focused on the increased prevalence of substance abuse and related harm around the beginning of the month, the so-called "check effect" (Grossman et al. 1997; Phillips, Christenfeld, and Ryan 1999; Catalano et al. 2000; Halpern and Mechem 2001).
However, no differences in drug use were observed in a comparison of homeless persons who received public support payments over a 3-month period and those who did not (Rosenheck, Lam, and Randolph 1997) and no increased substance use was found among homeless veterans awarded supplemental security income (SSI) or Social Security Disability Insurance (SSDI) compared with veterans whose applications were denied (Rosenheck et al. 2000). A cross-sectional analysis of 2,474 veterans enrolled in an outreach program also found no greater substance use among those receiving disability payments than among those not receiving them (Frisman and Rosenheck 1997).
It is thus possible that while receipt of disability payments alters the timing of substance abuse so that substance use increases when checks are received, it does not alter the total amount of abuse. Longitudinal studies are needed to better elucidate whether receipt of disability payments is associated with increased overall substance use.
The most informative longitudinal studies of the effect of disability payments on substance abuse have focused on participants in the SSA's drug addiction and alcoholism (DA&A) program (Swartz, Tonkin, and Baumohl 2003), which provided SSA benefits to beneficiaries specifically disabled by substance use until it was discontinued in 1996 (Hunt and Baumohl 2003). Two important studies have compared outcomes between DA&A beneficiaries who lost their benefits and those who continued to receive benefits for a disabling condition other than substance abuse. In one study, outcome toxicology screens did not differ between those whose benefits ended and those whose benefits were renewed (Swartz, Hsieh, and Baumohl 2003b). In the other, self-report data appeared to suggest that continued receipt of SSA benefits was associated with more severe drug problems, although the authors did not come to this conclusion (Guydish et al. 2003).
The current study is a longitudinal analysis of the relationship between receipt of Social Security benefits and subsequent substance use among participants in the access to community care and effective services and supports (ACCESS) demonstration, a 12-month outcome study involving over 7,000 homeless persons with severe mental illness in 18 U.S. communities. It differs from previous studies in that it involves a larger sample with longer follow-up, is not restricted to beneficiaries who receive disability as a result of substance abuse (the DA&A studies), and utilizes administrative Social Security records to corroborate benefit status. Homeless people with serious mental illness desperately need disability payments but are also at high risk to use such payments for alcohol and drugs. We hypothesized that participants newly awarded SSI or SSDI during the 12 months would have more subsequent drug and alcohol use over time than those not awarded SSA benefits, as evidenced by a significant group-by-time interaction.
METHODS
The ACCESS Program
In ACCESS, agencies in 18 communities in nine different states provided assertive community treatment (ACT) to approximately 7,000 homeless people with severe mental illness as part of a study of service systems integration (Randolph et al. 2002). The core features of ACT include providing diverse services in community settings, 24-hour availability, and targeting the full range of client needs (Stein and Test 1980; Lehman et al. 1997). Implementation of the ACT model in ACCESS was relatively faithful to the evidence-based model (Teague, Bond, and Drake 1998). Study participants received considerably more services after enrollment than they were receiving before enrollment, and showed marked clinical improvement in a wide range of outcome measures (Rosenheck and Dennis 2001).
One of two sites within each of nine states was randomly assigned to also receive approximately $250,000 per year to implement systems integration strategies. However while these efforts were modestly effective at the system level (Morrissey et al. 2002), they had no significant effect on individual client outcomes (Rosenheck et al. 2002). Thus, receipt of ACT was not affected by the implementation of special integration initiatives at half of the sites.
Eligibility Criteria and Sources of Data
Participants were eligible if they were homeless, suffered from severe mental illness (Shern et al. 1994), and were not currently involved in ongoing community treatment (Rosenheck and Lam 1997). People who agreed to participate were referred to intensive case management teams that provided ACT over the next 12 months. The current analysis of ACCESS data was approved by the Yale and VA Connecticut Institutional Review Boards.
Sampling
Assessments were completed upon enrollment and 3 and 12 months later. At least one follow-up assessment was collected from 6,585 of the 7,225 participants in the ACCESS study (91.1 percent)--the 3-month follow-up evaluation was completed by 5,800 (82.2 percent) and the 12-month by 5,471 (77.5 percent). The small number of participants (n = 386) who had received SSA benefits at baseline and later lost them were excluded, leaving a sample of 6,199.
SSA benefit status was determined by a series of questions concerning how much money the participant had received from various sources in the previous 30 days. Participants who reported having received an SSI or SSDI payment were considered SSA beneficiaries at the time of the interview. Participant SSA status was classified as one of the following four mutually exclusive categories: not receiving SSA benefits throughout the study (No SSA, n = 3,259), benefits newly acquired between and 3 months (SSA 3 Months, n = 385), benefits newly acquired between 4 and 12 months (SSA 12 Months, n = 819), or as having had benefits throughout (SSA Throughout, n = 1,736).
Self-reported benefit status was complemented by data on benefit status from the SSA's Commissioner for Research, Evaluation, and Statistics. SSA administrative files were matched with the date of each of the ACCESS follow-up interviews. Matches were identified between Social Security numbers of ACCESS participants and records of payments from the SSI and SSDI program files. The SSA only provided data when there was a corresponding Social Security number in SSA files, verified by dates of birth and gender. Thus, the absence of a match could indicate either that no SSA payments had been made, or that the client had...
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