Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Implementation Resource Kit User's Guide

Special Populations Appendix

A review of the literature addressing the range of populations for which the skills/strategies of integrated dual disorders treatment has demonstrated efficacy or effectiveness, including factors such as age, race, ethnicity, gender, institutional setting, sexual orientation, and geographic location.

Research on integrated treatment for dual disorders has focused mainly on the development and evaluation of comprehensive programs that incorporate the core ingredients of assertive outreach, motivation-based intervention (including stages of treatment), comprehensiveness, and a long-term perspective (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998b; Ley & Jeffery, 2002). While the general findings across the different studies provide support for the effectiveness of integrated services (Drake et al., 2001), only limited research has directly examined the question of whether integrated treatment is more effective for some clients than others. As a result, the evidence base for judging the differential effectiveness of integrated treatment for different subgroups of clients is quite limited at this point.

Despite the limited data available, research on integrated treatment for dual disorders has included clients with a wide range of different backgrounds. With respect to age, while there is a tendency for clients with dual disorders to be younger, all research on the topic includes a wide range of ages, with most clients between 18 and 55 (Barrowclough et al., 2001; Carmichael et al., 1998; Drake et al., 1998a; Drake, Yovetich, Bebout, Harris, & McHugo, 1997; Godley, Hoewing-Roberson, & Godley, 1994; Jerrell & Ridgely, 1995). Similarly, all these studies included both males and females, with males making up the majority of participants, consistent with the higher prevalence of substance abuse in men than women (Mueser, Yarnold, & Bellack, 1992; Mueser et al., 2000). Special issues have been identified related to the unique needs of women with dual disorders (Brunette & Drake, 1998; Brunette & Drake, 1997; Gearon & Bellack, 1999), but there is no evidence suggesting that women with dual disorders benefit less from integrated treatment.

Race or ethnicity have varied across the different studies, with most studies including a majority of Caucasian clients but also including some African American clients (Carmichael et al., 1998; Drake et al., 1998a; Godley et al., 1994; Jerrell & Ridgely, 1995). One study included only African American clients and reported very positive results from integrated treatment (Drake et al., 1997). A large, randomized controlled trial comparing the assertive community treatment approach with standard case management for integrated treatment of dual disorders in an inner-city, homeless population has recently been concluded and results are expected soon (Mueser, Essock, Drake, Wolfe, & Frisman, 2001). This study included predominantly African American clients, but some Caucasian and Latino clients also participated. More work is needed to evaluate the effectiveness of integrated dual disorders treatment for Latino clients.

The majority of studies of integrated treatment for dual disorders have been conducted on an outpatient basis, with positive results (Barrowclough et al., 2001; Carmichael et al., 1998; Drake et al., 1998a; Drake et al., 1997; Godley et al., 1994; Jerrell & Ridgely, 1995). Less research has examined the effectiveness of integrated treatment provided in inpatient, residential, or intensive day treatment programs. Most of the studies examining short-term residential or intensive day treatment (3-6 months) programs suffer from high dropout rates (Blankertz & Cnaan, 1994; Burnam et al., 1995; Penn & Brooks, 1999; Rehav et al., 1995). One longer-term residential program, integrated into the community with a gradual transition from the residence into the community, found very positive long-term outcomes (Brunette, Drake, Woods, & Hartnett, 2001). Shorter-term integrated inpatient treatment for dual disorders may have an important role to play in stabilizing clients, engaging them in treatment, providing education about mental illness and substance abuse interactions, and motivating them to work on their substance abuse problems (Franco, Galanter, Castaneda, & Patterson, 1995; Rosenthal, 2002). Research is needed to evaluate the effectiveness of programs such as these when they are provided in a coordinated fashion with integrated outpatient treatment for dual disorders.

Research studies on integrated treatment programs for dual disorders have included significant numbers of clients with housing instability and homelessness (Carmichael et al., 1998; Drake et al., 1998a; Drake et al., 1997; Meisler, Blankertz, Santos, & McKay, 1997). The evidence from these studies indicates that integrated treatment is effective at improving both substance abuse and housing outcomes. Presumably, the outreach component of integrated treatment is critical to successful outcomes in work with this challenging population.

Geographically, research on integrated treatment for dual disorders has been conducted in a variety of places. Several studies of treatment have been done in large urban areas (e.g., Washington, DC, Austin, Texas) (Carmichael et al., 1998; Drake et al., 1997; Jerrell & Ridgely, 1995), with two studies in more rural settings (Drake et al., 1998a; Godley et al., 1994). One study of integrated treatment for dual disorders was conducted in Manchester, England (Barrowclough et al., 2001). All of these studies have reported positive effects of integrated treatment, suggesting that the treatment principles are robust across a variety of geographical settings.

References

Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S., Moring, J., O'Brien, R., Schofield, N., & McGovern, J. (2001). Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. American Journal of Psychiatry, 158, 1706-1713.

Blankertz, L. E., & Cnaan, R. A. (1994). Assessing the impact of two residential programs for dually diagnosed homeless individuals. Social Service Review, 68, 536-560. Brunette, M., & Drake, R. E. (1998). Gender differences in homeless persons with schizophrenia and substance abuse. Community Mental Health Journal, 34, 627-642.

Brunette, M. F., & Drake, R. E. (1997). Gender differences in patients with schizophrenia and substance abuse. Comprehensive Psychiatry, 38, 109-116.

Brunette, M. F., Drake, R. E., Woods, M., & Hartnett, T. (2001). A comparison of long-term and short-term residential treatment programs for dual diagnosis patients. Psychiatric Services, 52, 526-528.

Burnam, M. A., Morton, S. C., McGlynn, E. A., Peterson, L. P., Stecher, B. M., Hayes, C., & Vaccaro, J. V. (1995). An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. Journal of Addictive Diseases, 14, 111-134.

Carmichael, D., Tackett-Gibson, M., O'Dell, L., Jayasuria, B., Jordan, J., & Menon, R. (1998). Texas Dual Diagnosis Project Evaluation Report 1997-1998. College Station, TX: Public Policy Research Institute/Texas A&M University.

Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., Lynde, D., Osher, F. C., Clark, R. E., & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52, 469-476.

Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. H. (1998a). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry, 68, 201-215.

Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998b). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.

Drake, R. E., Yovetich, N. A., Bebout, R. R., Harris, M., & McHugo, G. J. (1997). Integrated treatment for dually diagnosed homeless adults. Journal of Nervous and Mental Disease, 185, 298-305.

Franco, H., Galanter, M., Castaneda, R., & Patterson, J. (1995). Combining behavioral and self-help approaches in the inpatient management of dually diagnosed patients. Journal of Substance Abuse Treatment, 12, 227-232.

Gearon, J. S., & Bellack, A. S. (1999). Women with schizophrenia and co-occurring substance use disorders: An increased risk for violent victimization and HIV. Community Mental Health Journal, 35, 401-419.

Godley, S. H., Hoewing-Roberson, R., & Godley, M. D. (1994). Final MISA Report. Bloomington, IL: Lighthouse Institute.

Jerrell, J. M., & Ridgely, M. S. (1995). Comparative effectiveness of three approaches to serving people with severe mental illness and substance use disorders. Journal of Nervous and Mental Disease, 183, 566-576.

Ley, A., & Jeffery. (2002). Cochrane review of treatment outcome studies and its implications for future developments. In H. L. Graham, A. Copello, M. J. Birchwood, & K. T. Mueser (Eds.), Substance Misuse in Psychosis: A Handbook of Approaches to Treatment and Service Delivery (pp. 349-365). Chichester, England: John Wiley & Sons.

Meisler, N., Blankertz, L., Santos, A. B., & McKay, C. (1997). Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance disorders. Community Mental Health Journal, 33, 113-122.

Mueser, K. T., Essock, S. M., Drake, R. E., Wolfe, R., S., & Frisman, L. (2001). Rural and urban differences in dually diagnosed patients: Implications for service needs. Schizophrenia Research, 48, 93-107.

Mueser, K. T., Yarnold, P. R., & Bellack, A. S. (1992). Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder. Acta Psychiatrica Scandinavica, 85, 48-55.

Mueser, K. T., Yarnold, P. R., Rosenberg, S. D., Swett, C., Miles, K. M., & Hill, D. (2000). Substance use disorder in hospitalized severely mentally ill psychiatric patients: Prevalence, correlates, and subgroups. Schizophrenia Bulletin, 26, 179-192.

Penn, P. E., & Brooks, A. J. (1999). Comparing Substance Abuse Treatments for Dual Diagnosis: Final Report. Tucson, AZ: La Frontera Center, Inc.

Rehav, M., Rivera, J. J., Nuttbrock, L., Ng-Mak, D., Sturz, E. L., Link, B. G., Struening, E. L., Pepper, B., & Gross, B. (1995). Characteristics and treatment of homeless, mentally ill, chemical-abusing men. Journal of Psychoactive Drugs, 27, 93-103.

Rosenthal, R. (2002). An inpatient-based service model. In H. L. Graham, A. Copello, M. J. Birchwood, & K. T. Mueser (Eds.), Substance Misuse in Psychosis: A Handbook of Approaches to Treatment and Service Delivery (pp. 136-155). Chichester, England: John Wiley & Sons.

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