Treatment services and service delivery models for dually diagnosed clients: variations across mental health and substance abuse providers

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Classifying substance use disorder treatment facilities with co-located mental health services: A latent class analysis approach

BACKGROUND

The Affordable Care Act calls for increased integration and coordination of behavioral health services, as people with co-occurring disorders (CODs), meeting criteria for both substance use and psychiatric disorders, are overrepresented in treatment samples. Nationwide estimates of mental health (MH) service co-location in substance use disorder (SUD) treatment facilities are needed. We empirically derived a multiple-indicator categorization of services for CODs in SUD treatment facilities.

METHODS

We used latent class analysis to categorize 14,037 SUD treatment facilities in the United States and territories included in the 2012 National Survey of Substance Abuse Treatment Services. Latent class indicators included MH screening and diagnosis, MH support services, psychiatric medications, groups for CODs, and psychosocial approaches. Multinomial logistic regression compared facility-identified primary focus (i.e., SUD, MH, mix of SUD-MH, and general/other) and other facility characteristics across classes.

RESULTS

A four-class solution was chosen with the following classes: Comprehensive MH/COD Services (25%), MH without COD Services (25%), MH Screening Services (21%), and Limited MH Services (29%). The former two classes with co-located MH services were less likely to report a SUD-primary focus than the latter classes reporting only MH screening or Limited MH Services. Only the Comprehensive MH/COD Services class also had a high probability of providing special groups for CODs.

CONCLUSIONS

Approximately half of SUD treatment facilities were in classes with co-located mental health services, but only a quarter provided comprehensive COD services. Future studies should assess differences in patient experiences and treatment outcomes across facilities with and without COD services.

Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems

Despite increased awareness of the benefits of integrated services for persons with co-occurring substance use and psychiatric disorders, estimates of the availability of integrated services vary widely. The present study utilized standardized measures of program capacity to address co-occurring disorders, the dual diagnosis capability in addiction treatment and dual diagnosis capability in mental health treatment indexes, and sampled 256 programs across the United States. Approximately 18 % of addiction treatment and 9 % of mental health programs met criteria for dual diagnosis capable services. This is the first report on public access to integrated services using objective measures.

Dual Diagnosis Capability in Mental Health and Substance Use Disorder Treatment Programs

OBJECTIVE

Improved understanding of the relative strengths and weaknesses of treatment organizations' dual diagnosis capability is critical in order to guide efforts to improve services. This study assesses programs' capacity to meet the needs of clients with dual diagnosis, identifies areas where they are well equipped to serve these clients, and determines where programmatic improvement is needed. The study also undertakes an initial exploration of the potential impact that funding sources have on dual diagnosis capability.

METHODS

We administered Dual Diagnosis Capability in Addiction Treatment (DDCAT) and Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) assessments at 30 treatment programs in two California counties. Seven of the programs received funding to provide both mental health and substance use disorder services, 13 received funding to provide mental health services, and 10 received funding to provide substance use disorder services.

RESULTS

The mean DDCAT/DDCMHT score of programs in the sample was 2.83, and just over 43% of the sample met or exceeded DDCAT/DDCMHT criteria for dual diagnosis capability. Programs scored highest and had the highest rates of dual diagnosis capability in domains related to assessment, training, and staffing, whereas scores were weakest and rates of dual diagnosis capability were lowest in the program structure, treatment, and continuity of care domains. Programs that received funding to provide both mental health and substance use disorder services consistently scored higher than the other programs in the sample, and mental health programs scored higher than substance use disorder treatment programs both on the overall assessments and in most domains.

CONCLUSIONS

Findings suggest that programs in the sample are functioning at a nearly dual diagnosis capable level. However, structural barriers continue to limit providers' capacity to serve clients with co-occurring mental health and substance use disorders, and many organizations have not yet translated their potential to deliver dual diagnosis capable services into practice. By enhancing their program structure, treatment services, and continuity of care services, these treatment organizations should be able to deliver fully dual diagnosis capable services. Observed differences in dual diagnosis capability based on funding source indicate a need for further research to better understand the impact that funding streams have on dual diagnosis capability.

Impact of Abstinence Self-Efficacy and Treatment Services on Physical Health-Related Behaviors and Problems among Dually Diagnosed Patients

OBJECTIVE: Physical health problems are pervasive among patients with co-occurring substance use and mental disorders. Yet, drug treatment programs often ignore tobacco use and its association with health. Abstinence self-efficacy has been associated with improved outcomes for co-occurring disorders, which in turn may also impact physical health. This study had the goal of assessing whether abstinence self-efficacy for drugs and alcohol, and provision and use of services would influence tobacco use and other health-related outcomes among 351 individuals with co-occurring disorders in residential drug treatment. METHODS: Structural models tested the impact of baseline abstinence self-efficacy and treatment service characteristics on 6-month outcomes of health problems, functional limitations, health perceptions, and cigarette and heavy alcohol use. Demographics and baseline values for outcome variables were included as covariates. RESULTS: Correlations within time for poor health, cigarette use, and heavy alcohol use were substantial. A longer time in drug treatment was associated with less cigarette and heavy alcohol use at a 6-month follow-up. Baseline health problems were associated with more cigarette use and functional limitations at 6-months. Abstinence self-efficacy did not predict less cigarette use, but predicted less heavy alcohol use and fewer functional limitations. Availability of specialized dual-diagnosis groups and more on-site psychological services were not directly associated with outcomes, but had an impact through indirect effects on more psychological service utilization which predicted better subjective health. CONCLUSIONS: Improving overall treatment retention and services utilization among patients with co-occurring disorders may generalize to improved health perceptions, but specific health promotion and smoking-cessation interventions are warranted to improve health outcomes.

An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment

CONTEXT

Although depression frequently co-occurs with substance abuse, few individuals entering substance abuse treatment have access to effective depression treatment.

OBJECTIVE

The Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) study is a community-based effectiveness trial that compared residential substance abuse treatment with residential treatment plus group cognitive behavioral therapy for depression delivered by substance abuse treatment counselors. We hypothesized that intervention clients would have improved depression and substance use outcomes compared with those of clients receiving usual care.

DESIGN

A nonrandomized controlled trial using a quasi-experimental intent-to-treat design in which 4 sites were assigned to alternate between the intervention and usual care conditions every 4 months for 2½ years.

SETTING

Four treatment programs in Los Angeles County.

PARTICIPANTS

We screened 1262 clients for persistent depressive symptoms (Beck Depression Inventory-II score >17). We assigned 299 clients to receive either usual care (n = 159) or usual care plus the intervention (n = 140). Follow-up rates at 3 and 6 months after the baseline interview were 88.1% and 86.2%, respectively, for usual care and 85.7% and 85.0%, respectively, for the intervention group.

INTERVENTION

Sixteen 2-hour group sessions of cognitive behavioral therapy for depression.

MAIN OUTCOME MEASURES

Change in depression symptoms, mental health functioning, and days of alcohol and problem substance use.

RESULTS

Intervention clients reported significantly fewer depressive symptoms (P < .001 at 3 and 6 months) and had improved mental health functioning (P < .001 at 3 months and P < .01 at 6 months). At 6 months, intervention clients reported fewer drinking days (P < .05) and fewer days of problem substance use (P < .05) on days available.

CONCLUSIONS

Providing group cognitive behavioral therapy for depression to clients with persistent depressive symptoms receiving residential substance abuse treatment is associated with improved depression and substance use outcomes. These results provide support for a new model of integrated care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191788.

Stability of Outcomes Following Residential Drug Treatment For Patients with Co-occurring Disorders

OBJECTIVE: Few studies have examined the stability of both substance use and mental health outcomes following residential drug abuse treatment for individuals with co-occurring disorders (COD). This study examines outcomes at 6 and 12 months for individuals with COD, in relationship to services received over the follow-up period. METHODS: Participants with COD (N=310) were sampled from 11 residential drug abuse treatment programs and completed in-depth assessments within 30 days of intake and at 6- and 12-month follow-ups. A path model was developed testing the relationships among treatment participation and services received, psychological status, and substance use outcomes across the two follow-up points. RESULTS: Retention for at least 90 days in residential drug treatment was associated with less inpatient mental health treatment and more mental health services received at 6 months; outpatient mental health treatment was associated with reduced substance use at 6 months. Substance use at 6 months was associated with more psychological distress at both 6 and 12 months and more inpatient mental health treatment at 12 months. CONCLUSIONS: Findings suggest that receipt of mental health services following residential drug abuse treatment for patients with COD is critical to improving their longer-term outcomes.

Supporting good practice in the provision of services to people with comorbid mental health and alcohol and other drug problems in Australia: describing key elements of good service models

Background

The co-occurrence of mental illness and substance use problems (referred to as "comorbidity" in this paper) is common, and is often reported by service providers as the expectation rather than the exception. Despite this, many different treatment service models are being used in the alcohol and other drugs (AOD) and mental health (MH) sectors to treat this complex client group. While there is abundant literature in the area of comorbidity treatment, no agreed overarching framework to describe the range of service delivery models is apparent internationally or at the national level. The aims of the current research were to identify and describe elements of good practice in current service models of treatment of comorbidity in Australia. The focus of the research was on models of service delivery. The research did not aim to measure the client outcomes achieved by individual treatment services, but sought to identify elements of good practice in services.

Methods

Australian treatment services were identified to take part in the study through a process of expert consultation. The intent was to look for similarities in the delivery models being implemented across a diverse set of services that were perceived to be providing good quality treatment for people with comorbidity problems.

Results

A survey was designed based on a concept map of service delivery devised from a literature review. Seventeen Australian treatment services participated in the survey, which explored the context in which services operate, inputs such as organisational philosophy and service structure, policies and procedures that guide the way in which treatment is delivered by the service, practices that reflect the way treatment is provided to clients, and client impacts.

Conclusions

The treatment of people with comorbidity of mental health and substance use disorders presents complex problems that require strong but flexible service models. While the treatment services included in this study reflected the diversity of settings and approaches described in the literature, the research found that they shared a range of common characteristics. These referred to: service linkages; workforce; policies, procedures and practices; and treatment.

Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders

This study describes the prevalence of childhood traumatic events (CTEs) among adults with comorbid substance use disorders (SUDs) and mental health problems (MHPs) and assesses the relation between cumulative CTEs and adult health outcomes. Adults with SUDs/MHPs (N=402) were recruited from residential treatment programs and interviewed at treatment admission. Exposures to 9 types of adverse childhood experiences were summed and categorized into 6 ordinal levels of exposure. Descriptive analyses were conducted to assess the prevalence and range of exposure to CTEs in comparison with a sample from primary health care. Logistic regression analyses were conducted to examine the association between the cumulative exposure to CTEs and adverse health outcomes. Most of the sample reported exposure to CTEs, with higher exposure rates among the study sample compared with the primary health care sample. Greater exposure to CTEs significantly increased the odds of several adverse adult outcomes, including PTSD, alcohol dependence, injection drug use, tobacco use, sex work, medical problems, and poor quality of life. Study findings support the importance of early prevention and intervention and provision of trauma treatment for individuals with SUDs/MHPs.

Developing an integrated treatment for substance use and depression using cognitive-behavioral therapy

Providing a unified treatment approach to meet the substance abuse and mental health needs of clients is the preferred model for addressing co-occurring disorders. We developed a group-based cognitive-behavioral (CBT) integrated treatment for depression and substance use disorders (SUD) that could be delivered by counselors in SUD treatment settings and evaluated its feasibility and acceptability. We conducted an in-depth case study examining one implementation of the treatment using 15 focus groups with clients (n = 7) and semistructured interviews with counselors (n = 2) and administrators (n = 3). Using CBT as a treatment approach to integrate the treatment was widely accepted by clients, counselors, and administrators. Clients stated the treatment was applicable to multiple aspects of their lives and allowed them to recognize their clinical improvements over time. Counselors and administrators discussed challenges for long-term feasibility. Key decisions used to develop the treatment and recommendations for implementing integrated care in SUD settings are discussed.

Treatment approaches for dual diagnosis clients in England

INTRODUCTION

Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS).

DESIGN

A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey.

RESULTS

In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists.

CONCLUSIONS

Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Counselor and client characteristics in mental health versus substance abuse treatment settings providing services for co-occurring disorders

The study compares counselor and client characteristics of state-funded co-occurring disorder (COPSD) programs in mental health (MH) versus substance abuse (SA) settings. SA counselors more often had graduate degrees and MH counselors rated their knowledge and skills lower on two of nine COPSD best practice principles. MH clients were more frequently diagnosed with schizophrenia, depression, and bipolar disorder, whereas SA clients displayed evidence of greater substance use severity and had higher rates of treatment completion and abstinence at discharge. Results reveal significant implications for workforce development and potential system changes to enhance COPSD services that are unique to each setting.

Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders

This article describes factors that influence national policy and practice, with particular focus on the implications of epidemiological survey research. Examples of areas of concern to policymakers include treatment-seeking patterns, access to care at points of service in public health and social service systems, evidence-based practices, workforce development, and the complexities of reimbursement. In responding to data on systemic barriers to care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has sought to promote a no wrong door strategy to address the needs of persons with co-occurring disorders (CODs) involving their mental health and substance use. Examples of SAMHSA programs and policies addressing CODs discussed in this article include targeted partnerships with the states, mechanisms to enhance system infrastructure, technical assistance, and initiatives with special populations.

Mental health provider perspectives on co-occurring substance use among severely mentally ill clients

This qualitative study explores strategies used by mental health providers (N = 17) to address substance use problems among seriously mentally ill (SMI) clients and their perspectives on barriers to treatment and how treatment can be improved. Providers identified numerous strategies, yet these were countered with perceptions of multiple obstacles, leaving them frustrated, helpless, and hopeless about their clients' substance use. Results suggest that, in addition to improving access to quality dual-diagnosis treatment, larger issues of poverty and social isolation must also be addressed. Not doing so limits what providers can do for SMI clients and could reduce the effect of larger system-level improvements.

Role of social support and self-efficacy in treatment outcomes among clients with co-occurring disorders

Individuals with co-occurring substance use and psychiatric disorders have a more severe clinical course and poorer outcomes than do individuals with one disorder. In an attempt to find intervening variables that may contribute to improvement in treatment outcomes among individuals with co-occurring disorders, we investigated the roles of social support and self-efficacy in a sample of 351 clients with co-occurring disorders in residential drug abuse treatment programs (53% male; 35% African American, 13% Hispanic). Given their demographic variability, we also explored how ethnicity and age influence self-efficacy and access to social support, as well as their relationships to the outcomes. Structural equation modeling was used to examine the impact of the demographics and baseline psychological status, substance use, social support, and self-efficacy on mental health and substance use outcomes 6 months after treatment entry. Time in treatment was included as a control. Greater social support at baseline predicted better mental health status and less heroin and cocaine use; greater self-efficacy predicted less alcohol and cocaine use. Older clients reported less social support. African-American ethnicity was associated with more cocaine use at baseline and follow-up; however, African Americans reported more self-efficacy, which moderated their cocaine use. The current study highlights the potential therapeutic importance of clients' personal resources, even among a sample of severely impaired individuals.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE

This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up.

METHODS

Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up.

RESULTS

Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services.

CONCLUSIONS

Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.