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McGowan LJ, John DA, Kenny RPW, Joyes EC, Adams EA, Shabaninejad H, Richmond C, Beyer FR, Landes D, Watt RG, Sniehotta FF, Paisi M, Bambra C, Craig D, Kaner E, Ramsay SE. Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions. PLoS One 2024; 19:e0298885. [PMID: 38635524 PMCID: PMC11025870 DOI: 10.1371/journal.pone.0298885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.
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Affiliation(s)
- Laura J. McGowan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Deepti A. John
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ryan P. W. Kenny
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma C. Joyes
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma A. Adams
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Richmond
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Fiona R. Beyer
- Evidence Synthesis Group and Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - David Landes
- NHS England & Improvement, Newcastle Upon Tyne, United Kingdom
| | - Richard G. Watt
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Falko F. Sniehotta
- NIHR Policy Research Unit Behavioural Science, Newcastle University, Newcastle Upon Tyne, United Kingdom
- Department of Public Health, Social and Preventive Medicine, Centre for Preventive Medicine and Digital Health (CPD), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martha Paisi
- Faculty of Medicine and Dentistry, Peninsula Dental School, University of Plymouth, Plymouth, United Kingdom
| | - Claire Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eileen Kaner
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sheena E. Ramsay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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O'Shaughnessy BR, Michelle Greenwood R. Empowering Features and Outcomes of Homeless Interventions: A Systematic Review and Narrative Synthesis. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2020; 66:144-165. [PMID: 32176327 DOI: 10.1002/ajcp.12422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The purpose of this systematic review and narrative synthesis was to identify homeless interventions with empowering features and evaluate their effectiveness for developing the psychological empowerment of services users. To identify and evaluate intervention studies, we combined the theoretical frameworks of empowering settings and psychological empowerment (PE). Our conceptualization of PE included outcomes aligned with the intrapersonal, interactional, and behavioral components. Relational outcomes were also included and conceptualized as antecedents for PE development. After systematic searching and screening, 37 studies were included for review. Interventions with empowering features included supported housing, case management, skills and knowledge acquisition, and mutual support. Interventions that were competency-building effectively improved outcomes aligned with the intrapersonal PE component. Interventions that were collaborative and competency-building effectively improved outcomes aligned with the behavioral PE component. Weak evidence suggested that interventions with empowering features may effectively improve outcomes aligned with the interactional PE component. Interventions that promoted and developed support effectively improved relational antecedents. Findings align the empirical evidence for homeless interventions with theoretical conceptions of empowering features and processes. Findings may be applied to the design and implementation of homeless interventions to incorporate empowering features and to facilitate the development of homeless services users' PE. Highlights Empowerment theory was applied to review homeless interventions literature. Empowering homeless interventions included supported housing and mutual support, for example. Empowering interventions contributed to indicators of emotional and behavioral empowerment. Fewer empowering interventions contributed to indicators of cognitive empowerment. Service user involvement may facilitate improvements in indicators of psychological empowerment.
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Abstract
Purpose
The purpose of this paper is to analyse the clinical outcome data collected as part of an 18-week, abstinence-based residential therapeutic community (TC) programme, Higher Ground Drug Rehabilitation Trust (Higher Ground) in New Zealand. Lessons and implications for routine collection of clinical outcome data are identified.
Design/methodology/approach
Higher Ground collects longitudinal data on all consenting clients using a battery of validated psychometric tools, with repeated measures at up to nine points in time from first presentation through to 12-month post-discharge follow up. Data analysis covered clients who entered Higher Ground between 1 July 2012 and 2 June 2015 (n=524).
Findings
Clients presented with histories of addiction which often had significant negative associations with their physical and psychological health, their relationships, work, accommodation and criminal behaviour. By the time they exited the programme, clinically and statistically significant improvements were seen across multiple indicators including: substance use and abstinence; symptoms of post-traumatic stress disorder, depression, anxiety and stress; and a range of social indicators.
Research limitations/implications
Attrition in follow-up research is a significant challenge, with people completing the TC programme being more likely to participate than those who do not. This limits generalizability in post-discharge data. There was no control group, making causal attribution a challenge. Identifying suitable benchmarks from the literature is challenging because of the variety of outcome measures and research methodologies used.
Practical implications
Tracking client outcomes longitudinally using psychometric tools is potentially valuable for TCs and their funding bodies, as it provides insights into patterns of client recovery that can inform ongoing service improvements and resource allocation decisions. However, significant challenges remain.
Originality/value
The study demonstrates the value, and practical challenges, of collecting high-quality outcome data in a TC setting.
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Hunt GE, Siegfried N, Morley K, Sitharthan T, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2013:CD001088. [PMID: 24092525 DOI: 10.1002/14651858.cd001088.pub3] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. AUTHORS' CONCLUSIONS We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- Glenn E Hunt
- Discipline of Psychiatry, The University of Sydney, Concord Centre for Mental Health, Hospital Road, Sydney, NSW, Australia, 2139
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Therapeutic communities for addictions: a review of their effectiveness from a recovery-oriented perspective. ScientificWorldJournal 2013; 2013:427817. [PMID: 23401669 PMCID: PMC3562581 DOI: 10.1155/2013/427817] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 12/09/2012] [Indexed: 11/17/2022] Open
Abstract
Therapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live together in an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research tradition in TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applied a selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs for addictions with that of a control condition. The focus of this paper is on recovery, including attention for various life domains and a longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our search strategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Two out of three studies showed significantly better substance use and legal outcomes among TC participants, and five studies found superior employment and psychological functioning. Length of stay in treatment and participation in subsequent aftercare were consistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Since recovering addicts often cycle between abstinence and relapse, a continuing care approach is advisable, including assessment of multiple and subjective outcome indicators.
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Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: Crime outcomes. J Subst Abuse Treat 2012; 42:247-59. [DOI: 10.1016/j.jsat.2011.07.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 05/27/2011] [Accepted: 07/22/2011] [Indexed: 11/19/2022]
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Brunette MF, Mueser KT, Drake RE. A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug Alcohol Rev 2009; 23:471-81. [PMID: 15763752 DOI: 10.1080/09595230412331324590] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Substance use disorder is the most common and clinically significant co-morbidity among clients with severe mental illnesses, associated with poor treatment response, homelessness and other adverse outcomes. Residential programs for clients with dual disorders integrate mental health treatment, substance abuse interventions, housing and other supports. Ten controlled studies suggest that greater levels of integration of substance abuse and mental health services are more effective than less integration. Because the research is limited by methodological problems, further research is needed to establish the effectiveness of residential programs, to characterize important program elements, to establish methods to improve engagement into and retention in residential programs and to clarify which clients benefit from this type of service.
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Affiliation(s)
- Mary F Brunette
- New Hampshire--Dartmouth Psychiatric Research Center and Dartmouth Medical School NH, USA.
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8
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Cleary M, Hunt GE, Matheson S, Walter G. Psychosocial treatments for people with co-occurring severe mental illness and substance misuse: systematic review. J Adv Nurs 2009; 65:238-58. [DOI: 10.1111/j.1365-2648.2008.04879.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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De Leon G, Wexler H. The Therapeutic Community for Addictions: An Evolving Knowledge Base. JOURNAL OF DRUG ISSUES 2009. [DOI: 10.1177/002204260903900113] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The therapeutic community (TC) has become an established treatment approach serving thousands of substance abusers in community, institutional, and other settings. This article summarizes the research that contributed to the acceptance and growth of TCs and laid the groundwork for the establishment of TCs for substance abusers in correctional settings. The TC knowledge base has contributed to the revival of a rehabilitation philosophy in correctional policy, which is described in the second section. The reflections of the authors who have collaborated for about 40 years are provided at the end of the paper.
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Cleary M, Hunt G, Matheson S, Siegfried N, Walter G. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2008:CD001088. [PMID: 18253984 DOI: 10.1002/14651858.cd001088.pub2] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for substance reduction in people with a serious mental illness. SEARCH STRATEGY For this update (2007) we searched the Cochrane Schizophrenia Group Trials Register (May 2006) which is based on regular searches of major databases. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random effects model. We calculated numbers needed to treat/harm (NNT/NNH) where data were homogeneous. For continuous data, we calculated weighted mean differences (WMD) again based on a random effects model. MAIN RESULTS Evaluation of long-term integrated care included 4 RCTs (total n=735). We found no significant difference on measures of substance use (n=85, 1 RCT, RR 0.89 CI 0.6 to 1.3) or loss to treatment (n=603, 3 RCTs, RR 1.09 CI 0.8 to 1.5). For the non-integrated intensive case management trials (4 RCTs, total n=151) we also found no significant difference for loss (n=134, 3 RCTs, RR 1.35 CI 0.8 to 2.2). Motivational interviewing plus cognitive behavioural therapy (3 RCTs, total n=276) did not reveal any advantage for retaining participants (n=36, 1 RCT, RR lost to treatment 0.50 CI 0.1 to 5.0) or for relapse (n=36, 1 RCT, RR 0.58 CI 0.3 to 1.1), and no benefit for reducing substance use (n=119, 1 RCT, RR 0.19 CI -0.2 to 0.6). Cognitive behavioural therapy alone (4 trials, total n=260) showed fewer participants lost from treatment (n=260, 4 RCTs, p=0.02, RR 0.61 CI 0.4 to 0.9). No benefits were observed on measures of lessening cannabis use (n=47, 1 RCT, RR 1.30 CI 0.8 to 2.2) or on the number of participants using substances (alcohol; n=46, 1 RCT, RR 5.88 CI 0.8 to 44.0, drugs; n=46, 1 RCT, RR 2.02 CI 0.9 to 4.8) and no differences were observed on measures of mental state (n=105, 1 RCT, RR 0.52 CI -0.8 to 1.8). We found no advantage for motivational interviewing alone (5 trials, total n=338) in reducing 'lost to evaluation' (n=338, 5 RCTs, RR 0.96 CI 0.6 to 1.5) compared with treatment as usual, although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n=93, 1 RCT, RR 0.69 CI 0.5 to 0.9, NNT 4 CI 3 to 12). Some differences were observed in abstaining from alcohol favouring treatment (n=28, 1 RCT, RR 0.36 CI 0.2 to 0.8, NNT 2 CI 2 to 5), but not other substances (n=89, 1 RCT, RR -0.07 CI -0.6 to 0.4) and no differences were observed in mental state (n=30, 1 RCT, WMD -4.20 CI -18.7 to 10.3). Finally, we found no significant differences for skills training in the numbers lost to treatment by 12 months (n=94, 2 RCTs, RR 0.70 CI 0.4 to 1.1). AUTHORS' CONCLUSIONS We included 25 RCTs and found no compelling evidence to support any one psychosocial treatment over another to reduce substance use (or improve mental state) by people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results; high drop out rates, varying fidelity of interventions, varying outcome measures, settings and samples and comparison groups may have received higher levels of treatment than standard care. Further studies are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- M Cleary
- Sydney South West Area Health Service (Eastern Zone), Research Unit, Rozelle Hospital, P.O. Box 1, Rozelle, Australia, NSW 2039.
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Sacks JY, McKendrick K, Hamilton Z, Cleland CM, Pearson FS, Banks S. Treatment outcomes for female offenders: relationship to number of Axis I diagnoses. BEHAVIORAL SCIENCES & THE LAW 2008; 26:413-434. [PMID: 18683197 DOI: 10.1002/bsl.828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This article describes a study that examined the relationship between multiple Axis I mental health diagnoses and treatment outcomes for female offenders in prison substance abuse treatment programs. Preliminary findings of the effectiveness of therapeutic community (TC) treatment, modified for female offenders, relative to a control cognitive behavioral treatment condition, are presented. The hypothesis--that participants who fit into multiple diagnostic categories have more dysfunctional symptoms and behaviors at baseline--was confirmed; however, a hypothesized relationship between the number of Axis I diagnoses and 6 month treatment outcomes across five domains (mental health, trauma exposure, substance use, HIV needle risk behaviors, and HIV sexual risk) was not supported. Across all Axis I mental health groups, TC treatment was significantly more effective than the control condition overall, as well as on measures of mental health symptoms and HIV sexual risk. These findings suggest that this TC treatment program, as modified, is an effective model for women with varied diagnoses and diagnostic complexities.
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Affiliation(s)
- Joann Y Sacks
- Center for the Integration of Research and Practice, National Development and Research Institutes, Inc, New York, NY 10010, USA.
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Harrison L, Curtis R. Integrating traditional and non-traditional approaches to treat a client with a co-occurring addictive and mental disorder: A case study. COUNSELLING & PSYCHOTHERAPY RESEARCH 2006. [DOI: 10.1080/14733140212331384775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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French MT, Roebuck MC, McLellan AT. Cost estimation when time and resources are limited: the Brief DATCAP. J Subst Abuse Treat 2005; 27:187-93. [PMID: 15501371 DOI: 10.1016/j.jsat.2004.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2003] [Revised: 05/26/2004] [Accepted: 07/01/2004] [Indexed: 11/16/2022]
Abstract
The Drug Abuse Treatment Cost Analysis Program (DATCAP) was designed in the early 1990s as a research guide to collect and analyze financial data from addiction treatment programs. The addiction research community could clearly benefit from a version of the DATCAP that reduced the time and effort required for its administration without compromising the integrity of its cost estimates. This paper introduces the Brief DATCAP and presents some preliminary findings. Initial feedback from respondents suggests that the Brief DATCAP is understandable, and easier and quicker to complete than the DATCAP. More importantly, preliminary results indicate that cost estimates from the Brief DATCAP differ from those of the longer DATCAP by less than 2%. These results have important research and policy implications because a shorter yet reasonably accurate cost instrument will enhance the feasibility and precision of future economic evaluations of addiction interventions.
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Affiliation(s)
- Michael T French
- Department of Sociology, University of Miami, Coral Gables, FL 33124-2030, USA.
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Howell EM, Greifinger RB, Sommers AS. What Is Known About the Cost-Effectiveness of Health Services for Returning Prisoners? JOURNAL OF CORRECTIONAL HEALTH CARE 2004. [DOI: 10.1177/107834580301000308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Robert B. Greifinger
- NCCHC’s Health Status of Soon-tobe-Released Inmates: A Report to Congress in Dobbs Ferry, New York
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Sacks S, De Leon G, Sacks JY, McKendrick K, Brown BS. TC-oriented supported housing for homeless MICAs. J Psychoactive Drugs 2004; 35:355-66. [PMID: 14621133 DOI: 10.1080/02791072.2003.10400018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This article describes a TC-oriented aftercare program for homeless mentally ill chemical abusers (MICAs) in a supported housing facility, and presents some preliminary data on program effectiveness. The study divided the clients who had completed a residential modified TC program into two groups--those who participated in the TC-oriented supported housing program and those who did not. The data show similarities in the profile of the two groups. Improvement in negative behaviors (e.g., drug use and crime) occurred during the residential program and stabilized during the supported housing program, while improvement in prosocial behaviors (e.g., psychological functioning and employment) was incremental and continuous over the course of both programs. Those who participated in the TC-oriented supported housing program demonstrated significantly better outcomes than those who did not. These findings provide preliminary evidence for the effectiveness of a TC-oriented supported housing program as an aftercare strategy for homeless MICA clients following residential treatment.
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Affiliation(s)
- Stanley Sacks
- Center for the Integration of Research & Practice, National Development & Research Institutes, Inc., 71 West 23 Street, 8th Floor, New York, New York 10010, USA.
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McCollister KE, French MT. The relative contribution of outcome domains in the total economic benefit of addiction interventions: a review of first findings. Addiction 2003; 98:1647-59. [PMID: 14651494 DOI: 10.1111/j.1360-0443.2003.00541.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS This paper provides a focused summary of the relative contribution of addiction intervention outcomes to total economic benefit, based upon a compilation of published economic studies from the United States. DESIGN The relevant literature was searched extensively, and 11 economic studies were selected for review. SETTING The selected addiction interventions address both alcohol use/abuse and illicit drug use/abuse and represent various treatment modalities, including a brief physician intervention and long-term residential programs. PARTICIPANTS Study participants included community-based drug users, pregnant and/or parenting women, problem drinkers, and criminal offenders. MEASUREMENTS These studies estimated the economic benefits of an addiction intervention(s) in terms of one or more of the following outcome domains: criminal activity, health services utilization, employment earnings, and expenditures on illicit drugs and alcohol. FINDINGS The primary finding of this review was that avoided criminal activity was the greatest economic benefit of addiction interventions and contributed more, as a separate outcome domain, to the total economic benefit of addiction interventions than any other outcome domain. Reduced utilization of health care services was also a noteworthy economic benefit of addiction interventions. CONCLUSIONS This study provides a detailed exposition of economic benefits estimation and highlights the potential impact of individual outcomes, thus providing a useful resource for substance abuse researchers and administrators as they design and evaluate future interventions.
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Affiliation(s)
- Kathryn E McCollister
- Health Services Research Center and Department of Epidemiology and Public Health (D93), University of Miami, Miami, FL 33136, USA.
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Abstract
Scientific research and program evaluation have not played a major role in shaping the development of treatment services and systems in most countries. This has led to disparities in the development, management and monitoring of national treatment systems. In the evaluation of treatment for substance use disorders, the evaluation practitioner will usually be working at one of five levels: single case, treatment activity, treatment service, treatment agency or treatment system. One of the major barriers to undertaking internal program evaluation is the belief that it is a complicated research process best left to those with specific research training. Program managers and staff can plan and initiate an evaluation process for their program if they have access to research expertise when needed for certain parts of the process. There are seven main components of an evaluation process that can be planned and implemented: need assessment; evaluation planning, process evaluation, cost analysis, client satisfaction evaluation, outcome evaluation and economic evaluation. However, evaluation is more than the techniques and technology required to implement these types of activities. It also involves the routine questioning of current practice even if the feedback may be less positive than anticipated. A healthy culture for evaluation is one in which feedback loops are woven into the fabric of the treatment service or system. There are many barriers to evaluation in substance abuse services but these barriers can be overcome with careful planning and commitment to the delivery of evidence-based services.
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Affiliation(s)
- Brian Rush
- Centre for Addiction and Mental Health; University of Toronto
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18
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Sosin MR, Grossman SF. The individual and beyond: a socio-rational choice model of service participation among homeless adults with substance abuse problems. Subst Use Misuse 2003; 38:503-49. [PMID: 12747396 DOI: 10.1081/ja-120017384] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
While substance user service programs can help homeless adults solve their substance use and housing problems, relatively few needy individuals use and complete these programs. The lack of participation is poorly explained by typical empirical studies, most of which consider the role in service participation of various personal traits and client problems. The current article instead seeks to explain service participation through the application of an alternative, "socio-rational choice" model. This model has three premises: Clients weigh the costs and benefits of participating in services against alternative uses of their time and resources. The clients' weighing procedures reflect their personal situations and perceptions of the treatment environment. The perceptions of their personal situations and perceptions of the treatment environment are affected by the manner in which clients react to representatives of service systems, members of their social network including both housed and homeless persons, and other individuals. Secondary evidence supports many of the model's hypotheses and generally suggests that homeless clients may be heavily affected by their experiences with individuals and systems with which they come into contact.
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Affiliation(s)
- Michael R Sosin
- The School of Social Service Administration, The University of Chicago, Chicago, Illinois 60605, USA.
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19
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20
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McGeary KA, French MT, Sacks S, McKendrick K, De Leon G. Service use and cost by mentally ill chemical abusers: differences by retention in a therapeutic community. JOURNAL OF SUBSTANCE ABUSE 2001; 11:265-79. [PMID: 11026125 DOI: 10.1016/s0899-3289(00)00026-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Earlier research estimated the incremental costs and outcomes of a modified therapeutic community (modified TC) for mentally ill chemical abusers (MICAs) relative to a treatment-as-usual (TAU) control group. The present study extended the cost analysis by disaggregating the modified TC group into clients who completed the program (completers) and clients who dropped out (separaters). METHODS Bivariate and multivariate analyses were conducted to estimate differences in treatment and other service costs among completers, separaters, and TAU. Subjects were sequentially assigned to the modified TC (n = 171) or TAU (n = 47), and the analysis period covered 12 months post-baseline. Using a standardized instrument to collect resource use and cost data, the estimated weekly cost per client in the modified TC was $554, with completers showing a larger average cost of treatment ($27,595) than separaters ($9,986). RESULTS The average TAU subject had a much higher cost for other (non-modified TC) services ($29,795) relative to separaters ($22,048) or completers ($1,986). These findings suggest that, from baseline to the 12-month follow-up, the total cost of modified TC treatment and other services for completers may be slightly lower than the total cost for separaters or TAU subjects. Since the modified TC group had better outcomes than the TAU group, and the completers had better outcomes than the separaters, the modified TC program could be an effective mechanism to reduce the costs of service utilization as well as improve clinical outcomes. IMPLICATIONS This detailed investigation into service utilization and cost provides policy-makers and program directors with valuable information regarding potentially cost-effective interventions and further underscores the importance of retention in treatment for this vulnerable population.
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21
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Abstract
This paper surveys the mental health and drug user treatment literature, identifying promising approaches and research issues in the treatment of co-occurring mental illness and substance use disorders. The prevalence and classification of co-occurring disorders are briefly reviewed, and selected treatment models currently in use are described. Three models are cited as representing particularly promising approaches--comprehensive integrated treatment, assertive community treatment, and the modified therapeutic community--and best practices are summarized. This paper proposes a research agenda focused on relevant emerging treatment issues.
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Affiliation(s)
- S Sacks
- Center for the Integration of Research and Practice at National Development and Research Institutes, Inc., New York, New York 10048, USA.
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22
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De Leon G, Sacks S, Staines G, McKendrick K. Modified therapeutic community for homeless mentally ill chemical abusers: treatment outcomes. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2000; 26:461-80. [PMID: 10976669 DOI: 10.1081/ada-100100256] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This study compared homeless mentally ill chemical abuser (MICA) clients (n = 342), male and female, sequentially assigned to either of two modified therapeutic community programs (TC1 and TC2) and to a treatment-as-usual (TAU) control group. Follow-up interviews were obtained at 12 months postbaseline and at time F (on average more than 2 years postbaseline) on a retrieved sample of 232 (68%) clients and 281 (82%) clients, respectively. Outcome measures assessed five domains: drug use, crime, HIV risk behavior, psychological symptoms, and employment. Individuals in both modified TC groups showed significantly greater behavioral improvement than TAU at 12 months and time F, and the modified TC2, with lower demands and more staff guidance, was superior to modified TC1. Completers of both TC programs showed significantly greater improvement than dropouts and a subgroup of TAU clients with high exposure (i.e., more than 8 months) to other treatment protocols. The present findings support the effectiveness and longer term stability of effects of a modified TC program for treating homeless MICA clients.
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Affiliation(s)
- G De Leon
- Center for Therapeutic Community Research, National Development and Research Institutes, Inc., New York, New York 10048, USA.
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Sacks S, Sacks JY, De Leon G. Treatment for MICAs: design and implementation of the modified TC. J Psychoactive Drugs 1999; 31:19-30. [PMID: 10332635 DOI: 10.1080/02791072.1999.10471722] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
This article describes the main features of an innovative therapeutic community (TC) model adapted for use with mentally ill chemical abusers (MICAs). It describes the rationale for use of the modified TC with MICAs, the treatment structure and environment created, the essential components of the modified TC program, staffing, and the process and goals of client change. Details are given regarding issues and strategies for the implementation of the new program in terms of program planning, staff training, and system initiation. Evaluation data from the authors' research is summarized to support the adoption of the modified TC model. The article makes clear the feasibility of a modified TC model of established effectiveness with a MICA population. This model has now been successfully introduced into mental health, drug treatment, shelter, and correctional settings.
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Affiliation(s)
- S Sacks
- Center for Therapeutic Community Research, National Development and Research Institutes, Inc., New York 10048, USA.
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