Differential Service Utilization Associated With Trauma-informed Integrated Treatment for Women With Co-occurring Disorders

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.     

Changes in Treatment Content of Services During Trauma-informed Integrated Services for Women with Co-occurring Disorders

The experience of trauma is highly prevalent in the lives of women with mental health and substance abuse problems. We examined how an intervention targeted to provide trauma-informed integrated services in the treatment of co-occurring disorders has changed the content of services reported by clients. We found that the intervention led to an increased provision of integrated services as well as services addressing each content area: trauma, mental health and substance abuse. There was no increase in service quantity from the intervention. Incorporation of trauma-specific element in the treatment of mental health and substance abuse may have been successfully implemented at the service level thereby better serve women with complex behavioral health histories.     

Design strengths and issues of SAMHSA's Women, Co-occurring Disorders, and Violence Study

In 1998 the Substance Abuse and Mental Health Services Administration launched the Women, Co-occurring Disorders, and Violence Study (WCDVS). The WCDVS developed, implemented, and evaluated the outcomes and costs of comprehensive, trauma-informed treatment programs for women with a history of violence and trauma who have substance use and mental health disorders. This article discusses the overall design features of the study, issues related to such a design, results of the outcomes and cost evaluations, and suggestions for future research. The nine WCDVS sites were located across the continental United States, with six sites on the East Coast, two on the West Coast, and one in Colorado. A total of 2,729 women (1,415 in the intervention condition and 1,314 in the comparison condition) were enrolled over the 13.5-month baseline accrual period (January 2001 through February 2002). Follow-up interviews were conducted with all participants at three, six, nine and 12 months post-baseline. Women in the intervention and the comparison groups showed improvement in outcomes in four areas: alcohol use, drug use, mental health, and trauma. At six months women in the intervention group scored modestly better than women in the usual-care group for outcome measures for drug use, trauma, and mental health. At 12 months women in the intervention group maintained their improvement in drug use outcomes and continued to improve in mental health and trauma outcomes. After a start-up period, costs for services were not significantly different between the intervention and comparison groups at both follow-up points. Despite their very modest nature, the WCDVS results are promising.     

Service use and costs for women with co-occurring mental and substance use disorders and a history of violence

OBJECTIVES: This study examined the 12-month cost of the array of services used by women with co-occurring mental health and substance use disorders and a history of violence and trauma who participated in the Women, Co-occurring Disorders, and Violence Study (WCDVS). The study compared costs of the intervention and external services for women in the WCDVS intervention in outpatient and residential settings-which provided comprehensive, integrated, and trauma-informed services-with the costs for women in the usual-care comparison group. The study also compared costs with recorded clinical outcomes. METHODS: Costs of service use were examined for 2,026 women who participated in the WCDVS (N=1,018) and in the comparison group (N=1,008). Women were interviewed three, six, nine, and 12 months after baseline about any service use in the past three months. Costs for these services, along with indirect costs (participants' time and transportation) were estimated by using a variety of sources. A number of cost estimates were analyzed by using either ordinary least squares regression or two-part models. RESULTS: The average participant had almost 43,000 dollars in costs related to their service use during the 12 months after baseline. Women in the intervention group had lower service costs and higher overall costs than those in the comparison group, but the null hypotheses of no difference in any cost measure between groups was not rejected. Also, the null hypothesis of no difference in the probability of accessing services external to the study intervention was not rejected. CONCLUSIONS: Because no differences were detected in costs but improvements were seen in clinical outcomes, the interventions offered in the WCDVS may be more efficient than usual care.     

A voice for traumatized women: inclusion and mutual support

This paper reports experiences related to including women in recovery and peer support, in a project that developed integrated services for women with co-occurring mental health and substance use disabilities who have also survived violence. We describe strategies to include women in recovery and a unique peer-run group, which integrates trauma, mental health, and substance abuse recovery. Both research and perspectives of women in recovery are used to discuss the emerging themes of mutuality, bonding, and a focus on strengths.     

Impact of co-occurring substance use on 6 month outcomes for young people seeking mental health treatment

OBJECTIVE: Co-occurring substance use and mental health disorders are highly prevalent among young people attending services, yet few studies have examined the effect of such comorbidity among those referred for treatment. The aim of the current study was to examine the impact of co-occurring substance use disorders (SUDs) on 6 month outcomes for young people seeking mental health treatment. METHOD: One hundred and six young people (aged 15-24 years) with a non-psychotic DSM-IV Axis I disorder were assessed following referral to a specialist youth public mental health service. Participants were given a structured interview, as well as questionnaires assessing drug use, psychopathology, psychosocial functioning and self-esteem at baseline and 6 month follow up. RESULTS: At baseline, 23 participants met criteria for a co-occurring SUD and 83 had a non-psychotic Axis I disorder. Both the non-SUD and the co-occurring SUD groups had high levels of psychopathology, serious impairments in functioning and moderate levels of suicidal ideation, although those with co-occurring SUD had significantly poorer levels of functioning. At 6 month follow up the co-occurring SUD group continued to experience substantial problems with symptoms and functioning whereas the non-SUD group had significant improvement in both of these domains. CONCLUSIONS: The present findings are consistent with studies examining the impact of co-occurring substance use and mental health issues across different treatment settings, and reinforce recommendations that young people with co-occurring disorders require more intensive and integrated interventions. The present findings also highlight the need for routine assessment and management of substance use issues within youth mental health settings.     

Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months

OBJECTIVE: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. METHODS: A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. RESULTS: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. CONCLUSIONS: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost.     

Risk of Future Offense Among Probationers with Co-occurring Substance Use and Mental Health Disorders

The criminal justice system is the primary service delivery system for many adults with drug and alcohol dependence, mental health, and other health service needs. The purpose of this study was to examine the relationship between risk of future offense, mental health status and co-occurring disorders in a large substance abuse diversion probationer population. A purposive sample of 2,077 probationers completed an assessment to screen for mental health disorders, substance use disorders, risk of future crime and violence, and several demographic characteristics. Probationers who screened positive for co-occurring substance use and mental health disorders were significantly more likely to be at higher risk of future crime and violence compared to probationers who screened positive for only substance use, only a mental health disorder, or no substance use or mental health disorder. Implications for substance use and mental health service delivery are discussed, and recommendations are made for further research.     

Six-Month Outcomes of an Integrated Assertive Community Treatment Team Serving Adults with Complex Behavioral Health and Housing Needs

Assertive community treatment (ACT) and integrated dual disorders treatment (IDDT) have individually proven effective for treatment of adults with complex behavioral health and housing needs. This study evaluated the effectiveness of an ACT team that delivered integrated care consistent with IDDT principles. Participants included 60 adults with a history of chronic homelessness and co-occurring mental health and substance use disorders. Measures assessing mental health, substance use, and residential stability were completed at intake to the program and then 6 months later. Participants reported statistically significant improvements in mental health symptomatology and residential stability over time, although there were no changes in substance use. Findings support the effectiveness of the intervention for improving mental health and housing stability among adults with complex behavioral health and housing needs. Fidelity data support the notion that multiple evidence-based interventions can be integrated while still maintaining adequate fidelity to individual components.     

Characteristics of recent violence among entrants to acute mental health and substance abuse services

OBJECTIVE: The aim of this study was to describe the characteristics of recent interpersonal violence perpetrated and experienced by individuals recruited from acute crisis mental health and substance abuse treatment settings and to examine differences among incidents involving individuals with mental disorders only (MDO), substance use disorders only (SDO), and co-occurring mental and substance use disorders (COD). METHOD: Participants (N = 419) were interviewed about their involvement in specific acts of violence in the past 30 days. Participants were also asked about where each incident took place, who was involved, whether individuals were injured, and whether alcohol or drugs were used before the incident. We examined distributions of violence characteristics for the full sample and used logistic regression analyses to test differences among incidents involving participants with MDO, SDO, and COD. RESULTS: Approximately 41% (n = 171) of the sample was involved in at least one incident of violence as a perpetrator or a victim, generating a total of 379 incidents. Far more incidents of violence involved victimization (62%) than perpetration (38%). Most incidents were isolated and involved only perpetration or only victimization. However, a total of 98 (26%) incidents occurred with another incident and constituted 49 episodes of violence that included incidents of perpetration and victimization. Characteristics of perpetration and victimization incidents were similar, except that victimization incidents involved more serious types of violence. The majority of incidents took place outdoors and did not result in injuries. Participants used drugs or alcohol prior to over 40% of incidents. Most incidents of perpetration (70%) targeted someone known to the participant. Diagnostic group was the strongest predictor of type of injury, location of incident, and use of alcohol and drugs before the incident. Individuals with substance use disorders, either alone or co-occurring with mental disorders, were more likely to report that violent incidents took place outdoors. Individuals with mental disorders, either alone or co-occurring with substance use disorders, were less likely to report alcohol and drug use prior to involvement in violence. CONCLUSIONS: Violence is common among individuals entering acute crisis mental health and substance abuse treatment. We found that such persons are more likely to report being victims of violence than perpetrators of violence. In contrast to prior studies, we found that most incidents took place outdoors. Although individuals in different diagnostic groups were no more or less likely to perpetrate or experience violence, they perpetrated and experienced violence under different circumstances. Implications and directions for future research and practice are discussed.     

Assessing Multiple Outcomes for Women with Co-Occurring Disorders and Trauma in a Multi-Site Trial: A Propensity Score Approach

The current study assesses the ability of two promising propensity scoring methods to reduce selection bias in a set of secondary data from the women with co-occurring disorders and violence study (WCDVS), whose purpose was to evaluate the effect of integrated treatment for women with mental health, substance use, and trauma issues (N = 2,729). Weighting, the more successful method, is demonstrated in a re-analysis of 6- and 12-month WCDVS outcomes. In addition to demonstrating propensity score weighting, the current study increases confidence in earlier findings by considering multiple time points simultaneously and by controlling more completely for pre-treatment differences. An early version of this paper was presented as a poster in July, 2005 at the NIMH Mental Health Services Research Conference, Bethesda, MD.     

Targeting Trauma-related Interventions and Improving Outcomes for Women with Co-occurring Disorders

National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

A longitudinal investigation of intimate partner violence among mothers with mental illness

OBJECTIVE: Severe mental illness, substance use, and intimate partner violence have emerged as major intersecting public health problems that adversely and disproportionately impact the lives of women in the United States. This longitudinal study investigated the demographic and clinical correlates of intimate partner violence in a sample of 324 mothers with severe mental illness. METHODS: A secondary analysis of longitudinal data was conducted by using multiple logistic regression. Participants were part of a longitudinal, community-based study of mothers with severe mental illness, which was aimed at understanding how these mothers viewed motherhood. The women were interviewed initially at baseline (interviews were conducted between 1995 and 1996) and then about 20 months later at follow-up (interviews were conducted between 1997 and 1998). RESULTS: At follow-up the prevalence rate of intimate partner violence was 19%. Multiple logistic regression analyses showed a significant positive relationship between alcohol and drug misuse at baseline and intimate partner violence at follow-up, indicating that women with a co-occurring diagnosis of a substance use disorder (dual diagnosis) were more likely than women without such a diagnosis to report intimate partner violence. The number of lifetime psychiatric hospitalizations and the number of symptoms related to psychiatric disability exhibited at baseline were positively associated with intimate partner violence at follow-up, and age was inversely associated with intimate partner violence. CONCLUSIONS: Mental health professionals serving mothers with mental health problems need to be aware of and prepared to assess the significant correlation between these intersecting public health problems in order to influence successful interventions. Particular attention must be given to the special treatment needs related to dual diagnosis and victimization and the impact of these factors on this vulnerable population.     

Three-year outcomes of long-term patients with co-occurring bipolar and substance use disorders.

Little is known about the long-term outcomes of patients in the public mental health system who are disabled by co-occurring bipolar and substance use disorders. This article reports on the 3-year course of 51 patients with co-occurring bipolar and substance use disorders in the New Hampshire Dual Diagnosis Study. Participants received integrated dual disorders treatments in the state mental health system and were independently assessed with standardized measures at baseline and every 6 months for 3 years. Though psychiatric symptoms improved only modestly, participants improved steadily in terms of remission from substance abuse (61% in full remission at 3 years); they also achieved greater independent living (average 239 days in third year), competitive employment (49% in third year), regular social contacts with nonsubstance abusers (46% at 3 years), and quality of life (56% satisfied with life at 3 years). Different domains of outcome were only weakly related to each other. Long-term, disabled patients with co-occurring bipolar and substance use disorders have potential for remission from substance abuse and substantial improvements in functioning and quality of life.     

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.     

Mixing Oil and Water: Integrating Mental Health and Addiction Services to Treat People with a Co-occurring Disorder

Treatments for people with the co-occurring disorders of mental illness and substance use (abuse or dependence) have been evolving and improving since the mid 1980s. During this period substance abuse treatment programs reported between 50 and 75% of the people they served also had a mental health problem. At the same time, mental health programs reported between 20 and 50% of the people they served had a co-occurring problem of substance use or abuse. The proposed solution is to integrate the two treatment systems so as to treat both disorders at the same time. During the 1990s integrated treatment was proposed and several models of integrated care were evaluated. The fallacy of these conceptualizations is that the authors of these models presume that the numerous treatment interventions from both treatment traditions are compatible. This is a critical assumption. What if the two are not compatible? Rather than integrate the two systems of mental health and addiction treatment in whole, I would argue, a model is needed that selects the best interventions from each field and discard the rest. Suggestions are presented here for a beginning inventory of best practice interventions that could be the foundation for effectively treating people with co-occurring disorders.     

Relationship between diabetes and mortality among persons with co-occurring psychotic and substance use disorders

OBJECTIVE: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. METHODS: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. RESULTS: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12-year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. CONCLUSIONS: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances.     

Training Addiction Counselors to Implement CBT for Depression

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.