Modified Therapeutic Community for Co-Occurring Disorders: Single Investigator Meta Analysis

ABSTRACT

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.     

Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes

This article describes a randomized study to determine the effectiveness of a reentry modified therapeutic community (RMTC) for offenders with co-occurring substance use and mental disorders (co-occurring disorders or COD). Men with COD, approved for community corrections placement postrelease, were recruited from nine Colorado prisons and stratified according to the type of treatment received while incarcerated (i.e., a prison modified therapeutic community [MTC] program or standard care). When released, each offender was randomly assigned either to the experimental RMTC (E-RMTC) condition (n = 71) or to the control parole supervision and case management (PSCM) condition (n = 56). An intent-to-treat analysis 12 months postprison release showed that the E-RMTC participants were significantly less likely to be reincarcerated (19% vs. 38%), with the greatest reduction in recidivism found for participants who received MTC treatment in both settings. These findings support the RMTC as a stand-alone intervention and provide initial evidence for integrated MTC programs in prison and in aftercare for offenders with COD.     

Music therapy: a novel motivational approach for dually diagnosed patients

Co-occurring mental illness and addiction is very common and results in worse treatment outcomes compared to singly diagnosed addicted individuals. Integrated treatment for co-occurring disorders is associated with better treatment outcomes; however there is a wide range of what is included in integrated treatment. Due to patient and staff interests, integrated treatment often includes complementary and alternative therapies, including music and art therapy. There is a need to study how these approaches effect treatment engagement, retention, and outcome. This study was a prospective naturalistic non-randomized pilot study without a control group that sought to evaluate how participation in a music therapy program affected treatment outcomes for individuals with co-occurring mental illness and addiction. In summary, music therapy appears to be a novel motivational tool in a severely impaired inpatient sample of patients with co-occurring disorders. Future studies of music therapy in integrated co-occurring disorder setting should include a control group.     

Training substance abuse treatment staff to care for co-occurring disorders

Although co-occurring disorders have been associated with poorer substance abuse treatment outcomes and higher costs of care, few individuals with co-occurring disorders receive appropriate mental health care. This article describes the design and implementation of an intervention to improve the quality of mental health care provided in outpatient substance abuse treatment programs without requiring new treatment staff. The intervention focuses on individuals with affective and anxiety disorders and consists of three components: training and supervising staff, educating and activating clients, and linking with community resources. We evaluated three treatment programs (one intervention and two comparison) for the first component by having program staff complete both self-administered questionnaires and semistructured interviews. Staff knowledge and attitudes about co-occurring disorders, job satisfaction, and morale all indicated an improvement at the intervention relative to the comparison sites. The evaluation is still under way; results for implementation of the other two components and for outcomes will be reported later.     

Outcomes for women with co-occurring disorders and trauma: program and person-level effects

Six-month outcomes are evaluated from a 9-site quasi-experimental study of women with mental health and substance use disorders who have experienced physical or sexual abuse who enrolled in either comprehensive, integrated, trauma-informed, and consumer/survivor/recovering person-involved services (N = 1023) or usual care (N = 983). Mental health, post-traumatic stress symptoms, and substance use outcomes are assessed with multilevel regression models, controlling for program and personal characteristics. Person-level variables predict outcomes independent of intervention condition and, to a small extent, moderate intervention and program effects. In sites where the intervention condition provided more integrated counseling than the comparison condition, there are increased effects on mental health and substance use outcomes; these effects are partially mediated by person-level variables. These results encourage further research to identify the longer-term effects of integrated counseling for women with co-occurring disorders and trauma histories.     

A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders

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. [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 2004;23:471-481]     

Family Integrated Transitions: A Promising Program for Juvenile Offenders with Co-Occurring Disorders

This study evaluates the impact of the Family Integrated Transitions (FIT) program on juvenile recidivism. FIT is a family-based intervention for youths with co-occurring substance use and mental health disorders transitioning to home from incarceration. We used administrative data to compare 36-month recidivism rates for youths receiving FIT (N = 105) versus usual care (N = 169). Participation in FIT was associated with a 30% reduction in felony recidivism, but not related to overall, violent felony, or misdemeanor recidivism. This study provides cautious evidence for a promising approach toward reducing felony recidivism for youths with co-occurring disorders transitioning out of the juvenile justice system.     

A modified therapeutic community for homeless persons with co-occurring disorders of substance abuse and mental illness in a shelter: an outcome study

This article reports on a study conducted to determine the effectiveness of a modified therapeutic community (MTC) shelter on client outcomes. The seven-study hypotheses focused on whether greater effectiveness in the MTC would be demonstrated in longer periods of sobriety, fewer days of psychiatric hospitalization, shorter lengths of stay in a shelter, positive discharge from the shelter, medication compliance, housing placement within the first year, and appropriate housing placement according to level of functioning. The study utilized a quasi-experimental design with two groups: 1) an experimental group (E) homeless persons with co-occurring disorders (COD) of substance abuse/dependence and mental illness who reside in a modified therapeutic community (N = 70); and 2) a comparison group (C) of veterans with CODs living in a general shelter (N = 70). The data collection procedures involved a retrospective review of closed case records for subjects in the facilities from September 1, 1998-June 1, 2000 for the MTC shelter, and from June 1, 1999-June 1, 2000 for the general shelter. Baseline differences between the E and C groups were found in age, length of homelessness, years of education, years of work experience, veteran status, marital status, and psychiatric diagnosis; all except for veteran status were unrelated to outcomes and were controlled in subsequent analyses. Significant difference was found on medication compliance when controlled for both groups. Overall, this study showed some promise for the MTC approach. The study also raised a question as to the contribution of veteran status to the differences between groups and to treatment of CODs.     

Hospitalizations and hospital charges for co-occurring substance use and mental disorders

Most published studies have examined co-occurring disorders among mental health patients. Our objective was to compare the length of stay and hospital charges between hospitalized patients with alcohol- or substance-related disorders with and without co-occurring disorders. We analyzed nationally representative hospital discharge data (Nationwide Inpatient Sample, 2003-2007) and examined factors associated with length of stay and hospital charges. Forty-four percent of patients who were hospitalized with alcohol- or substance-related disorders were diagnosed with co-occurring mental disorders, representing 979,421 such disorders nationwide between 2003 and 2007. Females, those of White race, those who paid with insurance, and those who stayed in large, rural, nonteaching, and Midwest region hospitals had a high prevalence of co-occurring disorders. Co-occurring disorders were associated with longer hospital stays, but there were mixed results with hospital charges per discharge. An increase in co-occurring disorders among hospitalized patients with substance-related disorder may be due to the improvement in diagnosis and clinical attention.     

Responding to the challenge of co-occurring disorders: suggestions for future research

This special issue consolidates some recent research findings and scientific thought on co-occurring disorders from both the substance abuse and mental health fields. This summary article recaps and synthesizes the main findings and themes, then considers additional issues in the field today to arrive at an agenda for future co-occurring disorders research. Plans must: (1) encourage and assist further development of treatment programs that respond to an array of types and severities of co-occurring disorders while taking into account the limited resources typically available; (2) continue the development and testing of continuing care models by exploring strategies that will sustain the recovery of treated individuals who remain vulnerable to relapse; and (3) contribute to our understanding of the mechanisms and processes that enable new interventions and practices to be adopted, implemented, and sustained. "Co-occurring disorders" is a relatively new area of research; this special issue illustrates the productivity of work to date and indicates the potential for advances to come.     

Smoking Cessation Outcomes and Predictors Among Individuals With Co-occurring Substance Use and/or Psychiatric Disorders

Objective: Individuals with substance use and psychiatric disorders have a high prevalence of tobacco use disorders and are disproportionately affected by tobacco-related morbidity and mortality. However, it is unclear how having co-occurring disorders affects tobacco cessation. Our aim was to examine smoking cessation outcomes and relevant predictors of smoking cessation among smokers with substance use and/or psychiatric disorders. Methods: Data from medical records of 674 participants in a tobacco treatment program within mental health and addictions services in Vancouver, Canada, were analyzed. The 26-week treatment program included an 8-week structured behavioral counseling group, an 18-week support group, and 26 weeks of no-cost pharmacotherapy. Information on demographics, tobacco use and history, type of pharmacotherapy received, nicotine dependence, importance of and confidence in quitting smoking, expired carbon monoxide level, substance use and psychiatric disorder history, and total program visits were gathered. Results: Approximately 67% (n = 449) of participants had co-occurring substance use and psychiatric disorders, while 20% (n = 136) had substance use disorder only, 10% (n = 67) had psychiatric disorder only, and 3% (n = 22) had tobacco dependence only. Rates of tobacco cessation (i.e., 7-day point prevalence of abstinence verified by expired carbon monoxide of ≤8 ppm) by group in the 522 people who completed treatment were as follows: 38.2% for those with co-occurring disorders, 47.1% for those with tobacco dependence only, 47.1% for those with substance use disorder only, and 41.8% for those with psychiatric disorder only. Length of treatment was a significant predictor of smoking cessation for those with co-occurring disorders and substance use disorder only. In the final stratified multivariate analysis, for individuals with co-occurring disorders, having an opiate use disorder (as compared to an alcohol use disorder) and higher nicotine dependence scores at baseline were predictive of poor cessation outcomes, while greater length of treatment was predictive of successful smoking cessation. Conclusions: Tobacco cessation treatment for individuals with co-occurring substance use and psychiatric disorders is likely to be as effective as for smokers with either disorder alone. Treatment duration predicts success among these smokers so strategies to enhance engagement and retention are needed.     

Co-occurring mental and substance use disorders: promising approaches and research issues

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.     

Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers

As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 453 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.     

The Integrated Co-Occurring Treatment (ICT) Model

Abstract

While integrated treatment programs have been developed and researched nationally for adults with co-occurring disorders of substance abuse and mental illness, little movement has been made on developing and field testing integrated programs that address the needs of youth with co-occurring disorders. This article will present one treatment model that has been developed and piloted in Ohio. The Integrated Co-Occurring Treatment (ICT) model focuses on youth with co-occurring disorders of mental health and substance abuse who have also been involved with the juvenile justice system. To date, the use of the ICT model has resulted in positive outcomes for both the youth and their     

Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment

Epidemiological data from treatment and community samples of individuals with substance use disorders indicate that the rates of co-occurring psychiatric disorders are high and that these disorders are associated with poor treatment adherence and outcomes. A growing body of research indicates that continuing care adherence interventions positively impact treatment outcome. However, it is unclear whether these interventions are effective for individuals with co-occurring psychiatric disorders. This paper explores this question with data from 150 participants who were randomized to receive a behavioral continuing care adherence intervention involving contracting, prompting and reinforcing attendance (CPR), or standard treatment. Fifty-one percent of the participants had one or more co-occurring Axis I or Axis II psychiatric disorders in addition to a SUD diagnosis. Among individuals with co-occurring disorders, those who received the CPR intervention show increased duration of treatment and improved 1-year abstinence rates compared to those who received STX. Additionally, effects of the CPR intervention were generally more pronounced among persons with co-occurring Axis I and/or Axis II disorders than those without these disorders. Treatment implications are discussed.     

Factors predicting substance dependence and psychotropic medication use among offenders in community corrections

Co-occurring substance abuse and mental illness is prevalent among criminal offenders, but little is known about risk factors for these co-occurring disorders (COD) in community corrections population. To identify risk factors for COD in community corrections offenders, we analyzed assessment data from 5,595 offenders maintained under community supervision at a substance use diversion program. Three groups, offenders with substance use disorders who were taking psychotropic medications (SUPM), offenders with a substance use disorder (SUD) only and controls were compared. Logistic regressions were used to identify predictors of SUPM versus SUD only and controls. SUPM status was predicted by being White or Female, having some medical insurance (private or government aided), being unemployed, prior history of abuse/trauma, and prior history of suicidal ideation or behavior. Offenders with substance use disorders and co-occurring psychiatric problems face salient social risk that may need to be targeted through integrated services.     

Treatment Guidelines for Substance Use Disorders and Serious Mental Illnesses: Do They Address Co-Occurring Disorders?

Practice guidelines are important tools for improving the delivery of evidence-based practices and reducing inappropriate variation in current treatment approaches. This study examined the degree to which guidelines targeted to the treatment of substance use disorders or serious mental illness address treatment of co-occurring disorders. Guidelines archived by the National Guideline Clearinghouse (NGC) were retrieved in December 2007 and content analyzed. Nineteen pertinent guidelines were identified, and 11 included recommendations regarding the assessment and/or treatment of co-occurring disorders. None of the guidelines making recommendations for treatment of co-occurring disorders included outcomes that clearly targeted both substance use and mental health disorders. Limitations and implications of this study are noted.     

Interventions for co-occurring addictive and other mental disorders (AMDs)

While research on the management of co-occurring addictive and mental disorders (AMDs) has grown substantially in recent years, we still have little guidance on specific strategies. Consideration of epidemiological research and ethical principles can supplement existing clinical trials in providing a way forward. High frequencies of co-occurring disorders, equity of access for affected individuals and potential clashes between services in priorities and procedures, suggest that a stepped model of care by a single service may often be required. Typically, problems are multiple rather than dual, with potential for mutual influence, suggesting a need for interventions that are sensitive to and encompass complex co-occurring problems. Motivational problems are endemic, initial gains are often partial and unstable, and relapses potentially have serious consequences, suggesting a need for long-term, assertive follow-up. Principles such as these provide a solid framework for designing both services and interventions. However, there is a continuing need for controlled trials that unpack effective components of interventions, and increase their impact.     

Co-occurring mental health and drug dependency disorders: work-force development challenges for the AOD field

In this paper it is argued that the sheer extent of the co-occurrence of mental health and drug dependency disorders means inevitably that alcohol and other drug (AOD) staff encounter such problems. However, it is contended that the AOD work-force has a number of characteristics that often act as impediments to people with co-occurring disorders receiving, in that sector, appropriate, integrated, 'one-stop-shop' care. Nevertheless, because of the configuration of mental health services in Australia, as essentially acute services for people with severe mental illnesses, there has been, and will continue to be, an overspill of people with mental health disorders and drug problems disorders into the AOD sector. It is there absolutely necessary that initiatives are put into place that support and enable the AOD sector to respond more effectively to people with co-occurring disorders.     

Addiction treatment services and co-occurring disorders: the ASAM-PPC-2R taxonomy of program dual diagnosis capability

BACKGROUND: The ASAM-PPC-2R taxonomy of addiction treatment program dual diagnosis capability provides a conceptual model of services for persons with co-occurring substance use and psychiatric disorders. However, no objective study of this model has been conducted. METHOD: This paper describes a survey of addiction treatment providers (n = 453) who were asked to identify their program as Addiction Only Services (AOS), Dual Diagnosis Capable (DDC) or Dual Diagnosis Enhanced (DDE). The survey also queried providers on prevalence estimates, clinical practices, and perceived barriers to treating persons with co-occurring substance use and psychiatric disorders. RESULTS: With brief definitions available to respondents, 92.9% of providers surveyed categorized their program as: AOS (23.0%), DDC (65.3%) or DDE (11.6%). Patient characteristics, clinical practices, and barriers to effective treatments varied by program dual diagnosis capability. CONCLUSIONS: The findings support the utility of the ASAM dual diagnosis capability taxonomy, and suggest specific avenues for system and program assessment and future research.