Psychosocial treatments for people with co-occurring severe mental illness and substance misuse:...

REVIEW PAPER

Psychosocial treatments for people with co-occurring severe mental

illness and substance misuse: systematic review

Michelle Cleary, Glenn E. Hunt, Sandra Matheson & Garry Walter

Accepted for publication 25 September 2008

Correspondence to M. Cleary:

e-mail: [email protected]

Michelle Cleary PhD RN

Clinical Associate Professor Mental Health

Faculty of Nursing and Midwifery, University

of Sydney,

and Clinical Nurse Consultant

Research Unit, Sydney South West Area

Mental Health Service, New South Wales,

Australia

Glenn E. Hunt PhD

Senior Research Fellow

Discipline of Psychological Medicine,

University of Sydney and Research Unit,

Sydney South West Area Mental Health

Service, New South Wales, Australia

Sandra Matheson BSc

Research Officer

Research Unit, Sydney South West Area

Mental Health Service, New South Wales,

Australia

Garry Walter MBBS BMedSc PhD

Professor of Child and Adolescent Psychiatry

University of Sydney,

and Area Clinical Director

Child and Adolescent Mental Health

Services, Northern Sydney Central Coast

Health, New South Wales, Australia

CLEARY M., HUNT G.E. , MATHESON S. & WALTER G. (2009)CLEARY M., HUNT G.E. , MATHESON S. & WALTER G. (2009) Psychosocial

treatments for people with co-occurring severe mental illness and substance misuse:

systematic review. Journal of Advanced Nursing 65(2), 238–258

doi: 10.1111/j.1365-2648.2008.04879.x

AbstractTitle. Psychosocial treatments for people with co-occurring severe mental illness and

substance misuse: systematic review.

Aim. This study is a report of a systematic review to assess current evidence for the

efficacy of psychosocial interventions for reducing substance use, as well as improving

mental state and encouraging treatment retention, among people with dual diagnosis.

Background. Substance misuse by people with a severe mental illness is common and

of concern because of its many adverse consequences and lack of evidence for effective

psychosocial interventions.

Data sources. Several electronic databases were searched to identify studies published

between January 1990 and February 2008. Additional searches were conducted by

means of reference lists and contact with authors.

Review methods. Results from studies using meta-analysis, randomized and non-

randomized trials assessing any psychosocial intervention for people with a severe

mental illness and substance misuse were included.

Results. Fifty-four studies were included: one systematic review with meta-analysis,

30 randomized controlled trials and 23 non-experimental studies. Although some

inconsistencies were apparent, results showed that motivational interviewing had the

most quality evidence for reducing substance use over the short term and, when

combined with cognitive behavioural therapy, improvements in mental state were also

apparent. Cognitive behavioural therapy alone showed little consistent support.

Support was found for long-term integrated residential programmes; however, the

evidence is of lesser quality. Contingency management shows promise, but there were

few studies assessing this intervention.

Conclusion. These results indicate the importance of motivational interviewing in

psychiatric settings for the reduction of substance use, at least in the short term.

Further quality research should target particular diagnoses and substance use, as some

interventions may work better for some subgroups.

Keywords: dual diagnosis, nursing, psychosocial treatments, severe mental illness,

substance misuse, systematic review

238 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

Introduction

Having a lifetime severe mental illness is associated with

increased risk of having an alcohol or drug use disorder when

compared to people without severe mental illness (Regier

et al. 1990, Kessler et al. 1997, Kavanagh et al. 2004a). Even

patients with a mental illness who use substances in mild

doses can experience adverse effects, such as high rates of

relapse, treatment non-compliance, distorted perception and

cognition, suicidal ideation, incarceration, homelessness,

injury and disease, such as hepatitis (Dickey et al. 2000,

Barrowclough et al. 2001, Bennett et al. 2001, Carey et al.

2004, Todd et al. 2004, Hawton et al. 2005, Ziedonis et al.

2005, Janssen et al. 2006, Gregg et al. 2007).

People with mental illness use substances for a variety of

reasons, including the relief of depression, anxiety, boredom

or to relax and socialize (Addington & Duchak 1997, Fowler

et al. 1998), and they may benefit from psychosocial

interventions that target their substance use. Psychosocial

interventions in mental health settings are those that are non-

pharmaceutical, such as cognitive behavioural therapy (CBT)

and motivational interviewing (MI). They may be offered in a

variety of settings, can vary in intensity and duration, and

may be part of an integrated treatment programme. Inte-

grated programmes involve both the mental health and

substance use problems being treated simultaneously, within

the same service by the same clinician or team of clinicians.

Research into the effectiveness of psychosocial interven-

tions for reducing substance use by people with a severe

mental illness is still evolving. A recent Cochrane review

(Cleary et al. 2008) with a meta-analysis of 25 randomized

controlled trials (RCTs) and two recent descriptive reviews

(Donald et al. 2005, Tiet & Mausbach 2007) that included

RCTs and non-experimental studies, showed that no single

psychosocial treatment was superior to any other. In contrast,

other reviews including RCTs and non-experimental studies

have shown support for particular psychosocial interven-

tions, but with inconsistent results. For example, support has

been found for a motivational approach (Mueser et al. 2005,

Barrowclough et al. 2006, Laker 2007), group therapies

(Mueser et al. 2005, Drake et al. 2008), contingency

management (Drake et al. 2008) and residential programmes

(Drake et al. 2004, 2008, Mueser et al. 2005), as well as for

integrated models of treatment delivery (Drake et al. 1998b,

2004, Barrowclough et al. 2006, Tsuang et al. 2006).

Intensive case management (Dumaine 2003) and assertive

community treatment (ACT; Drake et al. 1998b) have,

however, received limited support. Notwithstanding this,

not all types of interventions were assessed in all reviews. For

example, Laker (2007) assessed only MI, Drake et al. (1998b)

assessed integrated care and Drake et al. (2008), Mueser et al.

(2005), Tiet and Mausbach (2007) and Tsuang et al. (2006)

were the only reviews to include contingency management

studies.

Conclusions from reviews may differ for a variety of

reasons. First, the way in which individual studies are

conducted may differ in terms of patient demographics,

settings, outcome measures and varying degrees of fidelity to

treatment standards. While most studies test one intervention

against a control condition (usually standard care), some

assess combinations of treatment components (e.g. Bellack

et al. 2006) and some compare one intervention with another

(e.g. Jerrell & Ridgely 1995). This makes allocating studies to

particular intervention categories difficult.

Different inclusion criteria also contribute to inconsistent

results. A recent Cochrane review (Cleary et al. 2008)

included only quality RCTs as these are considered more

reliable (Howland 2007), whereas other reviews have

included both RCTs and lesser quality, quasi-random or

non-random studies. Over-inclusiveness can be problematic.

For example, Drake et al. (2008) concluded that no consis-

tent evidence was available from eight RCTs of individual

interventions, and more consistent evidence was found for

residential treatment programmes; however, only one of the

12 studies assessing residential programmes was an RCT.

Thus, drawing conclusions based on combined results of

quality RCTs and lesser quality quasi-randomized and non-

randomized trials can be unreliable.

However, conducting RCTs at the best of times can be

challenging (Essock et al. 2003). Other study designs can also

provide useful and reliable information (Howland 2007), and

can assist to develop a more integrated picture of the

evidence, especially when combining studies with high

heterogeneity (Des Jarlais et al. 2004). Further, excluding

data from non-randomized trials may bias the evidence

towards interventions that are ‘easier’ to evaluate in an RCT

(Des Jarlais et al. 2004). Finally, taking into consideration the

issue of quality when drawing conclusions from a variety of

trials provides a more reliable and contemporary summary of

the available evidence. In view of these factors, it was

considered timely to undertake a systematic review of

psychosocial treatments for people with co-occurring severe

mental illness and substance misuse (dual diagnosis).

The review

Aim

The aim of this review was to assess the current evidence for the

efficacy of psychosocial interventions for reducing substance

JAN: REVIEW PAPER Psychosocial treatments for people with a dual diagnosis

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 239

use, as well as improving mental state and encouraging

treatment retention, among people with dual diagnosis.

Design

The guiding framework for this systematic review came from

recommendations of the Cochrane Collaboration Handbook

(Higgins & Green 2006) and the Australian National Health

and Medical Research Council (1999, 2000).

Search methods

Electronic searching was performed through the Cochrane

Schizophrenia Group Register and the Cochrane Central

Register of Controlled Trials, as well as CINAHL, PsycINFO,

Ovid Medline and PubMED. The following search phrases

and strategies were used: diagnosis-dual-psychiatry.mp,

schizo$ or SMI or bipolar or depression; comorbidity or

substance$ or drug abuse and mental$ and intervention or

clinical trial or intervention and further limitations were

publication in English, the time period January 1990 to

February 2008, and randomised or randomiz$ or trial.

Further searching was undertaken by means of reference lists

and contact with authors.

Inclusion criteria

• Any RCT, quasi-randomized or non-randomized trial of

varying quality with an independent comparison group of

any psychosocial intervention for people with a severe

mental illness (e.g. schizophrenia, schizoaffective disorder,

bipolar disorderormajordepression) andsubstancemisuse.

• Minimum of 10 participants in the experimental treat-

ment group.

• Outcomes must include substance use, mental state and/or

treatment retention.

• Any systematic review that includes a meta-analysis of

results from quality RCTs meeting the above criteria.

Exclusion criteria

• Studies including participants with less severe mental ill-

ness, such as personality disorders, unless a vast majority

had severe mental illness (>90%), or if those with severe

illness were reported separately.

• Reviews with pooled results from both RCTs and non-

experimental studies.

Search outcome

Diagnosis-dual-psychiatry (1750 hits) combined with

(schizo$ or SMI or bipolar or depression) resulted in 664

hits using the Medline database. Limits of English and 1990–

2008 reduced the number to 639. The following search terms

– comorbidity or substance$ or drug abuse and mental$ and

(intervention or clinical trial or random$) – resulted in 1953

hits with limitations of year (1990–2008) using PsycINFO.

This was further reduced to 417 hits when combined with the

following search – motivation$ or cognitive behaviour

therapy or psychosocial or integrated or assertive. Other

searches using the above terms on Medline, CINAHL,

PubMED and Cochrane register of controlled trials resulted

in a further 400 hits. The above searches were entered into a

Reference Manager database and, after duplicates were

excluded and other non-relevant studies deleted, this left

377 studies for further review. Of these, 92 were identified as

relevant and were examined to determine whether they met

inclusion criteria by two independent reviewers and grouped

by type of intervention.

Quality appraisal

This review followed quality guidelines as outlined by the

Australian National Health and Medical Research Council

(National Health and Medical Research Council 1999, 2000)

and the QUOROM statement for systematic reviews (Turpin

2005). RCTs are deemed of the highest quality, with the most

reliable results. Further, pooling RCT results into a meta-

analysis can provide additional quality evidence. Quality

RCTs, randomize participants using methods such as com-

puter-generated random number allocation sequences, con-

cealed to reduce the possibility of manipulating allocation

(Schulz & Grimes 2002a, Howland 2007). Although

researcher(s) may state that their trial is ‘randomized’, in

this review they were categorized as non-experimental if

participants were quasi-randomized (e.g. clinician, alternate

assignment or date of presentation allocation). Even methods

used to generate simple randomization sequences, such as

coin-tossing or dice-throwing may be manipulated and lead

to an unequal distribution of confounding factors across

groups (Schulz & Grimes 2002c). All clinical trials reports

should include baseline demographics and clinical character-

istics of each group.

Another quality issue is whether outcome raters are blind to

treatment condition (Schulz & Grimes 2002b). This is partic-

ularly important when subjective, self-report measures are

recorded as those assessing the person may intentionally or

unintentionally bias the results. This issue is not as important

when objective data, such as hospitalization rates, are collected

(National Health and Medical Research Council 1999, 2000).

Adequate sample size is important to ensure that there is

enough power to detect differences between groups (van den

M. Cleary et al.


Brink et al. 2006). However, high rates of attrition (>50%)

are not uncommon in this area of research, and participants

remaining in the treatment group may be more amenable to

treatment than those leaving the study early. Intention-

to-treat (ITT) analysis considers all those at the time of

randomization to be included in the final analysis.

Data abstraction and synthesis

Two independent reviewers extracted data and information

to be included in the tables. The reviewers were not blind to

the authors of the study. Type of study design, sample size,

participant characteristics, details of interventions and out-

come measures with time periods were noted. Statistically

significant results were recorded in the tables when individual

studies showed between group differences at P < 0Æ05, with

or without statistical adjustment or adjusted means. In this

review, we employed a narrative synthesis as there were

limited data that could be pooled due to heterogeneity in

designs, interventions and outcome measures. The quality of

the studies was assessed by details of randomization, alloca-

tion concealment, blinding, ITT analyses, attrition (noted if

>50%) and any baseline group differences were noted in the

tables. If these quality issues were not reported or if reporting

was unclear, this was also noted in the tables.

Classification of psychosocial interventions

Studies were categorized into the following: CBT, MI,

combined CBT and MI, group therapies, integrated ACT,

intensive case management, residential programmes, contin-

gency management and forensic settings. Where two or three

treatment components were combined (e.g. Bellack et al.

2006), the study was categorized according to the main

intervention being tested, and a footnote was made in the

other relevant tables. Where two or three treatment arms

were compared (e.g. Jerrell & Ridgely 1995), each treatment

arm was categorized to the corresponding intervention.

Cognitive behavioural therapy can be offered in individual

or group format (Kleber et al. 2007). The core features of

CBT are functional analysis of the link between mental state

and drug use, understanding the reasons for and conse-

quences of use, and skills training for recognizing and

avoiding vulnerable situations. The aim of CBT is to correct

the thoughts, feelings and actions of the recipient to promote

alternative ways of coping and to encourage treatment

adherence (Schmitz et al. 2002, Weiss et al. 2007).

Motivational interviewing is intended to enhance the

individual’s intrinsic motivation for change (Strong

Kinnaman et al. 2007) and can also be delivered in individual

or group format. The intervention matches the patient’s level

of problem recognition with specific strategies and goals. MI

is based on four principles: expressing empathy, developing

discrepancy, supporting self-efficacy and rolling with resis-

tance (Chanut et al. 2005), and is directed at five stages: pre-

contemplation, contemplation, preparation, action and main-

tenance (Tsuang et al. 2006).

Dual diagnosis group therapies such as Double Trouble in

Recovery (Magura et al. 2003) aim to improve interpersonal

and problem-solving skills to assist in establishing and

maintaining relationships with others, dealing with conflict

and handling social situations involving substance misuse

(Jerrell & Ridgely 1995, Mueser et al. 2005). They aim to

change social attitudes and behaviours, are potentially cost-

effective and provide a structure for daily living, along with a

commitment to stopping substance use (Mueser et al. 2005,

Tsuang et al. 2006).

Integrated ACT unifies mental health and substance use

services so that clients do not need to negotiate separate

treatment programmes (McHugo et al. 1999, Mueser et al.

2005). A multidisciplinary team of clinicians in one setting

provides long-term coordinated treatment which is tailored to

the individual’s readiness for change (Barrowclough et al.

2006, Green et al. 2007). The caseload is low (10–15 clients),

frequent home visits are made, and reluctant or uncoopera-

tive clients are actively contacted and offered services. For

studies to be placed under this category, they must have

offered both active outreach and integrated services.

Intensive case management and non-integrated ACT are

similar to integrated ACT, both having lower case loads than

standard case management and often coordinating mental

health and substance use services to suit individual clients’

needs. However, they may or may not offer both mental

health and substance use services directly, and often organize

additional substance use treatments for their clients.

Residential programmes are offered in-house and involve

differing durations and differing treatment components. Low

intensity programmes place few sanctions and demands on

residents and are flexible in accommodating individual needs.

Higher intensity programmes usually offer more treatment

components and are more demanding; privileges and rules of

conduct are well-defined and abstinence is usually a

prerequisite for the participant to stay in the residential

programme.

Contingency management is generally provided by way of

monetary reward or prizes dependent on reductions in or

abstinence from substances, usually measured by urinalysis/

breathalyser and self- report.

Forensic intervention studies included any study conducted

exclusively with inmates, ex-inmates or those diverted from



jail or court settings. These involve a variety of interventions,

from intensive case management to diverting people with a

dual diagnosis to treatment programmes.

Results

Of the 92 studies examined in full, 15 were reviews, of

which 13 were excluded because they were not conducted

systematically and/or did not include meta-analysis (Drake

et al. 1998b, 2004, 2008, Goldsmith & Garlapati 2004,

Rounsaville 2004, Donald et al. 2005, Mueser et al. 2005,

Barrowclough et al. 2006, Bogenschutz et al. 2006, Tsuang

et al. 2006, Brady et al. 2007, Laker 2007, Tiet &

Mausbach 2007). Another was excluded because data were

pooled from both RCTs and non-experimental studies

(Dumaine 2003). Only one systematic review met the

inclusion criteria (Ley et al. 2001, updated Cleary et al.

2008).

From the remaining 77 studies, 15 were excluded because

most or all of the study population did not have severe mental

illness (Mowbray et al. 1999, DiNitto et al. 2002, Hulse &

Tait 2002) and three (Brown et al. 1997, Milby et al. 2000,

Sacks et al. 2008b) included participants who did not meet

diagnostic criteria; rather, they had elevated symptom

ratings. Nine studies targeted participants with post-trau-

matic stress disorder, anxiety or personality disorders (Fisher

& Bentley 1996, Linehan et al. 1999a, 1999b, Bowen et al.

2000, Randall et al. 2001, Hien et al. 2004, Morrissey et al.

2005, Cohen & Hien 2006, Watt et al. 2006).

Of the remaining 62 papers, nine were adjunct publications

of other studies (Rahav et al. 1995, French et al. 1999,

Brooks & Penn 2003, Haddock et al. 2003, Sacks et al. 2004,

Timko & Sempel 2004a, Calsyn et al. 2005, Brown et al.

2006, Timko et al. 2006). This left 30 RCTs, 23 non-

experimental studies and one systematic review meeting

all inclusion criteria, totalling 54 studies with 11,734

participants.

Cognitive behavioural therapy

Eight studies (n = 565, see Table 1) showed limited support

for CBT in reducing substance use or improving mental state.

The two RCTs of highest quality (Naeem et al. 2005,

Edwards et al. 2006) reported no statistically significant

differences between groups on measures of substance use and

mental state. Only one RCT and one non-experimental study

reported reduced substance use and both had design flaws.

Weiss et al. (2007) did not make explicit their randomization

methods and in an earlier study used a non-experimental

design (Weiss et al. 2000). Both used raters who were not

blind to the treatment condition, although self-reported

substance use was verified by urinalysis.

One RCT (Schmitz et al. 2002) showed reduced manic

symptoms at the end of 3 months of treatment and one non-

experimental study (Brooks & Penn 2003) yielded fewer

hospital days. Schmitz et al. (2002) did not make explicit the

randomization methods or whether raters were blind to

treatment condition and found that reduced depressive

symptoms lasted for 2 weeks only. Brooks and Penn (2003)

used a non-random design and, while the treatment group

spent fewer days in hospital, no differences in psychiatric

symptoms were reported on the Addiction Severity Index

(ASI). Further, they reported reduced substance use for their

control group receiving 12-step group therapy; this was

similar to another non-experimental study (Glasner-Edwards

et al. 2007) that also showed reduced depressive symptoms

and increased treatment retention in a 12-step control group.

The findings of increased retention (Schmitz et al. 2002,

Weiss et al. 2007) drove the only statistically significant

pooled finding of the review (Cleary et al. 2008), with the

other two higher quality RCTs (Naeem et al. 2005, Edwards

et al. 2006) reporting no differences. We were unable to pool

much data due to skewness, differing outcome measures or

unclear reporting.

Motivational interviewing

In nine studies MI was assessed (n = 529, see Table 2). Four

of seven RCTs and one of two non-experimental studies

showed reductions in substance use. Kavanagh et al. (2004b)

made explicit their methods and ensured raters were blind to

treatment condition. They reported reduced substance use

lasting 12 months after 3 hours of MI; however, no differ-

ences were observed from the more conservative ITT anal-

ysis. Baker et al. (2002) also used blind raters and reported

reductions in polydrug use, yet this was not sustained after

3 months and no differences for alcohol and cannabis were

observed when data were analysed separately. Hickman

(1999) and Graeber et al. (2003) also reported reductions in

alcohol use after only one to three sessions, with effects

lasting between 3 and 4 months. Unfortunately, neither

stated whether outcome raters were blind to intervention

status, although they used self-report measures, so their

results may be biased. One non-experimental study (Santa

Ana et al. 2007) also showed reductions in alcohol consump-

tion and drug days lasting 1–3 months after two MI sessions.

However, there were no differences in abstinence rates or

days spent drinking. Daley et al. (1998) reported less time in

hospital and Hickman (1999) reported reduced symptoms on

some but not all SCL 90-R subscales.

M. Cleary et al.


Table

1C

ognit

ive

beh

avio

ura

lth

erapy

(CB

T)

Auth

ors

,des

ign

&

met

hod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Rev

iew

Cle

ary

etal

.(2

008)

4R

CT

s

260

(T:

146,

C:

114),

In/o

utp

ati

ents

,SM

I

T:

3–6

Mof

wee

kly

/fort

nig

htl

y

CB

T,

C:

gro

up

counse

llin

g,

med

icati

on

monit

ori

ng,

psy

cho-e

duca

tion

Duri

ng

T,

FU

,ra

ters

bli

nd

(2R

CT

s),

ITT

(3R

CT

s)

SU

:data

could

not

be

poole

d

MS:

data

could

not

be

poole

d

TR

:T

›re

tenti

on

[P=

0Æ0

2]

Exper

imen

tal

Edw

ard

set

al.

(2006)

Expli

cit

random

izati

on

and

all

oca

tion

conce

alm

ent

47

(T:

23,

C:

24),

Outp

ati

ents

,

Aust

rali

a,

Sch

izophre

nia

&

cannabis

BD

:N

D

T:

3M

of

wee

kly

sess

ions

of

cannabis

and

psy

chosi

sth

erapy

C:

men

tal

hea

lth

psy

cho-e

duca

tion

End

of

T,

FU

at

6M

,

rate

rsbli

nd,

ITT

SU

:N

D[C

ASU

AS]

MS:

ND

[BPR

S-E

,B

DI,

SA

NS]

TR

:N

D

Naee

met

al.

(2005)

Expli

cit

random

izati

on

and

all

oca

tion

conce

alm

ent

105

(T:

67,

C:

38),

Outp

ati

ents

,U

K,

Sch

izophre

nia

BD

:N

D

T:

3M

,6

sess

ions

plu

s

psy

cho-e

duca

tion

C:

SC

End

of

T,

rate

rsbli

nd,

ITT

SU

:N

D[H

oN

OS]

MS:

ND

[BSA

,C

PR

S,

MA

DR

S,

SC

R]

TR

:N

D

Sch

mit

zet

al.

(2002)

Sta

ted

random

ized

46

(T:

25,

C:

21),

Outp

ati

ents

,U

SA

,

Bip

ola

rdis

ord

er

BD

:m

ati

tal

statu

s

T:

3M

of

16

indiv

idual

CB

Tse

ssio

ns

plu

sm

edic

ati

on

monit

ori

ng

C:

med

icati

on

monit

ori

ng

Duri

ng

T,

uncl

ear

bli

ndin

g,

52%

att

riti

on

SU

:N

D

MS:

Tfl

dep

ress

ive

sym

pto

ms

at

2W

ks

[sel

fre

port

,

P<

0Æ0

4]

flm

anic

sym

pto

ms

at

2[P

<0Æ0

01],

8[P

<0Æ0

4]

&12

Wks

[P<

0Æ0

1]

TR

:T

›re

tenti

on

[P=

0Æ0

18]

Wei

sset

al.

(2007)

Sta

ted

random

ized

62

(T:

31,

C:

31),

Inpati

ents

,U

SA

Bip

ola

rdis

ord

er

BD

:N

D

T:

20

wee

kly

,1

hour

inte

gra

ted

gro

up

CB

T

rela

pse

pre

ven

tion

C:

20

wee

kly

1hour

gro

up

dru

gco

unse

ling

Duri

ng

T,

8M

FU

,

rate

rsnot

bli

nd,

ITT

SU

:T

flti

me

tofirs

tabst

inen

tm

onth

[ASI,

uri

naly

sis

ver

ified

;P<

0Æ0

3]

MS:

ND

[HA

M-D

,Y

MR

S]

TR

:T

›att

endance

[P<

0Æ0

5]

Non-e

xper

imen

tal

Bro

oks

and

Pen

n(2

003)

Alt

ernate

all

oca

tion

112

(T:

58,

C:

54),

In/o

utp

ati

ents

,U

SA

,SM

I

BD

:gen

der

T:

6M

gro

up

CB

T

C:

12-s

tep

gro

up

ther

apy

adapte

dfo

rdual

dia

gnosi

s.

Duri

ng

T,

12,

18

MFU

,

uncl

ear

bli

ndin

g,

56%

att

riti

on

SU

:C

flalc

ohol

18

M[A

SI,

regre

ssio

nm

odel

P<

0Æ0

5],

flm

ari

juana

2M

[uri

naly

sis,

OR

:0Æ0

5].

MS:

Tfld

ays

hosp

itali

zed

[P=

0Æ0

24].

ND

[ASI]

.

TR

:C

›days

[P<

0Æ0

28]

and

Wks

[P

=0Æ0

18]

Gla

sner

-Edw

ard

set

al.

(2007)

[see

Bro

wn

etal

.2006

for

sub-s

am

ple

analy

sis]

Seq

uen

tial

all

oca

tion

148

(T:

78,

C:

70),

Outp

ati

ent,

USA

,V

eter

ans,

Majo

rdep

ress

ion

BD

:N

R

T:

24

Wks

of

inte

gra

ted

CB

T

C:

12-s

tep

gro

up

ther

apy

12,

24

Wks

duri

ng

T,

uncl

ear

bli

ndin

g

SU

:C

›abst

inen

ce[P

=0Æ0

3].

MS:

Cfl

dep

ress

ion

[HA

M-D

;P

=0Æ0

4]

TR

:C

›att

endance

by

24

Wks

[P<

0Æ0

01]

Wei

sset

al.

(2000)

[pil

ot]

Seq

uen

tial

all

oca

tion

45

(T:

21,

C:

24),

Outp

ati

ents

,U

SA

,

Bip

ola

rdis

ord

er

BD

:age,

ASI

alc

ohol

T:

12–20

wee

kly

1hour

inte

gra

ted

gro

up

sess

ions

usi

ng

aC

BT

rela

pse

-

pre

ven

tion

model

,

C:

SC

Duri

ng

T,

6M

FU

,

rate

rsnot

bli

nd

SU

:T

fldru

gs

[ASI

com

posi

te,

regre

ssio

nm

odel

P<

0Æ0

3]

and

›abst

inen

ceby

2and

3M

[P<

0Æ0

06]

MS:

ND

[HA

M-D

,Y

MR

S,

hosp

itali

zati

ons]

TR

:N

D

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;

ASI,

addic

tion

sever

ity

index

;B

D,

base

line

dif

fere

nce

s;B

DI/

BD

I-II

,B

eck

dep

ress

ion

index

;B

PR

S/

BPR

S-E

,bri

efpsy

chia

tric

rati

ng

scale

/expanded

;B

SA

,bri

efsc

ale

for

anxie

ty;C

,co

ntr

ol;

CA

SU

AS,

cannabis

and

subst

ance

use

ass

essm

ent

sched

ule

;C

PR

S,co

mpre

hen

sive

psy

chopath

olo

gic

al

rati

ng

scale

;FU

,fo

llow

-up;

HA

M-D

,H

am

ilto

nra

ting

scale

for

dep

ress

ion;

HoN

OS,hea

lth

of

the

Nati

on

outc

om

esc

ale

;IT

T,in

tent-

to-t

reat;

M,m

onth

(s);

MA

DR

S,M

ontg

om

ery

Asb

erg

dep

ress

ion

rati

ng

scale

;M

S,m

enta

lst

ate

;N

D,no

stati

stic

all

ysi

gnifi

cant

dif

fere

nce

s;N

R,not

report

ed;SA

NS,sc

ale

for

the

ass

essm

ent

of

neg

ati

ve

sym

pto

ms;

SC

,st

andard

care

;SC

R,

schiz

ophre

nia

change

Sca

le;

SM

I,se

ver

em

enta

lil

lnes

s;SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on;

Wks,

wee

ks;

YM

RS,

young

mania

rati

ng

scale

.



Table 2 Motivational Interviewing (MI)

Authors, design

& method

Participants, settings

& baseline differences Interventions

Assessment,

blinding &

ITT analysis Results

Review

Cleary et al. (2008)

5 RCTs

338 (T: 170, C: 168),

In/outpatients, SMI

T: 1 to 9 sessions,

C: SC

Various, raters

blind (2 RCTs),

ITT (2 RCTs)

SU: data could not be pooled.

MS: data could not be pooled

TR: ND

Experimental

Baker et al. (2002)

Stated randomized

160 (T: 79, C: 81),

Inpatients, Australia, SMI

BD: ND

T: 1 session with

harm reduction

approach

C: SC

3, 6, 12 M,

raters blind

SU: T fl poly-drug use at 3 M [OTI,

P = 0Æ04], ND [alcohol and cannabis]

MS: ND [BSI]

TR: ND

Graeber et al. (2003)

[pilot], Stated

randomized

30 (T: 15, C: 15),

In/outpatients,

USA, Schizophrenia and

alcohol use disorder

BD: ethnic origin

T: 3 sessions

C: 3 sessions of

psychoeducation

4, 8, 24 Wks,

raters not blind

SU: T › abstinence 8, 24 Wks

[BDP, P < 0Æ008]. ND volume

MS: NR

TR: ND

Hickman (1999)

Stated randomized

30 (T: 15, C: 15),

Outpatients, USA,

Schizophrenia

and alcohol

BD: NR

T: 1 MI plus

routine care

C: step-wise

group therapy

3 M, unclear

blinding, ITT

SU: T fl alcohol use by 3 M [AUI, P = 0Æ04]

MS: T fl depression, anxiety and

interpersonal sensitivity [SCL-90-R, P < 0Æ05].

ND other subscales

TR: NR

Kavanagh

et al. (2004b)

Explicit

randomization

25 (T: 13, C: 12),

In/outpatients,

Australia, Psychotic

disorder,

BD: hospital days, living

with family/partner

T: 3 hours of MI

over 6–9 sessions

completed

within 10 days

C: SC

6 Wks, 3, 6, 12 M,

raters blind, ITT

SU: T fl non-ITT analysis [DrugCheck; 6 M,

12 M; P < 0Æ05], ND [ITT analysis]

MS: NR

TR: NR

Martino et al. (2000)

[pilot], stated

randomized

23 (T: 13, C: 10),

Inpatients, USA,

Psychotic disorder

BD: psychiatric symptoms

T: 1, 1 hour MI

C: SC

End of T only,

unclear blinding

SU: ND [abstinence, ASI]

MS: NR

TR: T fl tardiness and early

departures [P < 0Æ05]

Martino et al. (2006)

[pilot], Explicit

randomization

44 (T: 24, C: 20),

Outpatients, USA,

Psychotic disorder

BD: alcohol and

legal problem

T: 2, 1 hour

adapted MI,

C: 2 psychiatric

interviews

4, 8, 12 Wks, raters

not blind, ITT

SU: ND [ASI, urinalysis]

MS: ND [PANSS, BDI, ASI]

TR: ND

Swanson

et al. (1999)

explicit randomization

121, 93 with

dual diagnosis

(T: 48, C: 45),

Inpatients,

USA, Schizophrenia

BD: learning difficulties

T: 1, 15 minute

MI plus 1, 1 hour

MI prior to

discharge, C: SC

First aftercare

appointment,

unclear blinding

SU: NR

MS: NR

TR: T › attendance

at aftercare [P < 0Æ01]

Non-experimental

Daley et al. (1998)

[pilot], consecutive

allocation

23 (T: 11, C: 12),

Outpatients,

USA, depressive

disorder and cocaine

BD: ethnic background

T: 5 individual and

4 group integrated

MI over 1 M

C: SC

1, 3, 12 M, unclear

blinding, 61%

attrition 3 M

SU: NR

MS: T fl hospital days by 1 yr

[P = 0Æ03]. NR [BDI]

TR: T › retention at 1, 3 M [P < 0Æ01]

Santa Ana

et al. (2007)

Part randomized

101 (T: 50, C: 51),

Inpatients, USA, SMI

BD: ND

T: 2, 2 hour

sessions

C: 2, 2 hours

group discussions

1, 3 M FU,

raters blind

SU: T flalcohol 1 M & 3 M [adjusted for

baseline; P < 0Æ05], & binge

drinking 1 M & 3 M [P < 0Æ05],

fldrug days 1 M [P < 0Æ05]. ND abstinence

MS: NR

TR: T › attendance [3 M; P < 0Æ05]

› & fl, increase and decrease, respectively; ASI, addiction severity index; AUI, alcohol use inventory; BD, baseline differences; BDI/BDI-II, Beck

depression index; BDP, brief drinker profile; BSI, brief symptom inventory; C, control; FU, follow-up; ITT, intent-to-treat; M, month(s); MS, mental

state; ND, no statistically significant differences; NR, not reported; OTI, opiate treatment index; PANSS, positive and negative scale for schizophrenia;

SC, standard care; SCL-90-R, symptom checklist 90 revised; SMI, severe mental illness; SU, substance use; T, treatment; TR, treatment retention; Wks,

weeks; Yr, years(s).

M. Cleary et al.


Motivational interviewing plus cognitive behavioural

therapy

All four RCTs assessing MI + CBT (n = 360, see Table 3)

reported statistically significant improvements in substance

use, and all made explicit their randomization methods,

although one did not ensure their raters were blind to

treatment condition (Kemp et al. 2007). In this study, non-

blinded clinician raters were used and reduced alcohol and

drug use were observed 6 months after 4–6 hours of therapy.

After 10 weekly sessions, Baker et al. (2006) reported

reductions in cannabis use by 15 weeks and amphetamine

use by 6 months; however, no differences were observed for

alcohol or polydrug use or any substance by 12 months. They

also reported improved depressive symptoms. Barrowclough

et al. (2001) reported more days abstinent at 12 months after

9 months of treatment, although this was not for the most

frequently-used substance and was not sustained at

18 months. This study also showed fewer hospitalizations

and improvements on positive and negative symptoms lasting

up to 18 months. Bellack et al. (2006) reported more clean

urine after 6 months of treatment and increased attendance,

but no reductions on ASI or mental state scores.

Group approaches

With group approaches, limited support was found from the

one RCT and four non-experimental studies (n = 316, see

Table 4). The one RCT (Hellerstein et al. 1995) showed

increased retention, but no differences between groups on

substance use or mental state after eight months of integrated

group psychotherapy. Aubry et al. (2003) reported reduced

alcohol use after 9 months of staged group therapy; however,

this was limited to one (AUDIT) of five substance use

measures. After 6 weeks of group therapy, James et al. (2004)

reported reduced drug use and psychopathology, but no

differences for alcohol or dependence and symptom severity.

In a partly-randomized study, Jerrell and Ridgely (1995)

reported reduced alcohol and drug use and improved

psychopathology after 18 months of behavioural skills group

therapy. Bond et al. (1991) reported fewer hospitalizations

and increased treatment retention after 12 months of group

therapy with differences in retention lasting over the

18 months of treatment.

Contingency management

All three RCTs of contingency management (n = 92, see

Table 5) showed reduced substance use with treatment

varying between 4 and 27 weeks. None of these researchers

reported mental health outcome or retention rates. Only one

group (Ries et al. 2004) stated that raters were blind to

treatment condition. However, urinalysis was used as an

outcome measure by Ries et al. (2004) and Drebing et al.

(2005) and as verification of self-report outcome measures by

Tracy et al. (2007).

Integrated assertive community treatment

Five large studies assessed integrated ACT (n = 911, see

Table 6). Treatment duration varied between 6 months and

3 years. Drake et al. (1998a) and Ho et al. (1999) reported

reduced substance use at the end of treatment and increased

retention in their treatment groups and two authors reported

decreased number of hospitalizations (Essock et al. 2006,

Mangrum et al. 2006). However, newer studies showed less

consistent findings for reductions in substance use (Essock

et al. 2006, Morse et al. 2006).

Intensive case management

Eight researchers assessed intensive case management

(n = 1114, see Table 7), with most reporting no differences

between groups at any time point. Herman et al. (2000)

reported that, after 4 weeks of treatment, reduced alcohol use

at 2 months was not maintained at any other follow-up to

18 months. They did not make explicit the randomization

process nor whether raters were blind to treatment condition.

One non-experimental study (Drake et al. 1997) showed

reduced alcohol use, increased recovery and fewer days

institutionalized, but no differences in drug use or psychiatric

symptoms. One partially-randomized study (Jerrell &

Ridgely 1995) showed reduced mental health symptoms after

18 months of treatment but no differences on substance use

outcomes.

Residential programmes

Nine researchers assessed residential programmes (n = 3310,

see Table 8). The only RCT (Burnam et al. 1995) showed no

differences between the 3-month integrated residential

programme and standard (non-residential) care on any

outcome measure. Six non-experimental studies showed

fairly consistent reduced substance use, particularly during

treatment lasting between 3 months and 2 years (Blankertz

& Cnaan 1994, Nuttbrock et al. 1998, Anderson 1999, De

Leon et al. 2000, Brunette et al. 2001, Timko & Sempel

2004b). Six researchers reported increased treatment reten-

tion and four of these also reported improved mental state

(Blankertz & Cnaan 1994, Nuttbrock et al. 1998, De Leon



Table

3M

I+

CB

T

Auth

ors

,des

ign

&m

ethod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Rev

iew

Cle

ary

etal

.(2

008)

3R

CT

s

276

(T:

144,

C:

132),

Outp

ati

ents

,SM

I

T:

10

Wks

to9

Mof

MI

+C

BT

C:

SC

+fa

mil

ysu

pport

or

gro

up

ther

apy

Vari

ous,

none

state

dra

ters

blind,

ITT

(3R

CT

s)

SU

:data

could

not

be

poole

d

MS:

data

could

not

be

poole

d

TR

:data

could

not

be

poole

d

Exper

imen

tal

Baker

etal

.(2

006)

Explici

tra

ndom

izat

ion

and

all

oca

tion

conce

alm

ent

130

(T:

65,

C:

65),

Outp

ati

ents

,

Aust

rali

a,

Psy

choti

cdis

ord

er

BD

:N

R

T:

10

Wks

of

4·

1hour

MI

+6

·1

hour

CB

T

C:

self

hel

pbookle

tand

SC

15

Wks,

6,

12

M,

rate

rsbli

nd,

ITT

SU

:T

flca

nnabis

15

Wks

only

[OT

I,

P=

0Æ0

2],

flam

phet

am

ine

6M

only

[P=

0Æ0

4].

ND

[alc

ohol,

poly

dru

g,

abst

inen

ce]

MS:

Tfl

dep

ress

ive

sym

pto

ms

12

M

[BD

I-II

,P<

0Æ0

1]

TR

:N

D

Barr

ow

clough

etal

.(2

001)

[see

Haddock

etal

.2003

for

18

Moutc

om

es]

Explici

tra

ndom

izat

ion

and

all

oca

tion

conce

alm

ent

36

(T:

18,

C:

18)

Outp

ati

ents

,U

K

SM

I

BD

:N

D

T:

9M

,5

MI

and

appro

x18

wee

kly

and

6biw

eekly

sess

ions

CB

T

C:

SC

+fa

mil

ysu

pport

End

of

T,

12,

18

M,

FU

,

rate

rsbli

nd,

ITT

SU

:T

›abst

inen

ce12

M[t

ime-

line

follow

back

;adju

sted

for

base

line

P<

0Æ0

3]

but

not

for

the

most

freq

uen

tly

use

dsu

bst

ance

.N

D

[ASI

,L

DQ

]

MS:

Tfl

hosp

itali

zati

ons

12

M[P

<0Æ0

5].

flposi

tive

[12

M:

P<

0Æ0

1]

&neg

ativ

e

PA

NSS

[9M

:P<

0Æ0

2,

18

M:

P=

0Æ0

04].

ND

[PA

NSS

tota

l]

TR

:N

D

Bel

lack

etal

.(2

006)

Explici

tra

ndom

izat

ion

and

all

oca

tion

conce

alm

ent

175

(res

ult

sfo

r110

that

bec

am

een

gaged

;T

:61,

C:

49),

Outp

ati

ents

,U

SA

,SM

I

BD

:N

D

T:

6M

,3

MI,

CB

Tappro

ach

es,

conti

ngen

cyco

ntr

act

s,biw

eekly

gro

ups

C:

6M

of

gro

ups,

psy

cho-e

duca

tion,

wee

kly

uri

naly

sis

Duri

ng

T,

rate

rsbli

nd

SU

:T

›cl

ean

uri

ne

[1,

4W

kblo

ck,

1,

8W

kblo

ckP<

0Æ0

02].

ND

[ASI

]

MS:

ND

TR

:T

›fo

ren

gag

edsa

mple

[P=

0Æ0

09]

and

›se

ssio

ns

att

ended

[P<

0Æ0

01]

Kem

pet

al.

(2007)

[pilot]

Explici

tra

ndom

izat

ion

and

all

oca

tion

conce

alm

ent

19

(T:

10,

C:

9)

Outp

ati

ents

,A

ust

ralia,

Psy

choti

cil

lnes

s

BD

:A

UD

IT,

DA

ST

T:

4–6

hours

of

MI

+C

BT

,

C:

psy

cho-e

duca

tion

6M

,ra

ters

not

bli

nd

SU

:T

flfr

equen

cyby

6M

[P<

0Æ0

5].

ND

[quanti

ty]

MS:

ND

[PA

NSS,

DA

SS]

TR

:N

D

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;

ASI,

addic

tion

sever

ity

index

;A

UD

IT,

alc

ohol

use

dis

ord

erid

enti

fica

tion

test

;B

D,

base

line

dif

fere

nce

s;B

DI/

BD

I-II

,B

eck

dep

ress

ion

index

;C

,

contr

ol;

DA

SS,

dep

ress

ion

anxie

tysu

bsc

ale

;D

AST

,dru

gabuse

scre

enin

gte

st;

FU

,fo

llow

-up;

ITT

,in

tent-

to-t

reat;

LD

Q,

Lee

ds

dep

enden

cyques

tionnair

e;M

,m

onth

(s);

MS,

men

tal

state

;

ND

,no

stati

stic

ally

signifi

cant

dif

fere

nce

s;N

R,

not

report

ed;

OT

I,opia

tetr

eatm

ent

index

;PA

NSS

,posi

tive

and

neg

ati

ve

scale

for

schiz

ophre

nia

;SC

,st

andard

care

;SM

I,se

ver

em

enta

l

illn

ess;

SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on;

Wks,

wee

ks.

M. Cleary et al.


Table

4G

roup

appro

ach

es

Auth

ors

,des

ign

&m

ethod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

anal

ysi

sR

esult

s

Rev

iew

Cle

ary

etal

.(2

008)

2R

CT

s

94

(T:

45,

C:

49),

Outp

ati

ents

,SM

I

T:

up

to18

Mof

gro

up

ther

apy

C:

SC

or

12-s

tep

reco

ver

y

Vari

ous,

uncl

ear

blindin

g,

ITT

(1R

CT

)

SU

:data

could

not

be

poole

d

MS:

data

could

not

be

poole

d

TR

:data

could

not

be

poole

d

Exper

imen

tal

Hel

lers

tein

etal

.(1

995)

Sta

ted

random

ized

47

(T:

23,

C:

24),

Outp

ati

ents

,U

SA

,

Sch

izophre

nia

BD

:N

D

T:

up

to8

Mof

biw

eekly

inte

grate

d

gro

up

psy

choth

erapy/

educa

tion,

C:

SC

4,

8M

,uncl

ear

blindin

g,

ITT

SU

:N

D[A

SI].

MS:

ND

[hosp

itali

zati

on,

ASI]

.

TR

:T

›re

tenti

on

4M

[P=

0Æ0

41]

Non-e

xper

imen

tal

Aubry

etal

.(2

003)

Conse

cuti

ve

all

oca

tion

56

(T:

28,

C:

28),

Outp

ati

ents

,C

anada,

SM

I

BD

:re

adin

ess

for

change

T:

9M

of

staged

gro

up

ther

apy

C:

SC

End

of

T,

18,

24

M,

rate

rsnot

bli

nd

SU

:T

:fl

alc

ohol

9M

[AU

DIT

;P<

0Æ0

1].

ND

[AU

S,D

AST

,D

US,

SA

TS]

MS:

ND

[BSI]

TR

:N

R

Bond

etal

.(1

991)

2si

tes

random

ized

(met

hod

not

expli

cit)

,

thir

dsi

tecl

inic

ian

all

oca

ted

66

(T:

23,

C:

43),

Outp

ati

ents

,U

SA

,SM

I

BD

:T

rece

ivin

g

aft

erca

re,

med

icati

ons

T:

18

Mof

gro

up

ther

apy,

C:

SC

See

Tab

le7

for

oth

erT

arm

6,

12,

18

M,

uncl

ear

blindin

g,

ITT

:>

50%

att

riti

on

at

1si

teonly

SU

:N

D[D

APS,

self

report

]

MS:

Tflh

osp

itali

zati

ons

at

6,

12

M[P

<0Æ0

5]

TR

:T

›re

tenti

on

by

12

[P<

0Æ0

1]

and

18

M[P

<0Æ0

01]

Jam

eset

al.

(2004)

Alt

ernate

all

oca

tion

63

(T:

32,

C:

31),

Outp

ati

ents

,A

ust

rali

a,

schiz

ophre

nia

or

psy

choti

cdis

ord

er

BD

:N

D

T:

6w

ks

spec

iali

zed

gro

up

pro

gra

mm

e

C:

SC

3M

,ra

ters

bli

nd

SU

:T

fldru

g3

M[D

AST

;

P<

0Æ0

01].

ND

[AU

DIT

,SD

S]

MS:

Tfl

psy

chopath

olo

gy

[BPR

S;P<

0Æ0

1].

[ND

,G

SI]

TR

:N

D

Jerr

ell

and

Rid

gel

y(1

995)

Half

clin

icia

nall

oca

ted,

half

random

ized

,w

ith

met

hods

expli

cit

84

(T:

39,

C:

45),

Outp

ati

ents

,U

SA

,

Sch

izophre

nia

BD

:N

R

T:

12–18

Mof

wee

kly

beh

avio

ura

lsk

ills

C:

12

step

reco

ver

y

See

Tab

le7

for

oth

erT

arm

6,

12,

18

M,

uncl

ear

blindin

g

SU

:T

fl18

M[r

egre

ssio

n

model

,C

-DIS

-R,

P£

0Æ0

1]

MS:

Tfl

sym

pto

ms

schiz

ophre

nia

,dep

ress

ion,

mania

18

M[C

-DIS

-R,

P£

0Æ0

1]

TR

:N

R

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;A

SI,

addic

tion

sever

ity

index

;A

UD

IT,

alc

ohol

use

dis

ord

erid

enti

fica

tion

test

;A

US,

alc

ohol

use

scale

;B

D,

base

line

dif

fere

nce

s;B

PR

S/B

PR

S-E

,

bri

efpsy

chia

tric

rati

ng

scale

/expanded

;B

SI,

bri

efsy

mpto

min

ven

tory

;C

,co

ntr

ol;

C-D

IS-R

,co

mpute

rver

sion

of

the

dia

gnost

icin

terv

iew

sched

ule

;D

APS,dru

gand

alc

oholpro

ble

msc

ale

;

DA

ST,

dru

gabuse

scre

enin

gte

st;

DU

S,dru

guse

scale

;G

SI,

glo

balse

ver

ity

index

;IT

T,

inte

nt-

to-t

reat;

M,m

onth

(s);

MS,

men

talst

ate

;N

D,

no

stati

stic

ally

signifi

cant

dif

fere

nce

s;N

R,

not

report

ed;

SA

TS,

subst

ance

abuse

trea

tmen

tsc

ale

;SC

,st

andard

care

;SD

S,

the

sever

ity

of

dep

enden

cesc

ale

;SM

I,se

ver

em

enta

lil

lnes

s;SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on;

Wks,

wee

ks.



et al. 2000, Timko & Sempel 2004b). In most of these non-

experimental studies participants were allocated to one or

another residential programme by means of bed availability,

locality of the participant or via clinician allocation, and so

these results may be prone to bias. However, the substance

use reductions observed across studies generally favoured

integrated, long-term (>6 months) residential programmes

over other residential programmes.

Forensic settings

Seven researchers assessed treatments for forensic popula-

tions (n = 4537, see Table 9). One RCT showed decreased

substance use by 12 months post-release following a low

intensive, in-prison programme modified for dual diagnosis

compared with standard prison care (Sullivan et al. 2007).

This report did not make explicit the randomization methods

nor did it state whether outcome raters were blind to

treatment. Another RCT (Cosden et al. 2003, 2005) assessed

18 months of ACT and dropped charges for completers;

fewer drug-related problems and fewer psychiatric symptoms

were reported in the treatment group. While the authors

made explicit their randomization methods, they did not

specify whether raters were blind to treatment assignment. In

another RCT reduced hospital days were reported in those

receiving approximately 2Æ5 years of integrated treatment

(Chandler & Spicer 2006), but substance use was not

assessed. There was little consistent evidence for reducing

substance use in studies assessing diversion to treatment

therapy, although all reported increased service utilization,

which is to be expected in those diverted to treatment rather

than proceeding through the court system.

Discussion

In this review, we assessed the effectiveness of psychosocial

interventions for clients with dual diagnoses and provided

assessments of the quality of available evidence. Fifty-four

studies were included: one systematic review with meta-

analysis, 30 RCTs and 23 non-experimental studies.

Although some inconsistencies were apparent, results showed

that MI had the most quality evidence for reducing substance

use over the short term, and, when combined with CBT,

improvements in mental state were also apparent. This

finding is consistent with the literature (Mueser et al. 2005,

Barrowclough et al. 2006, Laker 2007). Long-term, inte-

grated residential programmes also showed fairly consistent

support for reducing substance use, although the quality of

the evidence was not as sound. Similar findings are reported

in the literature (Drake et al. 2004, 2008, Mueser et al.Table

5C

onti

ngen

cym

anagem

ent

Auth

ors

,des

ign

&

met

hod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Exper

imen

tal

Dre

bin

get

al.

(2005)

Sta

ted

random

ized

21

(T:

13,

C:

8),

Outp

ati

ent,

USA

Vet

erans

wit

hSM

I

BD

:N

D

T:

4M

of

support

edem

plo

ym

ent

+

conti

ngen

cym

anagem

ent;

addit

ional

cash

rew

ard

s,

C:

support

edem

plo

ym

ent

Tw

ice

wee

kly

for

16

wee

ks,

4M

FU

,

uncl

ear

blindin

g,(u

rinaly

sis)

SU

:T

fllo

nger

tim

eto

firs

t

posi

tive

subst

ance

scre

en[P

<0Æ0

5]

MS:

NR

TR

:N

D

Rie

set

al.

(2004)

Expli

cit

random

izati

on

41

(T:

22,

C:

19),

Outp

ati

ents

,U

SA

,SM

I

BD

:pri

or

adve

rse

even

ts

T:

27

wee

ks

of

conti

ngen

cy

managem

ent

of

supple

men

tary

soci

al

secu

rity

inco

me

C:

SC

Wee

kly

duri

ng

T,

rate

rsbli

nd,

ITT

SU

:T

flalc

ohol

[P<

0Æ0

1],

all

subst

ance

s[P

<0Æ0

5]

MS:

NR

TR

:N

D

Tra

cyet

al.

(2007)

Expli

cit

random

izati

on

30

(T:

15,

C:

15),

hom

eles

s

outp

ati

ents

,U

SA

,SM

I

BD

:gen

der

,co

cain

euse

T:

4w

eeks

of

low

cost

conti

ngen

cy

managem

ent;

chance

sto

win

pri

zes

C:

ass

essm

ents

only

Wee

kly

self

-rep

ort

duri

ng

T(v

erifi

cati

on

by

twic

ew

eekly

uri

nal

ysi

s/bre

ath

alyse

r

test

ing),

uncl

ear

blindin

g

SU

:T

flco

cain

e[s

elf-

report

,

P=

0Æ0

2],

alc

ohol

[P=

0Æ0

1]

MS:

NR

TR

:N

D

Bel

lack

etal

.(2

006)

als

ouse

dco

nti

ngen

cym

anagem

ent

wit

hC

BT

and

MI

–se

eT

able

3.

fldec

rease

;B

D,

base

line

dif

fere

nce

s;C

,co

ntr

ol;

FU

,fo

llow

-up;

ITT

,in

tent-

to-t

reat;

M,

month

(s);

MS,

men

tal

state

;N

D,

no

stati

stic

ally

signifi

cant

dif

fere

nce

s;N

R,

not

report

ed;

SC

,

standard

care

;SM

I,se

ver

em

enta

lil

lnes

s;SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on.

M. Cleary et al.


Table

6In

tegra

ted

ass

erti

ve

com

munit

ytr

eatm

ent

(AC

T)

Auth

ors

,des

ign

&

met

hod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

anal

ysi

sR

esult

s

Rev

iew

Cle

ary

etal

.(2

008)

4R

CT

s

812

(T:

455,

C:

357)

Outp

ati

ents

,SM

I

T:

9to

36

Mof

inte

gra

ted

AC

T

C:

SC

Rate

rsbli

nd

(3R

CT

s)

ITT

(1R

CT

)

SU

:data

could

not

be

poole

d

MS:

data

could

not

be

poole

d

TR

:data

could

not

be

poole

d

Exper

imen

tal

Dra

ke

etal

.(1

998a)

Sta

ted

random

ized

223

(T:

109,

C:

114)

Outp

ati

ents

,U

SA

SM

I

BD

:B

PR

Sdis

org

aniz

atio

n

T:

3Y

rsof

24

hour

per

day

inte

gra

ted

AC

T

C:

SC

6m

onth

lyover

3Y

rs,

rate

rsbli

nd

SU

:T

fl3

Yrs

[reg

ress

ion

model

,

Tass

igned

sam

ple

(n=223):

SA

TS,

AU

S;

P<

0Æ0

5,

Tex

pose

dsa

mple

(n=173):

SA

TS,

AU

S;

P<

0Æ0

5]

MS:

ND

[BPR

S]

TR

:T

›re

tenti

on

[P=

0Æ0

07]

Ess

ock

etal

.(2

006)

Sta

ted

random

ized

,2

site

s

198

(T:

99,

C:

99)

Outp

ati

ents

USA

SM

I

BD

:SA

TS

T:

3Y

rsof

24

hour

per

day

inte

gra

ted

AC

T

C:

SC

6m

onth

lyover

3Y

rs,

rate

rsbli

nd

SU

:T

fl36

Mdue

toea

rly

reduct

ions

at

1si

te[r

egre

ssio

nm

odel

SA

TS;

P<

0Æ0

5].

ND

[AU

S,

DU

S,SA

TS,

ASI,

days

report

ing].

MS:

Tfl

hosp

italize

ddays

[sit

e2

only

,P<

0Æ0

02],

flin

stit

uti

onali

zed

days

[sit

e2

only

,P<

0Æ0

2].

TR

:N

D

Mors

eet

al.

(2006)

Sta

ted

random

ized

95

(T:

46,

C:

49)

Outp

ati

ents

USA

Hom

eles

speo

ple

wit

hSM

I

BD

:B

PR

S

T:

2Y

rsof

inte

gra

ted

AC

T

C:

SC

See

Tab

le7

for

oth

erT

arm

3–6

month

lyover

2Y

rs,

uncl

ear

blindin

g

SU

:N

D(s

elf

report

)

MS:

ND

[BPR

S].

TR

:N

D

Non-e

xper

imen

tal

Ho

etal

.(1

999)

6m

onth

lysu

cces

sive

all

oca

tion

179

(T1:

20,

T2:

42,

T3:

50,

T4:

67)

Outp

ati

ents

,U

SA

Vet

erans

wit

hpsy

choti

c

illn

ess

BD

:N

D

T:

6M

of

T,

wit

hea

ch

gro

up

rece

ivin

gin

crea

sing

am

ounts

of

inte

gra

ted

AC

T

Month

lyduri

ng

each

6M

Tphase

,uncl

ear

blindin

g

(uri

nal

ysi

s)

1M

;52%

att

riti

on,

3M

;

61%

att

riti

on

SU

:T

›abst

inen

ce;

sequen

tial

impro

vem

ent

from

gro

up

T1–4

[uri

nal

ysi

s;P

=0Æ0

5]

MS:

ND

[hosp

italiza

tions]

TR

:T

›en

gagem

ent,

rete

nti

on,

att

endance

;se

quen

tial

impro

vem

ent

from

gro

up

T1–4

[P<

0Æ0

1].

Mangru

met

al.

(2006)

2si

tes

random

ized

(met

hod

not

expli

cit)

,th

ird

site

geo

graphic

all

yall

oca

ted

216

(T:

123,

C:

93)

Outp

ati

ents

,U

SA

SM

I

BD

:N

D

T:

1Y

rof

inte

gra

ted

AC

T

C:

non-i

nte

gra

ted

care

End

of

T,

1Y

rFU

,uncl

ear

bli

ndin

g(a

dm

inis

trati

ve)

ITT

SU

:N

R

MS:

Tfl

hosp

italiza

tions

[P=

0Æ0

001]

and

hosp

ital

days

[P=

0Æ0

4]

TR

:N

R

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;A

SI,

addic

tion

sever

ity

index

;A

US,alc

oholuse

scale

;B

D,base

line

dif

fere

nce

s;B

PR

S-E

,bri

efpsy

chia

tric

rati

ng

scale

/expanded

;C

,co

ntr

ol;

DU

S,

dru

guse

scale

;FU

,fo

llow

-up;IT

T,in

tent-

to-t

reat;

M,m

onth

(s);

MS,m

enta

lst

ate

;N

D,no

stati

stic

all

ysi

gnifi

cant

dif

fere

nce

s;N

R,not

report

ed;SA

TS,su

bst

ance

abuse

trea

tmen

tsc

ale

;SC

,

standard

care

;SM

I,se

ver

em

enta

lilln

ess;

SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on;

Yr,

yea

rs(s

).



Table

7In

tensi

ve

case

managem

ent/

non-i

nte

gra

ted

AC

T

Auth

ors

,des

ign

&m

ethod

Part

icip

ants

,se

ttin

gs

&base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Rev

iew

Cle

ary

etal

.(2

008)

3R

CT

s

142

(T:

81,

C:

61),

Outp

ati

ents

,

SM

I

T:

18

Mof

non-i

nte

gra

ted

AC

Tor

inte

nsi

ve

case

managem

ent

C:

SC

Vari

ous,

None

state

dra

ters

bli

nd

ITT

analy

sis

(2R

CT

s)

SU

:data

could

not

be

poole

d

MS:

data

could

not

be

poole

d

TR

:N

Dat

18

M

Exper

imen

tal

Burn

am

etal

.(1

995)

Sta

ted

random

ized

209

(T:

144,

C:

65),

Outp

ati

ents

,U

SA

,SM

I

BD

:m

ari

tal

statu

s

T:

3M

of

inte

nsi

ve

case

managem

ent

C:

SC

See

Table

8fo

roth

erT

arm

3,

6,

9M

,uncl

ear

bli

ndin

g,

ITT

SU

:N

D[d

ays

usi

ng,

level

s].

MS:

ND

[SC

L-9

0].

TR

:N

D

Godle

yet

al.

(1994)

2si

tes

random

ized

(met

hod

not

expli

cit)

,

97

(T:

25,

C:

31,

dro

pouts

41)

Outp

ati

ents

,U

SA

,SM

I

BD

:days

dri

nkin

g

T:

2Y

rsof

spec

iali

zed

case

managem

ent

C:

SC

6,

12,

18,

24

M,

uncl

ear

bli

ndin

gSU

:1

site

only

report

ed.

ND

[DA

Q]

MS:

ND

[Are

as

of

Dif

ficu

lty

chec

kli

st,

hosp

ital

adm

issi

ons,

days

hosp

itali

zed]

TR

:N

Rby

gro

up

Her

man

etal

.(2

000)

Sta

ted

random

ized

429

(T:

284,

C:

145),

Inpati

ents

,U

SA

,SM

I

BD

:N

D

T:

appro

xim

ate

ly4

wee

ks

of

staged

inte

gra

ted

gro

up,

indiv

idual

psy

choth

erapy

and

psy

cho-e

duca

tion.

C:

SC

2,

6,

10,

14,1

8M

FU

,

uncl

ear

bli

ndin

g

SU

:T

:fl

alc

ohol

2M

[reg

ress

ion

model

P<

0Æ0

1].

MS:

ND

TR

:N

D

Leh

man

etal

.(1

993)

Random

ized

,m

ethod

expli

cit

Tota

l54,

29

wit

hcu

rren

tSU

dis

ord

er(T

:14,

C:

15),

Outp

ati

ents

,U

SA

,SM

I

BD

:N

D

T:

12

Min

cludin

g5

·1

hour

sess

ions

per

wee

kof

gro

ups

C:

SC

End

of

T,

uncl

ear

bli

ndin

g,

ITT

SU

:N

D[A

SI]

MS:

ND

[ASI,

hosp

itali

zati

on]

TR

:N

D

Mors

eet

al.

(2006)

Sta

ted

random

ized

103

(T:

54,

C:

49),

Outp

ati

ents

,U

SA

,H

om

eles

s

peo

ple

wit

hSM

I

BD

:B

PR

S

T:

2Y

rsof

non-

inte

gra

ted

AC

TC

:SC

.

See

Table

6fo

roth

erT

arm

3–6

month

ly,

uncl

ear

bli

ndin

gSU

:N

D[d

ays

usi

ng].

MS:

ND

[BPR

S].

TR

:N

D

Non-e

xper

imen

tal

Bond

etal

.(1

991)

2/3

site

sra

ndom

ized

(met

hod

not

expli

cit)

,

oth

ersi

tecl

inic

ian

all

oca

ted

74

(T:

31,

C:

43),

Outp

ati

ents

,U

SA

,SM

I

BD

:aft

erca

re,

med

icati

on

T:

18

Mof

AC

T

C:

SC

See

Table

4fo

roth

erT

arm

6,

12,

18

M,

uncl

ear

bli

ndin

g,

ITT

:

>50%

att

riti

on

1si

te

SU

:N

D[s

elf-

report

eduse

,D

APS]

MS:

ND

[hosp

itali

zati

ons]

TR

:T

›ret

enti

on

by

12

&18

M[P

<0Æ0

1]

Dra

ke

etal

.(1

997)

Non-e

quiv

ale

nt

com

pari

son

gro

up

217

(T:

158,

C:

59),

Res

iden

tial,

USA

,H

om

eles

s

peo

ple

wit

hSM

I

BD

:pre

vio

us

hosp

itali

zati

ons,

psy

chia

tric

dia

gnosi

s,

days

hom

eles

s

T:

18

Mof

inte

nsi

ve

inte

gra

ted

case

managem

ent,

counse

llin

g

and

housi

ng

support

C:

18

Mof

non-i

nte

gra

ted

care

6,

12,

18

M,

rate

rsbli

nd

SU

:T

flalc

ohol

[AU

S;

P<

0Æ0

5].

ND

[DU

S].

›re

cover

y[S

AT

S;

P=

0Æ0

02].

MS:

Tfl

inst

ituti

onali

zed

days

[P<

0Æ0

1].

ND

[ASI,

BPR

S]

TR

:N

D

Jerr

ell

and

Rid

gel

y(1

995)

Half

clin

icia

nall

oca

ted,

half

random

ized

,w

ith

met

hods

expli

cit

93

(T:

48,

C:

45)

Outp

ati

ents

,U

SA

,

Sch

izophre

nia

BD

:N

R

T:

12–18

Mof

inte

nsi

ve

case

managem

ent

C:

12

step

reco

ver

y

See

Table

4fo

roth

erT

arm

6,

12,

18

M,

uncl

ear

bli

ndin

gSU

:N

D[C

-DIS

-R]

MS:

Tfl

sym

pto

ms

for

schiz

ophre

nia

,

dep

ress

ion,

mania

18

M[C

-DIS

-R,

P£

0Æ0

1]

TR

:N

R

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;

ASI,

addic

tion

sever

ity

index

;A

US,

alc

ohol

use

scale

;B

D,

base

line

dif

fere

nce

s;B

PR

S/

BPR

S-E

,bri

efpsy

chia

tric

rati

ng

scale

/expanded

;C

,co

ntr

ol;

C-D

IS-R

,co

mpute

r

ver

sion

of

the

dia

gnost

icin

terv

iew

sched

ule

;D

APS,dru

gand

alc

oholpro

ble

msc

ale

;D

AQ

,dru

g&

alc

oholques

tionnair

e;D

US,dru

guse

scale

;FU

,fo

llow

-up;IT

T,in

tent-

to-t

reat;

M,m

onth

(s);

MS,m

enta

lst

ate

;N

D,

no

stati

stic

all

ysi

gnifi

cant

dif

fere

nce

s;N

R,

not

report

ed;

SA

TS,

subst

ance

abuse

trea

tmen

tsc

ale

;SC

,st

andard

care

;SC

L-9

0-R

,sy

mpto

mch

eckli

st90

revis

ed;

SM

I,se

ver

em

enta

lil

lnes

s;SU

,su

bst

ance

use

;T

,

trea

tmen

t;T

R,

trea

tmen

tre

tenti

on;

Yr,

yea

rs(s

).

M. Cleary et al.


Table

8R

esid

enti

al

pro

gra

mm

es

Auth

ors

,des

ign

&

met

hod

Part

icip

ants

,se

ttin

gs

&

base

line

dif

fere

nce

sIn

terv

enti

ons

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Exper

imen

tal

Burn

am

etal

.(1

995)

Sta

ted

random

ized

132

(T:

67,

C:

65),

Res

iden

tial,

USA

SM

I

BD

:m

ari

tal

statu

s

T:

3M

inte

gra

ted

C:

SC

See

Table

7fo

roth

erT

arm

3,

6,

9M

,uncl

ear

bli

ndin

g,

ITT

SU

:N

D[d

ays

usi

ng,

level

s].

MS:

ND

[SC

L-9

0].

TR

:N

D

Non-e

xper

imen

tal

Aguil

era

etal

.(1

999)

Geo

gra

phic

all

oca

tion

86

(T:

40,

C:

46),

Res

iden

tial,

Hondura

s,hom

eles

s

men

wit

hSM

I

BD

:age,

convic

tions,

SU

,L

OS

etc

T:

3M

of

inte

gra

ted

C:

3M

resi

den

tial

alc

oholi

sm

pro

gra

mm

e

3M

,uncl

ear

bli

ndin

gSU

:N

D[r

elapse

]

MS:

C›

[LO

FA

,P<

0Æ0

5]

TR

:N

D

Ander

son

(1999)

Bed

avail

abil

ity

all

oca

tion

225

(T:

76,

C:

149),

Res

iden

tial,

USA

Hom

eles

sm

enw

ith

SM

I

BD

:age,

ethnic

back

gro

und,

alc

ohol

T:

6M

of

inte

gra

ted

C:

resi

den

tial

rehabil

itati

on

End

of

T,

9M

FU

,

uncl

ear

bli

ndin

g

SU

:T

fl9

M[A

SI;

P<

0Æ0

5]

MS:

ND

[ASI]

TR

:T

›9

M[P

<0Æ0

1]

Bla

nker

tzand

Cnaan

(1994)

Bed

avail

abil

ity

all

oca

tion

176,

data

for

com

ple

ters

;89

(T:

51,

C:

38),

Res

iden

tial,

USA

,

Hom

eles

speo

ple

wit

hSM

I

BD

:m

edic

ati

on

T:

up

to2

Yrs

of

psy

choso

cial

rehabil

itati

on

C:

modifi

edth

erapeu

tic

com

munit

y

6m

onth

ly,

3M

FU

aft

er

dis

charg

e,uncl

ear

bli

ndin

g

SU

:T

›abst

inen

ceduri

ng

T[A

SI:

P<

0Æ0

1]

MS:

T›

exit

ed‘s

ucc

essf

ull

y’

[P<

0Æ0

5]

TR

:T

›re

tenti

on

Bru

net

teet

al.

(2001)

Cli

nic

ian

all

oca

tion

82

(T:

43,

C:

39),

Res

iden

tial,

USA

SM

I

BD

:ed

uca

tion,

alc

ohol

use

T:

12

Mm

enta

lhea

lth

and

SU

C:

2M

short

-ter

mm

enta

l

hea

lth

and

SU

resi

den

tial

6M

,uncl

ear

bli

ndin

gSU

:T

›abst

inen

ce[P

<0Æ0

01].

ND

[AU

S,

DU

S]

MS:

ND

TR

:T

›en

gagem

ent

[P<

0Æ0

01]

De

Leo

net

al.

(2000)

Seq

uen

tial

all

oca

tion

342

(T1:

183,

T2:

93,

C:

66),

resi

den

tial,

USA

,

hom

eles

speo

ple

wit

hSM

I

BD

:N

D

T1:

12

Mof

modifi

ed

med

ium

inte

nsi

ty

ther

apeu

tic

com

munit

yT

2:

12

Mof

modifi

ed

low

inte

nsi

tyth

erapeu

tic

com

munit

yC

:SC

12

M,>

24

M,

uncl

ear

bli

ndin

g

ITT

analy

sis

SU

:T

2,

fl>

24

M[r

egre

ssio

n

model

,P<

0Æ0

5]

MS:

T2,

›>

24

Mdep

ress

ion

[BD

I;

P<

0Æ0

01]

anxie

ty[S

MA

S:

P<

0Æ0

5].

ND

[SC

L-9

0-R

].

TR

:›

rete

nti

on

T2

vs.

T1

[P<

0Æ0

02]

Kasp

row

etal

.(1

999)

Surv

eyvia

Dep

t.V

eter

ans

Aff

air

s,99

site

s

1495

(T:

957,

C:

538),

Res

iden

tial,

USA

,H

om

eles

s

vet

erans

wit

hSM

I

BD

:N

R

T:

men

tal

hea

lth

and

SU

pro

gra

mm

e

C:

SU

resi

den

tial

pro

gra

mm

e

Rep

ort

sco

mple

ted

by

case

manager

s

SU

:N

D[A

SI,

hosp

itali

zati

ons]

MS:

ND

[ASI,

hosp

itali

zati

ons]

TR

:T

flle

ftw

ithout

staff

consu

ltati

on

[reg

ress

ion

model

,P<

0Æ0

1]

Nutt

bro

cket

al.

(1998)

Bed

avail

abil

ity

wit

h

faci

lity

appro

val

694

(T:

373,

C:

321)

Res

iden

tial,

USA

Hom

eles

sm

enw

ith

SM

I

BD

:N

D

T:

12

Mof

hig

hin

tensi

ty

ther

apeu

tic

com

munit

y

C:

low

inte

nsi

tyco

mm

unit

y

resi

den

ces

(men

tal

hea

lth

focu

s)

2,

6,

12

M,

rate

rsnot

bli

nd,

appro

x

90%

att

riti

on

by

12

M

SU

:T

›cl

ean

uri

ne,

sub-s

am

ple

[P£

0Æ0

1]

MS:

Tfl

psy

chia

tric

dis

turb

ance

[GA

F,

2

&12

M],

[BPR

S,

2M

,re

gre

ssio

nm

odel

]

TR

:N

D

Tim

ko

and

Sem

pel

(2004a,

2004b))

,T

imko

etal

.2006,

Random

lyass

igned

and

clin

icia

nall

oca

ted

230,

(T:

110,

C:

120),

Res

iden

tial,

USA

,V

eter

ans

wit

hSM

I

BD

:psy

chia

tric

&fa

mil

y/s

oci

al

pro

ble

ms,

hosp

ital

days

T:

hig

hin

tensi

tyover

3si

tes

C:

low

inte

nsi

tyover

4si

tes

At

dis

charg

e,4,

12

MFU

,

uncl

ear

bli

ndin

g

SU

:T

fl(A

SI;

P<

0Æ0

1)

MS:

ND

[ASI]

TR

:T

›12-s

tep

att

endance

duri

ng

T

(P<

0Æ0

1),

C›a

tten

dance

post

-

dis

charg

e(P

<0Æ0

5)

›&

fl,in

crea

seand

dec

rease

,re

spec

tivel

y;A

SI,

addic

tion

sever

ity

index

;A

US,alc

oholuse

scale

;B

D,base

line

dif

fere

nce

s;B

DI/

BD

I-II

,B

eck

dep

ress

ion

index

;B

PR

S/B

PR

S-E

,bri

efpsy

chia

tric

rati

ng

scale

/expanded

;C

,

contr

ol;

DU

S,

dru

guse

scale

;FU

,fo

llow

-up;

GA

F,

glo

bal

ass

essm

ent

of

funct

ionin

g;

ITT

,in

tent-

to-t

reat;

LO

FA

,le

vel

sof

funct

ional

ass

essm

ent;

LO

S,

length

of

stay;

M,

month

(s);

MS,

men

tal

state

;N

D,

no

stati

stic

all

ysi

gnifi

cant

dif

fere

nce

s;N

R,not

report

ed;SC

,st

andard

care

;SC

L-9

0-R

,sy

mpto

mch

eckli

st90

revis

ed;SM

AS,sh

ort

ened

manif

est

anxie

tysc

ale

;SM

I,se

ver

em

enta

lil

lnes

s;SU

,su

bst

ance

use

;T

,tr

eatm

ent;

TR

,tr

eatm

ent

rete

nti

on;

Yr,

yea

rs(s

).



Table

9Fore

nsi

cse

ttin

gs

Auth

ors

,des

ign

&m

ethod

Part

icip

ants

&se

ttin

gs

Inte

rven

tions

Ass

essm

ent,

bli

ndin

g&

ITT

analy

sis

Res

ult

s

Exper

imen

tal

Chandle

rand

Spic

er(2

006)

Sta

ted

random

ized

182

(T:

103,

C:

79),

Outp

ati

ents

,U

SA

,

Rec

entl

yre

lease

din

mate

sw

ith

SM

I

BD

:N

D

T:

up

to2Æ5

Yrs

of

post

-

cust

ody

inte

gra

ted

trea

tmen

t

C:

bri

efin

terv

enti

on

(case

managem

ent)

Up

to18

M,

rate

rsnot

bli

nd

(adm

inis

trati

ve

data

),IT

T

SU

:N

R

MS:

Tfl

hosp

ital

days

[reg

ress

ion

model

,P<

0Æ0

14]

›outp

ati

ent

med

icati

on

[P<

0Æ0

01]

TR

:N

R

Cosd

enet

al.

(2003,

2005))

Expli

cit

random

izati

on

235

(T:

137,

C:

98),

Outp

ati

ents

,U

SA

,SM

I

BD

:A

SI

dru

gsc

ore

s

T:

18

Mof

AC

Tand

dro

pped

charg

esfo

rco

mple

ters

C:

adver

sari

al

court

pro

ceed

ings

6m

onth

lyfo

r2

Yrs

,ra

ters

not

bli

nd

SU

:T

fldru

gre

late

dpro

ble

ms

24

M[A

SI,

P<

0Æ0

1].

MS:

Tfl

sym

pto

ms

24

M

[BA

SIS

-32,

P<

0Æ0

1].

TR

:N

R

Malo

ney

(unpubli

shed

data

)

Expli

cit

random

izati

on

135

(T1:

18,

T2:

58,

T3:

16,

C:

43),

Jail

and

com

munit

y,

USA

,SM

Ife

male

s

BD

:N

D

T1:

inte

nsi

ve

jail

,T

2:

inte

nsi

ve

com

munit

y,

T3:

com

bin

edin

tensi

ve

jail

and

com

munit

ytr

eatm

ents

C:

SC

6m

onth

lyfo

r3

Yrs

,ra

ters

not

bli

nd

SU

:N

R

MS:

NR

TR

:re

port

ed,

but

not

by

Tgro

up.

Sull

ivan

etal

.(2

007)

[see

Sack

set

al.

(2004)

for

base

line

data

]

Sta

ted

random

izati

on

139

(T:7

5,

C:6

4),

Jail

,U

SA

,SM

Im

ale

s

BD

:age,

past

crim

e

T:

12

Mdual

dia

gnosi

sth

erapeu

tic

com

munit

y,

inpri

son

C:

SC

6,

12

Mpost

-pri

son

rele

ase

,

uncl

ear

bli

ndin

g,

ITT

SU

:T

fl12

M[r

egre

ssio

n

model

;P<

0Æ0

1]

MS:

NR

TR

:N

R

Non-e

xper

imen

tal

Bro

ner

etal

.(2

004)

Non-e

quiv

ale

nt

com

pari

son

gro

up

1966

(T:

971,

C:

995),

Outp

ati

ents

,U

SA

,SM

I

BD

:gen

der

,em

plo

ym

ent,

arr

ests

,ja

ildays,

SU

T:

jail

div

ersi

on

toT

from

pre

-

or

post

-bookin

g(a

rres

t),

over

8si

tes

(met

hod

vari

edby

site

)

C:

no

jail

div

ersi

on

3,

12

M,

uncl

ear

bli

ndin

gSU

:C

fldru

gs

3M

only

[reg

ress

ion

model

;P<

0Æ0

5].

ND

[alc

ohol]

MS:

T:

›se

rvic

euti

liza

tion

3M

[reg

ress

ion

model

;m

edic

ati

on;

P<

0Æ0

01,

counse

llin

g;

P<

0Æ0

1,

hosp

itali

zati

ons,

P<

0Æ0

01,

ER

vis

its;

P<

0Æ0

5]

and

12

M[h

osp

itali

zati

ons,

P<

0Æ0

01,

ER

vis

its;

P<

0Æ0

5].

flsy

mpto

ms

[MC

S-1

2,

P=

0Æ0

3].

ND

[CSI]

TR

:N

D

Shafe

ret

al.

(2004)

All

oca

tion

via

poli

ce,

jail

etc.

248

(T:

154,

C:

94),

Outp

ati

ents

,U

SA

,SM

I

BD

:SU

,vio

lent

crim

ehis

tory

T:

jail

div

ersi

on

toT

from

post

-bookin

g(a

rres

t)

C:

no

jail

div

ersi

on

3,

12

M,

uncl

ear

bli

ndin

gSU

:N

D[s

elf

report

]

MS:

T›

ER

12

M[r

epea

ted

mea

sure

sA

NO

VA

AN

OV

A;

P<

0Æ0

06],

flanxie

ty&

depre

ssio

n

sym

pto

ms

[CSI,

P<

0Æ0

25]

TR

:N

D

Ste

adm

an

and

Naple

s(2

005)

Non-e

quiv

ale

nt

com

pari

son

gro

up

1632

(T:

812,

C:

820),

Outp

ati

ents

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2005). With research in its infancy, contingency management

programmes show some promise, as in three RCTs reduced

substance use occurred and another RCT demonstrated

increased retention and drug-free urine when combined with

MI and CBT (Bellack et al. 2006).

The inconsistent support for CBT alone for reducing

substance use and/or improving mental state may be

explained by heterogeneous samples and interventions. The

two studies without statistically significant findings targeted

patients with schizophrenia offering between six and 12

individual sessions (Naeem et al. 2005, Edwards et al. 2006).

The studies with statistically significant findings targeted

patients with bipolar disorder, and offered between 16 and

20 sessions (Schmitz et al. 2002, Weiss et al. 2007). Further,

CBT can have various foci such as harm reduction or relapse

prevention, and so there could have been differences between

studies with regard to the specific interventions as well as

variety in the control conditions. Inconsistent results may also

be explained by differences in study quality, with those of

highest quality reporting no statistically significant results.

Nevertheless, as present there is little evidence that CBT

alone is an effective intervention for dual diagnosis clients

with schizophrenia.

In contrast to other reviews (Mueser et al. 2005, Drake

et al. 2008), little consistent support was found for group

therapy, which may be explained by differences in the way

studies were categorized. For instance, we allocated Bellack

et al. (2006) to MI + CBT and Weiss et al. (2000, 2007) to

CBT, rather than group therapy. Others reviewers have

categorized interventions as individual or group therapies

(Drake et al. 2008), psychiatric diagnoses (Tiet & Mausbach

2007) or not included contingency management studies

(Mangrum et al. 2006, Cleary et al. 2008). This is in contrast

to the present review, in which we grouped similar studies

according to interventions (e.g. CBT, MI and CBT + MI) to

assess the efficacy of stand-alone interventions.

Also, unlike previous reviews (Drake et al. 1998b, 2004,

Barrowclough et al. 2006, Tsuang et al. 2006), we found that

the evidence to support integrated ACT was inconsistent.

Older studies tended to show reduced substance use, while

more recent studies tended not to show such differences. This

may be due to increasing integration of standard care in

comparison groups (Ziedonis et al. 2005, Essock et al. 2006).

Future studies with consistent methodologies of high-fidelity

individual treatment components, offered singularly or in

various simple combinations and assessed over long periods

using standardized outcome measures, should allow more

consistent, quality evidence and facilitate meta-analysis.

Using sub-groups of patients may help to determine whether

certain interventions work best for certain patient subgroups

and allow differing treatment components to target particular

subgroups.

Review strengths and limitations

A strength of this review is the detailed assessment of trial

quality. Of all the studies included, only five fulfilled all

quality issues. Having access to both high and low quality

evidence, with quality made explicit, assists practitioners to

make informed and evidence-based treatment judgements

(Newhouse 2008). A recent Cochrane review (Cleary et al.

2008) excluded quasi-randomized and non-randomized tri-

als, those using non-validated scales or if there was high

attrition (>50%) or skewed data. To be more inclusive, we

included both randomized and non-randomized studies.

Thus, a limitation is that some study results may be based

on data of questionable reliability. Further, these samples are

heterogeneous, varying on mental health diagnoses and

severity, type of substance used, severity of use and other

factors that may have an impact on treatment outcomes, such

as culture, age and social support (Warren et al. 2007,

McGovern & McLellan 2008). Individuals with dual diag-

nosis have an array of problems and other outcome measures,

such as social functioning, medication compliance and crime,

are also important treatment outcomes (Sacks et al. 2008a).

In this review, we focussed on three main topics (substance

use, mental health and retention), but in future reviews

broader outcome measures might be incorporated to assess

treatment effectiveness further.

Conclusion

In this systematic review, comparisons of psychosocial

interventions were difficult because of the diversity of

interventions (including standard care), outcomes measures

and the variable trial quality. We found some support for the

effectiveness of MI for the reduction of substance use, at least

in the short term and, when combined with CBT over longer

periods, improvements in mental health were apparent. Trials

involving long-term residential programmes and contingency

management were also effective in reducing substance use,

but some of this evidence was based on lower quality trials.

Limited support was found for other interventions including

CBT as a stand alone intervention, intensive case manage-

ment or non-integrated ACT. Future RCTs are needed to

assess the long-term benefits for patients with different

diagnoses to determine whether certain interventions work

better for different diagnostic subgroups. Future high quality

trials should include larger sample sizes, standardized out-

come measures and have longer follow-up periods to enable



the effectiveness of various psychosocial interventions to be

assessed.

Funding

This study was supported by an Educational Grant from

Pfizer Australia.

Author contributions

MC, GH and GW obtained funding. MC, GH, SM and GW

were responsible for the study conception and design. SM,

MC and GH performed the data collection and conducted the

data analysis. MC, GH, SM, GW drafted the manuscript.

MC and GH supervised the study and all authors gave their

approval of the version to be published.

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