Utilization and outcomes of mental health services among patients in drug treatment

Utilization and Outcomes of Mental Health Services among Patients

in Drug Treatment

Yih-Ing Hser, Ph.D., Christine Grella, Ph.D., Elizabeth Evans, M.A., & Yu-Chuang Huang, Dr. P.H.

UCLA Integrated Substance Abuse ProgramsNeuropsychiatric Institute

University of California, Los Angeles

December 2004Correspondence: Yih-Ing Hser, Ph.D., UCLA Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 200, Los Angeles, CA 90025. Phone: (310) 445-0874, ext. 264; E-mail: [email protected]

Acknowledgment: The study was supported in part by the California Department of Alcohol and Drug Programs (ADP; ContractNo. 98-00245). Dr. Hser is also supported by an Independent Scientist Award from the National Institute on Drug Abuse (NIDA K02DA00139). The content of this publication does not necessarily reflect the views or policies of the funding agencies. The authors thank the publication support provided by staff at the UCLA Integrated Substance Abuse Programs.

Hser, Y.-I., Grella, C., Evans, E., & Huang, Y.-U. (2006). Utilization and outcomes of mental health services among patientsin drug treatment. Journal of Addictive Diseases, 25 (1): 73-85. PMID: 16597575.

document.doc10/16/20227:33 PM1

mailto:[email protected]

AbstractThis study examined utilization of mental health services and

treatment outcomes among 1,091 patients with mental health

problems recruited from 39 treatment programs in 13 California

counties. We compared three groups: one that received dual

treatment from drug and mental health programs (N = 294), one

that received mental health services only within drug treatment

programs (N = 578), and one that received no mental health

services (N = 219). Individuals who received dual treatment had

more severe substance use and mental health problems, followed in

severity by those who received mental health services within drug

treatment, and those who received no services. All groups

significantly reduced their psychiatric severity at the follow-

up, although there were no group differences in treatment

retention and drug use outcomes. These findings suggest that

individuals with mental health problems can be successfully

treated within drug treatment programs and/or in conjunction with

mental health providers.


Introduction

In the past 20 years, service providers have increasingly

recognized that individuals entering into substance abuse

treatment programs frequently have co-occurring mental disorders.

National epidemiological studies have demonstrated that

individuals with co-occurring disorders have higher utilization

rates for both mental health and substance abuse treatment.1-4

Moreover, the presence of a mental disorder has been shown to

affect the severity and course of co-occurring substance

dependence, such that both disorders interact and typically

require simultaneous treatment.5-8 Individuals with co-occurring

disorders have higher levels of psychological distress and poorer

psychosocial functioning, as compared with individuals with

substance dependence only, and hence may need more intensive

treatment and comprehensive services in order to benefit from

treatment.9-11 Further, there is evidence that substance abusers

with co-occurring mental disorders generally have shorter stays

in substance abuse treatment and poorer posttreatment outcomes,

as compared to individuals without co-occurring mental

disorders.12-17 As a result, there has been an increased


understanding of the need to provide simultaneous and coordinated

mental health and substance abuse treatment for individuals who

have co-occurring disorders.

Yet individuals who have co-occurring disorders face

numerous obstacles when seeking treatment for either or both

disorders.18-19 These obstacles stem from continuing

administrative and financial policies that undergird the

separation of substance abuse and mental health treatment into

two separate service systems.20 For example, exclusionary

criteria for admission to either type of program often restrict

treatment to individuals with one type of “primary” disorder.21

Publicly funded mental health programs are mandated to provide

treatment only to those individuals who meet the threshold of a

“severe and disabling” disorder, which excludes many others who

have mental health problems of lesser severity, but need

treatment nonetheless. Similarly, historically, individuals who

were taking psychotropic medications for psychiatric disorders

were commonly excluded from substance abuse treatment agencies

that adhered to a strict definition of “abstinence.” Although

there is evidence that such attitudes are changing, treatment


providers in the two systems still adhere to divergent

perceptions regarding appropriate treatment approaches for this

population, particularly regarding the issue of abstinence.22

Consequently, individuals with co-occurring disorders are often

referred back and forth across the two treatment systems or fail

to receive treatment for either disorder altogether.23-24

Nevertheless, progress has been made in recent years in the

development of clinical protocols for diagnosis and assessment,

motivational interventions, and relapse prevention for patients

with co-occurring disorders.25-30 Some substance abuse treatment

programs now “specialize” in providing treatment specifically for

this population and have adopted a “dual diagnosis” orientation

to treatment.31-33 Yet many, if not most, substance abuse

treatment programs are still not equipped to provide services to

this population. Data from the annual national survey of

substance abuse treatment programs conducted by the government

show that about half provide on-site services for individuals

with co-occurring disorders ,34 which is consistent with regional

35 and state-level surveys.36 Lacking the capacity to provide

mental health services on-site, many substance abuse programs


refer these patients for mental health services off-site,

although coordination of service delivery across treatment

systems presents additional obstacles to patient care.37-39

At present, most studies that examine the outcomes of

treatment for patients who have co-occurring disorders focus on

those who receive treatment within one system or the other. To

date, no studies have directly examined patient characteristics

and treatment outcomes associated with different patterns of

service delivery – either receipt of mental health services on-

site within substance abuse programs or receipt of mental health

services from a separate provider, in addition to substance abuse

treatment.

The present study takes advantage of data collected in the

California Treatment Outcome Project (CalTOP) as part of a pilot

implementation of an ongoing outcome monitoring system tracking

treatment of alcohol and drug abuse in California. CalTOP

included existing drug treatment programs in diverse communities

and collected assessment data from a large sample of patients in

these programs. Services provided by these programs were

obtained by a program survey. Services received by patients were


collected by a phone interview at 3-months following treatment

admission. Additionally, records were obtained from the

California Mental Health Department for individuals who received

publicly funded mental health services during the treatment and

follow-up period. Thus, we were able to categorize the sample

into three analytic groups: those receiving dual treatment from

both drug treatment and mental health programs, those receiving

mental health services from drug treatment programs only, and

those not receiving mental health services from either source.

By comparing the three analytic groups, we address the following

key research questions: (1) What were the patient

characteristics related to receiving dual treatment, receiving

mental health services only in the drug treatment programs, and

not receiving services from either source? (2) What types of

treatment services were provided to these patients in these two

types of settings? And (3) What were the treatment outcomes for

the three groups defined by type of service delivery?

Methods

Study Design


The source of the data examined in this study was CalTOP, a

multisite and multicounty prospective treatment outcome study.40

As part of the national Treatment Outcomes and Performance Pilot

Studies Enhancement (TOPPSII) funded by the Center for Substance

Abuse Treatment, CalTOP began data collection in April 2000 from

all adult patients consecutively admitted to 43 programs in 13

counties in California. Criteria for selecting the participating

counties and providers included demographic breadth and adequate

flow of the patient population, automation readiness, familiarity

with assessment tools, geographic scope, and commitment to

CalTOP. The participating programs represent all major

modalities currently available in California (25 outpatient drug-

free, 11 residential, 4 methadone maintenance, and 3 multiple

modality). The counties represented in the study (Alameda, El

Dorado, Kern, Lassen, Orange, Riverside, Sacramento, San Benito,

San Diego, San Francisco, San Joaquin, San Luis Obispo, and San

Mateo) cover wide geographic locations (e.g., northern, central,

and southern regions) and include both urban and rural areas.

As part of the evaluation of CalTOP, the first 3,314 adult

admissions in 2001 and 2002 were targeted for the 3-month follow-


up. Excluding the ineligible (5 deceased, 110 incarcerated, 17

deported or unable to answer the questions), 2,850 of the 3,182

eligible completed the interview (a 90% completion rate). For

the 9-month follow-up, in order to achieve the target of 2,700

completed interviews, the first 3,715 patients were targeted,

which included an additional 400 patients not targeted for the 3-

month interview. (The 2,700 subjects were determined by (1) a

statistical consideration to achieve adequate power for outcome

analyses, and (2) the logistic consideration for accomplishing

the task within the contract period.) Excluding the ineligible

(29 deceased, 182 incarcerated, 7 deported), 2,730 of the 3,497

eligible completed the interview (a 78% completion rate).

Because the present study focuses on the nature of mental

health service delivery, we include in the study sample only

those subjects who reported at least some mental health or

psychological problem at treatment intake (N = 1,091); excluded

were those who had no evidence of mental health problems as

revealed by a score of 0 on the Addiction Severity Index (ASI; n

= 977), or who did not have 3-month or 9-month follow-up

interviews.


Participants

As noted above, the present study includes 1,091 patients

who reported mental health or psychological problems at intake

(i.e., ASI psychiatric severity > 0) and who completed the intake

assessment and the 3-month and 9-month follow-up interviews. We

categorized the sample into three groups based on the type of

mental health services received: (1) Dual-Treatment Group, who

received services from both drug and mental health programs (N =

294, 27% of the sample), (2) Drug-Treatment Group, who received

services only from drug treatment (N = 578, 53% of the sample),

and (3) No-Service Group, who received no mental health services

(N = 219, 20% of the sample).

The overall study sample was 57.1% female, 58.9% White,

17.6% Black, 17.8% Hispanic, and 5.9% other ethnic groups. The

mean age at treatment admission was 34.9 + 9.8 years. Table 1

presents demographic and background characteristics of the three

groups and total study sample.

____________________

Insert Table 1 about here

____________________


Among patients in the Dual-Treatment Group, the leading

diagnosis (based on administrative records) was affective

psychoses (28.9%), followed by depressive disorder (18.4%), other

psychoses (8.4), adjustment reaction (8.5%), and schizophrenic

disorder (6.5%). For the most part, mental health services were

provided in outpatient (90%) and day services (8%), although a

small percentage (less than 2%) were provided within hospital or

other inpatient treatment.

Treatment Programs

Questionnaires completed by the program directors provided

the description of treatment characteristics of the participating

CalTOP facilities. The “typical” treatment facility had been in

operation for more than 15 years, was part of a larger

organization, and had an average daily census of 112 patients (a

median of 50). All were primarily drug treatment programs, as

opposed to alcohol-only treatment programs, and most had a

mixture of funding from both public and private sources.

Most programs offered intake assessment and both individual

and group alcohol and drug counseling. In terms of mental health

services, almost all programs provided biopsychosocial assessment


and referral and 25.6% conducted psychiatric or psychological

evaluation. More than half offered individual counseling (51.3%)

and group counseling (41.0%) specifically for mental health

issues. About 25.6% prescribed and/or monitored psychotropic

medications on-site.

Patient Intake Assessment and Follow-up

Patients were assessed at intake, discharge, 3-month follow-

up, and 9-month follow-up. Treatment staff at participating

programs completed an in-person assessment with all entering

adult patients as part of the normal admission process.

Treatment staff also completed an exit assessment. Follow-up

interviews were conducted by UCLA-trained interviewers over the

phone at 3 months and 9 months after treatment admission. Each

interview lasted approximately 30 minutes. Patients were paid

$10 for the 3-month interview and $15 for the 9-month interview.

Data Sources, Instruments, and Measures

Data sources included patient self-report at multiple

assessment points as well as official records for mental health

services utilization, arrests, and drug treatment participation.


Mental Health Services Data

Mental health services provided by the mental health

programs to CalTOP patients were obtained by searching the Client

and Service Information (CSI) database maintained by the

Department of Mental Health (DMH). The database includes all

Medi-Cal and state-funded mental health services, including 24-

hour, day services, and outpatient programs, and excluding state

hospitals. The Mental Health Client Service Information system

is an event database. Each service received is registered as a

record. Therefore, one client can have multiple records if more

than one service is received. The data linkage process linked

7,589 records to the 294 of the subjects during the follow-up

period (approximately 9 months) since treatment admission.40

Arrest Records

Arrest records for CalTOP clients were obtained from the

California Department of Justice (DOJ), which maintains the

Criminal Identification and Information (CII) database in the

Automated Criminal History System for all California criminal

justice records.

CalTOP Data System


Addiction Severity Index (ASI). The ASI 41-42 is a structured interview

that assesses problem severity in seven areas: alcohol use, drug

use, employment, family and social relationships, legal,

psychological, and medical status. A composite score can be

computed for each of the scales to indicate severity in that area;

the range of scores is 0 to 1 with higher scores indicating

greater severity. Also presented are selected individual items in

the psychiatric problem domain. Using a median split (.367) of

the ASI psychiatric severity score at intake, we calculated the

percentage of high severity versus low severity in each of the

three groups. The ASI was administered at treatment admission and

9 months post-admission. One major outcome measure is the

difference in ASI composite scores from baseline to the 9-month

follow-up.

Other intake measures. Additional derived measures at intake

included multiple drug use (use of three or more drugs), heavy

alcohol use (primary alcohol use and daily alcohol use in the

previous 30 days), criminally active (currently on

probation/parole, awaiting trial or case pending, or having been

arrested or incarcerated in the previous 30 days), and on public


assistance (receiving food stamps, Medi-Cal, etc.). All these

derived problem indicators were dichotomous variables.

Treatment Services Review (TSR). The TSR 43 was used to collect

information on services provided to patients during treatment.

The TSR recorded the number of professional services (e.g., doctor

appointments, medications) and discussion sessions (e.g., group or

individual counseling or education sessions, Alcoholic

Anonymous/Narcotics Anonymous meetings) that the patient received

in the previous 3 months in each of the seven problem areas of the

ASI. We reported mental health services received (either on-site

in the program or off-site through referrals) collected using the

TSR. This instrument was administered during the 3-month follow-

up interview.

Treatment retention was based on treatment records reported to

the California Alcohol and Drug Data System (CADDS), which is the

state database tracking all admission and discharge episodes

within publicly funded and/or licensed programs. Retention was

defined as the number of days between CalTOP program admission

and discharge. For those without discharge records, we

calculated their length of stay from admission to the last date


of program participation or the date of the 9-month interview.

Patients were classified as having sufficient retention if they

stayed in treatment for 90 days or longer, or if they completed

treatment as stipulated by the program. These retention

thresholds have been demonstrated to be predictive of positive

outcomes in previous treatment outcome research.44-45

Drug treatment success. Individuals are considered to be

successful if they reported no use of alcohol or drugs and had an

independent living arrangement in the community (i.e., not in a

controlled environment such as prison, jail, or hospital) in the

30 days prior to the 9-month follow-up interview.

Analytic approach

We conducted ANOVA to examine the main effects of mental

health service utilization patterns as represented by the three

analytic groups. Pair-wise post-hoc comparisons were conducted

to identify which group differences were significant if the main

group effect was significant. Changes in ASI psychiatric

severity scores for the three groups were tested using repeated

measures of ANOVA with Group, Time, and Group and Time

Interaction as the independent variables. To control for Type I


error due to multiple tests, we set the significance level at p <

.01 to be conservative.

Results

Pre-treatment Characteristics

Background. As shown in Table 1, the three analytic groups

did not differ in age at drug treatment admission and legal

status. However, the highest percentage of females was in the

Dual-Treatment Group, followed by the Drug-Treatment Group and

the No-Service Group. The No Service Group had more African

Americans and Latinos and fewer Whites than the Dual-Treatment

Group. Individuals receiving no services were also the most

likely to be employed and the least likely to be on public

assistance, while individuals in the Dual Treatment Group were

least likely to be employed and most likely to be on public

assistance.

Drug use, treatment, and criminal history. Patterns of drug use,

treatment participation, and criminal involvement at intake are

presented in Table 2. In general, the Dual Treatment Group had

the most severe use of alcohol and drugs, followed by the Drug

Treatment Group and the No Service Group, as reflected by higher


rates of using heroin and cocaine, younger ages at initiation

(e.g., alcohol), and more years of use (alcohol), although the

significant differences were mostly between the Dual Treatment

and No Services groups. There were no significant differences

among groups in the rates of multiple drug use, injection drug

use, or type of primary drug use. Individuals in the Dual

Treatment Group had the highest mean number of prior alcohol or

drug treatment episodes, followed by the Drug Treatment Group,

and the No Service Group. Not surprisingly, relative to the

other two groups, more individuals in the No Service Group were

treated in outpatient drug-free programs and less in residential

programs.

____________________


____________________

There were no significant differences among groups in regard

to criminal history; however, the No Service Group had the

highest rate of referral to treatment through the criminal

justice system, followed by the Drug –Treatment Group and Dual

Treatment Group. A greater proportion of the Dual Treatment


Group was referred by “other” providers, which can include mental

health or other types of health care providers and community

programs.

Psychiatric problems. The three groups differed significantly in

their lifetime utilization of mental health services, their

psychiatric symptoms, and perceived need for mental health

treatment at intake into the CalTOP treatment episode (Table 3).

The Dual Treatment Group consistently reported the highest rates

of prior mental health treatment, use of prescription medications

for mental health problems, current psychiatric symptoms, days

hospitalized in the previous 30, and days with psychiatric

problems in the previous 30, followed by the Drug Treatment Group

and the No Service Group. This group also reported being more

troubled by their mental health problems and as having a greater

need for mental health treatment. Consistent with these other

indicators, nearly three quarters of the Dual Treatment Group had

a “high” level of psychiatric severity (based on the median of

the intake sample), compared with fewer than half of the Drug

Treatment Group and less than one third of the No Services Group.

____________________



____________________

Mental Health Treatment Services, Drug Treatment Retention, and

Self-Help Participation


Table 4 presents the mental health services received during

the 3 months following treatment admission (for the Dual

Treatment Group and Drug Treatment Group) based on the TSR

collected at the 3-month follow-up interview. In these analyses,

we included the ASI psychiatric score as covariate in order to

control for the psychiatric severity at intake. A greater

proportion of individuals in the Dual Treatment Group than the

Drug Treatment Group reported receiving mental health tests,

hospitalization, and medication for psychiatric problems. In

contrast, a greater proportion of individuals in the Drug

Treatment Group than the Dual Treatment Group received mental

health services in forms of relaxation training and interpersonal

skills. There were no significant differences between groups

regarding receipt of behavioral modification (about one third of

both groups) or having “significant” discussions with a service

provider (e.g., with a mental health specialist, counselor, or

social worker in an individual or group session) related to one’s

psychological problems (about three quarters of both groups).

_____________________



_____________________

As shown in table 5, about 54% of the No Service Group

stayed in treatment for at least 90 days or completed treatment

(which in some programs was less than 90 days duration), as did

62% of the Drug Treatment Group, and 59% of the Dual Treatment

Group. Between 59% to 67% in each of the three groups attended

self-help groups in the month prior to the 9-month follow-up. No

group differences were found in either drug treatment retention

or self-help group participation.

_____________________


_____________________

Posttreatment Outcomes

Changes in the ASI psychiatric composite scores from

baseline to follow-up most succinctly summarize changes in mental

health problems after treatment. Repeated measures of ANOVA

showed significant time and group effects (p < .0001) but not

their interaction. As illustrated in Figure 1, significant

reductions in psychiatric severity were observed for all three


groups. Controlling for pretreatment differences, the Dual

Treatment Group continued to show the highest level of

psychiatric severity, followed by the Drug Treatment Group and

the No Service Group.

_____________________

Insert Figure 1 about here

_____________________

In terms of overall drug treatment success defined as no use

of alcohol or drugs and having a stable living in the community,

45% of the Dual Treatment Group and 51% to 52% of the other two

groups were considered as successful at 9 months following

treatment admission; again, no significant group difference was

found (Table 5). Combining across the three groups, there were

significant correlations between psychiatric severity and alcohol

use (.25, p < .001, at intake, .32, p < .001, at follow-up), and

drug use (.21, p < .001, at intake, .27, p < .001, at follow-up).

Discussion

This study is one of the first to examine the types of

mental health services utilization among patients in drug

treatment and the relationship of these service patterns to


posttreatment outcomes. Moreover, the study has the advantage of

a relatively large number of patients, multiple types of

programs, and the linkage of self-report data with information

from administrative data systems. The study demonstrated that

more than a quarter of those expressing some level of mental

health problems at admission into drug treatment also received

services from mental health programs (i.e., the Dual Treatment

Group), one-fifth received no services, and the remainder

received some type of mental health services within the context

of drug treatment only. The group receiving dual treatment

demonstrated the most severe profile of mental health problems,

both over the lifetime and at treatment intake. Individuals who

received dual treatment were more likely to be women (70%), to be

White (66%), and to rely on public assistance, and were less

likely to be employed at the time of intake. They also displayed

more severe drug use and were more likely to have a history of

prior drug treatment. This group was also more likely to use

more intensive mental health services (e.g., hospitalization,

medications).


In contrast, one-fifth of the sample did not receive any

mental health services (i.e., No Service Group) even though their

intake assessment indicated mental health problems. Relative to

the other two groups, the No Service Group had the lowest

percentage of female and individuals on public assistance, and

the highest percentages of African American and Latino/Hispanics

and individuals employed. Although the group’s mean ASI

psychiatric scores were lower than the other two groups, about

28% of this group had scores higher than the median (.366) of the

overall sample. It is unclear why this group did not receive

services addressing their mental health issues.

About half of the sample who reported mental health problems

at drug treatment intake received mental health services within

the drug treatment programs (Drug Treatment Group), and this

group’s outcomes often fell between the Dual Treatment Group and

No Service Group, particularly in terms of psychiatric severity

and service utilization, with some aspects (e.g., drug use) more

similar to the Dual Treatment Group, and other aspects (e.g.,

demographics, prior alcohol or drug treatment) more similar to

the No Service Group.


The three groups did not differ much in their stay in drug

treatment or later participation in self-help groups. Their

overall drug treatment success rates were also similar, ranging

from 45% to 52%. Although all three groups showed significant

improvement in level of psychiatric severity, the Dual Treatment

Group continued to have the highest severity and the No Service

Group the lowest, following the same order observed at intake.

The study suggests that individuals who access services from

mental health programs, rather than solely through drug

treatment, have more severe types of mental health problems that

require extended care or more intensive interventions. More than

35% of these dually treated individuals had affective or other

psychoses. Unfortunately, psychiatric diagnoses (which were

obtained from mental health records) were not available in the

other two groups to make further comparisons across diagnostic

categories. Other research has shown that patients with co-

occurring disorders, in either substance abuse or mental health

programs, differ in regard to types of mental disorders.21

However, the Dual Treatment Group reported the highest level of

mental health problem severity and service utilization.


Additionally, severity levels of alcohol and drug use increase

with psychiatric severity as evidenced by the significant

correlations between psychiatric severity and alcohol and drug

use at both intake and follow-up.

It is not clear why close to a quarter of those reporting

mental health problems at treatment admission did not receive any

services related to mental health issues. Service utilization

can be a function of access as well as compliance by the

patients. That is, some patients may fail to receive services

because they are treated in drug treatment programs that fail to

properly screen and assess for mental health disorders or that

lack the capability to either provide these services on-site or

to refer patients to off-site providers. Alternatively, the

failure to receive mental health services may reflect a patient’s

lack of interest or willingness to address these issues, or may

even reflect their inability to recall or to accurately report

having received these services.

It is important to note some cautions and limitations of the

present study. The counties and treatment programs participating

in CalTOP were not randomly selected. Observed patterns may not


be generalizable to other programs that do not provide similar

services to their patients. Some of the measures relied on data

derived from patient self-report; however, the instruments (e.g.,

ASI, TSR) and procedures used in this study are those most widely

used in the substance abuse treatment field and have been

validated in studies with similar populations. Additionally, the

study has been strengthened by including data sources obtained

from official records such as mental health and criminal justice

involvement.

Few studies are available to assess mental health service

utilization and treatment outcomes in community-based treatment

programs. The present study provides evidence that individuals

with mental health problems are found within mainstream

community-based drug treatment programs and that fully half of

them receive mental health services within the context of their

substance abuse treatment, while another quarter receives

treatment simultaneously from a separate mental health provider.

Future studies should assess the extent to which treatment across

substance abuse and mental health providers is coordinated and


identify ways to improve service delivery to dually diagnosed

individuals.


References

1. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M,

Eshleman S, Wittchen H, Kendler KS. Lifetime and 12-month

prevalence of DSM-III-R psychiatric disorders in the

United States: Results from the National Comorbidity

Study. Arch Gen Psychiatry. 1994; 51(1):8-19.

2. Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG,

Leaf PJ. The epidemiology of co-occurring addictive and

mental disorders: Implications for prevention and service

utilization. Am J Orthopsychiatry. 1996; 66:17-31.

3. Regier D, Narrow W, Rae D, Mandersheid R, Locke B, Goodwin

F. The de facto U.S. Mental and addictive disorders

service system. Arch Gen Psychiatry. 1993; 50:85-94.

4. Wu LT, Ringwalt CL, Williams CE. Use of substance abuse

treatment services by persons with mental health and

substance use problems. Psychiatr Serv. 2003; 54(3):363-69.

5. Bartels SJ, Drake RE, Wallach MA. Long-term course of

substance use disorders among patients with severe mental

illness. Psychiatr Serv. 1995; 46(3):248-51.

6. Drake RE, Mueser KT, Clark RE, Wallach MA. The course,


treatment, and outcome of substance disorder in persons

with severe mental illness. Am J Orthopsychiatry. 1996;

66(1): 42-51.

7. Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J.

Effects of major depression on remission and relapse of

substance dependence. Arch Gen Psychiatry. 2002;

59(4):375-80.

8. Minkoff K. Best practices: Developing standards of care

for individuals with co- occurring psychiatric and

substance use disorders. Psychiatr Serv. 2001a; 52:597-99.

9. McLellan AT, Luborsky L, Woody G , O'Brien, CP, Druley KA.

Predicting response to alcohol and drug abuse treatments.

Role of psychiatric severity. Arch Gen Psychiatry. 1983;

40(6):620-25.

10. McLellan AT, Alterman AI, Metzger DS, Grissom GR, Woody

GE, Luborsky L, O'Brien CP. Similarity of outcome

predictors across opiate, cocaine, and alcohol treatments:

Role of treatment services. J Consult Clin Psychol.

1994;62(6):1141-58.

11. Schmitz JM, Stotts AL, Averill PM, Rothfleisch JM,


Bailley SE, Sayre SL, Grabowski J. Cocaine dependence with

and without comorbid depression: A comparison of patient

characteristics. Drug Alcohol Depend. 2000; 60(2000):189-

98.

12. Brown RA, Monti PM, Myers MG, Martin RA, Rivinus T,

Dubreuil ME, Rohsenow DJ. Depression among cocaine abusers

in treatment: Relation to cocaine and alcohol use and

treatment outcome. Am J Psychiatry. 1998; 155(2):220-5.

13. Carroll KM, Power ME, Bryant K, Rounsaville BJ. One-

year follow-up status of treatment-seeking cocaine

abusers: Psychopathology and dependence severity as

predictors of outcome. J Nerv Ment Dis. 1993; 181(2):71-9.

14. Compton WM, Cottler LB, Jacobs JL, Ben-Abdallah A,

Spitznagel ED. The role of psychiatric disorders in

predicting drug dependence treatment outcomes. Am J

Psychiatry. 2003; 160(5): 890-5.

15. Rounsaville BJ, Kosten TR, Weissman MM, Kleber HD.

Prognostic significance of psychopathology in treated

opiate addicts: A 2.5-year follow-up study. Arch Gen

Psychiatry. 1986; 43(8):739-45.


16. Rounsaville BJ, Dolinsky ZS, Babor TF, Meyer RE.

Psychopathology as a predictor of treatment outcome in

alcoholics. Arch Gen Psychiatry. 1987; 44(6):505-13.

17. Weisner C, Matzger H, Kaskutas LA. How important is

treatment? One-year outcomes of treated and untreated

alcohol-dependent individuals. Addiction. 2003; 98:901-11.

18. Brown VB, Ridgely MS, Pepper B, Levine IS, Ryglewicz H.

The dual crisis: Mental illness and substance abuse. Am

Psychol. 1989; 44:565-9.

19. Zweben JE. Severely and persistently mentally ill

substance abusers: Clinical and policy issues. J

Psychoactive Drugs. 2000; 32: 383-389.

20. Osher FC, Drake RE. Reversing a history of unmet needs:

Approaches to care for persons with co-occurring addictive

and mental disorders. Am J Orthopsychiatry. 1996; 66(1):4-

11.

21. Primm AB, Gomez MB, Tzolova-Iontchev I, Perry W, Vu HT,

Crum RM. Mental health versus substance abuse treatment

programs for dually diagnosed patients. J Subst Abuse

Treat. 2000; 19(3): 285-90.


22. Grella CE. Contrasting the views of substance misuse

and mental health treatment providers on treating the

dually diagnosed. Subst Use Misuse. 2003; 38(10):1433-

1446.

23. Drake RE, Mueser KT. Psychosocial approaches to dual

diagnosis. Schizophr Bull. 2000; 26(1):105-18.

24. Watkins KE, Burnam A, Kung F, Paddock SA. A national

survey of care for persons with co-occurring mental and

substance use disorders. Psychiatr Serv. 2001; 52(8):

1062-68.

25. Barrowclough C, Haddock G, Tarrier N, Lewis SW, Moring

J, O'Brien R, Schofield N, McGovern J. Randomized

controlled trial of motivational interviewing, cognitive

behavior therapy, and family intervention for patients

with comorbid schizophrenia and substance use disorders.

Am J Psychiatry. 2001; 158(10):1706-13.

26. Carey KB. Substance use reduction in the context of

outpatient psychiatric treatment: A collaborative,

motivational, harm reduction approach. Community Ment

Health J. 1996; 32(3): 291-306.


27. Drake RE, Mercer-McFadden C, Mueser KT, McHugo GJ, Bond

GR. Review of integrated mental health and substance abuse

treatment for patients with dual disorders. Schizophr

Bull. 1998; 24(4):589-608.

28. Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K,

Kola L, Lynde D, Osher FC, Clark RE, Rickards L.

Implementing dual diagnosis services for clients with

severe mental illness. Psychiatr Serv. 2001; 52(4):469-76.

29. Roberts LJ, Shaner A, Eckman TA. Overcoming addictions:

Skills training for people with schizophrenia. New York:

W. W. Norton, 1999.

30. Ziedonis DM, Trudeau K. Motivation to quit using

substances among individuals with schizophrenia:

Implications for a motivation-based treatment model.

Schizophr Bull. 1997; 23(2):229-38.

31. Grella CE, Gilmore J. Improving service delivery to the

dually diagnosed in Los Angeles County. J Subst Abuse

Treat. 2002; 23:115-22.

32. Moos RH, Finney JW, Federman EB, Suchinsky R. Specialty

mental health care improves patients' outcomes: Findings


from a nationwide program to monitor the quality of care

for patients with substance use disorders. J Stud Alcohol.

2000; 61(5):704-13.

33. Sacks S. Co-occurring mental and substance use

disorders: Promising approaches and research issues. Subst

Use Misuse. 2000; 35(12-14):2061-93.

34. Substance Abuse and Mental Health Services

Administration, Office of Applied Studies. The DASIS

report: Facilities offering special programs for dually

diagnosed clients. Rockville, MD: U.S. Department of

Health and Human Services, 2002.

35. Grella CE, Hser YI. A county survey of mental health

services in drug treatment programs. Psychiatr Serv. 1997;

48(7):950-52.

36. Young N, Grella CE. Mental health and substance abuse

treatment services for dually-diagnosed clients: Results of

a state-wide survey of county administrators. J Ment Health

Adm. 1998; 25(1):83-92.

37. Drake RE, Wallach MA. Dual diagnosis: 15 years of

progress. Psychiatr Serv. 2000; 51(9):1126-1129.


38. Grella CE, Gil-Rivas V, Cooper L. Perceptions of mental

health and substance abuse program administrators and

staff on service delivery to persons with co-occurring

substance abuse and mental disorders. J Behav Health Serv

Res. 2004; 31(1):38-49.

39. Jerrell JM, Wilson JL, Hiller DC. Issues and outcomes

in integrated treatment programs for dual disorders. J

Behav Health Serv Res. 2000; 27:303-13.

40. Hser Y-I, Evans E, Teruya C, Hardy M, Urada D, Huang Y,

Picazo R, Shen H, Hsieh J, Anglin MD. Final report: The

California Treatment Outcome Project. California State

Department of Alcohol and Drug Programs. Los Angeles, CA:

UCLA Integrated Substance Abuse Programs, 2002.

41. McLellan AT, Luborsky L, Woody GE, O'Brien CP. An

improved diagnostic evaluation instrument for substance

abuse patients. The Addiction Severity Index. J Nerv Ment

Dis. 1980; 168:26-33.

42. McLellan AT, Kushner H, Metzger D, Peters R, Smith I,

Grissom G, Pettinati H, Argeriou M. The fifth edition of

the Addiction Severity Index. J Subst Abuse Treat. 1992;


9:199-213.

43. McLellan AT, Alterman AI, Cacciola J, Metzger D,

O'Brien CP. A new measure of substance abuse treatment.

Initial studies of the treatment services review. J Nerv

Ment Dis. 1992; 18:101-10.

44. De Leon G. Retention in drug-free therapeutic

communities. In: Pickens RW, Leukefeld CG, Schuster CR,

eds. Improving drug abuse treatment (NIDA Research

Monograph 106, DHHS Pub. No. ADM 91-1754; Rockville, MD:

National Institute on Drug Abuse, 1991.

45. Simpson DD, Joe GW, Fletcher BW, Hubbard RL, Anglin MD.

A national evaluation of treatment outcomes for cocaine

dependence Arch Gen Psychiatry. 1999; 56:507-14.


Table 1. Patient Background Characteristics by Service Status

No Services(N = 219)

Services inDrug

TreatmentOnly

(N = 578)

DualTreatment(N = 294)

Total(N = 1091)

Female, %*** 49.8 a 53.5 a 69.7 b 57.1Ethnicity, % **

a

a,b

b

White 48.6 59.0 66.2 58.9African American 20.6 18.2 13.5 17.4Latino/Hispanics 23.9 17.0 14.8 17.8Others 6.9 5.8 5.5 5.9

Age at admission, %Less than 25 24.6 19.7 18.0 20.326-35 34.3 29.9 33.3 31.736-45 29.7 36.5 34.4 34.546+ 11.4 13.9 14.3 13.5Mean age (SD) 33.7 (10.0) 35.2 (9.3) 35.3 (9.9) 34.9 (9.8)

Employed, %*** 44.2 a 29.5 b 12.3 c 27.8Received welfare inprevious 30 days, %**

18.7 a,b 13.3 a 21.1 b 16.5

Legal Status, %Probation 35.2 31.8 29.6 31.9Parole 8.7 6.2 3.7 6.1

Tests on differences among three groups, **p < 0.01, ***p < 0.001. Note:values with the same subscripts are not significantly different.

/tt/file_convert/631b877f93f371de1900ff97/document.doc rev. 2/27/2015 04:15:00 PM

Table 2. Drug Use, Treatment History, and Criminal History by Service Status

NoServices(N =219)

Services inDrug

TreatmentOnly

(N = 578)

DualTreatmen

t(N =294)

Total(N = 1091)

Drug use in the life timeAmphetamine used, % 57.1 61.3 64.3 61.2

Age of first use (SD) 20.5 (6.9)

19.6 (16.9) 18.7 (6.3)

19.6 (6.8)

Years of use (SD) 7.7 (6.0)

8.9 (6.9) 8.8 (7.5)

8.6 (6.9)

Heroin used, % ** 22.8 a 32.4 b 38.8 b 32.2Age of first use (SD) 22.1

(7.6)22.5 (8.2) 24.1

(8.8)22.9 (8.3)


7.0 (9.2) 7.5 (9.5)

7.2 (9.1)

Cocaine/Crack used, % ***

43.4 a 52.4 a,b 58.5 b 52.3

Age of first use (SD) 21.5 (6.4)

22.9 (7.1) 23.4 (9.2)

22.8 (7.6)


7.3 (7.0) 6.5 (6.3)

7.2 (6.8)

Marijuana used, % 70.3 68.2 69.4 68.9Age of first use (SD) 15.4

(5.2)14.6 (3.9) 15.4

(4.1)15.0 (4.3)


11.8 (8.5) 11.2 (8.9)

11.4 (8.8)

Alcohol used, % 84.5 88.4 91.2 88.4Age of first use (SD)**

15.5 (4.2) a

14.9 (15.1)a,b

14.0 (4.6) b

14.7 (4.8)

Years of use (SD)** 13.4 (9.6) a

14.9 (10.3)a,b

16.0 (10.7) b

14.9 (10.3)

Heavy alcohol use, % 34.3 41.4 43.2 40.4Multiple drug use, % 41.6 47.6 54.4 48.2IV Injection drug use, % 18.7 23.2 26.9 23.3Primary drug, %

Alcohol 25.6 30.6 33.0 30.3Cocaine 12.8 11.4 12.6 12.0Heroin 12.8 16.1 18.4 16.0Marijuana 15.5 8.5 8.2 9.8Amphetamine/Methamphetamine

28.8 30.3 25.2 28.6

Other drug 4.6 3.1 2.7 3.3Treatment History (SD)

Number of alcohol treatments**

0.8 (3.6) a

1.1 (3.3) 1.9 (3.6) c

1.3 (3.5)

Number of drug treatments **

1.5 (3.2) a

2.0 (3.8) a,b

2.7 (4.3) b

2.1 (3.8)

Criminal History, %Criminally active in previous 30 days

61.2 55.9 51.7 55.8

Ever arrested 79.9 79.1 77.2 78.7Arrest in the previous year

40.2 38.9 33.7 37.8

Treatment Modality, % *** a a

b

Methadone maintenance 5.5 4.3 6.5 5.1Outpatient drug-free 69.0 49.5 52.4 54.2Residential 25.6 46.2 41.2 40.7

Treatment Referral Sources, % ***

a a

b

AOD programs 10.6 13.0 11.6 12.2Criminal justice system 32.6 27.5 17.8 25.9Self referral 40.8 40.7 43.7 41.5Others 1 16.1 18.8 27.0 20.4

1 Others include community programs, health care, schools, employers and 12-step programs.Tests on differences among three groups, **p < 0.01, ***p < 0.001. Note: values with the same subscripts are not significantly different.

Table 3. Psychiatric Symptoms and Mental Health Treatment History by ServiceStatus (%)

NoServices(N = 219)

Servicesin DrugTreatment Only(N =578)

DualTreatmen

t(N =294)

Total(N =1091)

Ever had psychiatric inpatient treatment***

16.6 a 27.8 b 56.7 c 33.3

Ever had psychiatric outpatient treatment***

25.8 a 40.8 b 65.6 c 44.5

Pension for psychiatric disability currently***

1.4 a 4.4 a 18.8 b 7.7

Psychiatric symptoms, previous 30 days Serious depression, sadness*** 47.9 a 53.8 a 67.2 b 56.2 Serious anxiety/tension*** 56.7 a 65.6 a 75.4 b 66.5 Hallucinations*** 5.1 a 9.8 a 20.5 b 11.7 Trouble understanding, concentrating,

or remembering*** 39.2 a 47.0 a 63.5 b 49.9

Trouble controlling violent behavior 19.8 17.5 24.6 19.9 Serious thoughts of suicide*** 6.0 a 11.3 a 22.9 b 13.4 Attempted suicide** 0.9 a 2.3 a 6.8 b 3.2 Been prescribed medication for any

psychological problem***10.6 a 24.8 b 56.0 c 30.4

How much have been troubled by psychiatric problem***

a

b

c

Not at all 1.4 3.1 2.7 2.7Slightly 44.7 27.8 16.7 28.2Moderately 18.4 22.0 17.4 20.0Considerably 18.0 21.6 26.6 22.3Extremely 17.5 25.5 36.5 26.9

How important is treatment**

a

b

c

Not at all 9.2 8.0 5.5 7.6

Slightly 35.5 9.2 23.0 21.8Moderately 11.5 13.4 10.6 12.3Considerably 15.7 16.6 20.1 17.4Extremely 28.1 38.9 54.6 41.0

Days in hospital in the previous 30 days(SD)***

0.0 a 0.3 (1.5) b

0.6 (2.8) b

0.3 (1.8)

Days had problem in the previous 30 days(SD)***

10.1 (11.0) a

13.1 (12.1) b

17.2 (12.2) c

13.6 (12.2)

High ASI psychiatric severity *** 28.3 a 45.2 b 72.1 c 49.0Tests on differences among three groups, **p < 0.01, ***p < 0.001. Note: values with the same subscripts are not significantly different.

Table 4. Mental Health Treatment Services at 3-Month Follow-up by Service Status(%)

NoService

s(N =219)

Servicesin Drug

TreatmentOnly

(N = 578)

DualTreatmen

t(N =294)

Total(N =1091)

Hospitalized for mental health problems 0.0 0.9 5.1 1.8

Tested for mental health problems** 0.0 15.6 28.3 15.9

Medications for mental health problems***

0.0 29.1 54.6 30.1

Relaxation training** 0.0 40.5 31.1 29.8

Behavior modification 0.0 37.4 31.1 28.2

Interpersonal skills training** 0.0 59.0 47.8 44.1

“Significant” discussion of mental health problem

0.0 73.0 76.5 59.3

Tests on differences between “services in drug treatment” and “dual treatment” groups, controlling for baseline ASI psychiatric severity. **p < 0.01, ***p < 0.001

Table 5. Treatment Completion, Self-Help Participation and Drug-Use Outcomesat 9-month Follow-up (%)

NoService

s(N =219)

Servicesin Drug

TreatmentOnly

(N = 578)

DualTreatmen

t(N =294)

Total(N =1091)

Treatment completion or retention more than 90 days 53.9 61.6 58.5 59.2

Attended self-help groups in theprevious 30 days 58.9 63.7 66.8 63.5

Success in community (no alcoholor drug use, not arrested or incarcerated, not in controlled environment and with stable living status)

51.6 51.0 44.9 49.5

Tests on differences among three groups controlling for baseline ASI psychiatric severity, ***p < 0.001. Note : values with the same subscripts are not significantly different.

Utilization and outcomes of mental health services among patients in drug treatment

Documents

Transcript of Utilization and outcomes of mental health services among patients in drug treatment