Integrated Treatment for Co-Occurring Disorders: the Evidence

The Evidence Integrated Treatment for Co-Occurring Disorders

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Mental Health Services www.samhsa.gov

The Integrated Evidence Treatment for Co-Occurring Disorders

U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services Acknowledgments

This document was produced for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number 280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as the Government Project Officers.

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The views, opinions, and content of this publication are those of the authors and contributors and do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), SAMHSA, or HHS.

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Recommended Citation

Substance Abuse and Mental Health Services Administration. Integrated Treatment for Co-Occurring Disorders: The Evidence. DHHS Pub. No. SMA-08-4366, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2009.

Originating Office

Center for Mental Health Services Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, MD 20857

DHHS Publication No. SMA-08-4366 Printed 2009 The Evidence

The Evidence introduces all stakeholders to the research literature and other resources on Integrated Treatment for Co-Occurring Disorders. This booklet includes the following: Integrated

 Two key resources included in the KIT; Treatment for  Additional resources for further reading; and Co-Occurring  References for the citations presented throughout the KIT. Disorders This KIT is part of a series of Evidence-Based Practices KITs created by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

This booklet is part of the Integrated Treatment for Co-Occurring Disorders KIT that includes a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP What’s in The Evidence

Review of Research Literature...... 1 Integrated Selected Bibliography ...... 11 Treatment for References ...... 23 Co-Occurring Acknowledgments...... 27 Disorders

The Evidence

Review of Research Literature

A number of research articles summarize This article describes the critical the effectiveness of Integrated Treatment components of the evidence-based model for Co-Occurring Disorders. This KIT and its effectiveness. Barriers to includes a full text copy of one of them: implementation and strategies for overcoming them are also discussed, based Drake, R. E., Essock, S. M., Shaner, on experiences in several states. A., Carey, K. B., Minkoff, K., Kola, L., et al. (2001). Implementing dual This article may be viewed or printed from diagnosis services for clients with severe the CD-ROM in your KIT. For a printed mental illness. Psychiatric Services, copy, see page 3. 52(4), 469-476.

The Evidence 1 Review of Research Literature Center for Substance Abuse Treatment, Substance TIP 42 is accompanied by four supplements: Abuse Treatment for Persons with Co-Occurring n Quick Guide for Administrators Based on TIP Disorders, Treatment Improvement Protocol 42: Substance Abuse Treatment for Persons (TIP) Series 42, DHHS Publication No. (SMA) with Co-Occurring Disorders; 05-3992, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. n Quick Guide for Clinicians Based on TIP 42: Substance Abuse Treatment for Persons with Similar to this KIT, TIP 42 is a guide that provides Co-Occurring Disorders; resources for treating co-occurring mental illnesses and substance use disorders. It is an excellent n Substance Abuse Treatment for Persons with complement to the Integrated Treatment KIT. Co-Occurring Disorders: In-Service Training Based on a Treatment Improvement Protocol The primary audiences for TIP 42 are substance Tip 42; and abuse treatment practitioners with varying degrees of education and experience. Secondary audiences n Knowledge Application Program (KAP) Keys are policymakers and other professionals who work for Clinicians Based on TIP 42: Substance with consumers who have co-occurring disorders. Abuse Treatment for Persons with Co- Occurring Disorders. TIP 42 summarizes state-of-the-art treatment of co-occurring disorders. It has chapters on For a copy of TIP 42 and the supplemental guides terminology, assessment, and treatment strategies for the TIP, see the CD-ROM in this KIT or go to and gives suggestions for policy planning. www.ncadi.samhsa.gov. Concepts, models, and strategies outlined in TIP 42 are based on definitive research, empirical support, and agreements of a consensus panel. Successful models of treatment are portrayed and specific consensus panel recommendations are cited throughout the TIP.

Review of Research Literature 2 The Evidence Implementing Dual Diagnosis Services for Clients With Severe Mental Illness Robert E. Drake, M.D., Ph.D. Susan M. Essock, Ph.D. Andrew Shaner, M.D. Kate B. Carey, Ph.D. Kenneth Minkoff, M.D. Lenore Kola, Ph.D. David Lynde, M.S.W. Fred C. Osher, M.D. Robin E. Clark, Ph.D. Lawrence Rickards, Ph.D.

After 20 years of development and research, dual diagnosis services ubstance abuse is the most com- for clients with severe mental illness are emerging as an evidence- mon and clinically significant based practice. Effective dual diagnosis programs combine mental Scomorbid disorder among adults health and substance abuse interventions that are tailored for the with severe mental illness. In this pa- complex needs of clients with comorbid disorders. The authors de- per the term “substance abuse” refers scribe the critical components of effective programs, which include a to substance use disorders, which in- comprehensive, long-term, staged approach to recovery; assertive out- clude abuse and dependence. “Se- reach; motivational interventions; provision of help to clients in ac- vere mental illness” refers to long- quiring skills and supports to manage both illnesses and to pursue term psychiatric disorders, such as functional goals; and cultural sensitivity and competence. Many state schizophrenia, that are associated mental health systems are implementing dual diagnosis services, but with disability and that fall within the high-quality services are rare. The authors provide an overview of the traditional purview of public mental numerous barriers to implementation and describe implementation health systems. Finally, the term strategies to overcome the barriers. Current approaches to imple- “dual diagnosis” denotes the co-oc- menting dual diagnosis programs involve organizational and financing currence of substance abuse and se- changes at the policy level, clarity of program mission with structural vere mental illness. changes to support dual diagnosis services, training and supervision There are many populations with for clinicians, and dissemination of accurate information to consumers dual diagnoses, and there are other and families to support understanding, demand, and advocacy. (Psy- common terms for this particular chiatric Services 52:469–476, 2001) group. Furthermore, dual diagnosis is Copyright (2001). American Psychiatric Association. a misleading term because the individuals in this group are heteroge- neous and tend to have multiple im- pairments rather than just two illnesses. Nevertheless, the term appears

Psychiatric Services, consistently in the literature and has Dr. Drake and Dr. Clark are affiliated with the New Hampshire–Dartmouth Psychi- acquired some coherence as a refer- atric Research Center, 2 Whipple Place, Lebanon, New Hampshire 03766 (e-mail, ent to particular clients, treatments, [email protected]). Dr. Essock is with Mt. Sinai Medical School in New programs, and service system issues. York City. Dr. Shaner is affiliated with the School of Medicine at the University of Cal- ifornia, Los Angeles. Dr. Carey is with Syracuse University in New York. Dr. Minkoff is Since the problem of dual diagnosis in private practice in Boston. Dr. Kola is with Case Western Reserve University in Cleve- became clinically apparent in the ear- land, Ohio. Mr. Lynde is with West Institute in Concord, New Hampshire. Dr. Osher is ly 1980s (1,2), researchers have estab- with the University of Maryland School of Medicine in Baltimore. Dr. Rickards is with lished three basic and consistent find- the Center for Mental Health Services in Rockville, Maryland. ings. First, co-occurrence is common;

Reprinted with permission from the PSYCHIATRIC SERVICES April 2001 Vol. 52 No. 4 469

The Evidence 3 Review of Research Literature about 50 percent of individuals with nesses (16). In this context, “recov- severe mental disorders are affected Editor’s note: This article is ery” means that the individual with a by substance abuse (3). Second, dual part of a series of papers on evi- dual diagnosis learns to manage both diagnosis is associated with a variety dence-based practices being illnesses so that he or she can pursue of negative outcomes, including high- published in Psychiatric Ser- meaningful life goals (17,18). er rates of relapse (4), hospitalization vices this year. The papers focus (5), violence (6), incarceration (7), on mental health practices for Research on dual homelessness (8), and serious infec- which there is substantial evi- diagnosis practices tions such as HIV and hepatitis (9). dence of effectiveness and that In most states, the publicly financed Third, the parallel but separate men- should therefore be routinely of- mental health system bears responsi- tal health and substance abuse treat- fered in clinical settings. Articles bility for providing treatments and ment systems so common in the Unit- in previous issues have ad- support services for clients with se- ed States deliver fragmented and in- dressed implementing evi- vere mental illness. Dual diagnosis effective care (10). Most clients are dence-based practices for per- treatments for these clients have unable to navigate the separate sys- sons with severe mental illness therefore generally been added to tems or make sense of disparate mes- and in routine mental health set- community support programs within sages about treatment and recovery. tings and implementing sup- the mental health system. Often they are excluded or extruded ported employment as an evi- Early studies of dual diagnosis in- from services in one system because dence-based practice. Among terventions during the 1980s exam- of the comorbid disorder and told to other topics, future articles will ined the application of traditional return when the other problem is un- examine evidence-based prac- substance abuse treatments, such as der control. For those reasons, clini- tices for case management and 12-step groups, to clients with mental cians, administrators, researchers, assertive community treatment, disorders within mental health pro- family organizations, and clients illness self-management, chil- grams. These studies had disappoint- themselves have been calling for the dren’s services, and services for ing results for at least two reasons integration of mental health and sub- the elderly population. Robert (19). The clinical programs did not stance abuse services for at least 15 E. Drake, M.D., Ph.D., and take into account the complex needs years (10,11). Howard H. Goldman, M.D., of the population, and researchers Over that time, integrated dual di- Ph.D., are the series editors. had not yet solved basic methodolog- agnosis services—that is, treatments ic problems. For example, early pro- and programs—have been steadily grams often failed to incorporate out- developed, refined, and evaluated reach and motivational interventions, (11). This paper, part of a series on and evaluations were limited by lack specific evidence-based practices for into one coherent package. For the in- of reliable and valid assessment of persons with severe mental illness, dividual with a dual diagnosis, the substance abuse. Reviews based on provides an overview of the evolution services appear seamless, with a con- these early studies were understand- of dual diagnosis services, the evi- sistent approach, philosophy, and set ably pessimistic (20). dence on outcomes and critical com- of recommendations. The need to ne- At the same time, however, a series ponents, and the limitations of cur- gotiate with separate clinical teams, of demonstration projects using more rent research. We also address barri- programs, or systems disappears. comprehensive programs that incor- ers to the implementation of dual di- Integration involves not only com- porated assertive outreach and long- agnosis services and current strate- bining appropriate treatments for term rehabilitation began to show bet- gies for implementation in routine both disorders but also modifying tra- ter outcomes. Moreover, the projects mental health settings. ditional interventions (12–15). For developed motivational interventions example, social skills training empha- to help clients who did not perceive or Dual diagnosis services sizes the importance of developing acknowledge their substance abuse or Treatments, or interventions, are of- relationships but also the need to mental illness problems (21). fered within programs that are part of avoid social situations that could lead Building on these insights, projects service systems. Dual diagnosis treat- to substance use. Substance abuse in the early 1990s incorporated moti- ments combine or integrate mental counseling goes slowly, in accordance vational approaches as well as out- health and substance abuse interven- with the cognitive deficits, negative reach, comprehensiveness, and a tions at the level of the clinical inter- symptoms, vulnerability to confronta- long-term perspective, often within action. Hence integrated treatment tion, and greater need for support the structure of multidisciplinary means that the same clinicians or that are characteristic of many indi- treatment teams. These later studies, teams of clinicians, working in one viduals with severe mental illness. which were uncontrolled but incor- setting, provide appropriate mental Family interventions address under- porated more valid measures of sub- health and substance abuse interven- standing and learning to cope with stance abuse, generally showed posi- tions in a coordinated fashion. In oth- two interacting illnesses. tive outcomes, including substantial er words, the caregivers take responsi- The goal of dual diagnosis interven- rates of stable remission of substance bility for combining the interventions tions is recovery from two serious ill- abuse (22–25). Of course, uncon-

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Review of Research Literature 4 The Evidence trolled studies of this type often pro- relationship (engagement), helping are so demoralized, symptomatic, or duce findings that are not replicated the engaged client develop the moti- confused that they mistakenly be- in controlled studies; they should be vation to become involved in recov- lieve that alcohol and cocaine are considered pilot studies, which are ery-oriented interventions (persua- helping them to cope better than often needed to refine the interven- sion), helping the motivated client medications require education, sup- tion and the methodologies of evalua- acquire skills and supports for con- port, and counseling to develop hope tion and which should be followed by trolling illnesses and pursuing goals and a realistic understanding of ill- controlled investigation to determine (active treatment), and helping the nesses, drugs, treatments, and goals. evidence-based practice (26). client in stable remission develop Motivational interventions involve Controlled research studies of and use strategies for maintaining helping the individual identify his or comprehensive dual diagnosis pro- recovery (relapse prevention). her own goals and to recognize, grams began to appear in the mid- Clients do not move linearly through a systematic examination of 1990s. Eight recent studies with ex- through stages. They sometimes en- the individual’s ambivalence, that not perimental or quasi-experimental ter services at advanced levels, skip managing one’s illnesses interferes designs support the effectiveness of over or pass rapidly through stages, with attaining those goals (42). Re- integrated dual diagnosis treatments or relapse to earlier stages. They may cent research has demonstrated that for clients with severe mental illness be in different stages with respect to clients who are not motivated can be and substance use disorders (27–34). mental illness and substance abuse. reliably identified (43) and effectively The type and array of dual diagnosis Nevertheless, the concept of stages helped with motivational interven- interventions in these programs vary, has proved useful to program plan- tions (Carey KB, Carey MP, Maisto but they include several common ners and clinicians because clients at SA, et al, unpublished data, 2000). components, which are reviewed be- different stages respond to stage- low. The eight studies demonstrated specific interventions. Counseling a variety of positive outcomes in do- Once clients are motivated to manage mains such as substance abuse, psy- Assertive outreach their own illnesses, they need to de- chiatric symptoms, housing, hospi- Many clients with a dual diagnosis velop skills and supports to control talization, arrests, functional status, have difficulty linking with services symptoms and to pursue an abstinent and quality of life (19). Although and participating in treatment (38). lifestyle. Effective programs provide each had methodological limitations, Effective programs engage clients some form of counseling that pro- together they indicate that current and members of their support sys- motes cognitive and behavioral skills integrated treatment programs are tems by providing assertive out- at this stage. The counseling takes dif- more effective than nonintegrated reach, usually through some combi- ferent forms and formats, such as programs. By contrast, the evidence nation of intensive case management group, individual, or family therapy or continues to show that dual diagnosis and meetings in the client’s resi- a combination (15). Few studies have clients in mental health programs dence (21,32). For example, home- compared specific approaches to that fail to integrate substance abuse less persons with dual diagnoses of- counseling, although one study did interventions have poor outcomes ten benefit from outreach, help with find preliminary evidence that a cog- (35). housing, and time to develop a trust- nitive-behavioral approach was supe- ing relationship before participating rior to a 12-step approach (28). At Critical components in any formal treatment. These ap- least three research groups are active- Several components of integrated proaches enable clients to gain ac- ly working to refine cognitive-behav- programs can be considered evi- cess to services and maintain needed ioral approaches to substance abuse dence-based practices because they relationships with a consistent pro- counseling for dual diagnosis clients are almost always present in program over months and years. With- (12,13,44). These approaches often grams that have demonstrated good out such efforts, noncompliance and incorporate motivational sessions at outcomes in controlled studies and dropout rates are high (39). the beginning of counseling and as because their absence is associated needed in subsequent sessions rather with predictable failures (21). For Motivational interventions than as separate interventions. example, dual diagnosis programs Most dual diagnosis clients have lit- that include assertive outreach are tle readiness for abstinence-oriented Social support interventions able to engage and retain clients at a treatment (40,41). Many also lack In addition to helping clients build high rate, while those that fail to in- motivation to manage psychiatric ill- skills for managing their illness and clude outreach lose many clients. ness and to pursue employment or pursuing goals, effective programs other functional goals. Effective pro- focus on strengthening the immedi- Staged interventions grams therefore incorporate motiva- ate social environment to help them Effective programs incorporate, im- tional interventions that are de- modify their behavior. These activi- plicitly or explicitly, the concept of signed to help clients become ready ties, which recognize the role of so- stages of treatment (14,36,37). In the for more definitive interventions cial networks in recovery from dual simplest conceptualization, stages of aimed at illness self-management disorders (45), include social net- treatment include forming a trusting (12,14,21). For example, clients who work or family interventions.

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The Evidence 5 Review of Research Literature Long-term perspective African Americans, Hispanics, and diagnosis clients incur high treatment Effective programs recognize that re- other underserved groups, such as costs in usual services (54,55), and covery tends to occur over months or farm workers, homeless persons, care is costly to their families (56), but years in the community. People with women with children, inner-city resi- effective treatment may be even severe mental illness and substance dents, and persons in rural areas, more costly. Some studies suggest abuse do not usually develop stability could be engaged in dual diagnosis cost savings related to providing good and functional improvements quickly, services if the services were tailored services (57,58), but these are not de- even in intensive treatment pro- to their particular racial, cultural, and finitive. grams, unless they enter treatment at other group characteristics. Another limitation of the research an advanced stage (19). Instead, they Many dual diagnosis programs omit is the lack of specificity of dual diag- tend to improve over months and some of these critical components as nosis treatments. Interventions differ years in conjunction with a consistent evidence-based practices. However, across studies, manuals and fidelity dual diagnosis program. Effective one consistent finding in the research measures are rare, and no consensus programs therefore take a long-term, is that programs that show high fideli- exists on specific approaches to indi- community-based perspective that ty to the model described here— vidual counseling, group treatment, includes rehabilitation activities to those that incorporate more of the family intervention, housing, medica- prevent relapses and to enhance core elements—produce better out- tions, and other components. Current gains. comes than low-fidelity programs research will address some of these is- (32,48,49). A common misconception sues by refining specific components, Comprehensiveness about technology transfer is that although efficacy studies may identify Learning to lead a symptom-free, ab- model programs are not generalizable complex and expensive interventions stinent lifestyle that is satisfying and and that local solutions are superior. that will be impractical in routine sustainable often requires transform- A more accurate reading of the re - mental health settings. ing many aspects of one’s life—for ex- search is that modifications for cul- A majority of dual diagnosis clients ample, habits, stress management, tural and other local circumstances respond well to integrated outpatient friends, activities, and housing. There- are important, but critical program services, but clients who do not re- fore, in effective programs attention components must be replicated to spond continue to be at high risk of to substance abuse as well as mental achieve good outcomes. hospitalization, incarceration, home- illness is integrated into all aspects of lessness, HIV infection, and other se- the existing mental health program Limitations of the research rious adverse outcomes. Other than and service system rather than isolat- The design and quality of research one study of long-term residential ed as a discrete substance abuse treat- procedures and data across dual diag - treatment (33), controlled research ment intervention. Inpatient hospital- nosis studies are inconsistent. In ad- has not addressed clients who do not ization, assessment, crisis interven- dition, researchers have thus far respond to outpatient services. Other tion, medication management, mon - failed to address a number of issues. potential interventions include outpa- ey management, laboratory screen- Dual diagnosis research has studied tient commitment (59), treatments ing, housing, and vocational rehabili- the clinical enterprise, that is, treat- aimed at trauma sequelae (60), mon- tation incorporate special features ments and programs, with little atten- ey management (61), contingency that are tailored specifically for dual tion to the policy or system perspec- management (62), and pharmacologi- diagnosis patients. For example, hos- tive. Despite widespread endorse- cal approaches using medications pitalization is considered a compo- ment of integrated dual diagnosis such as clozapine (63), disulfiram nent of the system that supports services (13,50–53), there continues (64), or naltrexone. movement toward recovery by pro- to be a general failure at the federal Although a few studies have ex- viding diagnosis, stabilization, and and state levels to resolve problems plored the specific treatment needs linkage with outpatient dual diagnosis related to organization and financing of dual diagnosis clients who are interventions during acute episodes (see below). Thus, despite the emer- women (65,66) or minorities (21,67), (46). Similarly, housing and vocation - gence of many excellent programs particular program modifications for al programs can be used to support around the country, few if any large these groups need further validation. the individual with a dual diagnosis in mental health systems have been able For example, many dual diagnosis acquiring skills and supports needed to accomplish widespread implemen- programs have identified high rates of for recovery (47). tation of dual diagnosis services for trauma histories and sequelae among persons with severe mental illness. women (46,68,69), and studies have Cultural sensitivity We are aware of no specific studies of suggested interventions to address and competence strategies to finance, contract for, re - trauma; however, no data on out- A fundamental finding of the demon - organize, or train in relation to dual comes are yet available. stration programs of the late 1980s diagnosis services. was that cultural sensitivity and com- Lack of data on the cost of integrat- Implementation barriers petence were critical to engaging ed dual diagnosis services and the Although integrated dual diagnosis clients in dual diagnosis services (21). cost savings of providing good care services and other evidence-based These demonstrations showed that impedes policy development. Dual practices are widely advocated, they

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Review of Research Literature 6 The Evidence are rarely offered in routine mental ing dual diagnosis interventions and Implementation strategies health treatment settings (70). The lack the resources to train current There are no proven strategies for barriers are legion. supervisors and clinicians. overcoming the aforementioned barriers to implementing dual diagnosis Policy barriers Clinical barriers services, but some suggestions have State, county, and city mental health The beliefs of the mental health and come from systems and programs authorities often encounter policies substance abuse treatment traditions that have had moderate success. related to organizational structure, are inculcated in clinicians, which di- financing, regulations, and licensing minishes the opportunities for cross- Policy strategies that militate against the functional fertilization (73). Although an inte- Health care authorities in a majority integration of mental health and sub- grated clinical philosophy and a prac- of, and possibly all, states have cur- stance abuse services (71). The U.S. tical approach to dual diagnosis treat- rent initiatives for creating dual diag- public mental health and substance ment have been clearly delineated for nosis services. Because health care abuse treatment systems grew inde- more than a decade (16), educational policy is often administered at the pendently. In most states these serv- institutions rarely teach this ap- county or city level, hundreds of indi- ices are provided under the auspices proach. Consequently, mental health vidual experiments are occurring. of separate cabinet-level depart- clinicians typically lack training in One initial branch point involves the ments with separate funding dual diagnosis treatment and have to decision to focus broadly on the en- streams, advocacy groups, lobbyists, rely on informal, self-initiated oppor- tire behavioral health system—that is, enabling legislation, information sys- tunities for learning current interven- on all clients with mental health and tems, job classifications, and criteria tions (74). They often avoid diagnos- substance abuse problems—or more for credentials. Huge fiscal incen- ing substance abuse when they be- narrowly on services for those with tives and strong political allies act to lieve that it is irrelevant, that it will in- severe mental illness and co-occur- maintain the status quo. terfere with funding, or that they can- ring substance abuse. We examine Medicaid programs, which fund a not treat it. Clinicians trained in sub- here only strategies for dual diagnosis significant and growing proportion stance abuse treatment, as well as re - clients with severe mental illness, for of treatment for persons with severe covering dual diagnosis clients, could whom the implementation issues are mental illness, vary substantially add expertise and training, but they relatively distinct. from state to state in the types of are often excluded from jobs in the Commonly used system-level strat- mental health and substance abuse mental health system. egies include building a consensus services they fund. In most states, around the vision for integrated serv- mental health and substance abuse Consumer and family barriers ices and then conjointly planning; agencies have little control over how Clients and their families rarely have specifying a model; implementing Medicaid services are reimbursed or good information about dual diagno- structural, regulatory, and reimburse- administered, which makes it diffi- sis and appropriate services. Few pro- ment changes; establishing contract- cult for public systems to ensure that grams offer psychoeducational servic- ing mechanisms; defining standards; appropriate services are accessible. es related to dual diagnosis, although and funding demonstration programs Medicare, the federal insurance pro- practical help from families plays a and training initiatives (77). To our gram for elderly and disabled per- critical role in recovery (75). Family knowledge, few efforts have been sons, generally pays for a more limit- members are often unaware of sub- made to study these efforts at the sys- ed scope of mental health and substance abuse, blame all symptoms on tem level. stance abuse services. Together drug abuse, or attribute symptoms Anecdotal evidence indicates that Medicaid and Medicare pay for and substance use to willful misbe- blending mental health and sub- more than 30 percent of all behav- havior. Supporting family involve- stance abuse funds appears to have ioral health services, but their im- ment is an important but neglected been a relatively unsuccessful strate- pact on dual diagnosis services has role for clinicians. gy, especially early in the course of not been studied (72). Consumers often deny or minimize system change. Fear of losing money problems related to substance abuse to cover nontraditional populations Program barriers (40) and, like other substance ab- often leads to prolonged disagree- At the local level, administrators of users, believe that alcohol or other ments, inability to develop consensus, clinics, centers, and programs have drugs are helpful in alleviating dis- and abandonment of other plans. As a often lacked the clear service mod- tress. They may be legitimately con- less controversial, preliminary step, els, administrative guidelines, confused about causality because they the mental health authority often as- tractual incentives, quality assurance perceive the immediate effects of sumes responsibility for comprehen- procedures, and outcome measures drugs rather than the intermediate or sive care, including substance abuse needed to implement dual diagnosis long-term consequences (76). The treatment, for persons with severe services. When clinical needs com- net result is that the individual lacks mental illness, while the substance pel them to move ahead anyway, motivation to pursue active substance abuse authority assists by pledging to they have difficulty hiring a skilled abuse treatment, which can reinforce help with training and planning. workforce with experience in provid- clinical inattention. This limited approach enables the

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The Evidence 7 Review of Research Literature mental health system to attract and also emphasize client-centered out- ment specialists, and other staff. Un- train dual diagnosis specialists who comes, such as abstinence and em- til professional educational programs can subsequently train other clini- ployment. begin teaching current dual diagnosis cians and programs. Without struc- treatment techniques (87), mental tural, regulatory, and funding changes Clinical strategies health system leaders will bear the to reinforce the training, however, the Mental health clinicians need to ac- burden of training staff. expertise may soon disappear—a quire knowledge and a core set of Some staff will become dual diag- common experience after demonstra- skills related to substance abuse that nosis specialists and acquire more tion projects. Thus many experts ad- includes assessing substance abuse, than the basic skills. These individu- vise that policy issues should be ad- providing motivational interventions als will be counted on to lead dual di- dressed early in the process of imple- for clients who are not ready to partic- agnosis groups, family interventions, mentation to avoid wasting efforts on ipate in abstinence-oriented treat- residential programs, and other spe- training (78–80). ment, and providing counseling for cialized services. New costs to the mental health those who are motivated try to main- system for dual diagnosis training tain abstinence. Clinicians adopt new Consumer- and could be offset by greater effective- skills as a result of motivation, instruc- family-level strategies ness in ameliorating substance-abus- Clients and family members need ac- ing behaviors that are associated cess to accurate information. Other- with hospitalizations. However, sav- wise their opportunities to make in- ing costs over time assumes that formed choices, to request effective providers are at risk for all treatment Recent services, and to advocate for system costs, that is, that providers have in- changes are severely compromised. centives to invest more in outpatient research Consumer demand and family advo- services in order to spend less on in- cacy can move the health care system patient services. Despite the growth offers evidence toward evidence-based practices, but of managed care, providers rarely concerted efforts at the national, bear complete financial responsibili- that integrated dual state, and local levels are required. ty for the treatment of clients with Researchers can facilitate their ef- severe mental illness. diagnosis treatments forts by offering clear messages about the forms, processes, and expected Program strategies are effective, but basic outcomes of evidence-based prac- At the level of the mental health clin- tices. Similarly, local programs should ic or program leadership, the funda- interventions are rarely provide information on available dual mental task is to begin recognizing diagnosis services to clients and their and treating substance abuse rather incorporated into the families. than ignoring it or using it as a criteri- As consumers move into roles as on for exclusion (81). After consen- mental health programs providers within the mental health sus-building activities to prepare for system and in consumer-run services, change, staff need training and super- in which these they also need training in dual diag- vision to learn new skills, and they nosis treatments. Local educational must receive reinforcement for ac- clients receive programs, such as community col- quiring and using these skills effec- leges, as well as staff training pro- tively. One common strategy is to ap- care. grams should address these needs. point a director of dual diagnosis services whose job is to plan and over- Conclusions see the training of staff, the integra- Substance abuse is a common and tion of substance abuse awareness tion, practice, and reinforcement (84). devastating comorbid disorder among and treatment into all aspects of the Because substance abuse affects the persons with severe mental illness. mental health program, and the mon - lives of the great majority of clients Recent research offers evidence that itoring and reinforcement of these ac- with severe mental illness—as a co- integrated dual diagnosis treatments tivities through medical records, occurring disorder, family stressor, or are effective, but basic interventions quality assurance activities, and out- environmental hazard—all clinicians are rarely incorporated into the men- come data. should learn these basic skills. Other- tal health programs in which these Experts identify the importance of wise substance abuse problems will clients receive care. Successful imple- having a single leader for program continue to be missed and untreated mentation of dual diagnosis services change (82). Fidelity measures for in- in this population (85,86). within mental health systems will de- tegrated dual diagnosis services can For example, all case managers pend on changes at several levels: facilitate successful implementation should recognize and address sub- clear policy directives with consistent at the program level (50,83). Moni- stance abuse in their daily interac- organizational and financing sup- toring and reinforcing mechanisms tions, as should housing staff, employ- ports, program changes to incorpo-

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Review of Research Literature 8 The Evidence al: Cognitive-behavioral intervention for routine mental health service settings. Psy- rate the mission of addressing co-oc- clients with severe mental illness who have chiatric Services 52:179–182, 2001 curring substance abuse, supports for a substance misuse problem. Psychiatric Rehabilitation Skills 4:216–233, 2000 27. Godley SH, Hoewing-Roberson R, Godley the acquisition of expertise at the MD: Final MISA Report. Bloomington, Ill, clinical level, and availability of accu- 13. Bellack AS, DiClemente CC: Treating sub- Lighthouse Institute, 1994 rate information to consumers and stance abuse among patients with schizophrenia. Psychiatric Services 50:75–80, 28. Jerrell JM, Ridgely MS: Comparative effec- family members. 1999 tiveness of three approaches to serving people with severe mental illness and sub- Acknowledgments 14. Carey KB: Substance use reduction in the stance abuse disorders. Journal of Nervous context of outpatient psychiatric treatment: and Mental Disease 183:566–576, 1995 This review by a national panel was sup- a collaborative, motivational, harm reduc- ported by grant 036805 from the Robert tion approach. Community Mental Health 29. Drake RE, Yovetich NA, Bebout RR, et al: Wood Johnson Foundation and contract Journal 32:291–306, 1996 Integrated treatment for dually diagnosed homeless adults. Journal of Nervous and 280-00-8049 from the Center for Mental 15. Mueser KT, Drake RE, Noordsy DL: Inte- Mental Disease 185:298–305, 1997 Health Services. grated mental health and substance abuse treatment for severe psychiatric disorders. 30. Carmichael D, Tackett-Gibson M, Dell O, References Journal of Practical Psychiatry and Behav- et al: Texas Dual Diagnosis Project Evalua- ioral Health 4:129–139, 1998 tion Report, 1997–1998. College Station, 1. Pepper B, Krishner MC, Ryglewicz H: The Tex, Texas A&M University, Public Policy young adult chronic patient: overview of a 16. Minkoff K: An integrated treatment model Research Institute, 1998 population. Hospital and Community Psy- for dual diagnosis of psychosis and addic- chiatry 32:463–469, 1981 tion. Hospital and Community Psychiatry 31. Drake RE, McHugo GJ, Clark RE, et al: 40:1031–1036, 1989 Assertive community treatment for patients 2. Caton CLM: The new chronic patient and with co-occurring severe mental illness and the system of community care. Hospital 17. Mead S, Copeland ME: What recovery substance use disorder: a clinical trial. and Community Psychiatry 32:475–478, means to us: consumers’ perspectives. American Journal of Orthopsychiatry 68: 1981 Community Mental Health Journal 36: 201–215, 1998 315–328, 2000 3. Regier DA, Farmer ME, Rae DS, et al: Co- 32. Ho AP, Tsuang JW, Liberman RP, et al: morbidity of mental disorders with alcohol 18. Torrey WC, Wyzik P: The recovery vision as Achieving effective treatment of patients and other drug abuse. JAMA 264:2511– a service improvement guide for communi- with chronic psychotic illness and comorbid 2518, 1990 ty mental health center providers. Commu- substance dependence. American Journal nity Mental Health Journal 36:209–216, of Psychiatry 156:1765–1770, 1999 4. Swofford C, Kasckow J, Scheller-Gilkey G, 2000 et al: Substance use: a powerful predictor of 33. Brunette MF, Drake RE, Woods M, et al: A relapse in schizophrenia. Schizophrenia 19. Drake RE, Mercer-McFadden C, Mueser comparison of long-term and short-term Research 20:145–151, 1996 KT, et al: Review of integrated mental residential treatment programs for dual di- health and substance abuse treatment for agnosis patients. Psychiatric Services 52: 5. Haywood TW, Kravitz HM, Grossman LS, patients with dual disorders. Schizophrenia 526–528, 2001 et al: Predicting the “revolving door” phe- Bulletin 24:589–608, 1998 nomenon among patients with schizo- 34. Barrowclough C, Haddock G, Tarrier N, et phrenic, schizoaffective, and affective dis- 20. Ley A, Jeffery DP, McLaren S, et al: Treat- al: Randomised controlled trial of motiva- orders. American Journal of Psychiatry ment programmes for people with both se- tional interviewing and cognitive behav- 152:856–861, 1995 vere mental illness and substance misuse. ioural intervention for schizophrenia pa- Cochrane Library, Feb 1999. Available at tients with associated drug or alcohol mis- 6. Cuffel B, Shumway M, Chouljian T: A lon- http://www.update-software.com/cochrane/ use. American Journal of Psychiatry, in gitudinal study of substance use and com- cochrane-frame.html press munity violence in schizophrenia. Journal of Nervous and Mental Disease 182:704– 21. Mercer-McFadden C, Drake RE, Brown 35. Havassy BE, Shopshire MS, Quigley LA: 708, 1994 NB, et al: The community support program Effects of substance dependence on out- demonstrations of services for young adults comes of patients in a randomized trial of 7. Abram KM, Teplin LA: Co-occurring disor- with severe mental illness and substance two case management models. Psychiatric ders among mentally ill jail detainees: im- use disorders, 1987–1991. Psychiatric Re- Services 51:639–644, 2000 plications for public policy. American Psy- habilitation Journal 20(3):13–24, 1997 chologist 46:1036–1045, 1991 36. Osher FC, Kofoed LL: Treatment of pa- 22. Detrick A, Stiepock V: Treating persons tients with psychiatric and psychoactive 8. Caton CLM, Shrout PE, Eagle PF, et al: with mental illness, substance abuse, and substance use disorders. Hospital and Risk factors for homelessness among schiz- legal problems: the Rhode Island experi- Community Psychiatry 40:1025–1030, 1989 ophrenic men: a case-control study. Ameri- ence. New Directions for Mental Health can Journal of Public Health 84:265–270, Services, no 56:65–77, 1992 37. McHugo GJ, Drake RE, Burton HL, et al: 1994 A scale for assessing the stage of substance 23. Drake RE, McHugo G, Noordsy DL: abuse treatment in persons with severe 9. Rosenberg SD, Goodman LA, Osher FC, Treatment of alcoholism among schizo- mental illness. Journal of Nervous and et al: Prevalence of HIV, hepatitis B, and phrenic outpatients: four-year outcomes. Mental Disease 183:762–767, 1995 hepatitis C in people with severe mental ill- American Journal of Psychiatry 150:328– ness. American Journal of Public Health 329, 1993 38. Owen C, Rutherford V, Jones M, et al: Non- 91:31–37, 2001 compliance in psychiatric aftercare. Com- 24. Durell J, Lechtenberg B, Corse S, et al: In- munity Mental Health Journal 33:25–34, 10. Ridgely MS, Osher FC, Goldman HH, et tensive case management of persons with 1997 al: Executive Summary: Chronic Mentally chronic mental illness who abuse sub- Ill Young Adults With Substance Abuse stances. Hospital and Community Psychia- 39. Hellerstein DJ, Rosenthal RN, Miner CR: Problems: A Review of Research, Treat- try 44:415–416, 1993 A prospective study of integrated outpa- ment, and Training Issues. Baltimore, Uni- tient treatment for substance-abusing versity of Maryland School of Medicine, 25. Meisler N, Blankertz L, Santos AB, et al: schizophrenic patients. American Journal Mental Health Services Research Center, Impact of assertive community treatment on Addictions 42:33–42, 1995 1987 on homeless persons with co-occurring severe psychiatric and substance use disor- 40. Test MA, Wallish LS, Allness DG, et al: 11. Drake RE, Wallach MA: Dual diagnosis: 15 ders. Community Mental Health Journal Substance use in young adults with schizo- years of progress. Psychiatric Services 33:113–122, 1997 phrenic disorders. Schizophrenia Bulletin 51:1126–1129, 2000 15:465–476, 1989 26. Drake RE, Goldman HH, Leff HS, et al: 12. Barrowclough C, Haddock G, Tarrier N, et Implementing evidence-based practices in 41. Ziedonis D, Trudeau K: Motivation to quit

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The Evidence 9 Review of Research Literature using substances among individuals with pital and Community Psychiatry 45:808– agnoses: organizational and financing is- schizophrenia: implications for a motiva- 813, 1994 sues. Schizophrenia Bulletin 16:123–132, tion-based treatment model. Schizophrenia 1990 Bulletin 23:229–238, 1997 57. Clark RE, Teague GB, Ricketts SK, et al: Cost-effectiveness of assertive community 72. Mark T, McKusick D, King E, et al: Na- 42. Miller W, Rollnick S: Motivational Inter- treatment versus standard case manage- tional Expenditures for Mental Health, Al- viewing: Preparing People to Change Ad- ment for persons with co-occurring severe cohol, and Other Drug Abuse Treatment. dictive Behavior. New York, Guilford, 1991 mental illness and substance use disorders. Rockville, Md, Substance Abuse and Men- Health Services Research 33:1283–1306, tal Health Services Administration, 1998 43. Carey KB, Maisto SA, Carey MP, et al: 1998 Measuring readiness-to-change substance 73. Drainoni M, Bachman S: Overcoming misuse among psychiatric outpatients: I. re- 58. Jerrell JM: Cost-effective treatment for treatment barriers to providing services for liability and validity of self-report meas- persons with dual disorders. New Direc- adults with dual diagnosis: three approach- ures. Journal of Studies on Alcohol, in press tions for Mental Health Services, no 70:79– es. Journal of Disability Policy Studies 91, 1996 6:43–55, 1995 44. Roberts LJ, Shaner A, Eckman T: Over- coming Addictions: Skills Training for Peo- 59. O’Keefe C, Potenza DP, Mueser KT: Treat- 74. Carey KB, Purnine DM, Maisto SM, et al: ple With Schizophrenia. New York, Norton, ment outcomes for severely mentally ill pa- Treating substance abuse in the context of 1999 tients on conditional discharge to commu- severe and persistent mental illness: clini- nity-based treatment. Journal of Nervous cians’ perspectives. Journal of Substance 45. Alverson H, Alverson M, Drake RE: An and Mental Disease 185:409–411, 1997 Abuse Treatment 19:189–198, 2000 ethnographic study of the longitudinal course of substance abuse among people 60. Harris M: Trauma Recovery and Empow- 75. Clark RE: Family support and substance with severe mental illness. Community erment Manual. Edited by Anglin J. New use outcomes for persons with mental ill- Mental Health Journal 36:557–569, 2000 York, Free Press, 1998 ness and substance use disorders. Schizo- phrenia Bulletin, in press 46. Greenfield SF, Weiss RD, Tohen M: Sub- 61. Ries RK, Dyck DG: Representative payee stance abuse and the chronically mentally practices of community mental health cen- 76. Mueser KT, Drake R, Wallach M: Dual di- ill: a description of dual diagnosis treatment ters in Washington State. Psychiatric Ser- agnosis: a review of etiological theories. Ad- services in a psychiatric hospital. Commu- vices 48:811–814, 1997 dictive Behaviors 23:717–734, 1998 nity Mental Health Journal 31:265–278, 1995 62. Shaner A, Roberts LJ, Eckman TA, et al: 77. Co-occurring Psychiatric and Substance Monetary reinforcement of abstinence Disorders in Managed Care Systems. 47. Drake RE, Mueser KT: Psychosocial ap- from cocaine among mentally ill patients Rockville, Md, Mental Health Services, proaches to dual diagnosis. Schizophrenia with cocaine dependence. Psychiatric Ser- 1998 Bulletin 26:105–118, 2000 vices 48:807–810, 1997 78. Hesketh B: Dilemmas in training for trans- 48. Jerrell JM, Ridgely MS: Impact of robust- 63. Zimmet SV, Strous RD, Burgess ES, et al: fer and retention. Applied Psychology ness of program implementation on out- Effects of clozapine on substance use in pa- 46:317–386, 1997 comes of clients in dual diagnosis pro- tients with schizophrenia and schizoaffec- grams. Psychiatric Services 50:109–112, tive disorders: a retrospective survey. Jour- 79. Milne D, Gorenski O, Westerman C, et al: 1999 nal of Clinical Psychopharmacology 20:94– What does it take to transfer training? Psy- 98, 2000 chiatric Rehabilitation Skills 4:259–281, 49. McHugo GJ, Drake RE, Teague GB, et al: 2000 Fidelity to assertive community treatment 64. Mueser KT, Noordsy DL, Essock S: Use of and client outcomes in the New Hampshire disulfiram in the treatment of patients with 80. Rapp CA, Poertner J: Social Administra- dual disorders study. Psychiatric Services dual diagnosis. American Journal of Addic- tion: A Client-Centered Approach. White 50:818–824, 1999 tion, in press Plains, NY, Longman, 1992 50. Rach-Beisel J, Scott J, Dixon L: Co-occur- 65. Brunette MF, Drake RE: Gender differ- 81. Mercer-McFadden C, Drake RE, Clark ring severe mental illness and substance ences in patients with schizophrenia and RE, et al: Substance Abuse Treatment for use disorders: a review of recent research. substance abuse. Comprehensive Psychia- People With Severe Mental Disorders. Psychiatric Services 50:1427–1434, 1999 try 38:109–116, 1997 Concord, NH, New Hampshire–Dart- mouth Psychiatric Research Center, 1998 51. Mueser KT, Bellack A, Blanchard J: Co- 66. Alexander MJ: Women with co-occurring morbidity of schizophrenia and substance addictive and mental disorders: an emerg- 82. Corrigan PW: Wanted: champions of reha- abuse. Journal of Consulting and Clinical ing profile of vulnerability. American Jour- bilitation for psychiatric hospitals. Ameri- Psychology 60:845–856, 1992 nal of Orthopsychiatry 66:61–70, 1996 can Psychologist 40:514–521, 1995 52. Osher FC, Drake RE: Reversing a history 67. Quimby E: Homeless clients’ perspectives 83. Mueser KT, Fox L: Stagewise Family Treat- of unmet needs: approaches to care for per- on recovery in the Washington, DC, Dual ment for Dual Disorders: Treatment Man- sons with co-occurring addictive and men- Diagnosis Project. Contemporary Drug ual. Concord, NH, New Hampshire–Dart- tal disorders. American Journal of Or- Problems, Summer 1995, pp 265–289 mouth Psychiatric Research Center, 1998 thopsychiatry 66:4–11, 1996 68. Goodman LA, Rosenberg SD, Mueser KT, 84. Torrey WC, Drake RE, Dixon L, et al: Im- 53. Woody G: The challenge of dual diagnosis. et al: Physical and sexual assault history in plementing evidence-based practices for Alcohol Health and Research World 20:76– women with serious mental illness: preva- persons with severe mental illnesses. Psy- 80, 1996 lence, correlates, treatment, and future re- chiatric Services 52:45–50, 2001 search directions. Schizophrenia Bulletin 54. Bartels SJ, Teague GB, Drake RE, et al: 23:685–696, 1997 85. Shaner A, Khaka E, Roberts L, et al: Un- Service utilization and costs associated with recognized cocaine use among schizo- substance abuse among rural schizophrenic 69. Mueser KT, Goodman LB, Trumbetta SL, phrenic patients. American Journal of Psy- patients. Journal of Nervous and Mental et al: Trauma and posttraumatic stress dis- chiatry 150:777–783, 1993 Disease 181:227–232, 1993 order in severe mental illness. Journal of Consulting and Clinical Psychology 66: 86. Ananth J, Vandewater S, Kamal M, et al: 55. Dickey B, Azeni H: Persons with dual diag- 493–499, 1998 Missed diagnosis of substance abuse in psy- nosis of substance abuse and major mental chiatric patients. Hospital and Community illness: their excess costs of psychiatric care. 70. Surgeon General’s Report on Mental Psychiatry 40:297–299, 1989 American Journal of Public Health 86:973– Health. Washington, DC, US Government 977, 1996 Printing Office, 2000 87. Carey KB, Bradizza CM, Stasiewicz PR, et al: The case for enhanced addictions train- 56. Clark RE: Family costs associated with se- 71. Ridgely M, Goldman H, Willenbring M: ing in graduate programs. Behavior Thera- vere mental illness and substance use. Hos- Barriers to the care of persons with dual di- pist 22:27–31, 1999

476 PSYCHIATRIC SERVICES April 2001 Vol. 52 No. 4 The Evidence

Selected Bibliography

Literature reviews

Drake, R. E., & Brunette, M. F. (1998). Drake, R. E., Mueser, K. T., Brunette, M. Complications of severe mental F., & McHugo, G.J. (2004). A review of illness related to alcohol and other treatments for people with severe mental drug use disorders. In M. Galanter illnesses and co-occurring substance use (Ed.), Recent developments in disorders. Psychiatric Rehabilitation alcoholism (Vol. XIV, Consequences of Journal, 27(4), 360-374. alcoholism: medical, neuropsychiatric,  Is a comprehensive review of research economic, cross-cultural, pp. 285-299). on Integrated Treatment for Co- New York: Plenum. Occurring Disorders. Summarizes research on the effects  Covers a wide range of research, of alcohol and drug abuse on the course including early demonstration of severe mental illness. programs in establishing the feasibility of Integrated Treatment in community support service settings.

The Evidence 11 Selected Bibliography Drake, R. E., Essock, S. M., Shaner, A., Carey, U.S. Department of Health and Human Services. K. B., Minkoff, K., Kola, L., et al. (2001). (2002). Report to Congress on the prevention Implementing dual diagnosis services for clients and treatment of co-occurring substance abuse with severe mental illness. Psychiatric Services, disorders and mental disorders. Substance Abuse 52(4), 469-476. Mental Health Administration, Rockville, MD. Update on research on Integrated Treatment Includes a summary of the characteristics and for Co-Occurring Disorders. needs of people with co-occurring disorders, a description of evidence-based practices and Mueser, K. T., & Kavanagh, D. (2001). Treating a Five-Year Blueprint for Action. comorbidity of alcohol problems and psychiatric disorder. In N. Heather, T. J. Peters, & T. R. Stockwell (Eds.), International handbook of Historical context alcohol dependence and problems (pp. 627-647). for Integrated Treatment

Chichester, England: Wiley. for Co-Occurring Disorders  Provides an updated review of the epidemiology of co-occurring disorders. Kushner, M. G., & Mueser, K. T. (1993). Psychiatric co-morbidity with alcohol use  Describes integrated treatment approaches disorders. In Eighth special report to the U.S. for co-occurring disorders with specifc Congress on alcohol and health (NIH Pub. recommendations for different types of No. 94-3699, pp. 37-59). Rockville, MD: U.S. psychiatric disorders, including schizophrenia, Department of Health and Human Services. bipolar disorder, depression, and anxiety disorders.  Early comprehensive review of the epidemiology, correlates, and outcome Mueser, K. T., Drake, R. E., & Wallach, M. A. of co-occurring disorders. (1998). Dual diagnosis: A review of etiological  Summarizes research on the negative effects theories. Addictive Behaviors, 23(6), 717-734. of psychiatric comorbidity on the course and  Reviews the research literature on different outcome of treatment for substance abuse. theories accounting for the high rate of substance abuse in consumers. Polcin, D. L. (1992). Issues in the treatment of dual diagnosis clients who have chronic mental  Challenges the prevailing hypothesis that high illness. Professional Psychology: Research and rates of substance abuse and serious mental Practice, 23(1), 30-37. illness could be explained by “self-medicating” distressful symptoms. Describes obstacles in traditional treatment approaches to effective intervention for co-  Marshals evidence suggesting that some excess occurring disorders. comorbidity is due to increased biological sensitivity to the effects of drugs and alcohol Ridgely, M. S., Goldman, H. H., & Willenbring, M. in consumers. (1990). Barriers to the care of persons with dual diagnoses: Organizational and fnancing issues. Schizophrenia Bulletin, 16(1), 123-132.

Selected Bibliography 12 The Evidence Ridgely, M. S., Osher, F. C., Goldman, H. H.,  Explains the stages of treatment (engagement, & Talbott, J. A. (1987). Executive summary: persuasion, active treatment, relapse Chronic mentally ill young adults with substance prevention), which guide practitioners in abuse problems: A review of research, treatment, selecting interventions appropriate for and training issues. Baltimore: University of consumers’ level of motivation to address Maryland School of Medicine, mental Health substance use disorders. Policy Studies. Ziedonis, D., & Fisher, W. (1996). Motivation- These two publications summarize problems based assessment and treatment of substance with traditional approaches to co-occurring abuse in patients with schizophrenia. Directions disorders, including administrative, clinical, and in Psychiatry, 16, 1-7. philosophical barriers to accessing intervention for both disorders. Provides overview of motivation-based approach to assess and treat co-occurring disorders.

Principles of Integrated Implementation and Treatment for administrative issues Co-Occurring Disorders Drake, R. E., Essock, S. M., Shaner, A., Carey, Minkoff, K. (1989). An integrated treatment K. B., Minkoff, K., Kola, L., et al. (2001). model for dual diagnosis of psychosis and Implementing dual diagnosis services for clients addiction. Hospital and Community Psychiatry, with severe mental illness. Psychiatric Services, 40(10), 1031-1036. 52(4), 469-476. Describes essential ingredients for an integrated Covers issues related to implementing service system for treating serious mental and disseminating Integrated Treatment illnesses and substance use disorders. for Co-Occurring Disorders.

Mueser, K. T., Drake, R. E., & Noordsy, D. L. Fox, T., Fox, L., & Drake, R. E. (1992). (1998). Integrated mental health and substance Developing a statewide service system for abuse treatment for severe psychiatric disorders. people with co-occurring severe mental illness Practical Psychiatry and Behavioral Health, and substance use disorders. Innovations and 4, 129-139. Research, 1(4), 9-13.  Summarizes the fundamental ingredients Describes developing integrated co-occurring of effective Integrated Treatment programs, disorder services in the state of New Hampshire. including comprehensiveness, assertive outreach, assertive and protective living Torrey, W. C., Drake, R. E., Cohen, M., Fox, L. B., environment, motivation-based intervention, Lynde, D., Gorman, P., et al. (2002). The challenge and long-term perspective. of implementing and sustaining integrated dual disorders treatment programs. Community Mental Health Journal, 38(6), 507-521.

The Evidence 13 Selected Bibliography Clark, R. E., Ricketts, S. K., & McHugo, G. J. State and local (1999). Legal system involvement and costs for administrative perspectives persons in treatment for severe mental illness and substance use disorders. Psychiatric Services, Fox, T. S., & Shumway, D. L. (1995). Human 50, 641-647. resource development: Training and motivating staff to work with dually diagnosed clients. Addresses cost of legal system involvement in In A. F. Lehman & L.B. Dixon (Eds.), Double consumers with co-occurring disorders. jeopardy: Chronic mental illness and substance use disorders (pp. 265-276). Switzerland: Dickey, B., & Azeni, H. (1996). Persons with dual Harwood Academic Publishers. diagnoses of substance abuse and major mental illness: Their excess costs of psychiatric care. Describes how to cultivate practitioners American Journal of Public Health, 86(7), and administrators in developing Integrated 973-977. Treatment for Co-Occurring Disorders. Documents the high cost of standard (non- Mercer-McFadden, C., Drake, R. E., Clark, R. E., integrated) treatment approaches to substance Verven, N., Noordsy, D. L., & Fox, T. S. (1998). abuse in consumers. Substance abuse treatment for people with severe mental disorders: A program manager’s guide. Concord, NH: New Hampshire-Dartmouth Additional readings for program Psychiatric Research Center. leaders and public mental health Useful guide for program managers and authorities anyone else with administrative responsibility

for establishing and maintaining high-quality Batalden, P. B., & Stoltz, P. K. (1993). A framework integrated programs for co-occurring disorders. for the continual improvement of health care: Building and applying professional and improvement knowledge to test changes in daily work. Financing and cost-effectiveness The Joint Commission Journal on Quality Improvement, 19(10), 424–447. of Integrated Treatment for Co- Occurring Disorders Gowdy, E. A., & Rapp, C. A. (1989). Managerial behavior: The common denominators of effective Clark, R. E., Teague, G. B., Ricketts, S. K., Bush, community based programs. Psychosocial P. W., Xie, H., McGuire, T. G., et al. (1998). Rehabilitation Journal, 13(2), 31–51. Cost-effectiveness of assertive community treatment versus standard case management Mercer, C. C., Mueser, K. T., & Drake, R. E. for persons with co-occurring severe mental (1998) Organizational guidelines for dual illness and substance use disorders. Health disorders programs. The Psychiatric Quarterly Services Research, 33(5 Pt.1), 1285-1308. 69(3), 145–168. Describes cost-effectiveness analysis of study comparing Assertive Community Treatment Nelson, E. C., Batalden, P. B., Ryer, J. C. (Eds.). (ACT) with standard case management for (1998). Clinical improvement action guide. co-occurring disorders. Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations.

Selected Bibliography 14 The Evidence Rapp, C. A. (1993) Client-centered performance management for rehabilitation and mental health Practice manuals services. In R. W. Flexer & P. L. Solomon (Eds.), Center for Substance Abuse Treatment (2005). Community and social support for people with Substance abuse treatment for persons with co- severe mental disabilities. Boston, MA: Andover. occurring disorders. Treatment Improvement

pp. 183-192. Protocol (TIP) Series 42: DHHS Publication No. Rapp, C. A. (1993). Client-centered performance (SMA) 05-3922. Rockville, MD: Substance Abuse management and the inverted hierarchy. In R. and Mental Health Services Administration. W. Flexer & P. L. Solomon (Eds.), Community  Provides practical information about treating and social support for people with severe mental consumers with co-occurring disorders. disabilities. Boston, MA: Andover.  Has separate chapters on treatment systems,

Supervisor’s Tool Box. (1997). Lawrence: The linkages for mental health and substance

University of Kansas School of Social Welfare. abuse treatment, mood disorders, anxiety disorders, personality disorders, psychotic disorders, and pharmacology management. Fidelity measures for Integrated Treatment for Co-Occurring Drake, R. E., Merrens, M. R., & Lynde, D. W. Disorders (2005). Evidence-based mental health practice: A textbook. New York: W.W. Norton. Jerrell, J. M., & Ridgely, M. S. (1999). Impact  Introduces the concepts and approaches of of robustness of program implementation on evidence-based practices for treating serious outcomes of clients in dual diagnosis programs. mental illnesses. Psychiatric Services, 50(1), 109-112.  Describes the importance of research in Documents that better substance abuse outcomes intervention science and the evolution of in consumers with co-occurring disorders are evidence-based practices. associated with higher program fdelity to the Integrated Treatment model.  Includes a chapter for each of fve evidence-based practices and provides McHugo, G. J., Drake, R. E., Teague, G. B., & historical background, practice principles, Xie, H. (1999). Fidelity to assertive community and an introduction to implementation. treatment and client outcomes in the New Vignettes highlight the experiences of staff Hampshire dual disorders study. Psychiatric and consumers.

Services, 50(6), 818-824.  Provides an excellent, readable primer for the Shows that consumers in Assertive Community Evidence-Based Practices Implementation Treatment (ACT) programs that implemented Resource Kits. Integrated Treatment with high fdelity to the model had better substance abuse outcomes Mueser, K. T., Noordsy, D. L., Drake, R. E., & than those in low-fdelity programs. Fox, L. (2003). Integrated treatment for dual diagnosis: Effective intervention for severe mental illness and substance abuse. New York: Guilford Press.  Provides a comprehensive clinical guide for treating co-occurring disorders from which some of the material in the KIT is drawn.

The Evidence 15 Selected Bibliography  Has information on assessment, including forms and instruments. Assessment and treatment planning  Describes ancillary treatment strategies, such as residential and other housing approaches, Carey, K. B., & Correia, C. J. (1998). Severe mental involuntary intervention, vocational illness and addictions: Assessment considerations. rehabilitation, and psychopharmacology. Addictive Behaviors, 23(6), 735-748.  Gives detailed guidelines and vignettes. Discusses common issues practitioners face Individual (including case management, in assessing substance abuse in consumers motivational interviewing, and cognitive and provides solutions to those problems. behavioral counseling), group (including persuasion, active treatment, social skills Connors, G. J., Donovan, D. M., & DiClemente, training, and self-help groups), and family C. C. (2001). Substance abuse treatment and (including individual family and multiple- the stages of change: Selecting and planning family group) approaches are described. interventions. The Guilford substance abuse series. New York: Guilford Press.  Includes educational handouts that cover different topics on mental illness, substance A helpful book on treatment planning based abuse, and their interactions which can be on consumers’ motivation to change their duplicated for education with consumers and addictive behavior. family members. Donovan, D. M. and Marlatt, G. A (Eds.) (1988). Watkins, T. R., Lewellen, A., & Barrett, M. C. Assessment of addictive behaviors. The Guilford (2001). Dual diagnosis: An integrated behavioral assessment series. New York: approach to treatment. Thousand Oaks, CA: Guilford Press. Sage Publications.  The introductory chapter on assessment  Discusses strategies for integrating substance of addictive behaviors is outstanding. abuse treatment with care for mental illness.  This book also has many chapters on specifc  Has separate chapters that address different drugs and approaches that are quite good. psychiatric disorders, including schizophrenia, bipolar disorder, depression, anxiety disorders, Drake, R. E., Rosenberg, S. D., & Mueser, K. and severe personality disorders. T. (1996). Assessing substance use disorder in persons with severe mental illness. New Directions for Mental Health Services, 70, 3-17. Substance abuse Describes many obstacles to accurate assessment Johns, A. (2001). Psychiatric effects of cannabis. of substance abuse in consumers with co- The British Journal of Psychiatry 178; 116-122. occurring disorders and strategies for overcoming these obstacles. Kinney, J. (2000). Loosening the grip: A handbook of alcohol information (6th ed.). Boston: McHugo, G. J., Drake, R. E., Burton, H. L., & McGraw-Hill. Ackerson, T. H. (1995). A scale for assessing the Thombs, D. L. (1999). Introduction to addictive stage of substance abuse treatment in persons behaviors. 2nd ed. The Guilford substance abuse with severe mental illness. The Journal of series. New York: Guilford Press. Nervous and Mental Disease, 183(17), 762-767. Weiss, R. D., & Mirin, S. M. (1987). Cocaine. Contains information about assessing Washington, D.C.: American Psychiatric Press. stages of treatment for consumers with co-occurring disorders.

16 The Evidence Mueser, K. T., Drake, R. E., Clark, R. E., McHugo, G. J., Mercer-McFadden, C., & Ackerson, T. Engagement (1995). Toolkit for evaluating substance abuse Rapp, C. A. (1998). The strengths model: Case

in persons with severe mental illness. Cambridge, management with people suffering from severe

MA: Evaluation Center @ HSRI. and persistent mental illness. New York: Oxford  Describes three practitioner-administered University Press.

scales for consumers with co-occurring  Describes the engagement process

disorders, including the Alcohol Use Scale, in consumers. the Drug Use Scale, and the Substance Abuse Treatment Scale.  Helpful for anyone attempting to engage consumers with co-occurring disorders in a  Includes software with the scales and treatment relationship. psychometric testing for the scales.  Has information about training practitioners on using the scales, establishing and Stages of treatment and maintaining reliability, and validity. motivational enhancement

Noordsy, D. L., McQuade, D. V., & Mueser, K. Carey, K. B., Purnine, D. M., Maisto, S. A., T. (2002). Assessment considerations. In H. L. Carey, M. P., & Barnes, K. L. (1999). Decisional Graham, A. Copello, M. J. Birchwood, & K. T. balance regarding substance use among persons Mueser (Eds.), Substance misuse in psychosis: with schizophrenia. Community Mental Health approaches to treatment and service delivery Journal, 35(4), 289-299.

(pp. 159-180). Chichester, England: Wiley. Describes using decisional balance approach  Describes principles of assessing substance to help consumers with co-occurring disorders abuse in consumers. weigh the advantages and disadvantages of continued substance use.  Explains four steps of assessment: identifcation, classifcation, functional D’Zurilla, T. J., & Nezu, A. M. (1999). Problem- assessment and analysis, and solving therapy: A social competence approach treatment planning. to clinical intervention (2nd ed.). New York:  Describes specifc methods for linking Springer Publishing Comany. assessment to treatment. Explains problem-solving therapy, which can be applied to substance abuse or Rosenberg, S. D., Drake, R. E., Wolford, G. L., mental illness problems in consumers with Mueser, K. T., Oxman, T. E., Vidaver, R. M., et co-occurring disorders. al. (1998). The Dartmouth assessment of lifestyle instrument (DALI): A substance use disorder Graham, H. L., Copello, A., Birchwood, M. J., screen for people with severe mental illness. The Orford, J., McGovern, D., Maslin, J., et al. American Journal of Psychiatry, 155(2), 232-238. (2002). Cognitive-behavioral integrated approach  Describes brief screening instrument (DALI) for psychosis and problem substance use. In H. for identifying substance abuse in consumers. L. Graham, A. Copello, M. J. Birchwood, & K.  Presents data showing that DALI outperforms T. Mueser (Eds.), Substance misuse in psychosis: other screening instruments in consumers approaches to treatment and service delivery with co-occurring disorders. (pp. 181-206). Chichester, England: Wiley.

The Evidence 17 Selected Bibliography  Describes cognitive-behavioral approach Monti, P. M., Abrams, D. B., Kadden, R. M., to treating substance abuse in consumers. & Cooney, N. L. (1989). Treating alcohol dependence: A coping skills training guide  Includes numerous useful clinical examples. treatment manual for practitioners. New York: Guilford Press. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change.  About cognitive-behavioral treatment of (Second ed.). New York: Guilford Press. substance abuse.  About stages of change and recovery from  Provides an introduction to basic techniques substance abuse. that are effective for working with consumers with co-occurring disorders in the active  Useful for practitioners working with treatment stage. consumers with co-occurring disorders.

Osher, F. C., & Kofoed, L. L. (1989). Treatment of patients with psychiatric and psychoactive Group treatment substance use disorders. Hospital and for co-occurring disorders Community Psychiatry, 40, 1025-1030. Bellack, A. S., & DiClemente, C. C. (1999). Introduces and describes the concept of Treating substance abuse among patients with stages of treatment (engagement, persuasion, schizophrenia. Psychiatric Services, 50(1), 75-80. active treatment, relapse prevention) that help

practitioners gear treatment interventions to Describes social skills training approach

consumers’ individual motivational states. to co-occurring disorders treatment.

Rollnick, S., Mason, P., & Butler, C. (1999). Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, Health behavior change: A guide for J. (1997). Social skills training for schizophrenia: practitioners. Edinburgh: Churchill Livingstone. A step-by-step guide. Treatment manuals for practitioners. New York: Guilford Press.  Another helpful reference on the stages of change and recovery from substance abuse.  Addresses how to conduct social skills training groups for consumers.  Describes substance abuse counseling and relapse prevention counseling.  Gives specifc curriculum (steps of skills) for helping consumers refuse substances and deal Marlatt, G. A., & Gordon, J. R. (1985). Relapse with substance abuse situations. prevention: Maintenance strategies in the treatment of addictive behaviors. The Guilford Mueser, K. T., & Noordsy, D. L. (1996). Group clinical psychology and psychotherapy series. treatment for dually diagnosed clients. New New York: Guilford Press. Directions for Mental Health Services, 70, 33-51.  Describes principles of substance abuse  Describes four different types of group relapse prevention. interventions for co-occurring disorders, including educational, stage-wise (persuasion  Was written originally for work with and active treatment), social skills training, and

the substance abuse population. self-help groups.  Much of the book applies to consumers who  Uses brief clinical vignettes to illustrate have achieved sobriety and are motivated to different group treatment methods. prevent relapses of their substance abuse.

Selected Bibliography 18 The Evidence Noordsy, D. L., Schwab, B., Fox, L., & Drake, Hamilton, T., & Samples, P. (1994). The twelve R. E. (1996). The role of self-help programs in steps and dual disorders: A framework of the rehabilitation of persons with severe mental recovery for those of us with addiction and illness and substance use disorders. Community an emotional or psychiatric illness. Center City, Mental Health Journal, v. 32(1), pp. 71-81. MN: Hazelden. Summarizes diffculties and solutions Explains 12-Step approach to self-help substance associated with using self-help groups, such abuse treatment in consumers. as Alcoholics Anonymous, for consumers with co- occurring disorders. The Dual Disorder Recovery Book: A twelve- step program for those of us with addiction Roberts, L. J., Shaner, A., & Eckman, T. A. and an emotional or psychiatric illness. (1993) (1999). Overcoming addictions: Skills training Hazelden, Center City, Minnesota, 1993. for People with schizophrenia. New York: Discusses 12-step self-help approach to recovery W.W. Norton. for consumers with co-occurring disorders. Manual for providing social skills training to consumers with co-occurring disorders. Trimpey, J. (1996). Rational recovery: The new cure for substance addiction. New York: Pocket Books. Weiss, R. D., Greenfeld, S. F., & O’Leary, G.  Rational Recovery (RR) is a self-help (2002). Relapse prevention for patients with alternative to 12-step approaches (such bipolar and substance use disorders. In H. L. as Alcoholics Anonymous). Graham, A. Copello, M. J. Birchwood, & K. T. Mueser (Eds.), Substance misuse in psychosis:  RR is less spirituality-oriented and more Approaches to treatment and service delivery focused on helping consumers take control of (pp. 207-226). Chichester, England: Wiley. their lives by accepting personal responsibility of themselves and others.  Describes group intervention program for bipolar disorder and substance abuse. Vaillant, G. E. (1995). The natural history of  Includes useful clinical examples to illustrate alcoholism revisited. Cambridge, MA: Harvard group treatment methods. University Press. Analyzes natural pathways to recovery and explains how self-help and treatment can Self-help enhance the process. Alcoholics Anonymous (2005). The AA group: Where it all begins (rev.). New York: Alcoholics Anonymous. Family treatment Alcoholics Anonymous (AA) is the largest Barrowclough, C. (2002). Family intervention self-help organization for addiction. This book for substance misuse in psychosis. In H. L. describes its history, traditions, and approach Graham, A. Copello, M. J. Birchwood, & K. T. to recovery from addiction, based on the 12 Mueser (Eds.), Substance misuse in psychosis: Steps of AA. Available from http://www.aa.org/ Approaches to treatment and service delivery en_pdfs/p-16_theaagroup.pdf. (pp. 227-243). Chichester: Wiley. Describes family intervention approach for co-occurring disorders.

The Evidence 19 Selected Bibliography McFarlane, W. R. (2002). Multifamily groups in the treatment of severe psychiatric disorders. Psychopharmacological New York: Guilford Press. treatment

Provides detailed guidance on forming and Day, E., Georgiou, G., & Crome, I. (2002). running multi-family groups for consumers and Pharmacological management of substance their families. misuse in psychosis. In H. L. Graham, A. Copello, M. J. Birchwood, & K. T. Mueser Mueser, K. T., & Fox, L. (2002). A family (Eds.), Substance misuse in psychosis: intervention program for dual disorders. Approaches to treatment and service delivery Community Mental Health Journal, (pp. 259-280). Chichester, England: Wiley. 38(3), 253-270. Detailed chapter that describes pharmacologically  Describes family intervention program for co- managing substance use disorders, including occurring disorders that includes single-family stimulants, opioids, other drugs, and alcohol. sessions and multi-family group sessions.  Presents pilot data from study of Drake, R. E., Xie, H., McHugo, G. J., & Green, family program. A. I. (2000). The effects of clozapine on alcohol and drug use disorders among patients with Mueser, K. T., & Gingerich, S. L. (in press). schizophrenia. Schizophrenia Bulletin, 26(2), Coping with schizophrenia: A guide for 441-449. families (2nd ed.). New York: Guilford Press. Summarizes positive effects of clozapine  About family interventions. on alcoholism outcomes in people with schizophrenia.  Includes a chapter on how family

members can help a relative with a Green, A. I., Zimmet, S. V., Strous, R. D., &

co-occurring disorder. Schildkraut, J. J. (1999). Clozapine for comorbid substance use disorder and schizophrenia: Mueser, K. T., & Glynn, S. M. (1999). Behavioral Do patients with schizophrenia have a reward- nd family therapy for psychiatric disorders (2 ed.). defciency syndrome that can be ameliorated Oakland, CA: New Harbinger Publications. by clozapine? Harvard Review of Psychiatry,  Supplies a treatment manual for practitioners 6(6), 287-296. that describes family intervention model Theoretical paper in which authors suggest for mental illness, including strategies for that the neurobiology of schizophrenia makes addressing substance abuse in consumers consumers with this disorder more susceptible with co-occurring disorders. to substance abuse and more likely to beneft  Includes educational handouts on different from clozapine. psychiatric disorders, medications, and the interactions between mental illness and Mueser, K. T., & Lewis, S. (2000). Treatment of substance abuse. substance misuse in schizophrenia. In P. Buckley & J. L. Waddington (Eds.), Schizophrenia and mood disorders: The new drug therapies in clinical practice (pp. 286-296). Oxford: Butterworth-Heinemann. Brief chapter that includes recommendations for pharmacological treatment of consumers with co-occurring disorders.

Selected Bibliography 20 The Evidence Mueser, K. T., Noordsy, D. L., Fox, L., & Wolfe, R. (2003). Disulfram treatment for alcoholism First-person accounts

in severe mental illness. The American Journal Alverson, H., Alverson, M., & Drake, R. E. (2000).

on Addictions, 12(3), 242-252. An ethnographic study of the longitudinal course Quantitatively describes positive, long-term of substance abuse among people with severe outcomes of 30 consumers and alcoholism treated mental illness. Community Mental Health with disulfram (Antabuse). Journal, 36(6), 557-569. Alverson, H., Alverson, M., & Drake, R. E. (2001) Social patterns of substance use among people Infectious diseases with dual diagnoses. Mental Health Services Research, 3(1), 3-14. Bartlett, J. G., & Finkbeiner, A. K. (1998). The guide to living with HIV infection: Developed at Fox, L. (1999). Missing out on motherhood. the Johns Hopkins AIDS clinic. Johns Hopkins Psychiatric Services, 50(2), 193-194. Press Health Books. Baltimore, MD: The John Green, V. L. The resurrection and the life.

Hopkins University Press. The American Journal of Orthopsychiatry, Coping with HIV and hepatitis. 66(1), 12-16, 1996.

Eversen G. T., & Weinberg, H. L (1999). Living Family perspectives with Hepatitis C: A Survivor’s Guide. New York: Hatherleigh Press. Clark, R. E. (2001). Family support and substance Coping with HIV and hepatitis. use outcomes for persons with mental illness and substance use disorders. Schizophrenia Bulletin,

Razzano, L. (2002). Issues in comorbidity and 27(1), 93-101. HIV/AIDS. In H. L. Graham, A. Copello, M. J. Describes family members’ fnancial and time Birchwood, & K. T. Mueser (Eds.), Substance contributions in helping a relative with co- misuse in psychosis: Approaches to treatment occurring disorders and the relationship between and service delivery (pp. 332-346). Chichester, family assistance and improved outcomes. England: Wiley. Practical chapter on the nature of HIV/AIDS Schwab, B., Clark, R. E., & Drake, R. E. (1991). in consumers with co-occurring disorders and An ethnographic note on clients as parents. treatment approaches. Psychosocial Rehabilitation Journal, 15(2), 95-99. Describes challenges faced by consumers with co-occurring disorders who are parents.

The Evidence 21 Selected Bibliography

The Evidence

References The following list includes the references for all citations in the KIT.

Barrowclough, C., Haddock, G., Tarrier, Brunette, M., & Drake, R. E. (1998). N., Lewis, S. W., Moring, J., O’Brien, Gender differences in homeless persons R., et al. (2001). Randomized controlled with schizophrenia and substance abuse. trial of motivational interviewing, Community Mental Health Journal, cognitive behavior therapy, and family 34(6), 627-642. intervention for patients with comorbid Brunette, M. F., & Drake, R. E. (1997). schizophrenia and substance use Gender differences in patients disorders. The American Journal of with schizophrenia and substance Psychiatry, 158(10), 1706-1713. abuse. Comprehensive Psychiatry, Blankertz, L. E., & Cnaan, R. A. (1994). 38(2), 109-116. Assessing the impact of two residential Brunette, M. F., Drake, R. E., Woods, M., programs for dually diagnosed homeless & Hartnett, T. (2001). A comparison of individuals. Social Service Review, long-term and short-term residential 68(4), 536-560. treatment programs for dual diagnosis patients. Psychiatric Services, 52(4), 526-528.

The Evidence 23 References Burnam, M. A., Morton, S. C., McGlynn, E. A., Ganju, V. (2004). Evidence-based practices: Peterson, L. P., Stecher, B. M., Hayes, C., et al. Responding to the challenge. Presented at the (1995). An experimental evaluation of residential 2004 NASMHPD Commissioner’s Meeting, San and nonresidential treatment for dually Francisco, CA: June 22-24, 2004. diagnosed homeless adults. Journal of Addictive Gearon, J. S., & Bellack, A. S. (1999). Women Diseases, 14(4), 111-134. with schizophrenia and co-occurring substance Carmichael, D. M., Tackett-Gibson, L., O’Dell, use disorders: An increased risk for violent R., Menon, R., Jayasuria, B., & Jordan, J. (1998). victimization and HIV. Community Mental Texas dual diagnosis pilot project evaluation Health Journal, 35(5), 401-419. report. Final report submitted to the Texas Godley, S. H., Hoewing-Roberson, R., & Commission on Alcohol and Drug Abuse and the Godley, M. D. (1994). Final MISA report. Texas Department of Mental Health and Mental Bloomington, IL: Chestnut Health Systems/ Retardation. Public Policy Research Institute, Lighthouse Institute. Texas A&M University. Hyde, P. S., Falls, K., Morris, J. A., & Schoenwald, Drake, R. E., Essock, S. M., Shaner, A., Carey, S. K. (2003). Turning knowledge into practice: K. B., Minkoff, K., Kola, L., et al. (2001). A manual for behavioral health administrators Implementing dual diagnosis services for clients and practitioners about understanding and with severe mental illness. Psychiatric Services, implementing evidence-based practices. Boston: 52(4), 469-476. Technical Assistance Collaborative, Inc. Drake, R. E., McHugo, G. J., Clark, R. E., Teague, Available through http://www.tacinc.org G. B., Xie, H., Miles, K., et al. (1998a). Assertive or http://www.acmha.org. community treatment for patients with co- Institute of Medicine (2006). Improving the quality occurring severe mental illness and substance of health care for mental and substance-use use disorder: A clinical trial. The American conditions: Quality Chasm Series. Washington, Journal of Orthopsychiatry, 68(2), 201-215. DC: National Academy of Sciences. Drake, R. E., Mercer-McFadden, C., Mueser, Jerrell, J. M., & Ridgely, M. S. (1995). Comparative K. T., McHugo, G. J., & Bond, G. R. (1998b). effectiveness of three approaches to serving Review of integrated mental health and substance people with severe mental illness and substance abuse treatment for patients with dual disorders. abuse disorders. The Journal of Nervous and Schizophrenia Bulletin, 24(4), 589-608. Mental Disease, 183(9), 566-576. Drake, R. E., Yovetich, N. A., Bebout, R. R., Ley, A., & Jeffery, D. (2002). Cochrane Harris, M., & McHugo, G. J. (1997). Integrated review of treatment outcome studies and its treatment for dually diagnosed homeless implications for future developments. In H. L. adults. Journal of Nervous and Mental Disease, Graham, A. Copello, M. J. Birchwood, & K. T. 185(5), 298-305. Mueser (Eds.), Substance misuse in psychosis: Franco, H., Galanter, M., Castaneda, R., & Approaches to treatment and service delivery Patterson, J. (1995). Combining behavioral (pp. 349-365). Chichester, England: Wiley. and self-help approaches in the inpatient McHugo, G. J., Drake, R. E., Burton, H. L., & management of dually diagnosed patients. Ackerson, T. H. (1995). A scale for assessing Journal of Substance Abuse Treatment, the stage of substance abuse treatment in persons 12(3), 227-232. with severe mental illness. The Journal of Nervous and Mental Disease, 183(17), 762-767.

References 24 The Evidence Meisler, N., Blankertz, L., Santos, A. B., & McKay, Regier, D. A., Farmer, M. E., Rae, D. S., Locke, C. (1997). Impact of assertive community B. Z., Keith, S. J., Judd, L. L., et al. (1990). treatment on homeless persons with co- Comorbidity of mental disorders with alcohol occurring severe psychiatric and substance use and other drug abuse. Results from the disorders. Community Mental Health Journal, Epidemiologic Catchment Area (ECA) Study. 33(2), 113-122. JAMA, 264(19), 2511-2518. Mueser, K. T., Essock, S. M., Drake, R. E., Wolfe, Rosenberg, S. D., Drake, R. E., Wolford, G. L., R. S., & Frisman, L. (2001). Rural and urban Mueser, K. T., Oxman, T. E., Vidaver, R. M., et differences in patients with dual diagnosis: al. (1998). The Dartmouth assessment of lifestyle Implications for service needs. Schizophrenia instrument (DALI): A substance use disorder Research, 48(1), 93-107. screen for people with severe mental illness. The American Journal of Psychiatry, 155(2), 232-238. Mueser, K. T., Yarnold, P. R., & Bellack, A. S. (1992). Diagnostic and demographic correlates Rosenthal, R. N. (2002). An inpatient-based of substance abuse in schizophrenia and service model. In H. L. Graham, A. Copello, M. major affective disorder. Acta Psychiatrica J. Birchwood, & K. T. Mueser (Eds.), Substance Scandinavica, 85(1), 48-55. misuse in psychosis: Approaches to treatment and service delivery (pp. 136-155). Chichester, Mueser, K. T., Yarnold, P. R., Rosenberg, S. D., England: Wiley. Swett, C., Miles, K. M., & Hill, D. (2000). Substance use disorder in hospitalized severely U.S. Department of Health and Human Services. mentally ill psychiatric patients: Prevalence, (1999). Mental health: A report of the surgeon correlates, and subgroups. Schizophrenia general. Rockville, MD: U.S. Department of Bulletin, 26(1), 179-192. Health and Human Services, Substance Abuse and Mental Health Services Administration, National Advisory Mental Health Council Center for Mental Health Services, and National Workgroup on Child and Adolescent Mental Institutes of Health, National Institute of Health Intervention. Development and Mental Health. deployment. Blueprint for change: Research on child andadolescent mental health. U.S. Department of Health and Human Services. Washington, DC: 2001. Available through (2001). Mental health: Culture, race, and http://www.nimh.nih.gov. ethnicity. a supplement to mental health: A report of the surgeon general. Rockville, New Freedom Commission on Mental Health. MD: U.S. Department of Health and Human (2003). Achieving the promise: Transforming Services, Substance Abuse and Mental Health mental health care in America. Final report. Services Administration, Center for Mental DHHS Pub. No. SMA-03-3832. Rockville, MD. Health Services. Penn, P. E., & Brooks, A. J. (1999). Comparing substance abuse treatments for dual diagnosis: Final report. Tucson, AZ: La Frontera Center. Peters, T. J., & Waterman, R. H. (1982). In Search of excellence. New York: Harper & Row. Rahav, M., Rivera, J. J., Nuttbrock, L., Ng-Mak, D., Sturz, E. L., Link, B. G., et al. (1995). Characteristics and treatment of homeless, mentally ill, chemical-abusing men. Journal of Psychoactive Drugs, 27(1), 93-103.

The Evidence 25 References

The Evidence

Acknowledgments

The materials included in the Integrated Treatment KIT were developed through the National Implementing Evidence-Based Practices Project. The Project’s Coordinating Center—the New Hampshire-Dartmouth Psychiatric Research Center—in partnership with many other collaborators, including clinicians, researchers, consumers, family members, and administrators and operating under the direction of the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, developed, evaluated, and revised these materials.

We wish to acknowledge the many people who contributed to all aspects of this project. In particular, we wish to acknowledge the contributors and consultants on the next few pages.

The Evidence 27 Acknowledgments SAMHSA Center for Mental Health Services, Oversight Committee

Michael English Sushmita Shoma Ghose Division of Service and Systems Improvement Community Support Programs Branch Rockville, Maryland Division of Service and Systems Improvement Rockville, Maryland Neal B. Brown Community Support Programs Branch Patricia Gratton Division of Service and Systems Improvement Division of Service and Systems Improvement Rockville, Maryland Rockville, Maryland

Sandra Black Betsy McDonel Herr Community Support Programs Branch Community Support Programs Branch Division of Service and Systems Improvement Division of Service and Systems Improvement Rockville, Maryland Rockville, Maryland

Crystal R. Blyler Larry D. Rickards Community Support Programs Branch Homeless Programs Branch Division of Service and Systems Improvement Division of Service and Systems Improvement Rockville, Maryland Rockville, Maryland

Pamela J. Fischer Homeless Programs Branch Division of Service and Systems Improvement Rockville, Maryland

Co-Leaders

Mary Brunette David W. Lynde Dartmouth Psychiatric Research Center Dartmouth Psychiatric Research Center Lebanon, New Hampshire Concord, New Hampshire

Robert E. Drake Dartmouth Psychiatric Research Center Lebanon, New Hampshire

Acknowledgments 28 The Evidence Contributors

Stephen T. Baron Charlene LeFauve Department of Mental Health Co-occurring and Homeless Activities Branch Washington, D.C. Substance Abuse and Mental Health Services Administration Gary R. Bond Center for Substance Abuse Treatment

Indiana University–Purdue University Rockville, Maryland Indianapolis, Indiana Doug Marty John S. Caswell The University of Kansas

West Lebanon, New Hampshire Lawrence, Kansas Kevin Curdie Gregory J. McHugo

Concord, New Hampshire Dartmouth Psychiatric Research Center Michael J. Cohen Lebanon, New Hampshire

National Alliance on Mental Illness (NAMI) Alan C. McNabb

Concord, New Hampshire Ascutney, Vermont Cathy Donahue Matthew Merrens

Calais, Vermont Dartmouth Psychiatric Research Center Kana Enomoto Lebanon, New Hampshire

Substance Abuse and Mental Health Services Gary Morse

Administration Community Alternatives

Rockville, Maryland St. Louis, Missouri Carol Furlong Kim T. Mueser

Harbor Homes, Inc. Dartmouth Psychiatric Research Center

Nashua, New Hampshire Concord, New Hampshire Paul G. Gorman Fred C. Osher

Dartmouth Psychiatric Research Center University of Maryland School of Medicine

Lebanon, New Hampshire Baltimore, Maryland Pablo R. Hernandez Ernest Quimby

Wyoming State Hospital Howard University

Evanston, Wyoming Washington, D.C. Marta J. Hopkinson Charles A. Rapp

Mental Health Services The University of Kansas

University of Maryland–College Park Lawrence, Kansas College Park, Maryland Lawrence D. Rickards Lenore A. Kola Homeless Programs Branch

Center for Evidence-Based Practice at Case Substance Abuse and Mental Health Services

Western Reserve University Administration

Cleveland, Ohio Center for Mental Health Services Rockville, Maryland

The Evidence 29 Acknowledgments Dennis Ross Karin Swain Marshfeld, Vermont Dartmouth Psychiatric Research Center Lebanon, New Hampshire Marian Scheinholtz Community Support Programs Branch William Torrey Division of Service and Systems Improvement Dartmouth Medical School Rockville, Maryland Hanover, New Hampshire

Loralee West Westbridge Community Services Manchester, New Hampshire

Consultants to the National Implementing Evidence-Based Practices Project

Dan Adams Mike Brady St. Johnsbury, Vermont Adult and Child Mental Health Center Indianapolis, Indiana Diane C. Alden New York State Offce of Mental Health Ken Braiterman New York, New York National Alliance on Mental Illness (NAMI) Concord, New Hampshire Lindy Fox Amadio Dartmouth Psychiatric Research Center Janice Braithwaite Concord, New Hampshire Snow Hill, Maryland

Diane Asher Michael Brody The University of Kansas Southwest Connecticut Mental Health Center Lawrence, Kansas Bridgeport, Connecticut

Stephen R. Baker Mary Brunette University of Maryland School of Medicine Dartmouth Psychiatric Research Center Baltimore, Maryland Concord, New Hampshire

Stephen T. Baron Sharon Bryson Department of Mental Health Ashland, Oregon Washington, D.C. Barbara J. Burns Deborah R. Becker Duke University School of Medicine Dartmouth Psychiatric Research Center Durham, North Carolina Lebanon, New Hampshire Jennifer Callaghan Nancy L. Bolton The University of Kansas Cambridge, Massachusetts School of Social Welfare Lawrence, Kansas Patrick E. Boyle Case Western Reserve University Cleveland, Ohio

Acknowledgments 30 The Evidence Kikuko Campbell Molly Finnerty Indiana University–Purdue University New York State Offce of Mental Health Indianapolis, Indiana New York, New York

Linda Carlson Laura Flint University of Kansas Dartmouth Evidence-Based Practices Center Lawrence, Kansas Burlington, Vermont

Diana Chambers Vijay Ganju Department of Health Services National Association of State Mental Health Burlington, Vermont Program Directors Research Institute Alexandria, Virginia Alice Claggett University of Toledo College of Medicine Susan Gingerich Toledo, Ohio Narberth, Pennsylvania

Marilyn Cloud Phillip Glasgow Department of Health and Human Services Wichita, Kansas Concord, New Hampshire Howard H. Goldman Melinda Coffman University of Maryland School of Medicine The University of Kansas Baltimore, Maryland Lawrence, Kansas Paul G. Gorman Jon Collins Dartmouth Psychiatric Research Center Offce of Mental Health and Addiction Services Lebanon, New Hampshire Salem, Oregon Gretchen Grappone Laurie Coots Concord, New Hampshire Dartmouth Psychiatric Research Center Lebanon, New Hampshire Eileen B. Hansen University of Maryland School of Medicine Judy Cox University of Maryland, Baltimore New York State Offce of Mental Health New York, New York Kathy Hardy Strafford, Vermont Harry Cunningham Dartmouth Psychiatric Research Center Joyce Hedstrom

Concord, New Hampshire Courtland, Kansas Lon Herman Gene Deegan

University of Kansas Department of Mental Health

Lawrence, Kansas Columbus, Ohio Lia Hicks Natalie DeLuca

Indiana University–Purdue University Adult and Child Mental Health Center

Indianapolis, Indiana Indianapolis, Indiana Debra Hrouda Robert E. Drake

Dartmouth Psychiatric Research Center Case Western Reserve University

Lebanon, New Hampshire Cleveland, Ohio

The Evidence 31 Acknowledgments Bruce Jensen Anthony D. Mancini Indiana University–Purdue University New York State Offce of Mental Health Indianapolis, Indiana New York, New York

Clark Johnson Paul Margolies Salem, New Hampshire Hudson River Psychiatric Center Poughkeepsie, New York Amanda M. Jones Indiana University–Purdue University Tina Marshall Indianapolis, Indiana University of Maryland School of Medicine Baltimore, Maryland Joyce Jorgensen Department of Health and Human Services Ann McBride (deceased) Concord, New Hampshire Oklahoma City, Oklahoma

Hea-Won Kim William R. McFarlane Indiana University–Purdue University Maine Medical Center Indianapolis, Indiana Portland, Maine

David A. Kime Mike McKasson Transcendent Visions and Crazed Nation Zines Adult and Child Mental Health Center Fairless Hills, Pennsylvania Indianapolis, Indiana

Dale Klatzker Alan C. McNabb The Providence Center Ascutney, Vermont Providence, Rhode Island Meka McNeal Kristine Knoll University of Maryland School of Medicine Dartmouth Psychiatric Research Center Baltimore, Maryland Lebanon, New Hampshire Ken Minkoff Bill Krenek ZiaLogic Department of Mental Health Albuquerque, New Mexico Columbus, Ohio Michael W. Moore Rick Kruszynski Offce of Mental Health and Addiction Services Case Western Reserve University Salem, Oregon Cleveland, Ohio Roger Morin H. Stephen Leff The Center for Health Care Services The Evaluation Center at the Human Services San Antonio, Texas Research Institute Cambridge, Massachusetts Lorna Moser Indiana University–Purdue University Treva E. Lichti Indianapolis, Indiana National Association on Mental Illness (NAMI) Wichita, Kansas Kim T. Mueser Dartmouth Psychiatric Research Center Wilma J. Lutz Concord, New Hampshire Ohio Department of Mental Health Columbus, Ohio

Acknowledgments 32 The Evidence Britt J. Myrhol Diane Sterenbuch New York State Offce of Mental Health Bethesda, Maryland New York, New York Bette Stewart Bill Naughton University of Maryland School of Medicine Southeastern Mental Health Authority Baltimore, Maryland Norwich, Connecticut Steve Stone Nick Nichols Mental Health and Recovery Board Department of Health Ashland, Ohio Burlington, Vermont Maureen Sullivan Bernard F. Norman Department of Health and Human Services Northeast Kingdom Human Services Concord, New Hampshire Newport, Vermont Beth Tanzman Linda O’Malia Vermont Department of Health Oregon Health and Science University Burlington, Vermont Portland, Oregon Greg Teague Ruth O. Ralph University of Southern Florida University of Southern Maine Tampa, Florida Portland, Maine Boyd J. Tracy Angela L. Rollins Dartmouth Psychiatric Research Center Indian University–Purdue University Lebanon, New Hampshire Indianapolis, Indiana Laura Van Tosh Tony Salerno Olympia, Washington New York State Offce of Mental Health New York, New York Joseph A. Vero National Association on Mental Illness (NAMI) Diana C. Seybolt Aurora, Ohio University of Maryland School of Medicine Baltimore, Maryland Barbara L. Wieder Case Western Reserve University Patricia W. Singer Cleveland, Ohio Santa Fe, New Mexico Mary Woods Mary Kay Smith Westbridge Community Services University of Toledo Manchester, New Hampshire Toledo, Ohio

The Evidence 33 Acknowledgments Special thanks to

The SAMHSA Center for Substance Abuse Treatment (CSAT) for partnering in reviewing the KIT and coordinating the parallel distribution of TIP 42.

The following organizations are also recognized for their generous contributions:  The Robert Wood Johnson Foundation  The John D. & Catherine T. MacArthur Foundation  West Family Foundation

Production, editorial, and graphics support

Carolyn Boccella Bagin Chandria Jones Center for Clear Communication, Inc. Westat Rockville, Maryland Rockville, Maryland

Sushmita Shoma Ghose Tina Marshall Westat Gaithersburg, Maryland Rockville, Maryland Mary Anne Myers Julien Hofberg Westat Westat Rockville, Maryland Rockville, Maryland Robin Ritter Glynis Jones Westat Westat Rockville, Maryland Rockville, Maryland

Acknowledgments 34 The Evidence

DHHS Publication No. SMA-08-4366 Printed 2009

26443.0409.7765020404