Acknowledgements
The author wishes to acknowledge the
assistance
of Scott Bayliff, M.S.Ed., and Richard Holmes, Ph.D. in data
collection. She also wishes to thank Suzanne Austin Boren, M.H.A.
for her help with data analysis.
Abstract
The problem of co-occurring mental
health and
substance use disorders is one of the most intractable challenges
facing mental health treatment systems. Individuals with dual
diagnosis have lower levels of functioning and poorer life outcomes in
a broad range of areas. Treatment providers have gone from
parallel and sequential forms of treatment to an integrated
model. Places for People, Inc., a mental health agency in St.
Louis, implemented an integrated treatment program in 2001. This
study examines outcomes of this program.
Demographic and outcomes data were
collected on
a sample of 31 clients. Three of the 6 outcome measures were
found to have statistical significance: Global Assessment of
Functioning score, substance abuse/dual hospitalization rate, and
housing status. Participation
in the integrated treatment
program is associated with some positive change in life outcomes.
Though it is not possible to say for certain whether these gains were
caused by the program, the results are nonetheless encouraging.
Introduction
The
problem of patients who are dually diagnosed with substance use
disorders and severe mental illness is one of the most persistent
challenges in the mental health field. Individuals with dual
diagnoses consume more treatment resources (Drake, et. al., 1996), have
more frequent hospitalizations, have more trouble caring for
themselves, and exhibit more disruptive behaviors in the community than
individuals with a diagnosis of only serious mental illness (Drake
& Wallach, 1989).
Dual diagnosis is also more common than was
once thought. Thirty-seven percent of those who abuse alcohol and
53 percent of those who abuse drugs also meet diagnostic criteria for
at least one severe mental illness (NMHA, 2003).
For decades, the standard of treatment for dual
diagnosis was parallel treatment. The dually diagnosed person
would receive separate substance abuse services and mental health
services, often from two separate agencies, and would be responsible
him/herself for integrating the services and information received from
each (Drake, et. al., 1996). The other common scenario was
sequential treatment, in which the person with the dual diagnosis would
be treated by one service system, and then discharged to be treated by
the other system, with no communication or interplay between the mental
health and substance abuse agencies (Mueser, et. al., 2003). More
and more, however, the standard of care has become integrated
treatment, whereby substance abuse and mental health services are
delivered under the same roof, by the same clinicians, as one package
of services (Drake, McHugo, et. al., 1998). Reviews have been
conducted on the effectiveness of integrated treatment, and the
consensus seems to be that integrated treatment is more effective than
parallel or sequential treatment for individuals with dual diagnosis
(Drake, Mercer-McFadden, et. al., 1998).
Despite the fact that integrated treatment
seems to be the method of choice for intervention with dually-diagnosed
individuals, according to the Substance Abuse and Mental Health
Services Administration (SAMHSA), there is still lacking a strong
evidence base for which kinds of integrated interventions work the best
(SAMHSA, 2003). Case management, group therapy, and
individualized motivational techniques all show promise (Drake, McHugo,
et. al., 1998; Ridgely & Jerrell, 1996). Also of interest are
blends of these methodologies. More research is needed in order
to understand which programs and combinations of programs lead to
improved outcomes with this population.
Through this study, the author
hopes to add to the evidence base regarding effective interventions for
clients with co-occurring disorders.
This
purpose will be carried out through the following objectives:
1.
To describe the integrated treatment program at Places for People, Inc.
2. To analyze demographic and
outcomes data from 31 client charts and the Places for People
management outcomes database.
3. To learn from this
analysis whether the Places for People integrated treatment program is
associated with improved outcomes.
Places for People, Inc. is a small mental
health agency located in the Central West End neighborhood of St.
Louis, Missouri. The agency was founded in the early 1970s in
response to the de-institutionalization of many people with mental
illness who had spent much of their lives in state hospitals (Places
for People, 2003a). In the 1990s, the population served by the
agency began to shift to include more people with mental illness who
were younger and who were often homeless (Places for People,
2003b). The integrated treatment program at Places for People,
Inc. was started in the fall of 2001. Agency leaders recognized
that the problem of co-occurring disorders was becoming more and more
prevalent, and in early 2001, the position of Integrated Treatment
Specialist was created. An MSW-degreed staff person from within
the agency was hired to fill the position, and the program developed
under his leadership.
Integrated treatment at Places for People
consists of several different components. One is intensive case
management. Places for People operates five continuous treatment
teams, all of which serve homeless and dually-diagnosed
individuals. One clinical team, the HOME team, specializes in
outreach and engagement with clients who are homeless or in unstable
housing situations. All clinical teams have received training in
harm reduction (Marlatt, 1998) and motivational interviewing (Miller
& Rollnick, 2002). The integrated treatment specialist
consults with members of each continuous treatment team to help assess
what kinds of interventions might be most helpful to particular clients.
Another aspect of the integrated treatment
program consists of group interventions. Groups for
dually-diagnosed clients meet seven days a week at Places for
People. Five days a week, the integrated treatment specialist
coordinates the groups, which include Double Trouble, Dual Recovery
Anonymous, cognitive-behavioral therapy, and “persuasion” (Mueser, et.
al., 2003) groups. On the weekends, the integrated treatment
groups are peer-led.
The program also provides social support.
Several times a week, following their group meeting, members of the
integrated treatment program go to a neighborhood coffeehouse to play
pool and air hockey, drink coffee, and support one another.
Places for People has budgeted funds to pay for the first beverage of
the day for every participant.
Places for People also offers payeeship
services, nursing services, and a psychosocial rehabilitation program
to all of its clients. A “damp” housing development (Mueser, et.
al., 2003) is under construction .
Harm reduction is an essential theme in all of
Places for People’s services. The integrated treatment program
aims first to reduce the negative consequences created by substance use
behaviors, and then works with each individual to develop the
motivation to change those behaviors (Marlatt, 1998; DiClemente, 2003).
Six outcome measures of the integrated
treatment program will be examined: Global Assessment of
Functioning scores; psychiatric hospitalizations; substance abuse/dual
hospitalizations; medical hospitalizations; housing status; and arrest
rates.
The hypotheses that are being tested are as
follows:
•
Global Assessment of Functioning (American Psychiatric Association,
2000) scores will increase from the year before program implementation
to the year after its implementation. This is because reduced
substance use and stabilization of psychiatric symptoms will lead to
gains in levels of functioning.
• Psychiatric
hospitalizations will decrease from the year before to the year after
because involvement in treatment will help to mitigate psychiatric
symptoms.
• Substance
abuse/dual hospitalizations will increase as more clients enter the
action stage of readiness to change (DiClemente, 2003).
• Medical
hospitalizations will decrease as clients gain greater medical
stability.
• Fewer clients
will be homeless or housed in hotels during the second year examined
when compared to the first year examined.
• There will be
fewer arrests in the second year than in the first year, as clients
reduce their substance use and therefore become less likely to commit
crimes
This study has limitations that restrict the
ability of its results to be generalized to other programs and
settings. First of all, the sample size (N=31) is very small,
making the results less dependable. In order to obtain
consistency in the time period studied, it was necessary to include
only clients who began the dual diagnosis program in November,
2001. The integrated treatment program has actually enrolled over
80 clients during the past two years.
In the sample of dually-diagnosed clients whose
records were reviewed for this study, less than one-fourth of the
subjects were women. This makes generalizing the results of this
study to the experience of women with co-occurring disorders difficult.
Another limitation is that detailed demographic
data for Places for People’s clientele as a whole is unavailable at
this time, making it difficult to know whether the differences between
the integrated treatment sample and the entire agency’s population are
statistically significant.
In addition, it is, of course, impossible to
say for certain whether the improvements and setbacks noted in this
study are caused by the clients’ enrollment in integrated treatment, or
whether these events should be attributed to some other aspect of their
lives or involvement with Places for People.
Materials and Methods
Data for this study were obtained from the
Management Outcomes database and from the clients’ medical records at
Places for People, Inc. The sample was selected from the roster
of Places for People clients who have participated in intensive case
management since November, 2000 or before, and who began the integrated
treatment program in November, 2001. This yielded a sample size
of 31. Each subject in the sample possessed a diagnosis of severe
and persistent mental illness as defined by the Missouri Department of
Mental Health as well as a diagnosis of substance abuse or dependence.
The author was granted a waiver of informed
consent by the University of Missouri-Columbia Health Sciences
Institutional Review Board for the clients in this study on the
condition that the names of study participants not be available to
her. Therefore, in December, 2003, the Medical Records Manager
and the Clinical Director of Places for People extracted the data from
the client charts and the Management Outcomes database and created a
spreadsheet of client information, assigning a number to each client in
the sample. The following descriptive information was
collected: age, gender, and ethnicity of each client.
Information about the sample of dual diagnosis clients was compared to
demographic information reported in the Fiscal Year 2002 Management
Report of Places for People (Places for People, 2002).
Six different outcome measures were
collected. These were Global Assessment of Functioning (GAF)
scores; number of psychiatric, substance abuse/dual diagnosis, and
medical hospitalizations; housing status; and number of arrests.
GAF scores and housing status were assessed for November, 2001 and
November, 2002. Hospital admissions and arrest rates were
measured for the period from November, 2000 to October, 2001 and from
November, 2001 to October, 2002. In this way, outcomes for the
year prior to the start of the integrated treatment program could be
compared to outcomes for the first year of the program’s
operation. Selected outcomes were chosen largely because these
pieces of information were readily available in client charts and the
Management Outcomes database. An outcome related to reduction in
substance use was not chosen because Places for People does not put
initial emphasis on this outcome. The harm reduction approach
that Places for People uses makes improvement in housing status and
GAF, plus reduction in arrests and hospitalizations, more important
than reduction in overall use of substances.
Data for this study were analyzed using SPSS
9.0 for Windows. In analyzing the outcomes data, paired-samples
t-tests were performed.
Approval from the Health Sciences Institutional
Review Board of the University of Missouri-Columbia was granted on
September 15, 2003. A waiver of HIPAA authorizations was granted
on July 15, 2003. This protocol was found to be of minimal risk
to the research subjects. The author of this paper is employed by
Places for People but works in its residential program rather than in
the integrated treatment program.
Results
The following demographic information was collected about the 31
clients in the sample: age, gender, and ethnicity. The
results are as follows:Age
• The oldest client in the
sample was 56 years old.
• The youngest client was 30
years old.
• The average age was 42
years.
• The standard deviation was
6.94.
The Fiscal Year 2002 management report of
Places for People states that the average age of its clients is 47,
with an age range of 20 to 83 (Places for People, 2002). Clients
in dual diagnosis treatment were somewhat younger than the clients of
the agency in general.
Gender
•
24 clients were male. (70.8%)
• 7 clients were female.
(29.2%)
• Males outnumbered females
by more than 3 to 1.
Places for People as a whole had 45.7% female
African-American and European-American clients and 53.5% male
African-American and European-American clients in fiscal year 2002
(Places for People, 2002).
Ethnicity
•
18 clients were African-American. (58.1%)
• 13 clients were
European-American. (41.9%)
This reflects a higher percentage of
African-American clients than in the agency as a whole. According
to the Fiscal Year 2002 management report of Places for People, 42.9%
of the agency’s clients were African-American, and 56.4% were
European-American (Places for People, 2002).
Outcome MeasuresSummary of Outcome
Measures
The tables below provide a summary of
information regarding the six outcome measures. Measures that
represent a point in time are in Table 1, and measures that tallied
occurrences over a period of time are in Table 2.
|
Outcome |
Mean, 11/01 |
Standard Deviation, 11/01 |
Mean, 11/02 |
Standard Deviation, 11/02 |
p value |
|
Global Assessment of Functioning |
41.06 |
7.34 |
43.71 |
6.30 |
.048 |
|
Housing |
.23 (23% of the sample was homeless in 11/01)
|
n/a |
.00 (No clients in the sample were homeless in
11/02) |
n/a |
.006 |
|
Outcome |
Mean, 11/00-10/01 |
Standard Deviation, 11/00-10/01 |
Mean, 11/01-10/02 |
Standard Deviation, 11/01-10/02 |
p value |
|
Psychiatric admissions |
.81 |
1.60 |
2.06 |
5.18 |
.166 |
|
Substance abuse/dual admissions |
2.16 |
.3.09 |
.71 |
1.07 |
.011 |
|
Medical admissions |
.32 |
1.45 |
.01 |
.40 |
.415 |
|
Arrests |
.29 |
.59 |
.29 |
.82 |
1.000 |
Global
Assessment of Functioning
Global Assessment of Functioning scores were
examined twice, once in November, 2001, when the integrated treatment
program began; and again in November, 2002, after the program had been
operational for a year.
It was found that the difference in GAF scores
from November 2001 to November 2002 was statistically significant
(p=0.048). The range for both time periods was 25, with the
highest score being 55 and the lowest 30. The highest and lowest
scores did not change, but those in the middle of the range were
slightly higher. It is interesting to note that the average GAF
score during both periods represented a level of functioning so
impaired as to necessitate inpatient treatment in many cases
(Dziegielewski, 2002). This sample did experience quite a few
psychiatric and dual-diagnosis hospitalizations, but it is surprising,
perhaps, that there were not more.
Housing Status
Housing status for the 31 clients in the sample was compared from
November, 2001 to November, 2002. Clients were divided into two
groups: those who were homeless or living in a hotel; and those
who were living independently, with family/friends, or in a residential
care facility. Seven
clients were homeless or living in a hotel in 11/01.
• There were no clients in
11/02 who were homeless or living in a hotel.
• This difference is
statistically significant (p=.006).
Psychiatric Admissions
Inpatient admissions were tallied for the twelve months
before the integrated treatment program began, and for the twelve
months after the program’s inception. The mean number of
psychiatric hospitalizations per client for the period of 11/00 to
10/01 was 0.81. The mean for the period of 11/01 to 10/02 was
2.06 hospitalizations per client.
This is a startling increase from one year to
the next; however, it is not statistically significant (p=0.166).
Part of the increase from one year to the next can be attributed to one
particular client who had 27 psychiatric inpatient admissions from
11/01-10/02. The largest number of psychiatric hospitalizations
that any one client had in the previous time period was eight.
Substance
Abuse/Dual Hospitalizations
Substance abuse and dual hospitalizations were
counted for the same time period as psychiatric hospitalizations:
November 2000 to October 2001; and November 2001 to October 2002.
The mean number of hospitalizations during the first time period was
2.16 per client; during the second time period, this number had
decreased to 0.71. The decrease in substance abuse/dual inpatient
hospitalizations from one year to the next was found to be
statistically significant (p=.011). Broderick (personal
communication, December 20, 2003) has commented that substance
abuse/dual hospitalizations may have decreased because clients were no
longer needing to escape their situation or hide from someone to whom
they owed money.
Medical Hospitalizations
Inpatient medical admissions were also counted for the year before the
integrated treatment began and for the first year of the program’s
operation. There were very few medical hospitalizations among the
31 clients, making data analysis difficult. The total number of
medical admissions from 11/00-10/01 was ten; from 11/01-10/02, the
number was three. Analysis of the data showed that although there
was a decrease in medical admissions, the difference was not
statistically significant (p=.415).
Arrests
Data on arrests were collected from November
2000 to October 2001 and from November 2001 to October 2002.
There were a small number of occurrences of arrests during both time
periods.
•
Seven clients were arrested from 11/00-10/01 for a total of nine
arrests.
• Five clients were arrested
from 11/01-10/02 for a total of ten arrests.
• This difference is not
statistically significant (p=1.000).
• The standard deviation for
the first time period was 0.59; for the second period it was .82.
Discussion
Summary
A review of the literature on dual diagnosis
treatment shows that integrated treatment programs are favored over
parallel and sequential treatment modalities (Drake, Mercer-McFadden,
et. al., 1998). The Places for People program contains several
elements of programs that have been shown to be successful (Mueser, et.
al., 2003). These include intensive case management, outpatient
group interventions, and social support.
This project revealed that participation in
Places for People, Inc.’s integrated treatment program is associated
with several changes in client outcomes. Global Assessment of
Functioning scores increased significantly, as was hypothesized.
Housing status improved significantly, as none of the 31 participants
were homeless or in a hotel at the end of the program’s first
year. And, opposite of what was hypothesized, substance
abuse/dual diagnosis hospitalizations decreased significantly.
There were several outcomes that were not
associated with significant change. Psychiatric hospitalizations
increased from the year before the program’s genesis to the first year
of its implementation. The arrest rate stayed the same from one
year to the next, and though medical hospitalizations decreased from
one period to the next, the difference was not significant.
Conclusions
The Places for People integrated treatment
program appears to be associated with some positive changes for its
participants. The program participants show a great deal of
affection toward the Integrated Treatment Specialist, and according to
the Integrated Treatment Specialist, the clients find their
participation enjoyable and beneficial (A. J. Nave, personal
communication, December 30, 2003). Though it cannot be said that
the integrated treatment program caused these positive changes, the
association is important. As change in dually-diagnosed clients
must be measured in years rather than months or days, the program
should continue, striving to increase its fidelity with the
evidence-based integrated treatment model, and collecting more and
better outcome and demographic data (Mueser, et. al., 2003).
The Places for People integrated treatment
program has made a promising beginning. More rigorous data
collection, continued collaboration with other community organizations,
and continued emphasis on harm reduction should help the program
continue to grow and help more individuals with co-occurring disorders.
References
American
Psychiatric Association (2000). Diagnostic and statistical manual
of mental disorders (4th ed., text rev.) Washington, DC: American
Psychiatric Press.
DiClemente,
C. (2003). Addiction and change: How addictions develop and
addicted people recover. New York: The Guilford Press.
Drake, R. E., McHugo, G. J., Clark, R.
E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. (1998).
Assertive community treatment for patients with co-occurring severe
mental illness and substance use disorder: A clinical
trial. American Journal of Orthopsychiatry, 68(2), 201-215.
Drake, R. E., Mercer-McFadden, C.,
Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of
integrated mental health and substance abuse treatment for patients
with dual disorders. Schizophrenia Bulletin, 24(4), 589-608.
Drake, R. E., Mueser, K. T., Clark, R.
E., & Wallach, M. A. (1996). The course, treatment, and
outcome of substance disorder in persons with severe mental
illness. American Journal of Orthopsychiatry, 66(1), 42-51.
Drake, R. E., & Wallach, M. A.
(1989). Substance abuse among the chronically mentally ill.
(1989, October). Hospital and Community Psychiatry, 40(10),
1041-1046.
Dziegielewski, S. F. (2002).
DSM-IV-TR in action. New York: John Wiley & Sons, Inc.
Marlatt, G. A. (1998). Basic
principles and strategies of harm reduction. In G. A. Marlatt,
ed., Harm reduction: Pragmatic strategies for managing high risk
behaviors. New York: The Guilford Press.
Miller, W. R., & Rollnick, S.
(2002). Motivational interviewing (2nd ed.): Preparing
people for change. New York: The Guilford Press.
Mueser, K. T., Noordsy, D. L., Drake, R.
E., & Fox, L. (2003). Integrated treatment for dual
disorders: A guide to effective practice. New York: The
Guilford Press.
National Mental Health Association
(2003). Substance abuse—Dual diagnosis fact sheet.
Retrieved December 28, 2003 from
http://www.nmha.org/infoctr/factsheets/03.cfm
Places for People, Inc. (2002).
FY02 management report. St. Louis: Places for People, Inc.
Places for People, Inc. (2003).
About Places for People: History. Retrieved January 6, 2004
from http://www.placesforpeople.org/history.htm
Places for People, Inc. (2003).
Welcome to Places for People: A message from the executive
director. Retrieved January 6, 2004 from
http://www.placesforpeople.org/
Ridgely, M. S., & Jerrell, J. M.
(1996, December). Analysis of three interventions for substance
abuse treatment of severely mentally ill people. Community Mental
Health Journal, 32(6), 561-572.
Substance Abuse and Mental Health
Services Administration (2002). Report to Congress on the
prevention and treatment of co-occurring substance abuse disorders and
mental disorders. Retrieved December 21, 2002 from
http://www.samhsa.gov/reports/congress2002/
