INTEGRATED TREATMENT

By the late 1980's it had become increasingly clear that the traditional approach of treating dually diagnosed clients through separate mental health and substance abuse service systems was inadequate for persons with severe psychiatric disorders. A wide range of problems occurred with the parallel and sequential approach to treating comorbid psychiatric and substance use disorders (Minkoff and Drake 1991; Polcin 1992; Ridgely et al. 1987, 1990). For example, parallel treatment approaches tended to breed mistrust between those professionals whose primary focus was on mental illness and those working mainly with substance use disorders, with comorbid clients falling between the cracks of the system (Sellman 1989). Furthermore, because professionals were unaware of how to combine psychiatric and substance abuse services effectively, the burden of integrating the disparate messages of the two systems fell entirely on clients, who were ill-equipped to handle such a task. Finally, a wealth of evidence documents that traditional methods for treating primary substance use disorders are ineffective at meeting the needs of clients with heterogeneous psychiatric disorders (Baekeland et al. 1973; LaPorte et al. 1981; McLellan et al. 1983; Rounsaville et al. 1987; Woody et al. 1990). Thus, the poor outcome of these clients appears to stem from barriers within the traditional service system in which mental health and substance abuse services have separate and parallel programs, staff training, models of treatment and recovery, and funding streams (Ridgely et al. 1990).

In light of the poor outcome for dually diagnosed persons treated in parallel or sequential treatment systems, programs serving the severely mentally ill have moved towards integrating substance abuse and mental health treatment into comprehensive programs (Carey 1989; Drake et al. 1993c; Nikkel and Coiner 1991; Minkoff 1989; Ziedonis and Fisher 1994). Several different integrated treatment models have been developed (reviewed in Lehman and Dixon 1995; Minkoff and Drake 1991), and, despite differences across programs, all integrated treatment approaches share some common principles. At the most basic level, integrated treatment means that both mental health and substance abuse treatments are simultaneously (not sequentially) provided by the same person, team, or organization. In addition, most models include case management, group interventions (e.g., persuasion groups, social skills training), assertive outreach to engage people in treatment and to address pressing social or clinical needs, education about substance abuse and mental illness, focus on the motivational aspect of treatment (e.g., persuading clients to address alcohol- or drug abuse-related issues by identifying personal goals that are incompatible with continued substance use), and endorsement of a long-term perspective (rather than time-limited treatment). Furthermore, many, but not all, approaches utilize behavioral strategies for helping clients cope with urges to use substances and resist social overtures to use drugs or alcohol, work closely with patients' families and other members of their social network, and employ "stage-wise" treatment to ensure optimal timing of clinical interventions. For example, the New Hampshire integrated treatment model (Drake et al. 1993c) posits that recovery from substance use disorders progresses through four different stages, each with different goals and interventions: engagement (establishing a therapeutic relationship with the patient), persuasion (motivating the patient to address substance abuse), active treatment (working directly to reduce substance use behavior), and relapse prevention (developing strategies to reduce vulnerability to relapses). Table 1 summarizes the common ingredients of many integrated treatment programs and the function of each ingredient.

substance use disorders and schizophrenia who participated in a weekly outpatient group had decreased hospital use over 1 year compared to such use before treatment. Kofoed and associates (1986) treated 32 dually diagnosed clients in outpatient groups with a focus on substance abuse. The 21 clients who continued to abuse drugs or alcohol dropped out of treatment, whereas the 11 clients who remained in the program for at least 1 year reduced their substance use and had lower rates of hospital utilization. Ries and Elingson (1989) found that 12 of 17 dual-diagnosed clients who attended integrated treatment groups as inpatients reported they were abstinent 1 month after discharge. Bond (1989) reported that 56 severely mentally ill persons with cooccurring substance abuse had decreased hospital use during 1 year of intensive case management that addressed both substance abuse and mental health issues. More recently, Durell and colleagues (1993) reported on the outcomes of 84 severely mentally ill clients, of whom 43 (51 percent) were also substance abusers, followed in intensive case management for at least 18 months. For all clients, 76 percent showed increased community tenure and increased use of formal and informal community resources, and two-thirds of the dually diagnosed clients had reduced substance abuse at followup. A significant step forward occurred with the Community Support Program (CSP) demonstration project. This project involved 13 exploratory studies funded by the National Institute of Mental Health that were conducted between 1987 and 1990. These programs targeted several high-risk groups with dual disorders, including innercity residents, minorities, women with children, and migrant farmworkers. The studies were limited by the relatively brief followup period (12 to 18 months) and the fact that only two programs had control groups (Bond et al. 1991; Lehman et al. 1993a). The outcomes from the 13 projects were recently reviewed by MercerMcFadden and Drake (1995). The general findings can be summarized as follows: (1) all programs were successful in engaging clients in outpatient dual-diagnosis services; (2) engagement in outpatient-based services generally led to decreased utilization of inpatient and institutional services; and (3) there was minimal reduction in substance abuse over 1 year, although the interpretation of results was complicated by measurement difficulties (e.g., failure to employ instruments sufficiently sensitive to changes in substance use in the mentally ill population). Despite the limitations of these pilot studies, they provide initial encouragement and support for the notion

that integrated mental health and substance abuse services are required for clients with dual disorders. Jerrell and Ridgely (1995) have recently reported results similar to those found in the CSP demonstration projects. They followed 147 dually diagnosed clients receiving one of three forms of integrated treatment (case management, cognitive-behavior therapy, or a modified 12-step approach) over a 12- to 18-month period. Interviewer ratings indicated modest improvements in the areas of work, independent living, immediate and extended social relationships, self-reported satisfaction with work and family relationships, and psychiatric symptoms. Other areas of social adjustment did not change (e.g., work or family adjustment), and neither did the overall rate of alcohol symptoms, alcohol use, or drug use. Furthermore, there was no change in number of days hospitalized, although there was a decrease in emergency visits that accompanied an increase in medication and outpatient visits. The potential benefits of integrated treatment are also supported by a study in Washington, D.C., that was recently completed by the New Hampshire-Dartmouth Psychiatric Research Center (Drake et al. 1993d). In this study, 172 homeless persons with major mental illness plus substance disorder were randomly assigned to one of two forms of intensive case management: cognitive-behavioral case management, which focused on training skills that would enable clients to cope with urges to use substances and skills for resisting use in social situations, or social network case management, which focused on working with clients' social networks to enhance their ability to support abstinence as a therapeutic goal for the client. A matched comparison group of 67 homeless dually diagnosed persons received usual community services. Both experimental groups showed positive results in terms of decreased hospitalizations and homelessness, increased stable community housing, and decreased substance abuse over 18 months. Results favored the experimental groups over the matched comparison group, but marked differences did not appear to distinguish the two experimental groups (Drake et al., under review). A common limitation of much of the research on integrated treatment has been relatively brief followup periods (i.e., 18 months or less). One descriptive study found benefits for integrated treatment when it was provided over a significantly longer time interval (Drake et al. 1993e). Eighteen persons with schizophrenia and alcoholism received integrated treatment over 4 years in a program that included case management and dual-diagnosis groups. By the end of the followup

period, 11 clients (61 percent) had achieved stable abstinence (i.e., had not abused for 6 months). These results underscore the importance of providing integrated treatments that extend over relatively long periods of time (e.g., Durrell et al. 1993). Despite the lack of controlled studies, the weight of the evidence on the effects of integrated treatment from some 30 studies is overwhelmingly positive (Drake et al., in press). However, there is still a need for systematic, longer-term studies to quantify the effects of integrated treatments provided over several years. The preliminary results of one such study conducted by the New HampshireDartmouth Psychiatric Research Center are described below.