THE NEW HAMPSHIRE DUAL DISORDERS STUDY

This study compared the effects of two different case management methods for providing integrated treatment to clients with dual disorders: intensive case management teams based on the Assertive Community Treatment model (Stein and Test 1985) with clinician caseload ratios of 1 to 10 versus regular case management teams with ratios of 1 to 30. Both models included outreach, team orientation, integrated dual-diagnosis treatment, a longitudinal approach, and supportive housing. A total of 240 clients were recruited into the study, with followup data available for 215. At entry to the study all clients met criteria for major mental illness (schizophrenia, schizoaffective disorder, or bipolar disorder) plus recent substance use disorder (within the past 6 months). Clients were randomly assigned to one of the two integrated treatment programs in which they received treatment and were routinely assessed over 3 years. The characteristics of the sample are summarized in table 2. A comprehensive array of assessments was conducted at regular intervals of clients in both programs, including substance use behavior, symptoms, quality of life, and service utilization. The results of selected outcome measures are presented here. Alcohol and drug use disorders were rated by research staff using clinician rating scales (Drake et al. 1990) in which a 1 corresponds to no substance use, 2 refers to substance use but not abuse, 3 is substance abuse, and 4 and 5 are substance dependence.

TABLE 2. Demographic and diagnostic characteristics of patients.

Characteristic Age

Mean 35.6 Numbe r

(SD) (8.5) (%)

Sex Male Female

(75) (25)

Race White Black Native American Asian Hispanic

(95) (2) (2) (0.5) (0.5)

Marital status Never married Married Separated Divorced Widowed

(63) (7) (4) (25) (1)

Employment status Unemployed Sheltered employment Competitive employment Psychiatric diagnosis Schizophrenia Schizoaffective Bipolar Delusional disorder Current substance use disorder Alcohol abuse/dependence Drug abuse/dependence Alcohol and drug abuse/dependence Alcohol or drug abuse/dependence in remission

98

(85) (8) (7) (50) (23) (24) (3) (45) (13) (27) (15)

Stage of treatment was rated with the Stage of Treatment Scale (McHugo et al. 1995). For this scale, 1 and 2 correspond to the engagement phase, 3 and 4 are the persuasion phase, 5 and 6 are the active treatment phase, and 7 and 8 are the relapse prevention phase. Days of drug use and days of drinking to intoxication in the past 6 months were assessed using the timeline followback method (Sobell et al. 1988). Global adaptive functioning was assessed with the Global Adjustment Scale (GAS) (Endicott et al. 1976), which ranges between 0 and 100 with higher numbers indicating better functioning. Symptoms were rated using the expanded version of the Brief Psychiatric Rating Scale (Lukoff et al. 1986). For the data presented here, the number of symptoms rated greater than 4 (moderate severity) was summed to form an overall index of symptom severity. Overall life functioning (OLF) was rated on a 5-point scale (1 to 5) developed for the project, and the OLF ratings were based on changes from baseline in living situation (e.g., time in the hospital, jail, homeless), symptom severity, participation in activities in the community (e.g., school or work), and social contacts (e.g., visits or telephone calls with family members or friends). Each client began with a 3 rating at baseline, with lower ratings at subsequent assessments reflecting a worsening in OLF and higher ratings reflecting improvements in OLF. Satisfactory levels of interrater reliability were established for all measures. Preliminary analyses indicate that both programs were effective in ameliorating or decreasing substance abuse and in improving other outcomes, and the differences between the two programs are currently being examined. The changes in the outcome measures described above and days in the hospital during the 3 years are depicted in figures 1 and 2 for the combined treatment groups, including clients who dropped out of treatment but were followed for 3 years. Inspection of the figures suggests that the integrated treatments resulted in significant reductions in hospitalization in the first year of the study and that global improvements were evident throughout the 3 years in both substance abuse and other areas of functioning. As evident from the Stage of Treatment Scale, most of the clients moved steadily through motivational stages of treatment. In fact, by the end of the 3-year followup, approximately half of the clients had attained some degree of abstinence, a substantially higher proportion than would be expected from studies of

the natural course of dually disordered clients (Bartels et al. 1995). These generally very positive results, while preliminary, provide additional support for the beneficial effects of integrating substance abuse and mental health treatments for the population of severely ill psychiatric clients.