Gaining insight: who benefits from residential, integrated treatment for people with dual diagnoses?

Integrated Residential Treatment for Persons with Severe and Persistent Mental Illness: Lessons in Recovery

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Stability of Outcomes Following Residential Drug Treatment For Patients with Co-occurring Disorders

OBJECTIVE: Few studies have examined the stability of both substance use and mental health outcomes following residential drug abuse treatment for individuals with co-occurring disorders (COD). This study examines outcomes at 6 and 12 months for individuals with COD, in relationship to services received over the follow-up period. METHODS: Participants with COD (N=310) were sampled from 11 residential drug abuse treatment programs and completed in-depth assessments within 30 days of intake and at 6- and 12-month follow-ups. A path model was developed testing the relationships among treatment participation and services received, psychological status, and substance use outcomes across the two follow-up points. RESULTS: Retention for at least 90 days in residential drug treatment was associated with less inpatient mental health treatment and more mental health services received at 6 months; outpatient mental health treatment was associated with reduced substance use at 6 months. Substance use at 6 months was associated with more psychological distress at both 6 and 12 months and more inpatient mental health treatment at 12 months. CONCLUSIONS: Findings suggest that receipt of mental health services following residential drug abuse treatment for patients with COD is critical to improving their longer-term outcomes.

Housing Preferences among Adults with Dual Diagnoses in Different Stages of Treatment and Housing Types

Housing is an essential component of psychiatric rehabilitation, particularly for consumers with dual diagnoses. Research has not clearly examined why and when consumers prefer different types of housing. This exploratory study examined 1) whether housing preferences differ between stage of treatment for substance abuse, 2) whether consumers who prefer certain housing types have preferences for certain characteristics, and 3) whether consumers living in different types of housing report differences in social support, choice, and housing satisfaction. A total of 103 participants living in supervised housing (n= 65), independent apartment housing (n= 22), single room occupancy hotels (n= 11), and with family (n= 5) completed self-report questionnaires. Results showed that 1) the majority of participants preferred their own apartment or house across different stages of treatment, 2) preference for supervised housing was associated with on-site staff and peer support while preference for apartment housing was associated with autonomy and privacy, and 3) consumers in single room occupancies reported the least choice and lowest satisfaction. These findings contribute to the understanding of consumers' housing preferences and the differences consumers perceive between certain housing types.

Housing preferences and choices among adults with mental illness and substance use disorders: a qualitative study

Housing is a crucial issue for adults with severe mental illness and co-occurring substance use disorders, as this population is particularly susceptible to housing instability and homelessness. We interviewed 40 adults with dual disorders, living in either supervised or independent housing arrangements, to examine housing preferences, decision making processes surrounding housing choices, and perceived barriers to housing. We found that many clients indicated their housing preferences had changed over time, and some clients related housing preferences to recovery. Although the majority of clients preferred independent housing, many also described benefits of supervised housing. Clients' current living situations appeared to be driven primarily by treatment provider recommendations and availability of housing. Common barriers to obtaining desired housing were lack of income and information. These findings have implications for supported housing models and approaches to providing housing for clients.

How reliable is the current evidence looking at the efficacy of harm reduction and motivational interviewing interventions in the treatment of patients with a dual diagnosis?

Current policy from the Department of Health advocates for an integrated approach to treating patients with a dual diagnosis. However, pragmatic and clinically effective brief interventions that can be delivered by nurses across mental health settings remain underdeveloped. Motivational interviewing has had some successful exposure in the field of dual diagnosis; however, harm reduction remains unexplored both conceptually and in terms of clinical intervention. This literature review examines the notion of harm reduction as a method of identifying and reducing the harm associated with the misuse of drugs and alcohol in relation to mental health problems. Currently there is a paucity of good quality evidence for integrated interventions in the treatment of dually diagnosed patients. Therefore, the papers are analysed in respect of their methodological quality and contribution to the evidence base to inform both future research and mental health nursing practice.

Management of substance use disorder in schizophrenia patients: current guidelines

Substance use disorder is the most frequent and clinically significant comorbidity among schizophrenia patients today. All schizophrenia patients should be assessed and monitored carefully regarding their substance use. Those with any regular use of alcohol or other drugs should be considered at risk for multiple adverse effects. As therapies for co-occurring substance use disorders have evolved over the past 20 years, medication management, psychosocial interventions, and rehabilitation models have increasingly emphasized the integration of mental health and substance abuse treatments, attention to group and residential interventions, matching interventions to stage of treatment, comprehensiveness, and long-term perspectives on recovery. Clinicians should understand the implications of each of these principles of care.

Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders

The study examines 1-year treatment outcomes of 216 individuals with co-occurring severe and persistent mental illness and substance use disorders who were assigned to an integrated or parallel treatment condition. Comparisons indicated that the integrated group achieved greater reductions in the incidence of psychiatric hospitalization and arrest. The results of this study support the enhanced effectiveness of integrated treatment in decreasing the use of higher cost crisis-oriented services in clients with severe mental illness and substance use disorders.

Three-year recovery outcomes for long-term patients with co-occurring schizophrenic and substance use disorders

Little is known about the expected treatment outcomes of patients with co-occurring schizophrenic and substance use disorders. This paper reports 3-year outcomes for 152 patients with schizophrenia or schizoaffective disorder and substance use disorders, all of whom received integrated dual disorders treatments in the New Hampshire Dual Diagnosis Study. Outcomes are defined as positive coping behaviors identified by consumers as indicators of recovery. Participants improved steadily in terms of controlling symptoms of schizophrenia, actively attaining remissions from substance abuse, increasing competitive employment, increasing social contacts with non-substance abusers, and improving life satisfaction. Though successful in reducing hospitalization and homelessness, they did not increase time in independent living situations. Outcomes were only weakly interrelated, suggesting that recovery is a multidimensional concept. Neither psychotic diagnosis (schizophrenia vs. schizoaffective disorder) nor substance abuse diagnosis (alcohol vs. other drug disorder vs. both) was related to outcomes. However, these patients with co-occurring schizophrenic and substance use disorders did significantly less well than patients with co-occurring bipolar and substance use disorders in terms of hospitalization, independent living, and quality of life. Overall, the findings provide a hopeful long-term perspective for dual diagnosis patients.

Evolving a model for integrated treatment in a residential setting for people with psychiatric and substance use disorders

This paper discusses the implementation of a residential, integrated treatment program serving dually diagnosed people with histories of homelessness. Attention is focused on the program structure and how the program developed over time. Program modifications tended to relax program rules and embrace a motivational, stage-wise model using harm-reduction principles. Despite initial skepticism regarding these modifications, outcomes such as program retention, abstinence from substances, employment, and hospitalization improved.