Substance use is common in people who have severe mental health problems. This combination not only aggravates mental health but is associated with higher rates of homelessness and poorer physical health. All of which substantially shorten the lives of this client group. We still lack even the most basic information about dual diagnosis such as how many people are affected and what type of intervention works (Munafo, 2013).

Treatment can be fragmented for this group with mental health services refusing to treat an individual until they are drug free. Likewise substance use services can be reluctant to treat any drug problem until the person’s mental health has improved. This catch-22 continues to frustrate not only the clients but workers who feel that integrating mental health and substance use would be most effective.

But here’s the rub, despite intuitively feeling integrated care is the best option, the evidence to date doesn’t support its effectiveness.

So when a study is published exploring integrated care over a long time period for people with a dual diagnosis, it’s a must read.

Methods

This prospective study was led by Robert Drake who along with colleagues at Dartmouth (USA) have for decades led the way on dual diagnosis research (Drake 2016). The research group were keen to find out if the improvement they found in a previous study for clients with a dual diagnosis from a rural setting, would also be found for clients in an urban setting.

This was a naturalistic study following a three year randomised controlled trial comparing standard case management to a more intensive assertive outreach approach.

• 150 adults with schizophrenia and substance use disorder
• Participants were all from an urban setting in the USA
• All participants received integrated care for at least the first 3 years of the study
• Integrated care consisted of community assertive outreach delivered with small caseloads
• All assessed at baseline then annually for 7 years
• 6 clinical and functional outcomes measured

Results

The initial 3 year trial showed no difference in outcomes between the two groups.

The most common combination of problems was schizophrenia and alcohol or cannabis or cocaine.

Over 7 years, 6 clinical and functional outcomes were measured:

1. Symptoms
2. Substance use
3. Employment
4. Independent living
5. Life satisfaction
6. Social functioning

By year 7, all outcomes improved apart from social functioning. The rate at which individuals improved varied, with some fluctuating and others incrementally improving.

Conclusions

There is hope for this client group that recovery is possible, with the right treatment combination delivered over a long period of time. Specifically, people with co-occurring schizophrenia and substance use can be engaged and offered interventions that not only improve their mental health but reduce substance use. Most importantly, these people report significant improvement in quality of life.

Strengths and limitations

• The long-term (7 year) follow up period of this trial is a major strength
• However, 48 of the enrolled 198 participants did not consent to the 4 year follow up. No details are provided about these 48 people
• 106 (70.7%) completed at least one interview in the follow up period (4-7 years)
• Attrition bias may have affected the findings
• Connecticut is a relatively wealthy state which invests in services, the findings may not be replicated in less well of states or areas

Summary

This study offers useful intelligence to workers and hope to clients that recovery and change are possible. Sadly what this study also highlights is that change takes time. This is at odds with the way research funding is usually granted, typically for a short period of time. At the same time, clinicians are increasingly having to demonstrate effectiveness through a culture of contrived non-evidence based targets which are also time limited.

Both factors seem at odds with this new evidence for people with a dual diagnosis, which shows a persistent, assertive and long term view is what is needed. At a time when assertive outreach teams in mental health are being dismantled and substance use services are commissioned for 3 years at a time, we need to rethink how our current approach to treatment is at complete odds with the evidence.

Links

Primary paper

Drake RE, Luciano AE, Mueser KT, Covell NH, Essock SM, Xie H, McHugo GJ. (2015) Longitudinal Course of Clients With Co-occurring Schizophrenia-Spectrum and Substance Use Disorders in Urban Mental Health Centers: A 7-Year Prospective Study Schizophr Bull (2016) 42 (1): 202-211 first published online August 19, 2015 doi:10.1093/schbul/sbv110 [PubMed abstract]

Other references

Munafo M. (2013) Cochrane review finds no clear evidence for psychosocial interventions to help people with both severe mental illness and substance use. The Mental Elf, 19 November 2013.

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