Community Mental Health Journal

, Volume 42, Issue 4, pp 377–404 | Cite as

Treating Homeless Clients with Severe Mental Illness and Substance Use Disorders: Costs and Outcomes

  • Gary A. Morse
  • Robert J. Calsyn
  • W. Dean Klinkenberg
  • Thomas W. Helminiak
  • Nancy Wolff
  • Robert E. Drake
  • Robert D. Yonker
  • Gyanesh Lama
  • Matthew R. Lemming
  • Suzanne McCudden
Article

ABSTRACT

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.

KEY WORDS

dual disorder integrated treatment assertive community treatment costs 

References

  1. American Psychiatric Association (2000). Diagnostic and statistical manual for mental disorders (DSM-IV-IR). Washington, D.C., American Psychiatric AssociationGoogle Scholar
  2. Bartels S. J., Teague G. B., Drake R. E., Clark R. E., Bush P., Noordsy D. L. (1993). Service utilization and costs associated with substance abuse among rural schizophrenic patients. Journal of Nervous and Mental Disease 181: 227–232PubMedCrossRefGoogle Scholar
  3. Bassuk E.L. (2003). Supportive housing for homeless families: Setting a research and evaluation agenda. Presentation to the Bill & Melinda Gates Foundation, Seattle, WAGoogle Scholar
  4. Bond G. R., Drake R. E., Mueser K. T., Latimer E. (2001). Assertive community treatment for people with severe mental illness – Critical ingredients and impact on patients. Disease Management & Health Outcomes 9: 141–159CrossRefGoogle Scholar
  5. Brunette M., Drake R. E., Lynde D. W. (eds) (2002). Integrated dual disorders treatment implementation resource kit. Rockville, MD, Center for Mental Health Services Substance Abuse and Mental Health Services AdministrationGoogle Scholar
  6. Brunette M. F., Drake R. E., Woods M., Hartnett T. (2001). A comparison of long-term and short-term residential treatment programs for dual diagnosis patients. Psychiatric Services 52: 526–528PubMedCrossRefGoogle Scholar
  7. Brunette M. F., Mueser K. T., Drake R. E. (2004). A review of research on residential problems for people with severe mental illness and co-occurring substance use disorders. Drug and Alcohol Review 23: 471–481PubMedCrossRefGoogle Scholar
  8. Carey K. B., Coco K., Simons J. (1996). Concurrent validity of clinicians’ ratings of substance abuse among psychiatric outpatients. Psychiatric Services 47: 842–847PubMedGoogle Scholar
  9. Clark R. E., Teague G. B., Ricketts S. K., Bush P. W., Xie H., McGuire T. G., et al. (1998). Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders. Health Services Research 33: 1285–1308PubMedGoogle Scholar
  10. Culhane P. P., Metraux S., Hadley T. (2002). Public denies reductions associated with placement of homeless persons with severe mental illness in supporting housing. Housing Policy Debate 13: 107–163Google Scholar
  11. Dickey B., Azeni H. (1996). Persons with dual diagnosis of substance abuse and major mental illness: Their excess costs of psychiatric care. American Journal of Public Health 86: 973–977PubMedGoogle Scholar
  12. Drake R. E., Essock S. M., Shaner A., Carey K. B., Minkoff K., Kola L., et al. (2001a). Implementing dual diagnoses services for clients with severe mental illness. Psychiatric Services 52: 469–476CrossRefGoogle Scholar
  13. Drake R. E., Goldmann H. H., Leff H. S., Lehman A. F., Dixon L., Mueser K. T., et al. (2001b). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services 52: 179–182CrossRefGoogle Scholar
  14. Drake R. E., McHugo G. J., Clark R. E., Teague G. B., Xie H., Miles K., Ackerson T. H. (1998a). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry 68: 201–215CrossRefGoogle Scholar
  15. Drake R. E., Mercer-McFadden C., Mueser K. T., McHugo G. J., Bond G. R. (1998b). A review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin 24: 589–608Google Scholar
  16. Drake R. E., Mueser K. T., Brunette M. F., McHugo G. J. (2004). A review of treatments for people with severe mental illness and co-occurring substance use disorders. Psychiatric Rehabilitation Journal 27: 360–374PubMedCrossRefGoogle Scholar
  17. Drake R. E., Osher F. C., Wallach M. A. (1989). Alcohol use and abuse in schizophrenia: A prospective community study. Journal of Nervous and mental Disease 177: 408–414PubMedCrossRefGoogle Scholar
  18. Drake R. E., Yovetich N. A., Bebout R. R., Harris M., McHugo G. J. (1997). Integrated treatment for dually diagnosed homeless adults. Journal of Nervous and Mental Disease 185: 298–305PubMedCrossRefGoogle Scholar
  19. Erdfedler E., Faul F., Buchner A. (1996). G*Power. A general power analysis program. Behavior Research Methods, Instruments and Computers 29: 1–11Google Scholar
  20. Essock S. M., Frisman L. K., Kontos N. J. (1998). Cost-effectiveness of assertive community treatment teams. American Journal of Orthopsychiatry 68: 179–190PubMedCrossRefGoogle Scholar
  21. First M. B., Gibbon M., Spitzer R. L., Williams J. B. W. (1996). User’s guide for the structured clinical interview for DSM-IV Axis I disorders (research version 2.0). New York, American Psychiatric Publishing IncGoogle Scholar
  22. Holloway F., Carson J. (1998). Intensive case management for the severe mentally ill: Controlled trial. British Journal of Psychiatry 172: 19–22PubMedGoogle Scholar
  23. Jerrell J. M. (1996). Cost-effective treatment for persons with dual disorders. New Directions for Mental Health Services 70: 79–91PubMedCrossRefGoogle Scholar
  24. Lehman A. F., Dixon L., Hoch J. S., DeForge B., Kernan E., Frank R. (1999). Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. British Journal Psychiatry 174: 346–352CrossRefGoogle Scholar
  25. Lukoff D., Nuechterlein K. H., Ventura J. (1986). Manual for the expanded brief psychiatric rating scale. Schizophrenia Bulletin 2: 594–602Google Scholar
  26. McHugo, G.J., Drake, R.E., Burton, H.L., & Ackerson, T.H. (1995). A scale for assessing the stage of substance abuse treatment in persons with severe mental illness. Journal of Nervous and Mental Disease, 183, 762–767.PubMedCrossRefGoogle Scholar
  27. McHugo G. J., Drake R. E., Teague G. B., Xie H. (1999). Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services 50: 818–824PubMedGoogle Scholar
  28. Meisler N., Blankertz L., Santos A. B., McKay C. (1997). Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Mental Health Journal 33: 113–122PubMedCrossRefGoogle Scholar
  29. Morse, G. (1998). A review of case management for people who are homeless: Implications for practice policy and research. In L.B. Fosburg & D.O. Dennis (Eds.), Practical lessons: The 1998 National symposium on homeless research. U.S. Department of Housing and Urban Development/U.S. Department of Health and Human Services.Google Scholar
  30. Mueser K., Bond G. R., Drake R. E., Resnick S.G. (1998). Models of community care for severe mental illness. A review of research on use management. Schizophrenic Bulletin 24: 37–74Google Scholar
  31. Mueser K. T., Noordsy D. L., Drake R. E., Fox L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, Guildford PublicationsGoogle Scholar
  32. Phillips S. D., Burns B. J., Edgar E. R., Mueser K. T., Linkins K. W., Rosenheck R. A., Drake R. E., McDonel Herr E. C. (2001). Moving ACT into standard practice. Psychiatric Services 52(6): 771–779PubMedCrossRefGoogle Scholar
  33. President’s New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America. SAMHSA SMA 03-3832Google Scholar
  34. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. J., Goodwin F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. Journal of American Medical Association 264: 2511–2518CrossRefGoogle Scholar
  35. Smith J. E., Meyers R. J. (1995). Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed). Needham Heights, Allyn & BaconGoogle Scholar
  36. Sobell M. B., Maiston S. A., Sobell L. C. (1980). Developing a prototype for evaluating alcohol treatment effectiveness. In: Sobell L. C., Sobell M. B., Ward E. (eds) Evaluating alcohol and drug abuse treatment effectiveness. New York, PergamonGoogle Scholar
  37. Teague G. B., Bond G. R., Drake R. E. (1998). Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry 68: 216–232PubMedCrossRefGoogle Scholar
  38. Test M. A., Wallisch L. S., Allness D. J., Ripp K. (1989). Substance use in young adults with schizophrenic disorders. Schizophrenia Bulletin 15: 465–476PubMedGoogle Scholar
  39. UK 700 Group (1999). Intensive versus standard case management for severe psychotic illness: A randomized trial. Lancet 353:2185–2189CrossRefGoogle Scholar
  40. Weisbrod B. A. (1983). A guide to benefit-cost analysis, as seen through a controlled experiment in treating the mentally ill. Journal of Health Politics, Policy and Law 7: 808–845PubMedCrossRefGoogle Scholar
  41. Winter J.P., Calsyn R.J. (2000). The Dartmouth Assertive Community Treatment Scale (DACTS): A generalizability study. Evaluation Review 24: 319–388PubMedCrossRefGoogle Scholar
  42. Wolff N., Helminiak T. W., Diamond R. J. (1995). Estimated societal costs of assertive community mental health care. Psychiatric Services 46: 898–906PubMedGoogle Scholar
  43. Wolff N., Helminiak T. W., Morse G. A., Calsyn R. J., Klinkenberg W. D., Trusty M. L. (1997). Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. American Journal of Psychiatry 154: 341–348PubMedGoogle Scholar
  44. Wolff N., Helminiak T. W., Tebes J. (1997). Getting the cost right in cost-effectiveness analyses. American Journal of Psychiatry 154: 736–743PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Gary A. Morse
    • 1
  • Robert J. Calsyn
    • 2
  • W. Dean Klinkenberg
    • 4
  • Thomas W. Helminiak
    • 2
  • Nancy Wolff
    • 5
  • Robert E. Drake
    • 6
  • Robert D. Yonker
    • 3
  • Gyanesh Lama
    • 4
  • Matthew R. Lemming
    • 2
  • Suzanne McCudden
    • 4
  1. 1.Community AlternativesSt. LouisUSA
  2. 2.University of Missouri-St. LouisSt. LouisUSA
  3. 3.University of ToledoToledoUSA
  4. 4.Missouri Institute of Mental HealthSt. LouisUSA
  5. 5.Rutgers UniversityNew BrunswickUSA
  6. 6.Dartmouth Medical SchoolHanoverUSA

Personalised recommendations