Drug And Alcohol Treatment Facilities
Which substance abuse treatment facilities offer dual diagnosis programs?Ramin Mojtabai INTRODUCTION
Substance disorders are commonly associated with mental disorders in both population and clinical samples (1-4). According to one estimate, in any given year about 10 million individual suffer from comorbid substance and mental disorders across the United States (5). There is also some evidence that the course of mental health problems impacts the course of comorbid substance disorder (6,7). Nevertheless, traditionally, treatments for these comorbid conditions have been administered in separate services--a separation that has organizational and financial as well as ideological roots and is often a source of confusion and frustration to many clients and their advocates (8). Furthermore, this separation of services may lead to inefficient use of resources.
There have been attempts in recent years to address this problem by restructuring and integrating services. One such attempt is the implementation of specialized dual diagnosis treatment programs, where, ideally, treatments can be provided in one facility. Currently a large proportion of mental health and substance abuse treatment facilities offer such programs, perhaps indicating the widespread perceived need for integration of services.
Despite the enthusiastic reception of these programs in various settings, empirical evaluations of some of the earlier programs in mental health settings produced equivocal results (9,10). From reviewing this evidence. one may conclude that while integration of services for treating dual diagnosis clients is a desirable goal; it is not sufficient. This conclusion is further supported by the growing recognition of the .special needs of the dual diagnosis clients. Dual diagnosis is associated with increased vulnerability to occupational and housing instability (11-13), victimization (14), and medical complications such as HIV infection (15,16) and hepatitis (17). Meeting the special needs of dual diagnosis clients in these domains requires additional services and, often, intensive case-management--resources that are not available at many substance abuse treatment facilities.
More recent studies of comprehensive dual diagnosis programs in which at least ,some of these special needs of client are met, have produced encouraging results supporting the effectiveness and cost-effectiveness of dual diagnosis treatment programs (10). It is not clear, however, to what extent the dissemination of dual diagnosis programs across various treatment facilities in recent years has been matched by growth of these other needed services.
The present study addresses this question using data from a national survey of substance abuse treatment facilities, the National Survey of Substance Abuse Treatment Services (N-SSATS) (18).
More specifically, this report first examines the geographic distribution and characteristics of facilities that offer dual diagnosis treatment programs or groups and, second, it examines the other services available in these facilities. The emphasis is on services addressing the special needs of dual-diagnosis clients including psychosocial treatments, case management, transitional housing and job services, domestic violence and HIV education, and screening for HIV, hepatitis, and other health risks in this population.
METHOD Sample
The N-SSATS was designed by the Substance Abuse and Mental Health Services Administration (SAMHSA) to collect data on the location, characteristics, and use of alcohol and drug abuse treatment facilities and services throughout the United States (18). Facilities included in the NSSATS were selected from a continuously updated national inventory maintained by SAMHSA--the I-SATS (Inventory of Substance Abuse Treatment Services). The I-SATS provides a comprehensive listing of facilities approved by state substance abuse agencies, the majority of which are required by the state agencies to provide data. It also includes programs operated by federal agencies, the Department of Veterans Affairs. the Department of Defense, and the Indian Health Service. In more recent years, SAMHSA has attempted to extend the range of programs covered in the N-SSATS survey by including programs that are not approved by state substance abuse agencies. Most of these facilities are identified through periodic screening of alternative databases. However, facilities operated by the Bureau of Prisons, those offering only DUI (driving under influence) or DWI (driving while intoxicated) programs, and those treating incarcerated persons only are not included in N-SSATS.
Data Collection
A survey covering information on organizational and funding characteristics as well as services provided was directly mailed to each facility between October 2000 and April 2001. The facilities were instructed to provide all data as of October 1, 2000. The survey was conducted over the phone for facilities that had not returned the mailed survey 10-11 weeks after mailing (22.7% of all facilities). For 94% of facilities in the target list, it was possible to obtain a completed survey either by mail or phone or to determine that the facility had closed or was ineligible for inclusion in the N-SSATS.
Mail survey questionnaires were reviewed for inconsistencies and missing data, and when such inconsistencies or missing data were detected, follow-up telephone interviews were made with the facility director or the director's designee to verify and complete the survey. Automated quality assurance reviews were conducted after data were entered. As a final validity check, the state substance abuse agencies were asked to review and correct the data returned from the facilities.
The survey collected information on various characteristics of the facilities including geographical location, ownership, treatment modalities. and special programs and services offered at each facility, including comprehensive mental health assessment or diagnosis (e.g., psychological or psychiatric evaluation and testing) and various types of counseling. Availability of the dual diagnosis program/group was assessed by one question: "Does this facility offer a substance abuse treatment program or groups specially designed for dually diagnosed clients (mental and substance abuse disorders)."
Data Analysis
The unit of analysis in this study is the facility, defined as a specific physical location where treatment services are provided. Analyses were conducted in two stages. First, geographic distribution and characteristics of the facilities with dual diagnosis programs were examined. Second, mental health, social, and health services offered by facilities with dual diagnosis programs/groups were examined and compared to facilities without such programs. Contingency table analysis with Chi-square tests were used for these analyses.
RESULTS
Overall, 49.9% of all U.S. substance abuse treatment facilities offered dual diagnosis programs/groups. There were considerable variations across states, with Vermont having the highest proportion of facilities offering dual diagnosis programs/groups (70.8%) and Iowa having the lowest proportion (34.1%). In 42 states, between 40% to 59% of the facilities offered such programs. The variations across states did not appear to follow a distinct regional trend (Fig. 1).
[FIGURE 1 OMITTED]
There were considerable variations in availability of dual diagnosis programs according to ownership. State and federally owned facilities, as well as facilities categorized as owned by local/county/community governments were more likely to offer dual diagnosis programs/groups, and facilities owned by tribal governments were least likely to offer such services (Table l). Among federally owned facilities, those run by the Department of Veteran Affairs were most likely to offer dual diagnosis programs/groups and facilities run by the Department of Defense. least likely (Table l). Finally, inpatient substance abuse treatment facilities were most likely to offer such services and residential facilities, least likely (Table l).
Facilities with dual diagnosis programs/groups also varied considerably with regard to other health or social services offered (Table 2). While, overall, more services were available at facilities with dual diagnosis programs/groups compared to facilities without such programs, many facilities with dual diagnosis programs did not offer various mental health, continuity of care, or social/health services (Table 2).
DISCUSSION
It is encouraging to note that dual diagnosis has gained widespread recognition as a special need area and that almost half of all facilities across the country offer specialized programs for these groups of substance-abusing clients. Variations in spread of these programs based on ownership point to administrative and, perhaps, financial factors as important determinants of dissemination of dual diagnosis programs/groups. On the other hand, variations based on modalities of treatment may reflect differences in case-mix and treatment philosophy.
It is also encouraging that the large majority of facilities with dual diagnosis programs/groups offer various forms of counseling or therapy and that these facilities, overall, offer more services than facilities that do not offer dual diagnosis programs/groups. Nevertheless, it is of concern that many of these facilities lack the services required to meet the special needs of dual diagnosis clients; some of which are considered "critical components" of successful dual diagnosis treatment programs (4,10). Overall, 43.4% of facilities with dual diagnosis programs/groups did not offer prescription medications, 37.8% did not offer psychiatric or psychological assessment or diagnostic services, and 26.7% did not offer case management. Only a minority of the facilities with dual diagnosis programs/groups offered any transitional housing or employment assistance, HIV or domestic violence education, or health screening. Lack of these needed services may render dual diagnosis programs less effective.
One of the aims of the dual diagnosis treatment movement was to improve integration across the various services that clients need. As many of the clients in these programs would need to receive medication, treatment, housing and occupational support, case management, and other social services at other institutions, facilities that lack these services may fail to achieve effective integration of the care for these clients. The deficiencies with regard to case management and other continuity of care services are especially of concern since most of these clients would have to navigate a confusing maze of different service providers and organizations and many are at risk of falling through the cracks (8).
In interpreting the findings of this study the limitations of the data should be considered. First, the unit of analysis in N-SSATS is facility., with very little information about the composition of clients and the content of services in these programs. Second, the criteria for categorizing dual diagnosis clients likely varied across programs, as did the content, aims, and duration of programs and groups. Drake and colleagues (10). note that staged, motivational, and social support interventions, as well interventions that promote cognitive and behavioral skills for self-management of illness are critical components of successful dual diagnosis programs. The N-SSATS data, however, contain no information on the content of psychosocial interventions. Third, some of the clients in dual diagnosis programs/groups likely received services from different providers and the data on services available at each facility is not necessarily indicative of all the services available to clients in that facility. However, these data do reflect the level of integration of various services at the facility level. As noted earlier, integration of services was one of the aims of the dual diagnosis treatment programs. Fourth, the data were limited to substance abuse facilities, the distribution and correlates of dual diagnosis treatment programs in mental health settings might he very different. Fifth, due to the large sample size, results of statistical testing do not necessarily reflect meaningful differences. For example, the difference in the proportion of facilities offering individual therapy was only 3.2% (Table 2). Thus, the actual magnitude of the differences, reflected in the reported percentages is likely a more accurate measure of magnitude of effects. Finally, these analyses assumed that all services at a facility were available and accessed by clients in dual diagnosis programs/groups. This assumption may be overly optimistic as some dual diagnosis clients may not have access to other services available at that facility.
Despite these limitations, the N-SSATS data provide a unique source to assess the dissemination and availability of services at substance abuse treatment facilities across the United States. As these data indicate, by the year 2000 almost half of all substance abuse treatment facilities across the country offered specialized programs or groups for dual diagnosis clients. However, only a small proportion of these facilities have been able to bring under one roof all the services needed by these clients.
The results of this study, thus, highlight the need for establishing and implementing standard evidence-based guidelines for dual diagnosis programs. Early attempts at developing such guidelines are promising (10). but also point to the various implementation barriers. Despite the growing recognition of the special needs of this group of clients, much work remains to be done to achieve integration of all or most of the services often needed by this vulnerable group of clients.
Table 1. Characteristics of substance abuse treatment facilities
with dual diagnosis programs/groups.
Facilities with
dual diagnosis
program/groups
Percent of
Characteristic Total N N all facilities
Ownership
Private for-profit 3475 1692 48.7
Private non-profit 7985 3873 48.5
State government 413 253 61.3
Local/county/ 1067 623 58.4
community government
Tribal government 169 72 42.6
Federal government 310 183 59.0
Type of federal facility
Department of 152 110 72.4
Veteran Affairs
Department of Defense 112 45 40.2
Indian Health Services 40 26 65.0
Other 6 2 33.3
Treatment modalities offered at these facilities (a)
Outpatient 9,733 5,026 51.6
Residential 3,329 1,532 46.0
Inpatient treatment 994 753 75.8
Characteristic Chi-square tests
Ownership
Private for-profit
Private non-profit
State government
Local/county/
community government
Tribal government
Federal government [chi square] = 74.27. df = 5,
P < .001
Type of federal facility
Department of
Veteran Affairs
Department of Defense
Indian Health Services
Other [chi square] = 29.87. df = 3,
P < .001
Treatment modalities offered at these facilities (a)
Outpatient [chi square] = 59.37, df = 1,
P < .001 (b)
Residential [chi square] = 26.89, df = 1,
P < .001 (b)
Inpatient treatment [chi square] = 289.46, df = 1,
P < .001 (b)
(a) Some facilities offered more than one modality.
(b) Each type facility was compared to all other facility types.
Thus, for example, availability of duel diagnosis programs/groups
in outpatient facilities was compared with residential and inpatient
facilities combined.
Table 2. Services available at substance abuse treatment facilities
that offer dual diagnosis programs/groups.
Facilities that offer
this service
Among all facilities
Percent of
Service N all facilities
Mental health services
Individual therapy 12,702 94.7
Group therapy 11,871 88.5
Family therapy 10,391 77.5
Prescription medications 5,618 41.9
Comprehensive mental 5,915 44.1
health assessment
Continuity of care services
Transitional discharge 10,793 80.5
planning
Aftercare counseling 10,376 77.4
Case management 8,849 66.0
Outcome follow-up 6,590 49.2
Other social/health services
Transitional housing 4,117 30.7
assistance
Transitional 4,699 35.0
employment
Domestic violence 4,508 33.6
education
HIV/AIDs education 7,320 54.6
HIV screening 7,320 54.6
STD screening 3,292 24.6
TB screening 5,028 37.5
Hepatitis screening 3,383 25.3
Facilities that offer
this service
Among facilities
with dual diagnosis
program/groups
Percent of
Service N all facilities
Mental health services
Individual therapy 6,447 96.3
Group therapy 6,102 91.2
Family therapy 5,645 84.3
Prescription medications 3,787 56.6
Comprehensive mental 4,163 62.2
health assessment
Continuity of care services
Transitional discharge 5,734 85.7
planning
Aftercare counseling 5,455 81.5
Case management 4,905 73.3
Outcome follow-up 3,642 54.5
Other social/health services
Transitional housing 2,450 36.6
assistance
Transitional 2,670 39.9
employment
Domestic violence 2,692 40.2
education
HIV/AIDs education 3,929 58.7
HIV screening 3,929 58.7
STD screening 1,985 29.7
TB screening 2,829 42.3
Hepatitis screening 2,077 31.1
Facilities that offer
this service
Among facilities
without dual diagnosis
program/groups
Percent of
Service N all facilities
Mental health services
Individual therapy 6,255 93.1
Group therapy 5,769 85.9
Family therapy 4,746 70.7
Prescription medications 1,831 27.3
Comprehensive mental 1,752 26.1
health assessment
Continuity of care services
Transitional discharge 5,059 75.3
planning
Aftercare counseling 4,921 73.3
Case management 3,944 58.7
Outcome follow-up 2,948 43.9
Other social/health services
Transitional housing 1,667 24.8
assistance
Transitional 2,029 30.2
employment
Domestic violence 1,819 27.0
education
HIV/AIDs education 3,391 50.5
HIV screening 3,391 50.5
STD screening 1,307 19.5
TB screening 2,199 32.7
Hepatitis screening 1,306 19.5
Chi-aquare
Service tests
Mental health services
Individual therapy [chi square] = 67.55, df = 1,
P < .001
Group therapy [chi square] = 92.00, df = 1,
P < .001
Family therapy [chi square] = 359.23, df = 1,
P < .001
Prescription medications [chi square] = 1,183.80, df= 1,
P < .001
Comprehensive mental [chi square] = 1,773.04, df= 1,
health assessment P < .001
Continuity of care services
Transitional discharge [chi square] = 228.56, df = 1,
planning P < .001
Aftercare counseling [chi square] = 130.13, df= 1,
P < .001
Case management [chi square] = 315.90. df = 1,
P < .001
Outcome follow-up [chi square] = 148.96. df = 1,
P < .001
Other social/health services
Transitional housing [chi square] = 218.31. df = 1,
assistance P < .001
Transitional [chi square] = 138.02. df = 1,
employment P < .001
Domestic violence [chi square] = 261.57, df = 1,
education P < .001
HIV/AIDs education [chi square] = 91.17, df = 1,
P < .001
HIV screening [chi square] = 91.17, df = 1,
P < .001
STD screening [chi square] = 188.23. Df = 1,
P < .001
TB screening [chi square] = 129.94. Df = 1,
P < .001
Hepatitis screening [chi square] = 239.10. Df = 1,
P < .001
REFERENCES
(1.) Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 264(19):2511-2518.
(2.) Skinstad AH, Swain A. Comorbidity in a clinical sample of substance abusers. Am J Drug Alcohol Abuse 2001; 27(1):45-64.
(3.) Johnson ME, Brems C, Burke S. Recognizing comorbidity among drug users in treatment. Am J Drug Alcohol Abuse 2002; 28(2):243-261.
(4.) Drake RE, Mueser KT. Psychosocial approaches to dual diagnosis. Sch Bull 2000; 26(l):105-118.
(5.) Center for Mental Health Services. Addressing the Needs of Homeless Persons with Co-Occurring Mental Illness and Substance Use Disorders. Rockville, MD: SAMHSA, 1997.
(6.) Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry 2002; 59(4):375-380.
(7.) Greenfield SF, Weiss RD, Muenz LR, Vagge LM, Kelly JF, Bello LR, Michael J. The effect of depression on return to drinking: a prospective study. Arch Gen Psychiatry 1998; 55(3):259-265.
(8.) Shavelson L. Hooked: Five Addicts Challenge Our Misguided Rehab System. New York, NY: New Press, 2001.
(9.) Ley A, Jeffery DP, McLaren S, Siegfried N. Psychosocial Treatment Programmes for People with Both Severe Mental Illness and Substance Misuse (Cochrane Review). The Cochrane Library, 2003, Issue 1.
(10.) Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, Kola L, Lynde D, Osher FC, Clark RE, Rickards L. Implementing dual diagnosis, services for clients with severe mental illness. Psychol Serv 2001; 52(4):469-476.
(11.) Drake RE, Osher FC, Wallach MA. Homelessness and dual diagnosis. Am Psychol. 1991; 46(11):1149-1158.
(12.) Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Sch Res 1999; 35(suppl 1):S93-S100.
(13.) Laudet AB, Magura S, Vogel HS, Knight EL. Interest in and obstacles to pursuing work among unemployed dually diagnosed individuals. Subst. Use Misuse 2002; 37(2): 145-170.
(14.) Brekke JS, Prindle C, Bae SW, Long JD. Risks for individuals with schizophrenia who are living in the community. Psychol Serv 2001; 52(10):1358-1366.
(15.) Dausey DJ, Desai RA. Psychiatric comorbidity and the prevalence of HIV infection in a sample of patients in treatment for substance abuse. J Nerv Ment Dis 2003; 191(6):10-17.
(16.) McKinnon K, Cournos F. HIV infection linked to substance use among hospitalized patients with severe mental illness. Psychol Serv 1998; 49(10):1269.
(17.) Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, Constantine NT, Wolford GL. Salyers MP. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91(1):31-37.
(18.)Substance Abuse and Menial Health Services Administration, Office of Applied Studies. National Survey of Substance Abuse Treatment Services (N-SSATS): 2000. Data on Substance Abuse Treatment Facilities [DASIS Series: S-16, DHHS Publication No. (SMA) 02-3668] Rockville, MD, 2002, Available at: http://wwwdasis.samhsa.gov/ 00nssats/nssats2000intro.htm.
Ramin Mojtabai, M.D., Ph.D, M.P.H. *
Department of Psychiatry, Beth Israel Medical Center, New York, New York, USA
* Correspondence: Ramin Mojtabai, M.D., Ph.D., M.P.H., Department of Psychiatry, Beth Israel Medical Center, First Ave. at 16th St., New York, NY 10003, USA; E-mail: rm322@columbia.edu.
COPYRIGHT 2004 Taylor & Francis Ltd.
COPYRIGHT 2004 Gale Group
|
