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Part B

Comorbidity of Mental Disorders with Drug Abuse/Dependence
Annotated Bibliography
May, 1998

Barry S. Brown, Ph.D.
University of North Carolina at Wilmington

Part A:
General Population Surveys Regarding Comorbidity
Prevalence of Mental Disorders in Drug Abuse Populations
Prevalence of Drug Abuse/Dependence in Psychiatric Populations
Comorbidity and HIV Risk Behaviors
Psychotherapeutic Approaches and Comorbidity


 

OTHER PSYCHOSOCIAL INTERVENTIONS AND COMORBIDITY


De Leon, G. (1993). Modified therapeutic communities for dual disorders. In J. Solomon, S. Zimberg, & E. Shollar (Eds.), Dual diagnosis. Evaluation, treatment, training, and program development (pp. 147–170). New York: Plenum.

0 The author describes the rationale and structure of the therapeutic community (TC) modified to meet the needs of clients showing evidence of both drug abuse and other psychiatric symptoms. The modified TC retains an emphasis on peer relations and the community as the rehabilitative agent; however, it uses staff in roles of greater responsibility for community management and administration than is true of traditional TCs. The modified TC makes use of increased availability of psychotherapy and case management, and employs somewhat muted use of confrontation in modified encounter groups. Treatment appproaches also include medication and educational groups that embrace mental health issues. Greater emphasis is placed on issues involved in the transition from the TC to the general community.


Galanter, M., Franco, H., Kim, A., Metzger, E. J., & De Leon, G. (1993). Inpatient treatment for the dually diagnosed. A peer-led model for acute and intermediate care. In J. Solomon, S. Zimberg, & E. Shollar (Eds.), Dual diagnosis. Evaluation, treatment, training, and program development (pp. 171–191). New York: Plenum.

0 The authors detail an intervention for clients showing evidence of substance use disorder and psychiatric disorder. This inpatient program makes use of a token economy in an inpatient setting as well as group meetings and psychoeducational sessions, recreational activities, 12-step meetings, peer government, medication, and aftercare—where feasible—to outpatient or residential programs. The authors present clinical experiences and a case example, but indicate that careful evaluation remains to be completed.


Hellerstein, D. J., Rosenthal, R. N., & Miner, C. (1995). A prospective study of integrated outpatient treatment for substance-abusing schizophrenic patients. American Journal on Addictions, 4, 33–42.

0 This study explored the response to an innovative treatment form of a substance- abusing schizophrenic population. A total of 47 drug abuse clients were identified who met Research Diagnostic Criteria (RDC) for both schizophrenia and substance abuse/dependence. Cocaine, alcohol, and marijuana—typically in combination— were the most frequently abused drugs. Those clients were randomly assigned to receive "integrated" treatment (N = 23) or standard treatment (N = 24). Integrated treatment involved twice weekly outpatient supportive psychotherapy (individual and/or group), drug counseling, psychoeducation, and psychotropic medication—all provided at a single treatment site. Standard treatment consisted of the same number of hours of outpatient psychiatric services and drug abuse treatment services provided at two sites without effort at coordination. Baseline measures and 4- and 8-month follow-ups from the start of outpatient treatment were conducted using the Addiction Severity Index (ASI). If subjects did not attend at least two outpatient treatment sessions, they were considered to be "nonstarters" and were dropped from the study of retention. This reduced study Ns to 16 integrated treatment clients and 13 standard treatment clients. A significantly greater number of integrated treatment than standard treatment clients were retained in treatment at 4 months; differences approached but did not achieve significance at 8 months (79% of integrated treatment clients were retained compared to 46% of standard). Both integrated and standard treatment clients retained in treatment showed significant reductions in drug use and psychiatric severity measures on the ASI with no differences between groups.


PHARMACOTHERAPEUTIC APPROACHES AND COMORBIDITY


Kleber, H. D., Weissman, M. W., Rounsaville, B. J., Wilber, C. H., Prusoff, B., & Riordan, C. E. (1983). Imipramine as treatment for depression in addicts. Archives of General Psychiatry, 40, 649–653.

0 This study involved 46 stabilized methadone clients who met DSM-II criteria (DSM-III was not available at initiation of study) for depression and showed no evidence of debilitating physical illness. Clients were randomly assigned to receive imipramine or placebo (23 in each group) under double-blind conditions. Assessments were made using the Hamilton Rating Scale for Depression (Hamilton), the Raskin Depression Scale (Raskin), the Beck Depression Inventory (BDI), the Symptom Check List (SCL-90), the Social Adjustment Scale, and urinalysis findings. Typically, the measures were administered weekly through the 8 weeks of study. Of those receiving placebo, 48% dropped out of treatment over the course of the study compared to 57% of those receiving imipramine. Whereas no imipramine subjects dropped out of the study because of medication side effects, 21% of imipramine dropouts were for "symptomatic failure" (i.e., clients who had severe psychological symptoms or who were such severe disciplinary problems as to merit discharge from the program). Over the 8 weeks of study, both imipramine and placebo groups showed marked improvement in terms of measures of depression. No differences were seen between groups on these measures, on measures of social adjustment, or on urinalysis findings.


Nunes, E., Quitkin, F., Brady, R., & Post-Koenig, T. (1994). Antidepressant treatment in methadone maintenance patients. Journal of Addictive Diseases, 13, 13–24.

0 The authors summarize the findings from six placebo-controlled studies of the efficacy of tricyclic antidepressants conducted with methadone maintenance clients showing significant levels of depression at baseline. They report that available studies suggest the capacity of doxepin, but not imipramine, to reduce depressive symptoms to a significantly greater degree in medication than in placebo samples. They also report that, although some studies indicated that doxepin as an adjunctive medication was associated with reductions in opiate use or craving, studies were inconsistent in their reports of an impact of tricyclics on drug use.


Nunes, E. V., Quitkin, F. M., Brady, R., & Stewart, J. W. (1991). Imipramine treatment of methadone maintenance patients with affective disorder and illicit drug use. American Journal of Psychiatry, 148, 667–669.

0 A sample of 17 methadone maintenance clients who met DSM-III-R criteria for affective disorder (10 for major depressive disorder and 7 for dysthymia) was drawn for a study of impramine. To be eligible, clients also had to show evidence that their affective disorder either predated their substance use, occurred during a period of prolonged abstinence, or had lasted at least 6 months prior to treatment entry. Imipramine was administered in an open trial for a period of 6 weeks to 11 months. Depression was measured at baseline and at 6 and 12 weeks using the Hamilton Rating Scale for Depression (Hamilton), weekly self-reports of drug use, and urinalyses. Seven additional clients dropped out of the study within 3 weeks due to noncompliance (N = 5) or side effects (N = 2). Fifteen of the 17 imipramine clients demonstrated "marked reduction in depression and panic symptoms" (marked is not further defined). In addition, 9 of the 17 "either became completely abstinent [three clients are identified] or achieved at least 1 month of abstinence with intermittent lapses." As the authors report, "the study has serious limitations" and should be regarded as indicating that imipramine may have potential for dually diagnosed clients but requires controlled clinical trials to clarify its real utility.


Titievsky, J., Guillermo, S., Barranco, M., & Kyle, E. M. (1982). Doxepin as adjunctive therapy for depressed methadone maintenance patients: A double-blind study. Journal of Clinical Psychiatry, 43, 454–456.

0 The authors studied 76 methadone maintenance clients who obtained scores indicating significant depression on the Hamilton Rating Scale for Depression (Hamilton) and showed no evidence of organic or functional psychosis. The clients were randomly assigned to doxepin and placebo groups under double-blind conditions. Assessment was conducted through administration of the Hamilton, the Profile of Moods State (POMS), and the Clinical Global Impressions Scale (CGI) at baseline, and at weekly intervals from the start of the study. Results are reported for the first 4 weeks of treatment, after which end-point analysis is reported (for clients retained at least 3 weeks in the study). Although there was substantial attrition from both groups in the course of the study (16 of 38 doxepin clients dropped out in the first week), no dropouts were associated with medication side effects. Of clients retained for study (20 doxepin clients and 26 placebo at end-point analysis), the doxepin group showed consistently more positive results through the 4 weeks of reported findings and for the end-point analysis. In particular, the doxepin group had significantly more favorable scores for overall depression (Hamilton), for sleep disturbance (Hamilton), and for anxiety (POMS). The authors suggest that for several reasons (e.g., low abuse potential, sedating effects), doxepin may be preferable to other tricyclic antidepressants in the treatment of depression in methadone clients.


Woody, G. E., O'Brien, C. P., McLellan, A. T., Marcovici, M., & Evans, B. D. (1982). The use of antidepressants with methadone in depressed maintenance patients. Annals of the New York Academy of Science, 398, 120–127.

0 The authors summarize the results of several studies to conclude that doxepin administered in conjunction with methadone can be a useful adjunct to the treatment of depressed opiate-using clients. They describe a recommended treatment regimen for incorporating doxepin in the treatment of opiate clients and point to the low abuse potential of doxepin in their own and others' treatment experiences.


Woody, G. E., O'Brien, C. P., & Rickels, K. (1975). Depression and anxiety in heroin addicts: A placebo-controlled study of doxepin in combination with methadone. American Journal of Psychiatry, 132, 447–450.

0 The authors studied 35 newly admitted male methadone clients rated by a psychiatrist as showing evidence of significant depression. The clients were randomly assigned to doxepin (N = 17) or placebo (N = 18) groups in conjunction with methadone and psychosocial treatment. Both clients and treatment staff were blind to client assignment. Assessments were conducted at baseline and at 1, 2, 4, 8, 12, and 16 weeks after the initiation of treatment using the Beck Depression Inventory (BDI), the Zung Self-Rating Scale, and the Hamilton Depression Rating Scale (the latter was administered at baseline, 4, and 16 weeks only). In addition, measures were taken of client performance using psychiatrist, counselor, and client ratings and urinalyses. Only clients who were retained for at least 1 month (N = 13 doxepin clients; N = 11 placebo clients) were considered for study. Scores on the three measures of depression all showed significantly greater reductions for the doxepin than for the placebo group. Doxepin clients also reported significantly lower "nervousness" as well as craving for heroin. No differences were found for urinalysis results.


TREATMENT OUTCOMES FOR COMORBID POPULATIONS


Araujo, L., Goldberg, P., Eyma, J., Madhusoodanan, S., Buff, D. D., Shahim, K., & Brenner, R. (1996). The effect of anxiety and depression on completion/withdrawal status in patients admitted to a substance abuse detoxification program. Journal of Substance Abuse Treatment, 13, 61–66.

0 This study involved the consecutive admissions of 148 clients to an inpatient detoxification unit serving both alcohol and drug abuse clients. The primary drugs of abuse were reported as heroin (46%), cocaine (37%), alcohol (8%), and other (9%). All clients received the Hamilton Rating Scale of Depression (HRSD) and of Anxiety (HRSA) at treatment entry. Comparison was made between detoxification completers (5 days for alcohol and cocaine, 10 days for heroin) and detoxification leavers. No differences were found in retention to detoxification for the total sample, for heroin users (N = 68), or for cocaine users (N = 55) by scores on the HRSD or the HRSA. Only age of first drug use was found to be associated with retention to detoxification completion, with completers significantly more likely to have started drug use later than dropouts.


Greenberg, W. M., Otero, J., & Villanueva, L. (1994). Irregular discharges from a dual diagnosis unit. American Journal of Drug and Alcohol Abuse, 20, 355–371.

0 The authors studied 316 admissions to a 20-bed dual diagnosis inpatient unit to determine characteristics of those discharged in the first 7 days (N = 119) of a planned 45-day stay as compared with those receiving "regular discharges" (N = 197). Clients were described as dually diagnosed if, in addition to meeting diagnostic criteria for substance use disorder, they gave evidence of a second current or historic DSM-III-R disorder or showed significant functional impairment. DSM-III-R diagnoses were obtained from psychiatrists' discharge summaries. Irregular (i.e., early) discharges were the results of leaving against medical advice or elopement (74%), illegal or similarly disruptive behaviors (16%), and uncontrollable psychiatric disturbance (10%). Neither dual diagnosis nor any demographic or background variables differentiated irregular from regular discharges with the exception of age, such that younger clients were significantly more likely to be irregularly discharged. Within the irregularly discharged group, those who left very rapidly (within the first week) could be differentiated from those leaving later in terms of the early leavers being significantly less likely to have legal involvement on the one hand and to have an Axis I diagnosis on the other. However, in a comparison of regular and irregular discharges in which individual diagnostic categories were broken out, antisocial personality disorder was significantly linked to irregular (i.e., early) discharge. No other diagnostic category was associated with irregular discharge; indeed, the cluster of all personality disorders other than antisocial personality was significantly associated with regular discharge (i.e., longer retention).


Joe, G. W., Brown, B. S., & Simpson, D. D. (1995). Psychological problems and client engagement in methadone treatment. Journal of Nervous and Mental Disease, 183, 704–710.

0 The authors studied 462 admissions to three methadone maintenance treatment programs. To be eligible for study, treatment admissions had to be retained a minimum of 90 days and had to obtain scores on measures of psychological problems that placed them at extremes of "no problems suggesting psychopathology" or "high number of problems suggesting psychopathology." Evidence of psychological problems was assessed using baseline measures of depression, anxiety, suicide, and pathology (i.e., significant thought disorder and/or mood disturbance) to develop an overall psychological problems index of no problems (i.e., a summed score of 0 [N = 341]), and high problems (i.e., a summed score of 2 or greater [N = 121]). The authors explored the relationship between measures of high and low psychological problems and treatment compliance (attendance at counseling sessions), behaviors during the first 3 months of treatment, and topics covered in individual counseling sessions. Clients showing high problems were significantly more likely to attend individual but not group counseling sessions and significantly more likely to discuss psychological problems than were "no problem" clients. Moreover, supplemental analyses of all treatment admissions found that clients showing higher scores on measures of anxiety and pathology were significantly more likely to be retained through the first 3 months of treatment. Both the "no problem" and "high problem" groups significantly reduced their opiate and other drug-using behaviors, illicit behaviors, and days of any alcohol use as well as days of heavy alcohol use.


McLellan, A. T., Luborsky, L., Woody, G. E., O’Brien, C. T., & Druley, K. A. (1983). Predicting response to drug and alcohol treatments. Role of psychiatric severity. Archives of General Psychiatry, 40, 620–625.

0 This study included 879 male admissions to an alcohol treatment program (N = 554) and to a drug abuse treatment program (N = 325) where clients remained in treatment a minimum of 5 days. Clients could be admitted to any of three alcoholism or three drug abuse programs. The programs varied in several key areas: length of planned treatment, residential or outpatient, whether or not methadone was provided, and whether drug abuse and alcoholism clients were treated separately or together. All clients were administered the Addiction Severity Index (ASI) at baseline. Follow-up occurred 6 months later and also involved administration of the ASI. At follow-up, 460 alcoholism clients (83% of the baseline sample) and 282 drug abuse clients (87% of the baseline sample) were available. No differences were found within alcoholism and drug abuse samples by modality on follow-up ASI scores. However, there was a relationship between measures of psychiatric severity at baseline ASI and 6-month follow-up on five of seven ASI measures for alcoholism clients and on four of seven ASI measures for drug abuse clients. Psychiatric severity was the single best predictor of outcome, accounting for 12% of outcome variance across all seven ASI measures. Further analysis explored the outcomes for high psychiatric severity at baseline vis à vis other groups. Those with high psychiatric severity, unlike those with low, did not show a relationship between length of time in treatment and positive outcomes. Moreover, psychiatric severity—in conjunction with a limited number of other predictor variables—accounted for 48% of outcome variance for the high severity alcoholism sample and 54% of outcome variance for the high severity drug abuse sample. The authors emphasize the importance of attending to psychiatric factors in drug abuse treatment.


Ravndal, E., & Vaglum, P. (1995). The influence of personality disorders on treatment completion in a hierarchical therapeutic community for drug abusers: A prospective study. European Addiction Research, 1, 178–186.

0 The authors studied 144 consecutive entrants to a Norwegian therapeutic community to determine the relationship of psychological measures to retention in treatment. In addition to structured interviews, treatment entrants were given the Millon Clinical Multiaxial Inventory (MCMI) and the BCI (full name not given), a scale in use in Norway measuring avoidant, compulsive, and histrionic behaviors. Measures were administered at baseline and 1 year later to those retained in treatment. The treatment program involved 1 year of inpatient treatment followed by outpatient services. Scores on neither the MCMI nor the BCI differentiated between clients completing and dropping out over the course of the first year of inpatient treatment. However, completers of the total treatment program (inpatient and outpatient [N = 29]) had significantly lower scores on MCMI scales measuring schizoid and schizotypal behaviors than noncompleters (N = 115). At the same time, completers of 1 year of treatment (N = 36) showed significant and positive change on all MCMI scales from baseline to 1-year measures.


Rounsaville, B. J., Weissman, M. M., Crits-Christoph, K., Wilber, C., & Kleber, H. (1982). Diagnosis and symptoms of depression in opiate addicts. Course and relationship to treatment outcome. Archives of General Psychiatry, 39, 151–156.

0 This study involved 157 opiate addict admissions to a Connecticut multimodality drug abuse treatment program. At intake and prior to treatment assignment, clients were administered the Schedule for Affective Diseases–Lifetime (SADS-L) on the basis of which current and lifetime diagnoses were determined using the Research Diagnostic Criteria (RDC) scale, the Beck Depression Inventory (BDI), and the Symptom Check List (SCL-90). These measures were readministered 6 months after the initiation of treatment to 123 clients (78% of the baseline sample). At baseline, 17% of clients showed evidence of a current major depressive disorder, and 48% showed evidence of a lifetime major depressive disorder. Combining over major depression, intermittent depression, and labile personality, 44% showed evidence of a current dysphoric condition, and 70% showed evidence of a lifetime dysphoric condition. Using the BDI, it was found that 21% reported moderate to severe symptoms, 39% mild symptoms, and 40% no symptoms. At 6 months of treatment there was significant improvement over all symptom scores of the SCL-90 and the BDI. There was a diminution in RDC diagnoses of depression at 6 months; only 2% of all subjects showed major depression at both intake and at 6 months; 18% of subjects were depressed at intake and no longer showed evidence of depression 6 months later; and 10% of subjects showed no evidence of depression at intake and showed evidence of depression at 6 months. BDI scores were somewhat more consistent, with 21% depressed at intake and follow-up, 38% depressed at intake but not follow-up, and 9% depressed at follow-up but not intake. The follow-up subjects had enrolled in methadone maintenance treatment (66%), residential drug-free treatment (16%), and outpatient drug-free treatment (11%), and 7% received intake only. Of the follow-up sample, 49% were still in treatment; 34% had been in treatment less than 12 weeks. Length of time in treatment was significantly related to reduction in depression (BDI scores); however, type of treatment in terms of modality of assignment was not related to symptom reduction. Moreover, only 5% of clients received tricyclic antidepressants during time in treatment (only 1% for greater than 2 weeks), and 2% were administered lithium. That is, depression and other psychiatric symptoms were reduced in accord with a program of regular drug abuse counseling (at least 1 hour weekly of individual or group in outpatient programming and therapeutic community programming in the residential setting). In spite of the diminution in symptom scores, clients showing evidence of major or minor depression at intake were significantly more likely than others to use illicit drugs during the subsequent 6 months and obtained higher symptom levels at 6-month follow-up.


Saxon, A. J., & Calsyn, D. A. (1995). Effects of psychiatric care for dual diagnosis patients treated in a drug dependence clinic. American Journal of Drug and Alcohol Abuse, 21, 303–313.

0 The authors examined the response to drug abuse treatment of dually diagnosed and substance use only clients. Subjects for study were clients admitted to three VA treatment programs: methadone maintenance (N = 84), monitored naltrexone (N = 34), and drug-free intensive outpatient (N = 104). Clients, in conjunction with staff, could elect the modality seen as most appropriate to their needs. Each modality involved significant psychosocial intervention (e.g., weekly group therapy was required for the first 16 weeks of methadone treatment and for the length of naltrexone treatment; group therapy was provided 5 times a week during the first 10 weeks of outpatient drug-free treatment and weekly thereafter). In addition, all clients identified through psychiatric interview as showing evidence of an Axis I psychiatric diagnosis in addition to substance use/dependence received "routine psychiatric follow-up" consisting of psychotropic medication, where indicated, and "some informal supportive psychotherapy" in conjunction with that dosing. Comparison was made between the dual diagnosis (DD) group (N = 103) and the substance use only (SO) group (N = 119) in terms of retention in treatment and urinalysis findings. Overall, 46% of clients received dual diagnoses with 57% of primary opioid users and 29% of primary cocaine users receiving diagnoses for disorders in addition to substance use. Major depression was the most common diagnosis (20%) and tricyclic antidepressants the most commonly employed psychotropic medication (52% of DD clients), although 20% of DD clients did not receive any psychotropic medication. DD clients gave significantly more urines positive for opiates and for cocaine than SO clients during the first 6 months of treatment. DD clients receiving and not receiving medication did not differ in urine results. DD clients retained greater than 6 months (70% of total DD clients) significantly reduced their rates of positive urines and no longer differed from those SO clients retained beyond 6 months (59% of total SO clients). DD clients were retained significantly longer than SO clients (median of 14.3 months compared to 8.9 months). DD clients were more likely than SO clients to be in methadone or naltrexone treatment; consequently, retention comparisons were made by treatment modality. DD retention exceeded SO retention for each modality, although none of the comparisons achieved significance. DD clients receiving psychotropic medication were significantly more likely to be retained than DD clients not receiving medication.

 

COSTS ASSOCIATED WITH COMORBIDITY


Dickey, B., & Azeni, H. (1996). Persons with dual diagnoses of substance abuse and major mental illness: Their excess costs of psychiatric care. American Journal of Public Health, 86, 973–977.

0 This study examined the patterns and costs of Massachusetts Medicaid beneficiaries treated for schizophrenia or major affective disorder in 1992. Of the total 16,395 cases, 36% submitted a claim for treatment reimbursement in which substance abuse (including alcoholism) occurred as a primary or secondary diagnosis. Clients with substance abuse diagnoses were more likely to be male and to be younger than the remaining Medicaid population and were more likely to have a diagnosis of affective disorder (57% of those with substance abuse disorders). Inpatient, outpatient, and overall costs were calculated and compared for Medicaid psychiatric clients receiving and not receiving substance use diagnoses. Those with substance abuse diagnoses were four times more likely than those without substance abuse to be hospitalized for acute care and to spend more time hospitalized over the course of a year. Costs of treatment averaged $22,917 for those with treated substance abuse and $20,049 for those with untreated substance abuse compared to $13,930 for those without substance abuse. Differences between groups were most largely accounted for by days hospitalized. Only 25% of substance abuse clients received substance abuse treatment, virtually all receiving outpatient treatment averaging $868 for the year. In addition, 97% of Medicaid clients with substance abuse disorders received medical services other than hospital care, compared to 86% of those without substance abuse disorders, and averaged about $1,200 more in associated medical costs.

 

LITERATURE REVIEWS RELATING TO COMORBIDITY


De Leon, G. (1989). Psychopathology and substance abuse: What is being learned from research in therapeutic communities. Journal of Psychoactive Drugs, 21, 177–188.

0 In a review article summarizing findings from several studies conducted in therapeutic community (TC) settings, De Leon describes the psychological status of TC clients and response to treatment of clients showing psychopathology. In studies using the Minnesota Multiphasic Personality Inventory (MMPI), De Leon describes the typical client as showing confusion (high F), deviance (high Pd), and disturbed thinking and affect (high Sc). Lesser, but still important, deviance is seen in depression (D), hypomania (Ma), and psychoticism (Pt). Measures of self-concept, obtained through use of the Tennessee Self-Concept Scales (TSCS), are seen as reflecting low self-esteem, low personality integration, and adjustment problems. Diagnostic studies suggest that the majority of TC clients show evidence of dual disorder with the non-drug dependence diagnosis most likely to be anxiety disorder, phobic disorder, or antisocial personality disorder. Psychopathology is described as more severe for both female and white TC entrants. Scores on the MMPI and TSCS are described as worsening in studies of TC entrants in 1984 as compared to 1979. Depression has become a particular concern. De Leon further suggests that severe psychopathology is associated with early dropout; however, those who continue in treatment were found to show improvement in psychological as well as behavioral measures. De Leon notes the importance of developing modified TC programs to meet the needs of mentally ill chemical abusers (MICAs).


Drake, R. E., Osher, F. C., & Wallach, M. A. (1991). Homelessness and dual diagnosis. American Psychologist, 46, 1149–1158.

0 The authors review studies indicating that 30–40% of the homeless show evidence of alcohol problems, 10–20% show evidence of drug problems, and 10–20% show evidence of dual disorder problems involving mental illness and alcohol and/or drug abuse. Dual diagnosis also was a predictor of homelessness such that more than half of individuals diagnosed as showing substance use disorder as well as other psychiatric symptoms had been homeless at some time in the 6-month period prior to the interview. Findings show that dual diagnosis among the homeless is underidentified, and partly as a consequence, the homeless are unlikely to receive the range of services they need. The authors emphasize integrating mental health and substance abuse services; providing intensive case management; using group-oriented interventions; and separating treatment into component parts of engagement, persuasion to participate in the treatment program’s different services, active treatment (e.g., skills building), and relapse prevention. They discuss the obvious need for housing for this population as well as the need to attend to and deal with legal issues regarding the acquisition of housing and related services.


Kosten, T. R., & Kleber, H. D. (1988). Differential diagnosis of psychiatric comorbidity in substance abusers. Journal of Substance Abuse Treatment, 5, 201–206.

0 The authors review the literature regarding findings of psychiatric symptoms in substance-abusing populations. They relate psychiatric diagnosis to primary drug type and argue for the increased use of differential diagnosis to make available appropriate treatment to the drug abuse client. They present two case histories to illustrate issues in differential diagnosis.


Raskin, V. D., & Miller, N. S. (1993). The epidemiology of the comorbidity of psychiatric and addictive disorders: A critical review. Journal of Addictive Disorders, 12, 45–57.

0 The authors provide a critical overview of epidemiological studies of the relation between substance use and other psychiatric disorders. The authors describe the following issues in research design: (a) the need for assessment to take account of comorbid symptoms associated with drug treatment entry and detoxification, (b) investigator bias, (c) longitudinal study to understand the etiology and timing of psychiatric symptoms relative to the etiology and timing of drug use, and (d) differential and joint effects of pharmacological and psychosocial interventions on substance use and psychiatric symptoms.
 


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