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Abstract

People suffering from comorbid mental illness and substance abuse disorders (the dually diagnosed) are thought to constitute large portions of clients treated as outpatients by public-sector community-based mental health providers. These providers dispense units of ambulatory mental health services and treatments incrementally to maintain clients in the community and out of psychiatric hospitals. Community maintenance is one step, albeit critical, toward quitting drugs and eventual abstinence. Thus, there is a need for information that compares the effectiveness and cost of such services on dually diagnosed clients to identify appropriate low-cost high-yield treatment and service options and packages. This article provides a review of the literature on the effectiveness of ambulatory mental health services and recent emergent reports of cost-effectiveness of programs for the dually diagnosed, paying special attention to the gray areas and gaps. This article also describes a new project; an inexpensive add-on to an existing community mental health center. The project will be examining over 4 years of data to compare influence and cost of different ambulatory mental health services and treatments delivered to a matched pair group of clients with dual disorders and those with only mental illness. The intention of this project is not only to address gray areas and gaps in the literature, but also to inform a more rational deployment of mental health services.

Table of Content

CHAPTER ONE5

INTRODUCTION5

CHAPTER TWO10

LITERATURE REVIEW10

CHAPTER THREE43

METHODOLOGY43

CHAPTER FOUR44

CONCLUSION44

Chapter One

Introduction

People with severe and persistent mental illness and substance abuse disorders, the dually diagnosed, are thought to constitute a sizable portion of clients treated as outpatients by community-based public sector mental health providers. Among outpatients of these providers, epidemiological studies estimate the prevalence of dually diagnosed persons to be between 30 and 60% and as high as 86% for particular subgroups (Dixon; Ford; Galanter; Greenfield; Lehman et al. 1994; Regier; Warner and Ziedonis). Compared to clients with only diagnoses of mental illness, the dually diagnosed: (a) have worse psychiatric symptoms, treatment compliance, and prognosis; (b) use more treatment and service resources; (c) show a greater propensity toward suicide and self-destructive behaviors and generally poor physical health habits; (d) have few social supports or financial resources with which to seek treatment other than treatment on an outpatient basis from public sector community providers; and (e) exhibit the highest rates of expensive public psychiatric hospital admissions and criminal justice system involvement ( Addington; Bartels, S. J., Teague, G. B., Drake, R. E., Clark, R. E., Bush, P. W., & Noordsy, D. L. (1993). Substance abuse in schizophrenia: service utilization and costs. 144th Annual Meeting of the American Psychiatric Association, 1991, New Orleans, Louisiana. Journal of Nervous and Mental Disorders 181, 227-232..Bartels et al. 1993; Brunette and Caton; el-Mallaka, 1998; Grossman; Gupta; Haywood; Hofman; Lehman; Lesswing; Schmidt; Sloan; Swindle and Wilens; also see Drake; Kay and Lyons).

Public sector community mental health providers are more likely to treat the dually diagnosed. Due in part to their compounded disorders and resulting multifaceted problems, they lack resources to seek private ...