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.
Similar content being viewed by others
References
American Psychiatric Association (2000). Diagnostic and statistical manual for mental disorders (DSM-IV-IR). Washington, D.C., American Psychiatric Association
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: 227–232
Bassuk E.L. (2003). Supportive housing for homeless families: Setting a research and evaluation agenda. Presentation to the Bill & Melinda Gates Foundation, Seattle, WA
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: 141–159
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 Administration
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: 526–528
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: 471–481
Carey K. B., Coco K., Simons J. (1996). Concurrent validity of clinicians’ ratings of substance abuse among psychiatric outpatients. Psychiatric Services 47: 842–847
Clark R. E., Teague G. B., Ricketts S. K., Bush P. W., **e 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: 1285–1308
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: 107–163
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: 973–977
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: 469–476
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: 179–182
Drake R. E., McHugo G. J., Clark R. E., Teague G. B., **e 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: 201–215
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: 589–608
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: 360–374
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: 408–414
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: 298–305
Erdfedler E., Faul F., Buchner A. (1996). G*Power. A general power analysis program. Behavior Research Methods, Instruments and Computers 29: 1–11
Essock S. M., Frisman L. K., Kontos N. J. (1998). Cost-effectiveness of assertive community treatment teams. American Journal of Orthopsychiatry 68: 179–190
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 Inc
Holloway F., Carson J. (1998). Intensive case management for the severe mentally ill: Controlled trial. British Journal of Psychiatry 172: 19–22
Jerrell J. M. (1996). Cost-effective treatment for persons with dual disorders. New Directions for Mental Health Services 70: 79–91
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: 346–352
Lukoff D., Nuechterlein K. H., Ventura J. (1986). Manual for the expanded brief psychiatric rating scale. Schizophrenia Bulletin 2: 594–602
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.
McHugo G. J., Drake R. E., Teague G. B., **e H. (1999). Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services 50: 818–824
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: 113–122
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.
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: 37–74
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 Publications
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): 771–779
President’s New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America. SAMHSA SMA 03-3832
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: 2511–2518
Smith J. E., Meyers R. J. (1995). Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed). Needham Heights, Allyn & Bacon
Sobell M. B., Maiston S. A., Sobell L. C. (1980). Develo** 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, Pergamon
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: 216–232
Test M. A., Wallisch L. S., Allness D. J., Ripp K. (1989). Substance use in young adults with schizophrenic disorders. Schizophrenia Bulletin 15: 465–476
UK 700 Group (1999). Intensive versus standard case management for severe psychotic illness: A randomized trial. Lancet 353:2185–2189
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: 808–845
Winter J.P., Calsyn R.J. (2000). The Dartmouth Assertive Community Treatment Scale (DACTS): A generalizability study. Evaluation Review 24: 319–388
Wolff N., Helminiak T. W., Diamond R. J. (1995). Estimated societal costs of assertive community mental health care. Psychiatric Services 46: 898–906
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: 341–348
Wolff N., Helminiak T. W., Tebes J. (1997). Getting the cost right in cost-effectiveness analyses. American Journal of Psychiatry 154: 736–743
Acknowledgments
Financial support was provided by the National Institute of Mental Health, (MH 57154) and the University of Missouri-St.Louis.
Author information
Authors and Affiliations
Corresponding author
Additional information
The authors thank the study participants for their co-operation in this study; we hope that their lives have improved as a result of their participation. We also appreciate the co-operation of the many agencies that provided treatment to the study participants, particularly Community Alternatives, Places for People, and Peter and Paul Community Services. The following individuals were critical to the execution of the project: Ruth Smith, Mary Maguire, Bill Tourville, Joris Miller, Gretchen Gerteis, Gail Saulnier, Kecia Smith, Dorothy Gano, Jean Mayo and Melinda Bowen. We are also grateful to the many people and agencies who provided service utilization and cost information, particularly Mr. Ed Meyers of the Missouri Department of Mental Health, Mr. Richard Koon and Melanie Neal of the Missouri Department of Social Services, Ron Konkol of the Social Security Administration, Francie Broderick and Kelly Wilson of Places for People, Steve Campbell of Peter and Paul Community Services, Bob Harvey and Marsha Wood of Independence Center, Debra Wilderman of St. Louis University Hospital, Karen Jessop of St. Alexius Hospital, Julia Rogliano of South Pointe Hospital, Nelda James of Barnes Hospital, and Joyce Ellison of the St. Louis Veterans Administration Hospital. Financial support was provided by the National Institute of Mental Health, (MH 57154) and the University of Missouri-St. Louis. However, the views expressed in this paper are the sole responsibility of the authors.
Dr. Gary A. Morse is with Community Alternatives, St. Louis, MO, USA.
Drs. Robert J. Calsyn, Thomas W. Helminiak and Mr. Matthew R. Lemming are with the University of Missouri-St. Louis, St. Louis, MO, USA.
Dr. Robert D. Yonker is now with the University of Toledo, Toledo, OH, USA.
Dr. W. Dean Klinkenberg, Mr. Gyanesh Lama and Ms. Suzanne McCudden are with the Missouri Institute of Mental Health, St. Louis, MO, USA.
Dr. Nancy Wolff is with Rutgers University, New Brunswick, NJ, USA.
Dr. Robert E. Drake is at the Dartmouth Medical School, Hanover, NH, USA.
Rights and permissions
About this article
Cite this article
Morse, G., Calsyn, R., Dean Klinkenberg, W. et al. Treating Homeless Clients with Severe Mental Illness and Substance Use Disorders: Costs and Outcomes. Community Ment Health J 42, 377–404 (2006). https://doi.org/10.1007/s10597-006-9050-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10597-006-9050-y