Mark P. McGovern

A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders

Co-occurring posttraumatic stress disorder (PTSD) is prevalent in addiction treatment programs and a risk factor for negative outcomes. Although interventions have been developed to address substance use and PTSD, treatment options are needed that are effective, well tolerated by patients, and potentially integrated with existing program services. This paper describes a cognitive behavioral therapy (CBT) for PTSD that was adapted from a treatment for persons with severe mental illnesses and PTSD in community mental health settings. The new adaptation is for patients in community addiction treatment with co-occurring PTSD and substance use disorders. In this study, 5 community therapists delivered the CBT for PTSD. Outcome data are available on 11 patients who were assessed at baseline, post-CBT treatment, and at a 3-month follow-up post-treatment. Primary outcomes were substance use, PTSD severity, and retention, of which all were favorable for patients receiving the CBT for PTSD.

Impact of Substance Disorders on Medical Expenditures for Medicaid Beneficiaries With Behavioral Health Disorders

OBJECTIVE This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders. METHODS Claims for Medicaid beneficiaries with behavioral health diagnoses in 1999 from Arkansas, Colorado, Georgia, Indiana, New Jersey, and Washington were analyzed. Behavioral health and general medical expenditures for individuals with diagnoses of substance use disorders were compared with expenditures for those without such diagnoses. States were analyzed separately with adjustment for confounders. RESULTS A total of 148,457 beneficiaries met selection criteria, and 43,457 (29.3%) had a substance use diagnosis. Compared with other beneficiaries with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems in five of six states. Approximately half of the additional care and expenditures were for treatment of physical conditions. Differences declined but remained statistically significant after adjustment for higher overall disease burden among beneficiaries with addictions. Medical expenditures for individuals with diagnoses of substance use disorders increased significantly with age in five of six states, whereas behavioral health expenditures were stable or declined. Hospital admissions for psychiatric and general medical reasons were higher for those with diagnoses of substance use disorders. CONCLUSIONS The impact of addiction on Medicaid populations with behavioral health disorders is greater than the direct cost of mental health and addictions treatment. Higher medical expenditures can be partly attributed to greater prevalence of co-occurring physical disorders, but expenditures remained higher after adjustment for disease burden. Spending estimates based only on behavioral health diagnoses may significantly underestimate addictions-related costs, particularly for older adults.

Assessing the Dual Diagnosis Capability of Addiction Treatment Services: The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index

ABSTRACT Background: Addiction treatment systems and services are increasingly challenged to provide effective treatments for persons with co-occurring disorders. Evidence-based practices are still being developed, and practice benchmarks remain vague in guiding treatment providers in enhancing services, or in delineating standards with which to evaluate the quality of existing care for persons with dual disorders. The American Society of Addiction Medicine (ASAM) proposed a taxonomy of addiction treatment program dual-diagnosis capability, and provided a conceptual model of services for persons with co-occurring substance use and psychiatric disorders. Method: This article describes the development and application of the Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, which is designed to assess the dual diagnosis capability of addiction treatments services, and is based upon the ASAM taxonomy: Addiction Only Services (AOS), Dual Diagnosis Capable (DDC) or Dual Diagnosis Enhanced (DDE). Results: The DDCAT has been found to have acceptable psychometric properties (internal consistency, inter-rater agreement, kappa) and is sensitive to change. Three case examples illustrate its use in assessing the dual diagnosis capacity of treatment services, and in measuring the targets and impact of change strategies. Conclusions: The DDCAT has demonstrated practical value for addiction treatment systems and treatment service providers. Validity studies are in progress testing the relationship between the index and patient level outcomes.

Evidence-based practices for substance use disorders.

There are inherent complexities in evaluating EBPs for substance use disorders: the heterogeneity of the disorder itself, the variability in people who suffer from them, the range of settings in which services are provided, and multiple lines of research development. This article outlined four models for evaluating the evidence for interventions for substance use disorders, and presented brief descriptions of pharmacological, behavioral/psychosocial, and treatment services that have a clearly defined intervention (chemical agent or manual-guided therapy) and a documented record of objective evaluation. Although substantial work is underway to evaluate effectiveness in the real world, clinicians and individuals with substance use disorders and their families should be cognizant of the burgeoning array of effective treatment alternatives that are available.

The chemical use, abuse, and dependence scale (CUAD) ☆: Rationale, reliability, and validity

This article describes the rationale for the development of the Chemical Use, Abuse, and Dependence Scale (CUAD). The instrument is in a semistructured interview format; it derives both substance use severity scores and DSM-III-R substance use disorder diagnoses and can be administered in a short period with minimal training. The reliability and validity of the CUAD are reported and appear satisfactory. The CUAD is recommended for use as a detection, diagnostic, and treatment selection index in clinical, research, and program evaluation contexts.

A Randomized Controlled Trial Comparing Integrated Cognitive Behavioral Therapy Versus Individual Addiction Counseling for Co-occurring Substance Use and Posttraumatic Stress Disorders

Objective: Co-occurring posttraumatic stress (PTSD) and substance use disorders provide clinical challenges to addiction treatment providers. Interventions are needed that are effective, well-tolerated by patients, and capable of being delivered by typical clinicians in community settings. This is a randomized controlled trial of integrated cognitive behavioral therapy for co-occurring PTSD and substance use disorders. Methods: Fifty-three participants sampled from seven community addiction treatment programs were randomized to integrated cognitive behavioral therapy plus standard care or individual addiction counseling plus standard care. Fourteen community therapists employed by these programs delivered both manual-guided therapies. Primary outcomes were PTSD symptoms, substance use symptoms, and therapy retention. Participants were assessed at baseline, 3- and 6-month follow-up. Results: Integrated cognitive behavioral therapy was more effective than individual addiction counseling in reducing PTSD re-experiencing symptoms and PTSD diagnosis. Individual addiction counseling was comparably effective to integrated cognitive behavioral therapy in substance use outcomes and on other measures of psychiatric symptom severity. Participants assigned to individual addiction counseling with severe PTSD were less likely to initiate and engage in the therapy than those assigned to integrated cognitive behavioral therapy. In general, participants with severe PTSD were more likely to benefit from integrated cognitive behavioral therapy. Conclusions: The findings support the promise of efficacy of integrated cognitive behavioral therapy in improving outcomes for persons in addiction treatment with PTSD. Community counselors delivered both interventions with satisfactory adherence and competence. Despite several limitations to this research, a larger randomized controlled trial of integrated cognitive behavioral therapy appears to be warranted.

Improving the Dual Diagnosis Capability of Addiction and Mental Health Treatment Services: Implementation Factors Associated With Program Level Changes

OBJECTIVE: This study examined implementation factors associated with addiction and mental health treatment program improvement in services to persons with co-occurring substance use and psychiatric disorders. There were two primary aims: (a) to articulate factors associated with successful program change and (b) to determine whether the effective factors are different by program type. METHODS: Eighty-six programs (addiction treatment n = 54; mental health treatment n = 32) were assessed at baseline and 18-month follow-up using the Dual Diagnosis Capability in Addiction Treatment (DDCAT; McGovern, Matzkin, & Giard, 2007) or Dual Diagnosis in Mental Health Treatment (DDCMHT; Gotham, Claus, Selig, & Homer, 2010) indexes. At follow-up, program leaders were surveyed about implementation factors that may have accounted for changes in capability. RESULTS: Both addiction and mental health programs significantly improved dual diagnosis capability during the study period. Factors associated with positive change in addiction treatment programs included organizational and contextual components, use of the commonly recommended implementation strategies, and deploying evaluation methods. In mental health programs only the evaluation methods factor was uniquely significant, although the use of a variety of methods overall was associated with improvement. CONCLUSIONS: Both mental health and addiction treatment programs can enhance dual diagnosis capable services through a variety of implementation approaches. This study provides data to the emerging discipline of implementation science and suggests avenues for future research. (Journal of Dual Diagnosis, 6:237–250, 2010)

Addiction treatment services and co-occurring disorders: the ASAM-PPC-2R taxonomy of program dual diagnosis capability.

Abstract Background. The ASAM-PPC-2R taxonomy of addiction treatment program dual diagnosis capability provides a conceptual model of services for persons with co-occurring substance use and psychiatric disorders. However, no objective study of this model has been conducted. Method. This paper describes a survey of addiction treatment providers (n = 453) who were asked to identify their program as Addiction Only Services (AOS), Dual Diagnosis Capable (DDC) or Dual Diagnosis Enhanced (DDE). The survey also queried providers on prevalence estimates, clinical practices, and perceived barriers to treating persons with co-occurring substance use and psychiatric disorders. Results. With brief definitions available to respondents, 92.9% of providers surveyed categorized their program as: AOS (23.0%), DDC (65.3%) or DDE (11.6%). Patient characteristics, clinical practices, and barriers to effective treatments varied by program dual diagnosis capability. Conclusions. The findings support the utility of the ASAM dual diagnosis capability taxonomy, and suggest specific avenues for system and program assessment and future research.

Racial/Ethnic Disparities in Mental Health Treatment in Six Medicaid Programs

Little is known about ethnic and racial disparities in mental health care among Medicaid beneficiaries. The association between ethnicity and race and the utilization of mental health care was explored in six Medicaid programs. The analysis distinguished between different settings of care, including community-based, outpatient hospital, inpatient, and emergency departments (EDs). Racial and ethnic disparities in mental health care were observed across state Medicaid programs. Hispanic and African American beneficiaries with mental illness were much less likely than Whites to be treated in community-based settings. African Americans were more likely to receive mental health treatment in inpatient, ED, and outpatient hospital settings in some states. The implications of these findings and possible initiatives to enhance community-based mental health care among African American and Hispanic Medicaid beneficiaries are discussed.

Problem Severity and Symptomatology among Substance Misusers: Differences between African-Americans and Caucasians

Using data collected on 348 patients presenting to a hospital-based substance misuse treatment program, the present study compares psychiatric symptomatology and severity of substance misuse among African-American and Caucasian alcohol and drug misusers. African-Americans had a higher overall severity of substance misuse and reported using more substances than Caucasians. African-Americans also had higher levels of somatization, interpersonal problems, depression, hostility, obsessive/compulsive behavior, phobia, paranoia, and psychoticism than Caucasians. African-Americans exhibited higher levels of psychosocial stress and lower levels of global functioning than did Caucasians. The implications of the findings are discussed.