Dr. Mark McGovern is a Professor in the Department of Psychiatry & Behavioral Sciences and, by courtesy, the Department of Medicine at Stanford University School of Medicine. He is the Co-Chief of the Division of Public Mental Health and Population Sciences in the Department of Psychiatry, and Medical Director of Integrated Behavioral Health in the Division of Primary Care and Population Health in the Department of Medicine.
Dr. McGovern's overarching goal is to improve access to the most effective care possible for anyone who needs it.
His primary research focus is implementation science, with a specific emphasis on integrated behavioral health services for persons with co-occurring substance use and psychiatric disorders, as they present in both primary care and specialty settings. Dr. McGovern has received a National Institute on Drug Abuse (NIDA) career development award and NIDA and National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant funding to translate evidence-based therapies for complex patients into routine clinical settings. He has also received awards from the Robert Wood Johnson Foundation and the US Department of Health & Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) to advance a series of organizational measures of integrated service capacity. These measures, the Dual Diagnosis Capability in Addiction Treatment (DDCAT), Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) and Behavioral Health Integration in Medical Care (BHIMC), have been widely adopted and are being used to implement evidence-based treatments in community settings and systems throughout the United States and globally.
Presently, he leads national, State of California, and local efforts to combat the US opioid epidemic. Dr. McGovern's work is focused on scaling up access to FDA-approved medications, in specialty care and in primary care and other general medical practice settings. His work is supported by NIDA, SAMHSA and the California Health Care Foundation. He is also actively collaborating with health systems, including Stanford Health Care and Intermountain Healthcare, on implementable and sustainable models of integrated behavioral health in primary care practice. This work is funded by the Department of Medicine, the Stanford-Intermountain Collaborative Grant Program, and the Patient Centered Outcomes Research Initiative (PCORI).
He is the PI on the National Coordinating Office of the Mental Health Technology Transfer Center (MHTTC) Network funded by SAMHSA. The MHTTC Network consists of 10 regional centers and 1 Native American/Tribal Center and 1 Latino/Hispanic Center--12 centers in all. The overarching goal of this network is the implementation and sustainment of evidence-based mental health prevention and treatment practices across US states and territories.
Dr. McGovern has been actively involved in the education of medical students, psychiatric residents and fellows, and clinical psychology interns at Stanford, and previously at the medical schools at Dartmouth (Lebanon, New Hampshire) and Northwestern University (Chicago, Illinois). From 2009 to 2017, he served as the Editor-In-Chief for the Journal of Substance Abuse Treatment (JSAT), the leading scientific journal dedicated to addiction treatment services and implementation research. Dr. McGovern is on the Core Faculty of the National Institute for Mental Health Implementation Research Institute and is a mentor to NIDA Fellows. He also serves on the NIDA Scientific Review Committee for Interventions for the Prevention and Treatment of Addiction.
- Behavioral Health Integration in Primary Care
- Implementation and sustainment science
Professor - Med Center Line, Psychiatry and Behavioral Sciences
Professor - Med Center Line (By courtesy), Medicine - Primary Care and Population Health
Director, Center for Behavioral Health Services & Implementation Research, Department of Psychiatry (2017 - Present)
Medical Director, Integrated Behavioral Health, Division of Primary Care & Population Health, Department of Medicine (2017 - Present)
Co-Chief, Division of Public Mental Health & Population Sciences, Department of Psychiatry (2018 - Present)
Boards, Advisory Committees, Professional Organizations
Study Section Member, NIH Center for Scientific Review, Interventions for the Prevention & Treatment of Addictions (2016 - Present)
Member of National Board of Directors and Chairman of Quality and Program Committee, Phoenix House New York, New York (2017 - Present)
Editor Emeritus, Journal of Substance Abuse Treatment (2017 - Present)
Editor-In-Chief, Journal of Substance Abuse Treatment (2009 - 2017)
PhD Training: Temple University - Dept of Psychology (1986) PA
Fellowship, Northwestern University School of Medicine at Northwestern Memorial Hospital, Emergency and crisis intervention; Psychoanalytic psychotherapy (1985)
Internship: Northwestern University (1984) IL
BA, LaSalle College, Psychology (1977)
Current Research and Scholarly Interests
Our translational research portfolio is designed to directly benefit patients and families by improving their chances of receiving evidence-based treatments at the right time and the right place--whenever and wherever needed.
Our aim is PRECISION IMPLEMENTATION--tailoring the most effective and cost-efficient strategies to achieve patient and family benefit.
We have active implementation research projects currently underway with:
1) the states of California and Washington;
2) the counties of Fairfax (Virginia), Multnomah (Oregon) and Santa Clara (California);
3) by invitation from the people of Navajo Nation;
4) systems of care including US Veterans Affairs, Stanford Health Care (California) and InterMountain (Utah); and
5) national (US states and territories) and regional health care organizations (Comprehensive Options for Drug Abuse, Inc; Portland, Oregon).
Our implementation and sustainment activities are supported by the National Institutes of Health (NIDA, NIAAA, NIMH) and the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). Funding support may also provided by the entities wherein the projects take place.
At present, the content of implementation and sustainment projects includes:
a) integrating a unified model of behavioral health (mental health, addiction, chronic disease management) into routine medical practice settings such as primary care or emergency departments;
b) integrating mental health and addiction services into routine specialty care practices; and
c) expanding the access to and quality of using addiction medications for opioid use disorders in primary care and specialty practice settings.
All projects are co-designed and co-produced with key stakeholders involved in the implementation process, from top level leaders to care providers to patients and families.
Precision in measurement, procedural documentation, and transparency in data analyses and reporting ensure scientific reproducibility and public health impact brought to scale.
The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives.
Substance abuse treatment, prevention, and policy
2020; 15 (1): 84
BACKGROUND: The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding.METHODS: Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n=16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants.RESULTS: Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns.CONCLUSIONS: Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.
View details for DOI 10.1186/s13011-020-00326-x
View details for PubMedID 33148283
What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care.
Addiction science & clinical practice
2020; 15 (1): 29
BACKGROUND: Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers': 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics' ability to care for patients' behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery.RESULTS: Physicians, nurses/nurse practitioners, medical assistants, and other staff (N=59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M=3.5, SD=1.0) compared to those with mental health concerns (M=4.1, SD=0.7), chronic medical conditions (M=4.2, SD=0.7), and general health concerns (M=4.2, SD=0.7) (p<0.001). Physicians (M=3.0, SD=0.7) reported significantly lower levels of comfort than medical assistants (M=4.2, SD=0.9) (p<0.001) caring for patients who use substances.CONCLUSIONS: In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients' substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.
View details for DOI 10.1186/s13722-020-00202-w
View details for PubMedID 32727589
- Implementing Patient-Centred Behavioural Health Integration into Primary Care Using Model-Based Systems Engineering SYSTEMS RESEARCH AND BEHAVIORAL SCIENCE 2020
Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA.
Administration and policy in mental health
To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders' views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors' survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention's focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors' selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention's focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.
View details for DOI 10.1007/s10488-020-01048-9
View details for PubMedID 32399857
INTEGRATED BEHAVIORAL HEALTH: PATIENT AND PROVIDER PERSPECTIVES FROM TWO PRIMARY CARE CLINICS
OXFORD UNIV PRESS INC. 2020: S599
View details for Web of Science ID 000546262401421
ENHANCING INTEGRATED BEHAVIORAL HEALTH PRACTICES: EVALUATION AND MEASUREMENT OF REAL-WORLD IMPLEMENTATION
OXFORD UNIV PRESS INC. 2020: S5
View details for Web of Science ID 000546262400015
Advancing Evidence Synthesis from Effectiveness to Implementation: Integration of Implementation Measures into Evidence Reviews
SPRINGER. 2020: 1219–26
In order to close the gap between discoveries that could improve health, and widespread impact on routine health care practice, there is a need for greater attention to the factors that influence dissemination and implementation of evidence-based practices. Evidence synthesis projects (e.g., systematic reviews) could contribute to this effort by collecting and synthesizing data relevant to dissemination and implementation. Such an advance would facilitate the spread of high-value, effective, and sustainable interventions.The objective of this paper is to evaluate the feasibility of extracting factors related to implementation during evidence synthesis in order to enhance the replicability of successes of studies of interventions in health care settings.Drawing on the implementation science literature, we suggest 10 established implementation measures that should be considered when conducting evidence synthesis projects. We describe opportunities to assess these constructs in current literature and illustrate these methods through an example of a systematic review.Twenty-nine studies of interventions aimed at improving clinician-patient communication in clinical settings.We identified acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, intervention complexity, penetration, reach, and sustainability as factors that are feasible and appropriate to extract during an evidence synthesis project.To fully understand the potential value of a health care innovation, it is important to consider not only its effectiveness, but also the process, demands, and resource requirements involved in downstream implementation. While there is variation in the degree to which intervention studies currently report implementation factors, there is a growing demand for this information. Abstracting information about these factors may enhance the value of systematic reviews and other evidence synthesis efforts, improving the dissemination and adoption of interventions that are effective, feasible, and sustainable across different contexts.
View details for DOI 10.1007/s11606-019-05586-3
View details for Web of Science ID 000544932500033
View details for PubMedID 31848862
View details for PubMedCentralID PMC7174479
Implementing integrated services in routine behavioral health care: primary outcomes from a cluster randomized controlled trial.
BMC health services research
2019; 19 (1): 749
BACKGROUND: An estimated 8.2 million adults in the United States live with co-occurring mental health and substance use disorders. Although the benefits of integrated treatment services for persons with co-occurring disorders has been well-established, gaps in access to integrated care persist. Implementation research can address this gap. We evaluated if the Network for the Improvement of Addiction Treatment (NIATx) implementation strategy was effective in increasing integrated services capacity among organizations treating persons with co-occurring disorders.METHODS: This study employed a cluster randomized waitlist control group design. Forty-nine addiction treatment organizations from the State of Washington were randomized into one of two study arms: (1) NIATx strategy (active implementation strategy), or (2) waitlist (control). The primary outcome was a standardized organizational measure of integrated service capability: the Dual Diagnosis in Addiction Treatment (DDCAT) Index. Intent-to-treat analyses and per-protocol analyses were conducted to address the following questions: (1) Is NIATx effective in increasing integrated service capacity? and (2) Are there differences in organizations that actually use NIATx per-protocol versus those that do not?RESULTS: From baseline to one-year post active implementation, both the NIATx strategy and waitlist arms demonstrated improvements over time in DDCAT Index total and DDCAT dimension scores. In intent-to-treat analyses, a moderate but statistically significant difference in improvement between study arms was seen only in the Program Milieu dimension (p=0.020, Cohen's d=0.54). In per-protocol analyses, moderate-to-large effects in Program Milieu (p=0.002, Cohen's d=0.91) and Continuity of Care (p=0.026, Cohen's d=0.63) dimensions, and in total DDCAT Index (p=0.046, Cohen's d=0.51) were found.CONCLUSIONS: Overall, organizations in both study arms improved DDCAT Index scores over time. Organizations in the NIATx strategy arm with full adherence to the NIATx protocol had significantly greater improvements in the primary outcome measure of integrated service capacity for persons with co-occurring disorders.TRAIL REGISTRATION: ClinicalTrials.gov, NCT03007940 . Retrospectively registered January 2017.
View details for DOI 10.1186/s12913-019-4624-x
View details for PubMedID 31651302
Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact.
Journal of substance abuse treatment
As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid f specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.
View details for DOI 10.1016/j.jsat.2019.07.013
View details for PubMedID 31399272
"No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder.
Journal of substance abuse treatment
2019; 97: 28–40
INTRODUCTION: Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings.METHODS: Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut.RESULTS: We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC.CONCLUSIONS: Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.
View details for PubMedID 30577897
Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol.
Pain medicine (Malden, Mass.)
Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology.EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions.The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.
View details for DOI 10.1093/pm/pnz285
View details for PubMedID 31876947
Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review.
BMC family practice
2019; 20 (1): 157
The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine.Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings.Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients.Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.
View details for DOI 10.1186/s12875-019-1047-z
View details for PubMedID 31729957
Integration of care for HIV and opioid use disorder.
AIDS (London, England)
2019; 33 (5): 873–84
We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.Systematic review.We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
View details for PubMedID 30882491
Integration of care for HIV and opioid use disorder: a systematic review of interventions in clinical and community-based settings.
AIDS (London, England)
OBJECTIVE: We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.DESIGN: Systematic review.METHODS: We searched Ovid MEDLINE, PubMed, Embase, and PsycINFO and pre-identified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.RESULTS: Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low to moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV- and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.CONCLUSION: Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.REGISTRATION: A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
View details for PubMedID 30585841
- Is Integrated CBT Effective in Reducing PTSD Symptoms and Substance Use in Iraq and Afghanistan Veterans? Results from a Randomized Clinical Trial COGNITIVE THERAPY AND RESEARCH 2018; 42 (6): 735–46
Using NIATx strategies to implement integrated services in routine care: a study protocol
BMC HEALTH SERVICES RESEARCH
2018; 18: 431
Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial.This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC).This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders.ClinicalTrials.gov NCT03007940 . Registered 02 January 2017 - Retrospectively Registered.
View details for PubMedID 29884164
Operationalizing the Consolidated Framework for Implementation Research into a mixed methods measure: the CFIR Index
BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428652000122
A Unified Model of Behavioral Health Integration in Primary Care
View details for DOI 10.1007/s40596-018-0887-5
A Unified Model of Behavioral Health Integration in Primary Care.
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry
2018; 42 (2): 265–68
View details for PubMedID 29488173
Trends in inequalities in child stunting in South Asia
Maternal & Child Nutrition 2017
2018; 14: 1-12
View details for DOI 10.1111/mcn.12517
Impact of age of onset of psychosis and engagement in higher education on duration of untreated psychosis
JOURNAL OF MENTAL HEALTH
2018; 27 (3): 257–62
The average age of onset of psychosis coincides with the age of college enrollment. Little is known about the impact of educational engagement on DUP in a college-aged population.To determine DUP, and the impact of educational engagement, for college-aged participants of the RAISE study (n = 404).We conducted secondary data analyses on the publicly available RAISE dataset. Subsamples were analyzed to determine the impact of age and educational engagement on DUP.DUP was significantly shorter (p < 0.02) for participants who were college-aged (18-22 years, n = 44) and engaged in post-secondary education (median = 12 weeks, mean = 29 weeks) compared with participants who were college-aged and not engaged in higher education (n = 92, median = 29 weeks, mean = 44 weeks).Educational engagement appears to be associated with a shorter DUP. This may be partially explained by the presence of on-site wellness centers in college settings. However, even among young people who engaged in post-secondary education DUP was still at, or beyond, the upper limit of WHO recommendations in this group. Future research exploring how colleges could improve their capacity to detect and refer at risk students for treatment at an earlier stage is recommended.
View details for PubMedID 29707996
Individual Placement and Support (IPS) for Methadone Maintenance Therapy Patients: A Pilot Randomized Controlled Trial.
Administration and policy in mental health
Individual Placement and Support (IPS) is an evidence-based employment model for people with severe mental illness, but it has not been evaluated for clients enrolled in substance abuse treatment programs. This study evaluated the effectiveness of IPS for people with opioid use disorders enrolled in an opioid treatment program. Within a randomized controlled experiment, 45 patients receiving methadone maintenance therapy were assigned to either IPS or a 6-month waitlist. The waitlist group received IPS after 6 months. The primary outcome assessed over 1 year compared the attainment of a job for the IPS condition to the waitlist comparison group. During the first 6 months after enrollment, 11 (50%) active IPS participants gained competitive employment compared to 1 (5%) waitlist participant (Χ (2) = 12.0, p < 0.001). Over 12 months of enrollment, 11 (50%) IPS participants gained competitive employment compared to 5 (22%) waitlist participants (Χ (2) = 3.92, p = 0.07). We conclude that IPS holds promise as an employment intervention for people with opioid use disorders in methadone maintenance treatment, but larger trials with longer follow-up are needed.
View details for DOI 10.1007/s10488-017-0793-2
View details for PubMedID 28213673
- Developing an integrated behavioral health system using engineering design. Industrial and Systems Engineering Conference 2017
The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD
JOURNAL OF SUBSTANCE USE
2016; 21 (3): 237-243
Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD).A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression.At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up.For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
View details for DOI 10.3109/14659891.2015.1005184
View details for Web of Science ID 000375171700004
View details for PubMedID 27182200
View details for PubMedCentralID PMC4864012
Using a Learning Collaborative Strategy With Office-based Practices to Increase Access and Improve Quality of Care for Patients With Opioid Use Disorders
JOURNAL OF ADDICTION MEDICINE
2016; 10 (2): 117-123
Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont.We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology.Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%).Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.
View details for DOI 10.1097/ADM.0000000000000200
View details for Web of Science ID 000374748800007
View details for PubMedID 26900669
View details for PubMedCentralID PMC4865252
- Responding to the opioid epidemic: Vermont’s hub and spoke model as a system of care. American Psychological Association Division 50 Addictions Newletter. 2016 ; Addictions Newsletter (2): 32–34
The Impact of Addiction Medications on Treatment Outcomes for Persons With Co-Occurring PTSD and Opioid Use Disorders
AMERICAN JOURNAL ON ADDICTIONS
2015; 24 (8): 722-731
Previous research has been inconclusive about whether adding psychosocial treatment to medication assisted treatment (MAT) improves outcomes for patients with co-occurring psychiatric and opioid use disorders. This study evaluated the impact of MAT and psychosocial therapies on treatment outcomes for patients with co-occurring opioid use disorders and PTSD.Patients meeting criteria for PTSD and substance use disorders were randomly assigned to one of three treatment conditions: Standard Care (SC) alone, Integrated Cognitive Behavioral Therapy (ICBT) plus SC, or Individual Addiction Counseling (IAC) plus SC. Substance use and psychiatric symptoms were assessed at baseline and 6 months. Only patients with opioid use disorders were included in the present analyses (n = 126). Two-way ANOVAS and logistic regression analyses were used to examine associations between treatment conditions and MAT, for substance use and psychiatric outcomes.MAT patients receiving ICBT had significantly decreased odds of a positive urine drug screen, compared to non-MAT patients receiving SC alone (OR = .07, 95% CI = .01, .81, p = .03). For PTSD symptoms, a significant MAT by psychosocial treatment condition interaction demonstrated that MAT patients had comparable declines in PTSD symptoms regardless of psychosocial treatment type (F(2, 88) = 4.74, p = .011). Non-MAT patients in ICBT had significantly larger reductions in PTSD.For patients with co-occurring opioid use disorders and PTSD, MAT plus ICBT is associated with more significant improvement in substance use. For non-MAT patients, ICBT is most beneficial for PTSD symptoms.
View details for DOI 10.1111/ajad.12292
View details for Web of Science ID 000368506100005
View details for PubMedID 26388539
View details for PubMedCentralID PMC4866634
Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2015; 41 (6): 527-534
The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented.This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes.Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up.Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity.The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.
View details for DOI 10.3109/00952990.2015.1062894
View details for Web of Science ID 000364408700007
View details for PubMedID 26286351
View details for PubMedCentralID PMC4698972
A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder
2015; 110 (7): 1194-1204
Post-traumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of integrated cognitive-behavioral therapy (ICBT) plus standard care, individual addiction counseling plus standard care and standard care alone on substance use and PTSD symptoms.Three-group, multi-site randomized controlled trial.Seven addiction treatment programs in Vermont and New Hampshire, USA.Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n = 73), individual addiction counseling (IAC) plus SC (n = 75) or SC only (n = 73). One hundred and seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence and recovery. SC are intensive out-patient program services that include 9-12 hours of face-to-face contact per week over 2-4 days of group and individual therapies plus medication management.Primary outcomes were PTSD severity and substance use severity at 6 months. Secondary outcomes were therapy retention.PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC [comparison with IAC, parameter estimate: 1.10; confidence interval (CI) = 0.17-2.04; comparison with SC, parameter estimate: 1.13; CI = 0.18-2.08] and had a greater reduction in reported drug use than SC (parameter estimate: -9.92; CI = -18.14 to -1.70). ICBT patients had better therapy continuation versus IAC (P<0.001). There were no unexpected or study-related adverse events.Integrated cognitive behavioral therapy may improve drug-related outcomes in post-traumatic stress disorder sufferers with substance use disorder more than drug-focused counseling, but probably not by reducing post-traumatic stress disorder symptoms to a greater extent.
View details for DOI 10.1111/add.12943
View details for Web of Science ID 000356808500023
View details for PubMedID 25846251
View details for PubMedCentralID PMC4478141
The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders
JOURNAL OF PSYCHOACTIVE DRUGS
2015; 47 (1): 42-50
Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.
View details for DOI 10.1080/02791072.2014.977501
View details for Web of Science ID 000349897500006
View details for PubMedID 25715071
View details for PubMedCentralID PMC4876862
Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2014; 40 (4): 304-311
Prescription opioids are the most rapidly growing category of abused substances, and result in significant morbidity, mortality and healthcare costs. Co-occurring with psychiatric disorders, persons with prescription opioid problems have negative treatment outcomes. Data are needed on the prevalence of co-occurring prescription opioid abuse and specific disorders, such as posttraumatic stress disorder (PTSD), to better inform clinical practice.To determine prevalence rates of current co-occurring prescription opioid use problems and PTSD symptom severity among patients in community addiction treatment settings.We abstracted administrative and chart information on 573 new admissions to three addictive treatment agencies during 2011. Systematic data were collected on PTSD symptoms, substance use, and patient demographics.Prescription opioid use was significantly associated with co-occurring PTSD symptom severity (OR: 1.42, p < 0.05). Use of prescription opioids in combination with sedatives (OR: 3.81, p < 0.01) or cocaine (OR: 2.24, p < 0.001) also were associated with PTSD severity. The odds of having co-occurring PTSD symptoms and prescription opioid use problem were nearly three times greater among females versus males (OR: 2.63, p < 0.001). Younger patients (18-34 years old) also were at higher risk (OR: 1.86, p < 0.01).Prescription opioid use problems are a risk factor for co-occurring PTSD symptom severity. Being female or younger increase the likelihood of this co-morbidity. Further research is needed to confirm these finding, particularly using more rigorous diagnostic procedures. These data suggest that patients with prescription opioid use problems should be carefully evaluated for PTSD symptoms.
View details for DOI 10.3109/00952990.2014.910519
View details for Web of Science ID 000338194000008
View details for PubMedID 24809229
View details for PubMedCentralID PMC4883674
Dual Diagnosis Capability in Mental Health and Addiction Treatment Services: An Assessment of Programs Across Multiple State Systems
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2014; 41 (2): 205-214
Despite increased awareness of the benefits of integrated services for persons with co-occurring substance use and psychiatric disorders, estimates of the availability of integrated services vary widely. The present study utilized standardized measures of program capacity to address co-occurring disorders, the dual diagnosis capability in addiction treatment and dual diagnosis capability in mental health treatment indexes, and sampled 256 programs across the United States. Approximately 18 % of addiction treatment and 9 % of mental health programs met criteria for dual diagnosis capable services. This is the first report on public access to integrated services using objective measures.
View details for DOI 10.1007/s10488-012-0449-1
View details for Web of Science ID 000331200300006
View details for PubMedID 23183873
View details for PubMedCentralID PMC3594447
Integrated Cognitive Behavioral Therapy (ICBT) For PTSD and Substance Use in Iraq and Afghanistan Veterans: A Feasibility Study.
Journal of Traumatic Stress Disorders & Treatment
2014; 3 (4)
Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is prevalent in military Veterans and is associated with poorer outcomes than either disorder alone. The current pilot study examines the feasibility of delivering integrated cognitive behavioral therapy (ICBT) for co-occurring PTSD-SUD to Veterans who served in Iraq and Afghanistan. Our primary aims were testing the feasibility of engaging and retaining Veterans with a complex clinical presentation in a 12-week structured therapy. We focused on two feasibility outcomes: 1) acceptability; and 2) tolerability. We also examined clinically meaningful change in PTSD and depressive symptoms as a secondary aim. Over the course of the study, we recruited 12 eligible Veterans, 6 of whom completed ICBT. We encountered challenges related to engaging and retaining Veterans in treatment and discuss adaptations and refinements of ICBT or other integrated treatments for returning Veterans with co-occurring PTSD-SUD to increase feasibility with military Veterans.
View details for PubMedID 25580442
View details for PubMedCentralID PMC4288018
- A manual-guided therapy for co-occurring substance use and psychiatric disorders delivered by community addiction counselors: Are outcomes different from psychotherapy delivered by mental health professionals? Journal of Addictive Behaviors, Therapy and Rehabilitation 2014; 3 (3)
Assessing the Co-occurring Capability of Mental Health Treatment Programs: the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index
JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH
2013; 40 (2): 234-241
The Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index was developed to assess the capability of mental health programs to provide substance abuse and co-occurring treatment services. The DDCMHT is an objective scale rated following a site visit that includes semi-structured interviews with staff at all levels, review of program documents and client charts, and ethnographic observation of the milieu and setting. Using data from 67 mental health programs across six states, this study found that the DDCMHT had excellent total score reliability, variable subscale reliability, high inter-rater reliability (n = 18), and moderate construct validity (n = 22). Results also suggest that many mental health programs are at a relatively low level of capability for the delivery of care to individuals with co-occurring disorders. Results from this important new benchmark measure, the DDCMHT, can be used with programs in implementation planning and with treatment systems, states, or national organizations to guide policy change.
View details for DOI 10.1007/s11414-012-9317-8
View details for Web of Science ID 000318518100009
View details for PubMedID 23334656
- Substance abuse treatment implementation research JOURNAL OF SUBSTANCE ABUSE TREATMENT 2013; 44 (1): 1-3
Organizational Capacity to Address Co-occurring Substance Use and Psychiatric Disorders: Assessing Variation by Level of Care
JOURNAL OF ADDICTION MEDICINE
2013; 7 (1): 25-32
There is widespread recognition that services to persons with co-occurring substance use and psychiatric disorders should be accessible, yet most persons with these disorders do not receive care for both problems. Estimates of available services vary widely and have not examined potential variation by level of care.The present study samples 180 community addiction treatment programs and utilizes a standardized observational assessment of these programs using the dual diagnosis capability of addiction treatment (DDCAT) index. By level of care, the sample consisted of 53 outpatient programs, 50 intensive outpatient programs, and 77 residential programs.Overall, approximately 81.1% of programs across levels of care offered addiction-only services, 18.3% dual diagnosis capable services, and less than 1% dual diagnosis enhanced services. Relative to residential and intensive outpatient programs, outpatient programs were more likely to have greater dual diagnosis capability (dual diagnosis capable services). Outpatient programs scored significantly higher on the DDCAT dimensions associated with program policies and continuity of care. Specific DDCAT benchmark items revealing detailed differences were found in these dimensions and specific assessment and treatment practices. Access to physician-prescriber or to psychotropic medications did not differ by level of care.The findings suggest that across levels of care, addiction-treatment systems and programs must continue to improve capacity for patients with co-occurring disorders. The application of a standardized, objective, and observational instrument may be useful to guide and measure the effectiveness of these efforts.
View details for DOI 10.1097/ADM.0b013e318276e7a4
View details for Web of Science ID 000314825100004
View details for PubMedID 23188042
- Measuring Organizational Capacity to Treat Co-Occurring Psychiatric and Substance Use Disorders. Journal of dual diagnosis 2013; 9 (2): 165-170
Development and initial feasibility of an organizational measure of behavioral health integration in medical care settings
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 43 (4): 402-409
In the advent of health care reform, models are sought to integrate behavioral health and routine medical care services. Historically, the behavioral health specialty has not itself been integrated, but instead bifurcated by substance use and mental health across treatment systems, care providers and even research. With the present opportunity to transform the health care delivery system, it is incumbent upon policymakers, researchers and clinicians to avoid repeating this historical error, and provide integrated behavioral health services in medical contexts. An organizational measure designed to assess this capacity is described: the Dual Diagnosis Capability in Health Care Settings (DDCHCS). The DDCHCS was used to assess a sample of federally-qualified health centers (N=13) on the degree of behavioral health integration. The measure was found to be feasible and sensitive to detecting variation in integrated behavioral health services capacity. Three of the 13 agencies were dual diagnosis capable, with significant variation in DDCHCS dimensions measuring staffing, treatment practices and program milieu. In general, mental health services were more integrated than substance use. Future research should consider a revised version of the measure, a larger and more representative sample, and linking organizational capacity with patient outcomes.
View details for DOI 10.1016/j.jsat.2012.08.013
View details for Web of Science ID 000311063000005
View details for PubMedID 22999813
An intervention to increase alcohol treatment engagement: A pilot trial
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 43 (2): 161-167
Previous research has documented the difficulty individuals with alcohol use disorders have initiating alcohol treatment. This study assessed the feasibility of a brief, cognitive-behavioral intervention designed to increase treatment initiation among individuals with alcohol use disorders.This randomized controlled trial included 196 participants who screened positive for a possible alcohol use disorder on the alcohol use disorders identification test. Randomly assigned intervention participants were administered a brief cognitive-behaviorally-based intervention by telephone designed to modify beliefs that may interfere with treatment-seeking behavior. Beliefs about treatment and treatment-seeking behavior were assessed postintervention.Participants receiving the intervention had significantly improved their attitudes toward addiction treatment (p < .002) and increased their reported intention-to-seek treatment (p < .000) postintervention. Further, intervention participants were almost three times more likely to attend treatment within a 3-month period (odds ratio = 2.60, p < .025) than participants in the control group.A brief, cognitive-behavioral intervention delivered by telephone and focused on modifying treatment-interfering beliefs holds promise for increasing alcohol treatment seeking among individuals in need.
View details for DOI 10.1016/j.jsat.2011.10.028
View details for Web of Science ID 000307207100003
View details for PubMedID 22138200
View details for PubMedCentralID PMC3297732
- Journal of Substance Abuse Treatment: Tradition, change and opportunity JOURNAL OF SUBSTANCE ABUSE TREATMENT 2012; 42 (1): 1-3
A Randomized Controlled Trial Comparing Integrated Cognitive Behavioral Therapy Versus Individual Addiction Counseling for Co-occurring Substance Use and Posttraumatic Stress Disorders
JOURNAL OF DUAL DIAGNOSIS
2011; 7 (4): 207-227
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 warranted.
View details for DOI 10.1080/15504263.2011.620425
View details for Web of Science ID 000300007600003
View details for PubMedID 22383864
View details for PubMedCentralID PMC3289146
- The boundaries of addiction treatment services research JOURNAL OF SUBSTANCE ABUSE TREATMENT 2011; 40 (1): 1-2
- Co-occurring Substance Use and Posttraumatic Stress Disorders: Reasons for Hope JOURNAL OF DUAL DIAGNOSIS 2011; 7 (4): 187-193
Co-Occurring Medical, Psychiatric, and Alcohol-Related Disorders Among Veterans Returning From Iraq and Afghanistan
2010; 51 (6): 503-507
Soldiers often return from war with a variety of combat-related mental health conditions, including posttraumatic stress disorder, depression, and substance-use disorders.The authors investigated common co-occurring medical and psychiatric conditions and patterns of conditions among returning Iraq/Afghanistan veterans using the Veterans Administration (VA) healthcare systems.Common clusters of ICD-9 diagnostic-related conditions among returning soldiers (N=293,861) were extracted from the VA data center.Diagnoses involving pain are extremely common among returning veterans seeking health care at the VA. In addition to pain-related conditions, psychiatric disorders rank second most prevalent. Psychiatric disorders, and in particular the multimorbid triad of pain, posttraumatic stress disorder, and depression frequently overlap.As more veterans return from war, there will be greater need for effective services. Given the findings of high rates of comorbidity and multimorbidity, VA services should be reorganized so as to co-locate psychiatric staff in pain centers, simultaneously targeting pain and psychiatric disorders.
View details for Web of Science ID 000283851800008
View details for PubMedID 21051682
- Improving the Dual Diagnosis Capability of Addiction and Mental Health Treatment Services: Implementation Factors Associated With Program Level Changes JOURNAL OF DUAL DIAGNOSIS 2010; 6 (3-4): 237-250
- Co-occurring substance abuse and psychiatric disorders. The Robert Wood Johnson Foundation, Substance Abuse Policy Research Program. http://www.saprp.org/knowledgeassets/Knowledge.cfm. 2010
A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders
2009; 34 (10): 892-897
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.
View details for DOI 10.1016/j.addbeh.2009.03.009
View details for Web of Science ID 000269170300015
View details for PubMedID 19395179
View details for PubMedCentralID PMC2720425
Racial/Ethnic Disparities in Mental Health Treatment in Six Medicaid Programs
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2009; 20 (1): 165-176
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.
View details for Web of Science ID 000263480000017
View details for PubMedID 19202255
Impact of Substance Disorders on Medical Expenditures for Medicaid Beneficiaries With Behavioral Health Disorders
2009; 60 (1): 35-42
This study measured the impact of substance use disorders on Medicaid expenditures for behavioral and physical health care among beneficiaries with behavioral health disorders.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.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.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.
View details for Web of Science ID 000262049600007
View details for PubMedID 19114568
- The status of addiction treatment research with co-occurring substance use and psychiatric disorders JOURNAL OF SUBSTANCE ABUSE TREATMENT 2008; 34 (1): 1-2
Co-occurring psychiatric and substance use disorders: A multistate feasibility study of the quadrant model
2007; 58 (7): 949-954
The quadrant model was developed to organize the heterogeneous group of persons with co-occurring psychiatric and substance use disorders and to anticipate differential use of systems of care. The purpose of the study presented here was to test the feasibility of applying the model to classify persons with co-occurring disorders, examine the reliability of quadrant prevalence and distribution, and test the validity of differential service use by quadrant.Medicaid claims data from 1999 from six states were analyzed, and 22,912 individuals with co-occurring disorders were classified into quadrants, by severity of substance use and psychiatric disorders. Distribution by quadrant and the utilization of emergency and inpatient services were analyzed.A majority of cases were classified in quadrant IV (52.5%) (high severity of psychiatric and substance use disorders), and fewest were classified in quadrant I (8.2%) (low severity of psychiatric and substance use disorders). There was equivalence in distribution for quadrant III (19.8%) (high severity of substance use disorders and low severity of psychiatric disorders) and quadrant II (19.4%) (high severity of psychiatric disorders and low severity of substance use disorders). Distribution was consistent across states, and service utilization was most associated with quadrant IV. Persons with the more severe psychiatric problems (quadrants II and IV) were more likely to be female, to be older, and to have been hospitalized or to have visited an emergency department. Another important finding is the high rate of persons with substance dependence disorders (quadrants III and IV).The feasibility of applying the quadrant model was supported. The quadrant model has been well adopted conceptually by community providers and policy makers. The consistency of the findings across six state Medicaid systems supports the potential utility of the model to articulate patient characteristics and service use patterns. Further application and research with this model is proposed.
View details for Web of Science ID 000253360400010
View details for PubMedID 17602011
Treatment for co-occurring mental and substance use disorders in five state Medicaid programs
2007; 58 (7): 942-948
This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states.Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated.A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone.Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.
View details for Web of Science ID 000253360400009
View details for PubMedID 17602010
Addiction treatment services and co-occurring disorders: The ASAM-PPC-2R taxonomy of program dual diagnosis capability
JOURNAL OF ADDICTIVE DISEASES
2007; 26 (3): 27-37
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.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.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.The findings support the utility of the ASAM dual diagnosis capability taxonomy, and suggest specific avenues for system and program assessment and future research.
View details for DOI 10.1300/J069v26n03_04
View details for Web of Science ID 000248992800004
View details for PubMedID 18018806
Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2006; 31 (3): 267-275
As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 453 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.
View details for DOI 10.1016/j.jsat.2006.05.003
View details for Web of Science ID 000241215900006
View details for PubMedID 16996389
A systematic analysis of college substance use policies
JOURNAL OF AMERICAN COLLEGE HEALTH
2005; 54 (3): 169-176
College substance use policies provide guidelines for student behavior and influence campus culture. Although they are the primary environmental strategy to address campus substance use, policies have not been systematically compared and studied. We constructed a systematic review method to examine the accessibility, comprehensiveness, enforcement procedures, and clarity of college substance use policies. We developed an objective evaluation scheme for each of these 4 dimensions and then applied it to documented substance use policies from a sample of colleges and universities (N = 24). Policies were found to vary considerably but tended to specify compliance with local laws and emphasize student health and well-being. The next stage of campus policy review should examine actual implementation, evaluate potential differentiating factors among institutions, and assess the influence of policy on campus climate and student outcomes.
View details for Web of Science ID 000233811500006
View details for PubMedID 16335317
Relapse of substance use disorder and its prevention among persons with co-occurring disorders
2005; 56 (10): 1270-1273
This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.
View details for Web of Science ID 000232470100013
View details for PubMedID 16215194
Future directions in preventing relapse to substance abuse among clients with severe mental illnesses
2005; 56 (10): 1297-1302
The authors review the literature on substance use disorders among persons with severe mental illnesses, including the other papers in this special section on relapse prevention, and suggest future directions. Although prevention of relapse to substance abuse has a well-developed theoretical and empirical base, this perspective has rarely been applied to persons with co-occurring severe mental illness. Research indicates that clients with co-occurring disorders are highly prone to relapse to substance abuse, even after they have attained full remission. Their risk factors include exacerbations of mental illness, social pressures within drug-using networks, lack of meaningful activities and social supports for recovery, independent housing in high-risk neighborhoods, and lack of substance abuse or dual diagnosis treatments. The evidence in hand suggests several steps: developing healthy and protective environments that are experienced as nurturing of recovery; helping people make fundamental changes in their lives, such as finding satisfying jobs, abstinent friends, networks of people who are in the process of recovery, and a sense of meaning; providing specific and individualized treatments for mental illnesses, substance use disorders, and other co-occurring problems; and developing longitudinal research on understanding and preventing relapse that addresses social context as well as biological vulnerabilities and cognitive strategies.
View details for Web of Science ID 000232470100018
View details for PubMedID 16215199
Physicians and nurses with substance use disorders
JOURNAL OF ADVANCED NURSING
2004; 47 (5): 561-571
The literature addressing substance use patterns among medical professionals suggests that specialty, gender, age, familial substance abuse, and access/familiarity with prescription drugs are associated with particular chemical dependencies. These studies have rarely compared nurses and physicians directly, thereby making if difficult to tailor interventions to the potentially unique needs of each group.This paper reports a study to compare the initial clinical presentations, service utilization patterns, and post-treatment functioning of nurses and physicians who received services in an addiction treatment programme.This exploratory study combined data collected through retrospective record reviews and prospective questionnaires. There were three types of dependent variables: initial clinical characteristics, treatment utilization patterns, and post-treatment functioning. The independent variable was membership of either professional group. Time both in treatment and between discharge and follow-up were covariates.Nurses and physicians showed comparable results in most domains. Among the statistically significant differences between groups, a subset was particularly noteworthy. Prior to participating in the programme nurses showed significantly less personality disturbance than physicians, although they tended to work and live in environments with more triggers to relapse, such as other substance users. After the index hospitalization, nurses received less primary treatment, worked longer hours, and were more symptomatic than physicians. Furthermore, nurses reported more frequent and severe work-related sanctions as a consequence of their behavioural disorders.In most areas of study, nurses and physicians demonstrated comparable results; however, a series of statistically significant differences suggest that these groups may have unique clinical needs. The policy implications of these findings are discussed.
View details for Web of Science ID 000223281600012
View details for PubMedID 15312119
A survey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment system
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2004; 26 (4): 305-312
Addiction research is challenged to disseminate evidence-based practices into routine clinical settings. The successful adoption of innovation must consider issues of fit, such as the characteristics, readiness, and attitudes of clinicians in the community. We constructed a survey to assess clinical practices and readiness to adopt certain evidence-based practices in addiction treatment programs. The instrument was administered to directors (n = 21) and clinicians (n = 89) from 24 public addiction treatment programs in New Hampshire (USA). Clinicians are more motivated to adopt some evidence-based practices (twelve-step facilitation, cognitive behavioral therapy, motivational interviewing, relapse prevention therapy) than others (contingency management, behavioral couples therapy, pharmacotherapies). Translational strategies for treatment development and research dissemination are discussed.
View details for DOI 10.1016/j.jsat.2004.03.003
View details for Web of Science ID 000222018400008
View details for PubMedID 15182895
Evidence-based practices for substance use disorders
PSYCHIATRIC CLINICS OF NORTH AMERICA
2003; 26 (4): 991-?
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.
View details for DOI 10.1016/S0193-953X(03)00073-X
View details for Web of Science ID 000187528500013
View details for PubMedID 14711132
View details for PubMedCentralID PMC3678283
Gender of physicians with substance use disorders: Clinical characteristics, treatment utilization, and post-treatment functioning
SUBSTANCE USE & MISUSE
2003; 38 (7): 993-1001
Gender has emerged as an important variable in both the course and treatment of substance-use disorders. This study examines the role of gender in a sample of physicians (n = 73) treated for substance-use disorders. Pilot data gathered on physicians treated during 1995 to 1997, included initial pretreatment characteristics, service utilization, and posttreatment functioning. Although there were many similarities, important differences emerged among the groups. These differences have implications for physician education and training and warrant more systematic clinical research.
View details for DOI 10.1081/JA-120017620
View details for Web of Science ID 000183310300009
View details for PubMedID 12801152
Psychiatric comorbidity and physicians with substance use disorders: A comparison between the 1980s and 1990s
JOURNAL OF ADDICTIVE DISEASES
2003; 22 (3): 79-87
The assessment and treatment of physicians with substance use disorders has been of considerable interest over the past twenty years. This study compares two cohorts of addicted physicians treated at a single program. Data from 101 physicians treated during 1985 to 1987 were compared with 73 physicians treated from 1995 to 1997. Although the cohorts were similar on demographic, physician specialty, and drug of choice variables, psychiatric comorbidity was significantly more prevalent in the later sample.
View details for DOI 10.1300/J069v22n03_07
View details for Web of Science ID 000186710000007
View details for PubMedID 14621346
- Psychiatric comorbidity and physicians with substance use disorders: Clinical characteristics, treatment experiences, and post-treatment functioning. Addictive Disorders & Their Treatment 2002; 1 (3): 89-98
Characteristics of physicians presenting for assessment at a behavioral health center
JOURNAL OF ADDICTIVE DISEASES
2000; 19 (2): 59-73
Physician health and impairment have been of considerable interest in recent years. This study contributes detailed clinical data to the existing body of knowledge, by drawing from a sample of physicians assessed at a behavioral health center over a two year time frame. Demographic, referral, and clinical data were gathered using a systematic medical record review procedure, based on 108 physicians who were evaluated within an intensive multidisciplinary assessment program. The majority suffered from active substance use disorders (52.8%), with other psychiatric disorders (29.6%), and substance use disorders in remission (17.6%) the other largest categories. Of those with an active substance use disorder, primary drugs of choice were alcohol and prescription opiates. Over half had comorbid psychiatric disorders (Axis I, II, or both). Significant relationship, employment, and emotional problems were found in all three groups. The significant increase in presentation and/or detection of psychiatric and behavioral problems, both comorbid with and not substance use related, confirms the need for a revision and expansion of views about physicians' behavioral health concerns.
View details for Web of Science ID 000086601700005
View details for PubMedID 10809520
Training in substance use disorders assessment and intervention: Design and implementation of a model within a traditional mental health clinic
PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE
1999; 30 (4): 411-414
View details for Web of Science ID 000081608300014
Diagnosis and treatment of psychiatric comorbidity in alcoholics and drug addicts
1998; 28 (12): 705-?
View details for Web of Science ID 000077513400006
Female physicians and substance abuse - Comparisons with male physicians presenting for assessment
JOURNAL OF SUBSTANCE ABUSE TREATMENT
1998; 15 (6): 525-533
As with women in general, the vicissitudes of the female physician who suffers from a substance use disorder have been understudied, and such persons remain underrepresented in treatment. The purpose of the present study is to describe the similarities and differences between female and male physicians presenting for assessment; 108 physicians in total were included in the study, 10 of whom were female. Demographically, we found that the female physicians were more likely to be single and younger than their male counterparts. On clinical indices, females showed less impairment on legal and medical functioning, and better capability in sustaining abstinence and eliminating environmental cues to relapse. Of the women with substance use disorders, higher rates of comorbidity were found than with males. Although there were no significant differences in overall severity, males were more likely to be recommended to more intensive levels of care for either substance use or psychiatric disorders. The female physicians were recommended to a level of care of a lower intensity, but more often to a treatment with a dual-diagnosis focus. These findings are discussed in terms of the vulnerabilities of the female physician, barriers to treatment, tailoring treatment to female needs, and opportunities for prevention and further research.
View details for Web of Science ID 000077210000006
View details for PubMedID 9845866
Differential therapeutics and the impaired physician: Patient-treatment matching by specificity and intensity
JOURNAL OF ADDICTIVE DISEASES
1998; 17 (2): 93-107
The objective of this study was to determine the nature and degree of patient to treatment matching for a sample of physicians based on differential problem type and severity. Methods included a single assessment of variables using retrospective chart review. Subjects included 108 physicians (98 men and 10 women), who were sampled consecutively from assessments performed over a 2-year period. They represented a variety of specialties, and most were third-party referred, predominantly by state medical societies. Main outcome measures included demographic information, DSM-IV multiaxial diagnoses, the Severity of Substance-Related Disorder scale, and the type and intensity of recommended treatment. It was found that the physicians presented with a variety of conditions that were clustered into three categories: active substance use disorders (52.8%), substance use disorders in remission (17.6%), and psychiatric/behavioral problems (29.6%). An analysis of the appropriateness of matching types of treatment to these problem categories appeared to support a differential assignment process. A range in severity was also found within problem categories and was subsequently tested for correspondence with the range in intensity of recommended treatment. It was found that severity correlated strongly with recommended treatment intensity for all groups. In addition, multiple regression analyses showed that two factors, ability to sustain abstinence and emotional disturbance, were predictive of treatment intensity for the two substance use disorder subgroups (64% of variance accounted for). In the psychiatric/behavioral problem subgroup, such analysis demonstrated that the severity of difficulties with one's significant other was predictive of treatment intensity (89% of variance accounted for).
View details for Web of Science ID 000073093900007
View details for PubMedID 9567228
- Triaging the impaired physician: Patient-treatment matching by specificity and intensity. Epikrisis 1998; 9 (6): 1-2
Treatment matching and the impaired physician: Assessment of substance use, psychiatric, and behavioral problems
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD. 1997: A1–A1
View details for Web of Science ID A1997WP06400009
Utility of the chemical use, abuse, and dependence scale in screening patients with severe mental illness
1996; 47 (6): 647-649
The Chemical Use, Abuse, and Dependence (CUAD) Scale was administered with other scales to 100 consecutive admissions to a psychiatric hospital. Moderately high correlations with other measures of drug and alcohol use were obtained. Although more research with the CUAD is necessary, it may be potentially useful in screening for substance use among severely mentally ill patients.
View details for Web of Science ID A1996UN31900018
View details for PubMedID 8726496
OBJECT RELATIONS AND SOCIAL FUNCTIONING OF SCHIZOPHRENIC AND BORDERLINE PATIENTS - A CROSS-SECTIONAL DEVELOPMENTAL PERSPECTIVE
JOURNAL OF CLINICAL PSYCHOLOGY
1993; 49 (3): 319-326
Using a cross-sectional design, this study compared patients with schizophrenic and borderline personality disorders on measures of object relations and social functioning. Although we found that on measures of object relations the borderline group remained less impaired than the schizophrenics, during the course of the lifespan the schizophrenic patients appeared to surpass the borderlines on social functioning. These results are integrated with the literature that compares the long-term course and outcomes for these disorders and are discussed within the context of differential adaptive capacities, change mechanisms, and treatment interventions.
View details for Web of Science ID A1993LE86300002
View details for PubMedID 8315032
PROBLEM SEVERITY AND SYMPTOMATOLOGY AMONG SUBSTANCE MISUSERS - DIFFERENCES BETWEEN AFRICAN-AMERICANS AND CAUCASIANS
INTERNATIONAL JOURNAL OF THE ADDICTIONS
1993; 28 (9): 909-922
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.
View details for Web of Science ID A1993LP99400007
View details for PubMedID 8359947
- The clinician factor in addiction treatment: Implications for differential practices. Alcoholism and Drug Research 1992; 3 (3): 10
THE CHEMICAL USE, ABUSE, AND DEPENDENCE SCALE (CUAD) - RATIONALE, RELIABILITY, AND VALIDITY
JOURNAL OF SUBSTANCE ABUSE TREATMENT
1992; 9 (1): 27-38
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.
View details for Web of Science ID A1992HR00500005
View details for PubMedID 1317464
- Psychiatric symptomatology among alcoholics: Comparisons between African-Americans and Caucasians. Psychology of Addictive Behaviors 1992; 6 (4): 219-224
CAPITATION PAYMENT SYSTEMS AND PUBLIC MENTAL-HEALTH-CARE - IMPLICATIONS FOR PSYCHOTHERAPY WITH THE SERIOUSLY MENTALLY-ILL
AMERICAN JOURNAL OF ORTHOPSYCHIATRY
1990; 60 (2): 298-304
The evolution, rationale, and implications of capitation payment systems in public mental health are discussed. These systems will unify the clinical, administrative, and fiscal structures of state and community mental health providers. Psychotherapeutic practice may shift to more action-oriented, problem-focused, brief and crisis interventions. The diminishing prospects for long-term intensive psychotherapy and the need to demonstrate its clinical efficacy and economic feasibility are discussed.
View details for Web of Science ID A1990DC17500016
View details for PubMedID 2111638
- Capitation payment systems and public mental health care: Implications for psychotherapy with the chronic and severely disturbed. American Journal of Orthopsychiatry 1990; 60 (2): 298-304
- Decision-making in the emergency room: A reply American Journal of Psychiatry 1989; 146 (2): 291-292
- Co-existing serious mental illness and substance abuse: Impact on hospital length of stay, re-hospitalization, and aftercare linkage. Hospital and Community Psychiatry 1989; 40: 1067-1069
- The relationship between years of psychotherapy experience and conceptualizations, interventions, and treatment plan costs. Professional Psychology 1989; 29: 59-61
- EVALUATING TRAINEES RELATIVE TO THEIR SUPERVISORS DURING THE PSYCHOLOGY INTERNSHIP JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY 1988; 56 (5): 659-665
PSYCHIATRIC DECISION-MAKING IN THE EMERGENCY ROOM - A RESEARCH OVERVIEW
AMERICAN JOURNAL OF PSYCHIATRY
1988; 145 (8): 918-925
In an overview of the research on psychiatric decision making in the emergency room, the authors discuss studies done between 1963 and 1977, which suffered from an overreliance on univariate statistical techniques, problems with the reliability and validity of the instruments used for data collection, and the lack of alternatives to hospitalization for emergency room patients. More recent studies of emergency room decision making are then reviewed, with particular attention to those that had multivariate statistical designs. The article concludes with a synthesis of the research findings to date and recommends multivariate approaches and choices of variables for future studies.
View details for Web of Science ID A1988P500800002
View details for PubMedID 3293473
- Evaluating the conceptualizations and treatment plans of interns and supervisors during a psychology internship. Journal of Consulting and Clinical Psychology 1988; 56 (5): 659-665
PSYCHIATRIC CHRONICITY - A SINGLE SYSTEM MODEL
ADMINISTRATION AND POLICY IN MENTAL HEALTH
1988; 16 (2): 79-84
View details for Web of Science ID A1988AE97700003
- On the integration of state hospital and community-based services for the chronic mentally ill: A systemic case study. Hospital and Community Psychiatry 1988; 39 (5): 553-555
- The implementation of a single system model for psychiatric chronicity: The initial stage and its analysis Administration and Policy in Mental Health 1988; 16 (2): 79-87
SIMPLE MEASURES OF CASE MIX IN MENTAL-HEALTH-SERVICES
EVALUATION AND PROGRAM PLANNING
1987; 10 (3): 197-200
The concept of Case Mix in community mental health service program evaluation can be useful in mental health program evaluation if the definition of case mix is expanded beyond Diagnostic Related Groups (DRG), where DRG is solely based upon diagnosis and length of hospitalization stay. A case mix definition based upon two principal characteristics is offered. One characteristic is clinical status defined in terms of diagnostic signs and symptoms, level of functioning, and age. The other characteristic is typical treatment strategy for a given period of time (e.g., 13 weeks). Two cases mixes typical of services designed for the chronically mentally ill are discussed.
View details for Web of Science ID A1987J916300003
View details for PubMedID 10312179
- The role of academic psychiatry in public mental health. Contemporary Psychiatry 1987; 6 (2): 73-76
- Emergency psychiatry comes of age. Contemporary Psychiatry 1987; 6 (4): 238-239
- METATHEORETICAL ASSUMPTIONS AND PSYCHOTHERAPY ORIENTATION - CLINICIAN ATTRIBUTIONS OF PATIENTS PROBLEM CAUSALITY AND RESPONSIBILITY FOR TREATMENT OUTCOME JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY 1986; 54 (4): 476-481
- PSYCHOTHERAPEUTIC ORIENTATIONS - A COMPARISON OF CONCEPTUALIZATIONS, INTERVENTIONS, AND TREATMENT PLAN COSTS JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY 1986; 54 (3): 369-374
- Medical versus social treatment of alcohol withdrawal. Digest of Alcoholism Theory and Application 1984; 4 (1): 60-68
COMPARATIVE-EVALUATION OF MEDICAL VS SOCIAL TREATMENT OF ALCOHOL WITHDRAWAL SYNDROME
JOURNAL OF CLINICAL PSYCHOLOGY
1983; 39 (5): 791-803
Compared medical and social setting detoxification treatments of alcohol withdrawal syndrome on the degree to which each involved alcoholics in ongoing rehabilitative efforts. Two hundred patients were selected randomly from both treatments and administered the Physical Problem Inventory, Short Michigan Alcoholism Screening Test, Assessment of Life Experience, and Level of Motivation scales. Analysis of covariance with multiple covariates was employed to assess the effect of the treatment model on willingness to continue rehabilitation as measured by the dependent variable, ongoing referral status. The difference between detoxification treatment models was highly significant, and none of the covariates, which controlled for pretest differences and the assignment process, was significant. Results are discussed in the context of current notions of pharmacotherapy, learning, and physiological models of withdrawal treatment. In addition, expectancies, in terms of perceived responsibility for outcome, are discussed as important factors that contribute to the discrepancy between medical vs. social models in the treatment of alcoholism.
View details for Web of Science ID A1983RH79000026
View details for PubMedID 6630559
A MULTIPLE PERSPECTIVE ANALYSIS OF SCHIZOPHRENICS SYMPTOMS AND COMMUNITY FUNCTIONING
AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY
1983; 11 (5): 593-607
The present investigation examined the extent of agreement among schizophrenic clients, hospital clinicians, and independent evaluators' views of the client's symptoms and community functioning status using the Symptom Checklist-90, the Denver Community Mental Health Questionnaire, and the Personal Adjustment and Role Skills Inventory. The results suggest there is significant agreement among viewpoints and that this finding is generalizable across community assessment instruments. The average shared variance among the three perspectives across the three instruments was .68. The estimates of shared variance between the SCL-90, the DCMHQ, and the PARS ranged from .54 to .85, indicating these outcome instruments measure a common phenomenon or share significant method variance. The previously assumed necessity of multiple perspective assessment as the only valid approach is challenged.
View details for Web of Science ID A1983RK46900008
View details for PubMedID 6650463
OUTCOME PREDICTION OF INPATIENT ALCOHOL DETOXIFICATION
1983; 8 (2): 167-171
A wide range of patient characteristics was assessed to determine their relative contribution upon alcohol detoxification treatment outcome. The outcome criteria were length of stay and commitment to ongoing rehabilitation, of which 17% and 24% of respective variance was accounted for by the predictor variables. The Internal-External Locus of Control scale was the most significant predictor, with internals tending toward successful treatment outcomes. The measures which tapped degree of socio-economic life satisfaction and physiological complications due to alcohol abuse, were inversely related to positive outcomes.
View details for Web of Science ID A1983QX55000010
View details for PubMedID 6613715
- A multiple perspective analysis of schizophrenics' symptoms and community functioning. American Journal of Community Psychology 1983; 11 (5): 593–607
A naturalistic assessment of partial-hospital treatment.
International journal of partial hospitalization
1982; 1 (4): 311-326
Three hundred fifty-eight consecutive admissions to 13 partial hospitals were evaluated over an 8-month period. The design of the study focused on an unobstrusive measurement process involving clinical judgment of outcome. Analyses revealed that the clinical judgment process generated data which were both reliable and valid. The results of the study indicate that partial-hospital treatment is most effective for chronic and acute schizophrenic conditions, paranoid schizophrenia, and affective disorders and least so far patients diagnosed as adjustment disorders. Patients in the organic and neurotic diagnostic categories tended to remain stable. As in previous research, the pretreatment levels of the dependent variables were the best predictors of improvement, but the present study also reveals that progressive amounts of partial-hospital treatment lead to a greater improvement in patient functioning.
View details for PubMedID 10260152
ALCOHOLISM IN SOUTHEAST-ASIA PREVALENCE AND TREATMENT
INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY
1982; 28 (1): 36-44
A pilot, field investigation of the prevalence and treatment of alcoholism in Southeast Asia (Singapore, Indonesia, Malaysia, Burma, and Thailand) and conducted. The methodology combined an informant study, interviewing leading alcohol and drug abuse authorities; utilising existing data; and clinical and naturalistic observation. The effects of modernisation, multiracial culture, and the unilateral focus on opiates are discussed; recommendations on treatment, education, and research are presented.
View details for Web of Science ID A1982ND10000005
View details for PubMedID 6980858