Research & Treatment of Research & Treatment of Persons with SUDS & Persons with SUDS & Psychotic DisordersPsychotic Disorders

Kim T. Mueser, Ph.D.Kim T. Mueser, Ph.D.Professor of PsychiatryProfessor of Psychiatry

Dartmouth Medical SchoolDartmouth Medical School

Kim.t.mueser@dartmouth.eduKim.t.mueser@dartmouth.edu

NIDA Blending ConferenceNIDA Blending Conference

April 22, 2010April 22, 2010

OverviewOverview

Comorbidity of substance use & severe psychiatric Comorbidity of substance use & severe psychiatric disordersdisorders

Distinguishing features of psychotic disorders with Distinguishing features of psychotic disorders with comorbid addictioncomorbid addiction

Understanding comorbidity: models of etiology & Understanding comorbidity: models of etiology & treatment implicationstreatment implications

Special treatment needs of psychotic & other severe Special treatment needs of psychotic & other severe psychiatric disorders with comorbid addictionpsychiatric disorders with comorbid addiction

Research reviews of integrated treatment for co-Research reviews of integrated treatment for co-occurring disordersoccurring disorders

New research on treatment of co-occurring disordersNew research on treatment of co-occurring disorders ResourcesResources

Any Substance Use Disorder

0

10

20

30

40

50

60

Prev

alen

ce %

of S

ubst

ance

Use

Di

sord

er

Gen.Pop Schiz BPD MD OCD Phobia PD

Rates of Lifetime Substance Use Disorder (SUD) among Recently Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients (N = 325) Admitted Psychiatric Inpatients (N = 325)

(Mueser et al., 2000)(Mueser et al., 2000)

0

25

50

75

100

% o

f Clie

nts

with

SU

D

Schizophrenia Schizoaffective Disorder Bipolar Disorder Major Depression

Regier et al, JAMA 1990

Prevalence of Mental Prevalence of Mental Illness in Alcohol Disorder Illness in Alcohol Disorder

SamplesSamples

0

10

20

30

40

50

60

70

Community SATreatment

In community, In community, 24.4% have mental 24.4% have mental illness illness

In institutions, In institutions, 55% have mental 55% have mental illnessillness

In substance In substance abuse treatment, abuse treatment, 65% have mental 65% have mental illnessillness

Severe Mental Illnesses (SMI)Severe Mental Illnesses (SMI) Psychiatric disorder that has profound effect on:Psychiatric disorder that has profound effect on:

– Work or schoolWork or school– ParentingParenting– Self-careSelf-care– Social relationshipsSocial relationships

People often on disability due to mental illness (e.g., SSI, SSDI)People often on disability due to mental illness (e.g., SSI, SSDI) Common SMIs:Common SMIs:

– Schizophrenia & schizoaffective disorderSchizophrenia & schizoaffective disorder– Bipolar disorderBipolar disorder– Major depressionMajor depression– PTSDPTSD– Borderline personality disorderBorderline personality disorder

Often present for treatment in psychiatric settings, but also Often present for treatment in psychiatric settings, but also common in addiction treatment settingscommon in addiction treatment settings

Psychotic DisordersPsychotic Disorders Psychosis = “Lack of contact with reality”Psychosis = “Lack of contact with reality” Common psychotic symptoms:Common psychotic symptoms:

– HallucinationsHallucinations– DelusionsDelusions– GrandiosityGrandiosity– SuspiciousnessSuspiciousness– Bizarre behaviorBizarre behavior– Formal thought disorder (disordered or disorganized speech)Formal thought disorder (disordered or disorganized speech)– Conceptual disorganizationConceptual disorganization

Psychotic symptoms common in schizophrenia, schizoaffective & bipolarPsychotic symptoms common in schizophrenia, schizoaffective & bipolar Psychotic symptoms relatively common in major depression & PTSDPsychotic symptoms relatively common in major depression & PTSD Presence of psychotic symptoms associated with more severe mental Presence of psychotic symptoms associated with more severe mental

illness & greater co-occurring addictionillness & greater co-occurring addiction

Understanding Comorbidity: Why are the Understanding Comorbidity: Why are the Rates of SMI/Psychotic Disorder so High?Rates of SMI/Psychotic Disorder so High?

Self-medicationSelf-medication Other common motives for usingOther common motives for using Super-sensitivitySuper-sensitivity Common factors for mental illness & substance Common factors for mental illness & substance

misusemisuse

Self-MedicationSelf-Medication Many clients report using substance for at least some reasons Many clients report using substance for at least some reasons

related to symptoms, BUT:related to symptoms, BUT: More symptomatic clients don’t use more than less symptomatic More symptomatic clients don’t use more than less symptomatic

onesones No relationship between symptoms & types of substances usedNo relationship between symptoms & types of substances used No relationship between psychiatric diagnosis and types of No relationship between psychiatric diagnosis and types of

substances usedsubstances used Many clients report using DESPITE awareness it worsens Many clients report using DESPITE awareness it worsens

symptoms or triggers relapsessymptoms or triggers relapses Strongest case for self-medication: alcohol use disorder in PTSD Strongest case for self-medication: alcohol use disorder in PTSD

frequently related to sleep problemsfrequently related to sleep problems Self-medication/use for coping purposes is one of host of Self-medication/use for coping purposes is one of host of

motivations related to SMI for using substances, but doesn’t motivations related to SMI for using substances, but doesn’t explain all comorbidityexplain all comorbidity

Other Common Motives for UsingOther Common Motives for Using

SocializationSocialization Leisure & recreationLeisure & recreation Dealing with stressDealing with stress Escaping the stigma of mental illnessEscaping the stigma of mental illness Lack of structured timeLack of structured time Lack of engagement in personally meaningful Lack of engagement in personally meaningful

roles (e.g., worker, student, parent)roles (e.g., worker, student, parent)

Supersensitivity to Alcohol & Supersensitivity to Alcohol & DrugsDrugs

Biological sensitivity increases vulnerability to Biological sensitivity increases vulnerability to effects of substanceseffects of substances

Smaller amounts of substances result in Smaller amounts of substances result in problemsproblems

““Normal” substance use is problematic for Normal” substance use is problematic for clients with SMI but not in general populationclients with SMI but not in general population

Sensitivity to substances, rather than high Sensitivity to substances, rather than high amounts of use, makes many clients with amounts of use, makes many clients with mental illness different from general mental illness different from general populationpopulation

Stress-Vulnerability ModelStress-Vulnerability Model

BiologicalVulnerabilit

y

SubstanceAbuse

Medication Stress Coping

Severityof SMI

Status of Moderate Drinkers with Status of Moderate Drinkers with Schizophrenia 4 - 7 Years Later (N=45)Schizophrenia 4 - 7 Years Later (N=45)

55.6

20.0 24.4

0%

20%

40%

60%

80%

100%

Abstinent ModerateDrinker

AlcoholUse

Disorder

Source: Drake & Wallach (1993)

Common Factors for SMI & Addiction: Common Factors for SMI & Addiction: Conduct Disorder (CD) & Antisocial Conduct Disorder (CD) & Antisocial

Personality Disorder (ASPD)Personality Disorder (ASPD) ASPD has highest addiction comorbidity of all ASPD has highest addiction comorbidity of all

psychiatric disorders (60-70% in most estimates)psychiatric disorders (60-70% in most estimates) CD is powerful predictor of later onset of SUDCD is powerful predictor of later onset of SUD ASPD associated with earlier onset of addictionASPD associated with earlier onset of addiction CD & ASPD more common in SMI than general CD & ASPD more common in SMI than general

populationpopulation CD/ASPD increase risk of addiction in SMICD/ASPD increase risk of addiction in SMI CD/ASPD related to more severe addiction in co-CD/ASPD related to more severe addiction in co-

occurring disordersoccurring disorders Estimated prevalence in co-occurring population: 20-Estimated prevalence in co-occurring population: 20-

25%25%

Alcohol Use Disorder

29.3

41.7

60.0 63.2

0%

10%

20%

30%

40%

50%

60%

70%

CD, ASPD, and Recent SUD in Clients with SMI CD, ASPD, and Recent SUD in Clients with SMI (N = 293)(N = 293)

Cocaine Use Disorder

4.9

12.58.0

36.8

0%

10%

20%

30%

40%No ASPD/CD

CD Only

Adult ASPD Only

Full ASPD

Cannabis Use Disorder

13.8

25.0

36.0

52.6

0%

10%

20%

30%

40%

50%

60%

Source: Mueser et. al. (1999)

Other Potential Common Factors Other Potential Common Factors Leading to Increased ComorbidityLeading to Increased Comorbidity

Poverty/deprivationPoverty/deprivation Neurocognitive impairmentNeurocognitive impairment TraumaTrauma

Special Treatment Needs of Co-Special Treatment Needs of Co-Occurring SMI/Psychotic DisorderOccurring SMI/Psychotic Disorder

Integration of mental illness & substance use Integration of mental illness & substance use disorder treatmentdisorder treatment– Concurrent treatmentConcurrent treatment– Same treatment providersSame treatment providers– Integrated treatment of both disordersIntegrated treatment of both disorders

Minimization of treatment-related stressMinimization of treatment-related stress Outreach & engagementOutreach & engagement Close monitoring, especially for co-occurring Close monitoring, especially for co-occurring

disorder clients with ASPDdisorder clients with ASPD

Special Treatment Needs: Special Treatment Needs: Motivational EnhancementMotivational Enhancement

Stages of changeStages of change Stages of treatmentStages of treatment

– EngagementEngagement– PersuasionPersuasion– Active treatmentActive treatment– Relapse preventionRelapse prevention

Adapted motivational interviewingAdapted motivational interviewing– Articulation of personal goalsArticulation of personal goals– Active work towards goalsActive work towards goals– Supportive self-efficacy for goal attainment & Supportive self-efficacy for goal attainment &

substance reduction/abstinencesubstance reduction/abstinence

Motivational Enhancement (Con’d)Motivational Enhancement (Con’d)

Concept of recovery from mental illnessConcept of recovery from mental illness– Recovery defined by client, not in traditional Recovery defined by client, not in traditional

medical termsmedical terms– Recovery possible despite continued symptomsRecovery possible despite continued symptoms– Instills hopeInstills hope– Common themes: social relationships, role Common themes: social relationships, role

functioning, community membership, respect for functioning, community membership, respect for self & from otherself & from other

Special Treatment Needs: Special Treatment Needs: Management of Cognitive ImpairmentManagement of Cognitive Impairment

Smaller “chunks” of informationSmaller “chunks” of information Asking questions so client actively processes informationAsking questions so client actively processes information Frequent review of materialFrequent review of material Shaping approach to reinforcing successive steps towards desired Shaping approach to reinforcing successive steps towards desired

goalsgoals Patience & abundant reinforcement in light of small changesPatience & abundant reinforcement in light of small changes Programming generalization of skills to natural environment byProgramming generalization of skills to natural environment by

– Home practice assignmentsHome practice assignments– Involvement of significant others in practicing skillsInvolvement of significant others in practicing skills– Involvement of paraprofessionals in helping clients practice Involvement of paraprofessionals in helping clients practice

skillsskills

Special Treatment Needs: Special Treatment Needs: Training in Illness Self-ManagementTraining in Illness Self-Management

Information about mental illness & its treatmentInformation about mental illness & its treatment Stress-vulnerability modelStress-vulnerability model Involvement of family or significant other personsInvolvement of family or significant other persons Driven by personal goalsDriven by personal goals Principles of relapse prevention:Principles of relapse prevention:

– Medication adherenceMedication adherence– Minimization of alcohol & drug useMinimization of alcohol & drug use– Stress reductionStress reduction– Meaningful but not over-demanding daily structureMeaningful but not over-demanding daily structure– Coping & competence skillsCoping & competence skills– Social supportSocial support– Relapse prevention planRelapse prevention plan

Special Treatment Needs: Special Treatment Needs: Psychiatric RehabilitationPsychiatric Rehabilitation

Address motives underlying substance use Address motives underlying substance use Skills training to address social motives, independent Skills training to address social motives, independent

living skillsliving skills Coping skills training/CBT for persistent symptomsCoping skills training/CBT for persistent symptoms Targeted CBT to address primary or comorbid Targeted CBT to address primary or comorbid

depression, anxiety, PTSD symptomsdepression, anxiety, PTSD symptoms Supported employment/education for competitive work Supported employment/education for competitive work

or return to schoolor return to school Family psychoeducation to reduce family stress & Family psychoeducation to reduce family stress &

burden, & facilitate management of co-occurring burden, & facilitate management of co-occurring disordersdisorders

Cognitive remediation for cognitive impairmentCognitive remediation for cognitive impairment Supported housing for housing instabilitySupported housing for housing instability

Special Treatment Needs: Special Treatment Needs: Psychiatric MedicationsPsychiatric Medications

Primary medications for schizophrenia-spectrum Primary medications for schizophrenia-spectrum disorders & bipolar disorder effective despite active disorders & bipolar disorder effective despite active substance usesubstance use

When in doubt, assume both disorders are primary & When in doubt, assume both disorders are primary & pharmacologically treat psychiatric disorderpharmacologically treat psychiatric disorder

Medication non-adherence highMedication non-adherence high– Fear of interactions with substances despite rarity (main Fear of interactions with substances despite rarity (main

exception: MAOIs)exception: MAOIs)– Denial/minimization of psychiatric disorderDenial/minimization of psychiatric disorder– Forgetting to take medication: behavioral tailoring to Forgetting to take medication: behavioral tailoring to

integrate into daily routineintegrate into daily routine– Simplify medication regimen complexitySimplify medication regimen complexity

Promote dialogue between client & prescriberPromote dialogue between client & prescriber

Special Treatment Needs: Special Treatment Needs: Medications for AlcoholismMedications for Alcoholism

Naltrexone established efficacy for alcoholism Naltrexone established efficacy for alcoholism in SMIin SMI

Disulfirim effective in SMI, but psychiatrists Disulfirim effective in SMI, but psychiatrists reluctant to prescribe itreluctant to prescribe it

Research Reviews of Research Reviews of Treatment of Co-Treatment of Co-

Occurring DisordersOccurring Disorders Drake et al. (1998): 36 studies, including pre-post, Drake et al. (1998): 36 studies, including pre-post,

quasi-experimental, and RCTsquasi-experimental, and RCTs Brunette et al. (2004): 10 quasi-exp or RCTs of Brunette et al. (2004): 10 quasi-exp or RCTs of

residential programs for DDresidential programs for DD Drake et al. (2004): 26 recent studies, quasi-exp Drake et al. (2004): 26 recent studies, quasi-exp

or RCTs (1994-2004)or RCTs (1994-2004) Donald et al. (2005): 10 RCTsDonald et al. (2005): 10 RCTs Mueser et al. (2005): 30 studies of specific Mueser et al. (2005): 30 studies of specific

interventions, including pre-post, quasi-exp, & interventions, including pre-post, quasi-exp, & RCTsRCTs

Kavanagh & Mueser (2007): 17 RCTsKavanagh & Mueser (2007): 17 RCTs Cleary et al. (2008): 25 RCTsCleary et al. (2008): 25 RCTs Drake et al. (2008): 22 RCTs, 23 quasi-expDrake et al. (2008): 22 RCTs, 23 quasi-exp

Summary of Research on Summary of Research on Treating Co-Occurring Treating Co-Occurring

Disorders in SMIDisorders in SMI Limited impact of brief interventionsLimited impact of brief interventions

– Primary purpose is to engage in Primary purpose is to engage in treatmenttreatment

– Useful for enhancing follow through for Useful for enhancing follow through for mental illness & substance misuse mental illness & substance misuse treatmenttreatment

Limited gain from providing more Limited gain from providing more intensive case management, such as intensive case management, such as Assertive Community TreatmentAssertive Community Treatment

But, effects of intensity of service may But, effects of intensity of service may interact with client characteristics, such interact with client characteristics, such as ASPDas ASPD

Study Design (Essock et al., 2006)Study Design (Essock et al., 2006)

198 clients with SMI198 clients with SMI 2 sites in Connecticut: Hartford & Bridgeport2 sites in Connecticut: Hartford & Bridgeport 3 year follow-up period with assessments every 3 year follow-up period with assessments every

6 months6 months Randomized to ACT (N = 99) or SCM (N = 99)Randomized to ACT (N = 99) or SCM (N = 99) Everyone received integrated treatment for co-Everyone received integrated treatment for co-

occurring disordersoccurring disorders

1

2

3

4

5

6

7

8

0 6 12 18 24 30 36

Site 1 ACTSite 1 STDSite 2 ACTSite 2 STD

SATS Predicted and Actual MeansSATS Predicted and Actual MeansS

AT

S M

ean

Study MonthsEssock, Mueser, Drake et al. Psychiatr Serv. 2006

05

101520253035404550

Total Site 1 Site 2

Total Psychiatric Hospital Days During Total Psychiatric Hospital Days During Entire Study PeriodEntire Study Period

Mea

n Nu

mbe

r of D

ays

Spen

t in

Hosp

ital

23(68)26(48)

15(27)

12(28)

32(91)

41(60)

MWU=3971, p=.12 MWU=1043, p=.35 MWU=713, p=.002*

Essock, Mueser, Drake et al. Psychiatr Serv. 2006

ACTStandard

Did Clients with ASPD Benefit Did Clients with ASPD Benefit from ACT Treatment More?from ACT Treatment More?

Secondary data analysis (Frisman et al., 2009)Secondary data analysis (Frisman et al., 2009) Focused on most extreme subgroups: Full ASPD (N = Focused on most extreme subgroups: Full ASPD (N =

36) or No CD/ASPD (N = 88)36) or No CD/ASPD (N = 88) Outcomes = AUS, DUS, days alcohol use, days drug Outcomes = AUS, DUS, days alcohol use, days drug

use, SATS, BPRS, hospital days, homeless days, jail use, SATS, BPRS, hospital days, homeless days, jail daysdays

Statistical analyses: mixed effects linear modeling with Statistical analyses: mixed effects linear modeling with time, treatment group, and ASPD group, with test of time, treatment group, and ASPD group, with test of primary interest being the 3-way interactionprimary interest being the 3-way interaction

Significant interactions 2 variables: AUS and days in Significant interactions 2 variables: AUS and days in jailjail

ASPD group

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

0 1 2 3 4 5 6Time

ACT

TAU

ACT-O

TAU-OFig

ure

1. M

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eff

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an

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(ob

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est

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an

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for

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y A

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D a

nd

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atm

ent

grou

ps

grou

ps

alco

hol c

onse

nsus

rat

ing

No ASPD group

1.001.502.002.503.003.504.004.505.00

0 1 2 3 4 5 6

Time

Fig

ure

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D a

nd

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ent

grou

ps

grou

ps

alco

hol c

onse

nsus

rat

ing

ASPD group

0.000.100.200.300.400.500.600.700.800.901.00

0 1 2 3 4 5 6Time

ACT

TAU

ACT-Obs

TAU-ObsFig

ure

2. E

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per

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of

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. Est

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me

by

AS

PD

gro

up

% jail

No ASPD group

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 1 2 3 4 5 6

Time

Fig

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Summary of Research on Summary of Research on Treating Co-Occurring Treating Co-Occurring

Disorders in SMIDisorders in SMI

Co-occurring treatment associated Co-occurring treatment associated with better substance abuse & with better substance abuse & psychiatric outcomespsychiatric outcomes

Strongest effects for group Strongest effects for group counseling, contingency counseling, contingency management, & residential management, & residential treatmenttreatment

Group counseling most studied Group counseling most studied treatment modalitytreatment modality

Integrated Group Therapy Integrated Group Therapy (IGT) for BPD & SUD (Weiss (IGT) for BPD & SUD (Weiss

et al., 2007)et al., 2007)• Supported by NIDA Behavioral Therapies

Development Program• Goal: to develop & test an integrated group

therapy for clients with bipolar disorder & substance misuse

• 20 sessions that have 12 repeating topics, “rolling admissions”

• Identifies thoughts & behavior patterns common to recovery from & relapse/recurrence to substance use and psychiatric symptoms

• Evaluated in RCT comparing IGT with Group Drug Counseling (GDC)

0

3

6

9

12

15

1 2 3 4 5 6 7 8

IGT

GDC

Days of Substance Days of Substance Use/Month Use/Month

by Treatment Over Time by Treatment Over Time (p<.001)(p<.001)

Month

Days

use

d

Baseline

0

20

40

60

80

100

1 2 3 4 5 6 7 8

IGT

GDC

Time to First Abstinent Time to First Abstinent Month Month

by Treatment (p<.03)by Treatment (p<.03)

MonthMonth

Ab

stin

en

t (%

)A

bst

inen

t (%

)

BaselineBaseline

Summary of Research on Summary of Research on Integrated Treatment for Integrated Treatment for

SMISMI

Cognitive-behavioral therapy (CBT) Cognitive-behavioral therapy (CBT) approaches appear promising than approaches appear promising than supportive, educational, or 12-step supportive, educational, or 12-step approachesapproaches

Program fidelity to principles of Program fidelity to principles of integrated treatment contributes to integrated treatment contributes to better outcomesbetter outcomes

Fidelity to IDDT Model Fidelity to IDDT Model Improves Outcome Improves Outcome

(McHugo et al., 1999)(McHugo et al., 1999)*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38

Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).

0

10

20

30

40

50

60

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.

Efforts to Provide Integrated Efforts to Provide Integrated Treatment of Anxiety Treatment of Anxiety

Disorders & Substance AbuseDisorders & Substance Abuse

RCTs of integrated treatment for panic RCTs of integrated treatment for panic disorder & social phobia indicate disorder & social phobia indicate improvement in anxiety & substance improvement in anxiety & substance misuse for both integrated & substance misuse for both integrated & substance treatment groupstreatment groups

No trials of integrated treatment for GAD No trials of integrated treatment for GAD or OCDor OCD

Limited success thus far with integrated Limited success thus far with integrated PTSD treatment, but new developments PTSD treatment, but new developments under wayunder way

Integrated Treatments for Integrated Treatments for PTSD & AddictionPTSD & Addiction

• Substance Dependence PTSD Therapy (Triffleman, Substance Dependence PTSD Therapy (Triffleman, 1999)1999)

• Exposure-based, 40 sessions, no RCTsExposure-based, 40 sessions, no RCTs• Concurrent Treatment of PTSD & Cocaine Concurrent Treatment of PTSD & Cocaine

Dependence (Brady et al, 2001)Dependence (Brady et al, 2001)• Exposure-based, high dropout rate (62%), no RCTsExposure-based, high dropout rate (62%), no RCTs

• Transcend (Donovan et al, 2001)Transcend (Donovan et al, 2001)• Broad-based, residential, 60 session, no RCTsBroad-based, residential, 60 session, no RCTs

• Seeking Safety (Najavits, 2003; Hien et al, 2004)Seeking Safety (Najavits, 2003; Hien et al, 2004)• Ecclectic, moderate dropout rate (35-40%), RCTs Ecclectic, moderate dropout rate (35-40%), RCTs

don’t support treatment over standard substance don’t support treatment over standard substance abuse treatmentabuse treatment

Cognitive Restructuring Cognitive Restructuring for PTSD in Vulnerable for PTSD in Vulnerable

PopulationsPopulations

12-16 week standardized treatment program 12-16 week standardized treatment program for PTSD developed by Mueser et al. (2009)for PTSD developed by Mueser et al. (2009)

Core components: breathing retraining, Core components: breathing retraining, education about PTSD, cognitive education about PTSD, cognitive restructuringrestructuring

Feasibility established in SMI, addiction, Feasibility established in SMI, addiction, adolescents, ethnic/cultural minorities, adolescents, ethnic/cultural minorities, disaster/mass violence survivorsdisaster/mass violence survivors

RCTs completed on SMI (Mueser et al., RCTs completed on SMI (Mueser et al., 2008) & addiction (McGovern et al., in pres) 2008) & addiction (McGovern et al., in pres) populationspopulations

STAGE I Phase II.a: Feasibility STAGE I Phase II.a: Feasibility StudyStudy

Main Outcomes (McGovern et Main Outcomes (McGovern et al.)al.)

0

25

50

75

100

Baseline

% P

TSD

Posit

ive

Post-Treatment

3 MonthFollow-up

PTSD Diagnosis

0

20

40

60

80

Baseline Post-Treatment

3 MonthFollow-up

Mean C

APS S

coreClinician Administered PTSD Scale (CAPS)

0.000

0.100

0.200

0.300

0.400

0.500

Mean A

SI C

om

posit

e

Alcohol

Drug

Baseline Post-Treatment

3 MonthFollow-up

Addiction Severity Index (ASI) CompositeNumber of days using in past 3 months

051015202530

Baseline

Mean n

um

ber

of

days

Post-Treatment

3 MonthFollow-up

Alcohol

Drug

Clinical ResourcesClinical Resources Bellack, A. S., Bennet, M. E., & Gearon, J. S. (2007). Bellack, A. S., Bennet, M. E., & Gearon, J. S. (2007). Behavioral Treatment for Substance Abuse in People with Serious Behavioral Treatment for Substance Abuse in People with Serious

and Persistent Mental Illnessand Persistent Mental Illness. New York: Taylor and Francis.. New York: Taylor and Francis. Center for Substance Abuse Treatment. (2005). Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring DisordersSubstance Abuse Treatment for Persons With Co-Occurring Disorders. .

(Vol. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration.(Vol. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration. Centre for Addiction and Mental Health. (2001). Centre for Addiction and Mental Health. (2001). Best Practices: Concurrent Mental Health and Substance Use DisordersBest Practices: Concurrent Mental Health and Substance Use Disorders. .

Ottowa: Health Canada.Ottowa: Health Canada. IDDT Toolkit: http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.aspIDDT Toolkit: http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp Graham, H. L., Copello, A., Birchwood, M. J., & Mueser, K. T. (Eds.). (2003). Graham, H. L., Copello, A., Birchwood, M. J., & Mueser, K. T. (Eds.). (2003). Substance Misuse in Psychosis: Approaches Substance Misuse in Psychosis: Approaches

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