A new intervention enhances prospects for substance abusers whose mental illness complicates the path to recovery. In a recent clinical trial, a 6-month course of Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS) reduced drug abuse, boosted treatment-session attendance, and improved the quality of life of outpatients with a wide spectrum of mental disorders.
A Focus on Extra Obstacles
Dr. Alan S. Bellack and colleagues at the University of Maryland School of Medicine in Baltimore designed BTSAS to counter the factors that make recovery from addiction especially difficult for people who have co-occurring severe and persistent mental illness. These factors include frequent failure to meet their own and others' expectations, inconsistent motivation, and social and personal pressure to appear normal.
|Drug-free Urine Samples||59%||25%|
|Four Weeks of Abstinence||54%||16%|
|Multiple 4-Week Blocks||44%||10%|
|Eights Weeks of Abstinence||33%||8%|
BTSAS: Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness
STAR: Supportive Treatment for Addiction Recovery.
BTSAS therapy comprises six integrated components:
- motivational interviews (directive counseling that explores and resolves ambivalence) to increase the desire to stop using drugs;
- contingency contracts linking drug-free urine samples with small financial rewards;
- realistic, short-term, structured goal-setting sessions;
- training in social and drug-refusal skills;
- information on why and how people become addicted to drugs and the dangers of substance use for people with mental illness; and
- relapse-prevention training that inculcates behavioral strategies for coping with cravings, lapses, and high-risk situations.
Twice-weekly sessions begin with urine tests. Patients who have provided drug-free urine samples are praised by the therapists and group members. They also receive financial incentives that start at $1.50 for the first drug-free sample and increase in $0.50 increments for every consecutive one thereafter, up to $3.50. The amount is set back to $1.50 after a drug-positive sample or an absence.
When participants submit drug-positive samples, the group takes a nonaccusatory approach by focusing on problem solving to help them achieve future abstinence. Each participant agrees upon a personal goal for drug abuse reduction or abstinence that he or she believes is achievable during the coming week and signs a contract stating that he or she will strive for it. The rest of the session consists of drug abuse education plus training in social skills and relapse-prevention strategies.
Substance abuse is common among the mentally ill. For example, surveys estimate that 48 percent of those with schizophrenia, 56 percent with bipolar disorder, and as many as 65 percent with severe and persistent mental illness have abused substances.
Dr. Bellack's research team recruited 175 patients from community clinics and a Veterans Affairs medical center in Baltimore. All had a dual diagnosis of severe and persistent mental illness and an addiction to cocaine, heroin, or marijuana. Among the participants, 38.3 percent met the diagnostic criteria for schizophrenia or schizoaffective disorders, 54.9 percent for major affective disorders, and the remainder for other mental disorders. Cocaine was the predominant drug abused by 68.6 percent of participants, opiates by 24.6 percent, and marijuana by 6.8 percent.
The researchers assigned half the trial participants to BTSAS group therapy and half to a program called Supportive Treatment for Addiction Recovery (STAR), which is the typical treatment at the University of Maryland clinics. Unlike participants in BTSAS, those in STAR do not follow a structured format but instead select their own topics and work at their own pace. Patient interaction with other patients is encouraged but not required as it is with BTSAS. Although urine samples are collected before each session, results are not discussed in the group, and no systematic feedback is provided to the patient.
Assignments to the BTSAS and STAR groups were balanced for gender, psychiatric diagnosis, type of drug dependency, and number of substance use disorders. Treatment groups of four to six participants met twice a week for 6 months. BTSAS and STAR group sessions were all led by trained therapists and lasted from 60 to 90 minutes. Group meetings were videotaped weekly and then reviewed and assessed by independent reviewers to verify that the therapists were following the programs' parameters correctly.
The BTSAS group fared better than the STAR group on a wide range of treatment-related criteria. For example, more people in the BTSAS group stayed in treatment throughout the 6-month trial period (57.4 percent versus 34.7 percent). The BTSAS group produced more drug-free urine samples and had longer periods of abstinence (see table, above). They also had better clinical and general living outcomes than people in the STAR group (see table, below) and reported larger improvements in their ability to perform the activities of daily living.
|Frequency of Arrests||31.0%||12.8%||22.9%||27.3%|
* Pretreatment: 90-day period before study
** Posttreatment: 90-day period following study
*** Rates of inpatient admissions for either psychiatric problems or substance abuse
**** Percentage of participants reporting having enough money for food, clothing, housing, and transportation
"It was apparent from watching videotapes of treatment sessions that subjects in BTSAS valued the intervention and were learning important skills for reducing drug use," says Dr. Bellack. "We were very gratified that the data supported our clinical observations."
The researchers reported that the extra costs of running the BTSAS program were modest. For the 6-month trial, monetary rewards averaged roughly $60 per patient; total per-patient cost, including therapist time, was $372.
The trial data indicate that patients who remain in BTSAS for at least three sessions are much more likely to finish the 6-month program than patients who do not make it through the third session. Because a third of individuals initially recruited for the study left before the third treatment session, the researchers are currently developing new intervention strategies to keep people in the program until they have truly given it a chance. The innovation has two key components: a structured intervention to help patients overcome obstacles to treatment and an intervention to enlist family and friends as partners to connect patients with treatment.
"The BTSAS program will help clinicians make a difference in the lives of a very difficult-to-treat population," says Dr. Dorynne Czechowicz of NIDA's Division of Clinical Neuroscience and Behavioral Research. "One of its key strengths is that it positively affects many aspects of patients' lives. Moreover, as an outpatient treatment, it is well-suited to the situation. Most mentally ill people who abuse drugs live in the community, not in a sheltered facility, and this is where the majority of clinicians must treat them."
Bellack, A.S., et al. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness. Archives of General Psychiatry 63(4):426-432, 2006. [Full Text (PDF, 127KB)]
Kinnaman, J.E., et al. Assessment of motivation to change substance use in dually-diagnosed schizophrenia patients. Addictive Behaviors 32(9):1798-1813, 2007. [Abstract]