People with co-occurring mental health & substance use disorders tend to experience worse treatment outcomes than individuals with one or the other.
People with co-occurring mental health & substance use disorders tend to experience worse treatment outcomes than individuals with one or the other.
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This study examines if chronic care management in a primary care setting benefits people with co-occurring substance use disorder and one of two mental health disorders—major depressive disorder (MDD) or post-traumatic stress disorder (PTSD).
This study used data from the AHEAD study, a randomized controlled trial testing the effectiveness of CCM for SUD in primary care.
Patients were assigned to receive CCM or usual primary care. CCM included the following services: clinical case management, motivational enhancement therapy, relapse prevention counseling, addiction pharmacotherapy, and referral to specialty addiction treatment and mutual-help groups. Standard primary care to which CCM was compared included an appointment with a primary care physician and providing a list of addiction treatment resources.
This study focused on two subgroups: participants with current (i.e., past two week) MDD and participants with current PTSD (i.e., past month). Outcomes included any stimulant or opioid use or heavy drinking in the past 30 days, mental health symptom severity, and treatment utilization including emergency department visits, hospitalizations, addiction treatment, and mental health treatment.
Analyses were adjusted for the following variables:
Of all participants (N = 563), 443 (79%) met diagnostic criteria for major depressive disorder (MDD) and 205 (36%) met criteria for post-traumatic stress disorder (PTSD). Two hundred and nineteen participants with MDD (49%) and 100 participants with PTSD (49%) were randomized to chronic control management (CCM). A majority of participants were male, had alcohol and drug use disorders, experienced homelessness in the past 3 months, and had been previously incarcerated. The average scores for psychiatric symptoms were indicative of moderately severe depression and severe anxiety.
For both the major depressive disorder (MDD) and PTSD groups, participation in chronic control management (CCM) did not have a significant effect on substance use or mental health outcomes in the adjusted models. However, compared to the primary care group, CCM was significantly associated with greater receipt of addiction treatment, addiction medicine, mental health treatment, and psychiatric medication for the MDD subgroup. These results were similar for the PTSD group except greater addiction treatment utilization was not significant. The largest effect was seen in receipt of mental health treatment.
Despite providing an intervention offering a wide array of services, chronic control management was not effective at improving substance use or mental health outcomes among patients with co-occurring PTSD or major depressive disorder in addition to substance use disorder, many of whom had very challenging social circumstances including homelessness. While patients in the chronic control management group were more likely to use relevant treatment services, this did not translate into symptom improvement.
Chronic control management (CCM) effectively connected patients with treatment services but different types of services may have provided better outcomes. While CCM was effective for patients with diabetes and heart disease, it may not be suitable for addiction and those with a co-occurring mental health disorder.
While this model has been successful with chronic illness such as diabetes, congestive heart failure, and mental illness alone (e.g., depression and anxiety), it was not shown to be effective for health-related outcomes including substance use among people with addiction in a recent randomized controlled trial (see here for the results of the Addiction Health and Evaluation and Disease Management [AHEAD] study). Given CCM’s benefit for some mental disorders, Park and colleagues hypothesized that individuals with co-occurring disorders participating in the AHEAD study may have benefitted from this intensive, integrated care model.
Chronic control management (CCM) was significantly associated with greater receipt of mental health and addiction treatment services. This population was characterized by scores indicating moderately severe depression and severe anxiety so it is possible that CCM may be effective in a population with less severe psychiatric illness. In order to better address the needs of this population with co-occurring disorders, services need to cater to psychosocial issues (e.g., low socioeconomic status, criminal justice involvement, and homelessness) that may be impacting patients’ ability to benefit from treatment. Such services will improve recovery capital, the resources such as housing and employment that are needed to begin and maintain recovery.
Given the clinical severity of this study population, it cannot be concluded that chronic control management (CCM) is ineffective for all individuals with co-occurring disorders. Future treatment development can be informed by the patients themselves by conducting qualitative research with a sample of this population to identify why more treatment engagement did not result in better outcomes. Researchers could also replicate this intervention in samples with less severe symptoms and/or different mental health disorders (e.g., bipolar disorder).
Park, T. W., Cheng, D. M., Samet, J. H., Winter, M. R., & Saitz, R. (2015). Chronic care management for substance dependence in primary care among patients with co-occurring disorders. Psychiatr Serv, 66(1), 72-79. doi:10.1176/appi.ps.201300414
l
This study examines if chronic care management in a primary care setting benefits people with co-occurring substance use disorder and one of two mental health disorders—major depressive disorder (MDD) or post-traumatic stress disorder (PTSD).
This study used data from the AHEAD study, a randomized controlled trial testing the effectiveness of CCM for SUD in primary care.
Patients were assigned to receive CCM or usual primary care. CCM included the following services: clinical case management, motivational enhancement therapy, relapse prevention counseling, addiction pharmacotherapy, and referral to specialty addiction treatment and mutual-help groups. Standard primary care to which CCM was compared included an appointment with a primary care physician and providing a list of addiction treatment resources.
This study focused on two subgroups: participants with current (i.e., past two week) MDD and participants with current PTSD (i.e., past month). Outcomes included any stimulant or opioid use or heavy drinking in the past 30 days, mental health symptom severity, and treatment utilization including emergency department visits, hospitalizations, addiction treatment, and mental health treatment.
Analyses were adjusted for the following variables:
Of all participants (N = 563), 443 (79%) met diagnostic criteria for major depressive disorder (MDD) and 205 (36%) met criteria for post-traumatic stress disorder (PTSD). Two hundred and nineteen participants with MDD (49%) and 100 participants with PTSD (49%) were randomized to chronic control management (CCM). A majority of participants were male, had alcohol and drug use disorders, experienced homelessness in the past 3 months, and had been previously incarcerated. The average scores for psychiatric symptoms were indicative of moderately severe depression and severe anxiety.
For both the major depressive disorder (MDD) and PTSD groups, participation in chronic control management (CCM) did not have a significant effect on substance use or mental health outcomes in the adjusted models. However, compared to the primary care group, CCM was significantly associated with greater receipt of addiction treatment, addiction medicine, mental health treatment, and psychiatric medication for the MDD subgroup. These results were similar for the PTSD group except greater addiction treatment utilization was not significant. The largest effect was seen in receipt of mental health treatment.
Despite providing an intervention offering a wide array of services, chronic control management was not effective at improving substance use or mental health outcomes among patients with co-occurring PTSD or major depressive disorder in addition to substance use disorder, many of whom had very challenging social circumstances including homelessness. While patients in the chronic control management group were more likely to use relevant treatment services, this did not translate into symptom improvement.
Chronic control management (CCM) effectively connected patients with treatment services but different types of services may have provided better outcomes. While CCM was effective for patients with diabetes and heart disease, it may not be suitable for addiction and those with a co-occurring mental health disorder.
While this model has been successful with chronic illness such as diabetes, congestive heart failure, and mental illness alone (e.g., depression and anxiety), it was not shown to be effective for health-related outcomes including substance use among people with addiction in a recent randomized controlled trial (see here for the results of the Addiction Health and Evaluation and Disease Management [AHEAD] study). Given CCM’s benefit for some mental disorders, Park and colleagues hypothesized that individuals with co-occurring disorders participating in the AHEAD study may have benefitted from this intensive, integrated care model.
Chronic control management (CCM) was significantly associated with greater receipt of mental health and addiction treatment services. This population was characterized by scores indicating moderately severe depression and severe anxiety so it is possible that CCM may be effective in a population with less severe psychiatric illness. In order to better address the needs of this population with co-occurring disorders, services need to cater to psychosocial issues (e.g., low socioeconomic status, criminal justice involvement, and homelessness) that may be impacting patients’ ability to benefit from treatment. Such services will improve recovery capital, the resources such as housing and employment that are needed to begin and maintain recovery.
Given the clinical severity of this study population, it cannot be concluded that chronic control management (CCM) is ineffective for all individuals with co-occurring disorders. Future treatment development can be informed by the patients themselves by conducting qualitative research with a sample of this population to identify why more treatment engagement did not result in better outcomes. Researchers could also replicate this intervention in samples with less severe symptoms and/or different mental health disorders (e.g., bipolar disorder).
Park, T. W., Cheng, D. M., Samet, J. H., Winter, M. R., & Saitz, R. (2015). Chronic care management for substance dependence in primary care among patients with co-occurring disorders. Psychiatr Serv, 66(1), 72-79. doi:10.1176/appi.ps.201300414
l
This study examines if chronic care management in a primary care setting benefits people with co-occurring substance use disorder and one of two mental health disorders—major depressive disorder (MDD) or post-traumatic stress disorder (PTSD).
This study used data from the AHEAD study, a randomized controlled trial testing the effectiveness of CCM for SUD in primary care.
Patients were assigned to receive CCM or usual primary care. CCM included the following services: clinical case management, motivational enhancement therapy, relapse prevention counseling, addiction pharmacotherapy, and referral to specialty addiction treatment and mutual-help groups. Standard primary care to which CCM was compared included an appointment with a primary care physician and providing a list of addiction treatment resources.
This study focused on two subgroups: participants with current (i.e., past two week) MDD and participants with current PTSD (i.e., past month). Outcomes included any stimulant or opioid use or heavy drinking in the past 30 days, mental health symptom severity, and treatment utilization including emergency department visits, hospitalizations, addiction treatment, and mental health treatment.
Analyses were adjusted for the following variables:
Of all participants (N = 563), 443 (79%) met diagnostic criteria for major depressive disorder (MDD) and 205 (36%) met criteria for post-traumatic stress disorder (PTSD). Two hundred and nineteen participants with MDD (49%) and 100 participants with PTSD (49%) were randomized to chronic control management (CCM). A majority of participants were male, had alcohol and drug use disorders, experienced homelessness in the past 3 months, and had been previously incarcerated. The average scores for psychiatric symptoms were indicative of moderately severe depression and severe anxiety.
For both the major depressive disorder (MDD) and PTSD groups, participation in chronic control management (CCM) did not have a significant effect on substance use or mental health outcomes in the adjusted models. However, compared to the primary care group, CCM was significantly associated with greater receipt of addiction treatment, addiction medicine, mental health treatment, and psychiatric medication for the MDD subgroup. These results were similar for the PTSD group except greater addiction treatment utilization was not significant. The largest effect was seen in receipt of mental health treatment.
Despite providing an intervention offering a wide array of services, chronic control management was not effective at improving substance use or mental health outcomes among patients with co-occurring PTSD or major depressive disorder in addition to substance use disorder, many of whom had very challenging social circumstances including homelessness. While patients in the chronic control management group were more likely to use relevant treatment services, this did not translate into symptom improvement.
Chronic control management (CCM) effectively connected patients with treatment services but different types of services may have provided better outcomes. While CCM was effective for patients with diabetes and heart disease, it may not be suitable for addiction and those with a co-occurring mental health disorder.
While this model has been successful with chronic illness such as diabetes, congestive heart failure, and mental illness alone (e.g., depression and anxiety), it was not shown to be effective for health-related outcomes including substance use among people with addiction in a recent randomized controlled trial (see here for the results of the Addiction Health and Evaluation and Disease Management [AHEAD] study). Given CCM’s benefit for some mental disorders, Park and colleagues hypothesized that individuals with co-occurring disorders participating in the AHEAD study may have benefitted from this intensive, integrated care model.
Chronic control management (CCM) was significantly associated with greater receipt of mental health and addiction treatment services. This population was characterized by scores indicating moderately severe depression and severe anxiety so it is possible that CCM may be effective in a population with less severe psychiatric illness. In order to better address the needs of this population with co-occurring disorders, services need to cater to psychosocial issues (e.g., low socioeconomic status, criminal justice involvement, and homelessness) that may be impacting patients’ ability to benefit from treatment. Such services will improve recovery capital, the resources such as housing and employment that are needed to begin and maintain recovery.
Given the clinical severity of this study population, it cannot be concluded that chronic control management (CCM) is ineffective for all individuals with co-occurring disorders. Future treatment development can be informed by the patients themselves by conducting qualitative research with a sample of this population to identify why more treatment engagement did not result in better outcomes. Researchers could also replicate this intervention in samples with less severe symptoms and/or different mental health disorders (e.g., bipolar disorder).
Park, T. W., Cheng, D. M., Samet, J. H., Winter, M. R., & Saitz, R. (2015). Chronic care management for substance dependence in primary care among patients with co-occurring disorders. Psychiatr Serv, 66(1), 72-79. doi:10.1176/appi.ps.201300414
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