Co-occurring disorders lead to worse treatment outcomes

People with co-occurring mental health & substance use disorders tend to experience worse treatment outcomes than individuals with one or the other.

While primary care can address addiction severity in and of itself, it may also provide a potential venue for integrating care for co-occurring disorders.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Due to the nature of these diseases, chronic care management may be an appropriate framework for treatment in this population.

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).

HOW WAS THIS STUDY CONDUCTED?

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:

time,
substance of dependence (alcohol, drug, or both)
race-ethnicity
sex
baseline depression symptom severity
baseline anxiety severity
substance use disorders (SUD) treatment prior to study entry
history of injection drug use

WHAT DID THIS STUDY FIND?

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.

The odds of receiving mental health treatment were over 2.5x higher for patients with major depressive disorder receiving chronic control management (vs. those receiving primary care alone) & 3x higher for post-traumatic stress disorder patients in chronic control management (vs. primary care alone).

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.

WHY IS THIS STUDY IMPORTANT

Chronic control management (CCM) is a long-term approach that includes patient education and self-care and assists patients in understanding their healthcare needs and seeking the appropriate services (e.g., specialty treatment and community-based mutual-help meetings).

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.

LIMITATIONS

As the authors point out, one limitation of this study is that baseline psychiatric assessments were conducted while a majority of patients were undergoing detoxification which may have implications for the generalizability of results. It is possible that major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) were overestimated in this sample because depression and anxiety are common during substance withdrawal from addiction.
Also, since this was a secondary analysis of a randomized controlled trial, the study was not designed to detect differences within subgroups and may have been underpowered (i.e., not have a large enough sample for each of the subgroups) to detect the observed associations.

NEXT STEPS

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).

BOTTOM LINE

For individuals & families seeking recovery: Co-occurring disorders such as post-traumatic stress disorder (PTSD) or major depressive disorder (MDD), chronic control management (CCM) may increase treatment services you receive, but this may not translate into improved substance use or mental health outcomes. Other resources provided by employment and housing services may help improve your recovery capital and ultimately help you begin and sustain recovery.
For scientists: While current research indicates the chronic control management (CCM) is not effective for individuals with substance use disorders (SUD) including those with co-occurring disorders, future research should focus on identifying why it was not effective and how it can be improved to better cater to the needs of this population.
For policy makers: At present, there is no evidence supporting the use of chronic control management (CCM) in primary care for patient with co-occurring disorders. However, as a chronic disease, other longitudinal care models may be useful for people with an addiction. For example, recovery management checkups are an effective method for intervention and are associated with improved long-term outcomes.
For treatment professionals and treatment systems: This study showed that despite increased receipt of treatment services, chronic control management (CCM) patients did not experience better results than the primary care control group. Greater attention to functional in addition to clinical recovery barriers, like the negative impact of homelessness and/or extensive histories of criminal justice involvement on one’s ability to obtain employment, may be needed to improve outcomes.