This pilot study evaluated the effectiveness of enhanced case management for substance abusers with comorbid major depression, which was an integrated approach to care. One hundred and 20 participants admitted to drug treatment who also met Computerized Diagnostic Interview Schedule criteria for major depression at baseline were randomized to enhanced case management (ECM) (n = 64) or treatment as usual (TAU) (n = 56). Both groups were followed up at six and 12 months. Participants' current clinical status across a broad range of domains in the past 90 days was assessed using the Global Appraisal of Individual Needs and included their Depressive Symptom Scale, Homicidal-Suicidal Thought Index, and Mental Health Treatment Index scores. The findings did not reveal any statistically significant effects of ECM on outcome measures. However, in view of the high rates of adverse treatment outcomes among comorbid groups, including suicide, the finding of a clinically significant reduction in homicidal and suicidal thoughts warrants further research; the comprehensive approach to treatment tested may be especially helpful to depressed substance abusers with such ideations.
KEY WORDS: case management; comorbidity; depression; integrated care; suicide
Substance use disorders and depression often coexist; in the United States, about 15% of individuals meeting criteria for past-12-month substance use disorder also met criteria for major depressive disorder (Grant et al., 2004). Comorbid substance use with depression tends to worsen clinical course and outcomes (Bums & Teesson, 2002; Bums, Teesson, & O'Neill, 2005; Hasin et al., 2002), and those with such comorbidity are at a high risk of suicide (Davis, Uezato, Newell, & Frazier, 2008; Davis et al., 2006; Yaldizli, Kuhl, Graf, Wiesbeck, & Wurst, 2010). Appropriate interventions that have been empirically tested and that take into consideration the additional treatment needs of this population are needed.
In the past 10 years, integrated treatment for comorbid groups has been advocated to avoid a fragmentary approach to care and to facilitate coordinated, comprehensive, and efficient treatment (Chi, Satre, & Weisner, 2006; Nunes & Levin, 2004; Substance Abuse and Mental Health Services Administration, 2002). A meta-analysis of integrated treatment for coexisting depression and substance use disorders (Hesse, 2009) showed that integrated psychosocial treatment targeting both conditions (as compared with single-focus treatments) was related positively to improved outcomes in temas of percentage of days abstinent, depressive symptoms, and retention in treatment. Hesse concluded that although integrated treatment seems to be promising, more trials are needed to replicate such findings.
In the current study, we compared an enhanced case management (ECM) model with treatment as usual (TAU) at a substance abuse treatment facility. ECM was based on motivational interviewing, an integrated approach to address both substance abuse and comorbid depression. The focus was on providing information from standardized psychiatric assessments to the case managers to improve detection of the comorbid psychiatric disorder, to actively engage patients in depression treatment, to educate them about the relationship between the substance use and depressive symptoms, to identify and overcome barriers to care, and to increase retention in the treatment program. We hypothesized that compared with TAU participants, participants who received ECM would show increased involvement with mental health treatment services for continued management of substance use and coexisting depression, a decrease in depressive symptoms, and a decrease in homicidal or suicidal thoughts.
MATERIALS AND METHOD
The study was a collaborative project between Washington University School of Medicine (WUSM) and six adult treatment units (three intensive outpatient and three regular outpatient treatment units) within the facilities of the Madison County, Illinois, Chestnut Health Systems (CHS) drug abuse treatment system. A two-group (ECM versus TAU) experimental approach with measurement of outcomes at six and 12 months following the intervention was adopted to evaluate the effectiveness of ECM.
Participants were recruited over a 12-month baseline field period. In all, 822 potential participants were referred to the study through entrance into mandated drug or alcohol treatment from 2001 to 2004. Of these, 10 were duplicates, 112 refused enrollment, eight could not be located, and 295 never returned to the treatment provider to be included. This left 397 subjects who were eligible for inclusion in the study. To be eligible, they needed to provide written inforuled consent to be randomized to ECM or TAU if they met criteria for major depression on the Computerized Diagnostic Interview Schedule-IV (CDIS-IV) (Robins et al., 2000), be willing and able to provide validated locator information for follow-up, and be at least 18 years old.
At each facility, subjects were approached by the study coordinator, and the study was briefly described. If a subject agreed to participate, the informed consent was administered by WUSM stale no one refused at this point. Subjects were then interviewed, and those who screened positive for depression (N= 120) were randomized into the ECM (n = 64) or the TAU (n = 56) group. Randomization was completed by the research statistician; assignment was placed in a sealed envelope by assigned ID and opened after the baseline, in front of the participant.
Six- and 12-month follow-up interviews were completed; out of the 120 participants enrolled, 107 were interviewed at six months (92% follow-up rate), and 109 were interviewed at 12 months (94% follow-up rate). For their time and effort in the research, participants were paid $20 at the completion of the baseline interview, $30 at the six-month follow-up interview, and $50 at the 12-month follow-up interview.
The Global Appraisal of Individual Needs (GAIN) (Dennis, Titus, White, Unsicker, & Hodgkins, 2003) was used to measure substance use disorders (alcohol, amphetamines, marijuana, cocaine...