Treating Homeless Clients with Severe Mental Illness and Substance Use Disorders: Costs and Outcomes

Abstract

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.

The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements

“…21,37,38 Although the study by Drake and colleagues found evidence that individuals involved in ACT reported decreased substance use on some measures relative to individuals in the control condition, 2 recent investigations tested an enhanced form of ACT that included ACT staff with expertise in treating substance use and did not find evidence that these enhancements were associated with superior outcomes for substance abuse. 21,37,38 Specifically, Essock et al 38 compared the enhanced ACT condition with an intense clinical case management program that also had dual diagnosis expertise and did not find evidence for differences across groups on substance abuse outcomes. Likewise, Morse et al 21 compared ACT with substance abuse expertise (so-called integrated ACT) with ACT alone and with standard care and also failed to find differences in substance use across conditions.…”

“…[8][9][10][11][12][13][14][15][16][17][18] In turn, individuals assigned to the ACT condition used fewer emergency services and more outpatient services, including financial and housing assistance, relative to individuals in the control conditions. 13,14,16,19,23 A few studies also found that individuals assigned to the ACT condition reported decreased symptomatology, 17,20,22,24,25 increased medication adherence, 10,17 more contact with the treatment team, 23,26 more days in stable community housing, 7,12,13,17,19,21,25 and greater satisfaction with treatment among patients and their family members relative to the control condition.…”

“…29 Since the last Schizophrenia PORT review, investigations examining ACT have continued to support its efficacy in decreasing homelessness and improving housing stability. 7,21 A meta-analysis by Coldwell and Bender 6 including the results of 6 randomized trials found that ACT was associated with a 37% greater reduction in homelessness relative to standard community care. These results are consistent with a review by Nelson et al 31 suggesting that involvement in ACT led to greater improvements in housing stability compared with standard care.…”

“…21,37,38 Specifically, Essock et al 38 compared the enhanced ACT condition with an intense clinical case management program that also had dual diagnosis expertise and did not find evidence for differences across groups on substance abuse outcomes. Likewise, Morse et al 21 compared ACT with substance abuse expertise (so-called integrated ACT) with ACT alone and with standard care and also failed to find differences in substance use across conditions. However, Morse et al 21 found that individuals in both ACT conditions reported more days in stable housing relative to individuals in standard care.…”

“…Likewise, Morse et al 21 compared ACT with substance abuse expertise (so-called integrated ACT) with ACT alone and with standard care and also failed to find differences in substance use across conditions. However, Morse et al 21 found that individuals in both ACT conditions reported more days in stable housing relative to individuals in standard care. Notably, Essock et al 38 found that ACT was superior to intensive case management in reducing hospitalization at 1 of 2 sites that had higher rates of institutionalization prior to the study.…”