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Effectiveness of inpatient treatment programs for dually diagnosed patients

Research project DR/08 (Research action DR)


Persons :


Description :

The purpose of the present study is twofold since the present research team not only investigates whether dually diagnosed patients are effectively treated by inpatient integrated treatments, but also whether these patients are more effectively treated by inpatient integrated treatments than by inpatient standard treatments.

Within the framework of this research project, only dually diagnosed patients with coexisting severe psychotic and substance use disorders will be examined. These patients are usually young, single, poorly educated and unemployed men with pronounced social and sexual deficits (e.g., Dixon et al., 1991; Gearon et al., 2001; Salyers & Mueser, 2001; Cantwell, 2003). Their living and housing situation is unstable (e.g., Kavanagh et al., 2002).

Given the fact that dually diagnosed patients have comorbid psychotic and substance use disorders, it is not surprising that they have symptoms of psychotic and addicted or dependent patients. The interaction between these disorders seems to have a negative impact on the onset, process and treatment of both disorders (e.g., Mueser et al., 1992; Negrete, 2003). Furthermore, dually diagnosed patients frequently have comorbid medical, forensic and cognitive conditions. This means that these patients have more medical illnesses, are more impulsive and/or violent, and are more cognitively disturbed than psychotic patients (e.g., U.S. Department of Mental Health and Human Services, 1994; Ries et al., 2000; Gearon et al., 2001).

At present, most eminent researchers argue that dually diagnosed patients are best treated in integrated treatment services (e.g., Drake et al., 2001; Department of health, 2002). This means that both disorders are consistently and simultaneously treated by a multidisciplinary and crosstrained team (e.g., Polstra, 1999). Although there are certain differences between all of these treatment programs, each integrated treatment program can be seen as a combination of two or more of the following components:

1. A specialised assessment (Todd et al., 2002).
2. Outreaching work (aim: the creation of a therapeutic relationship) (Drake et al., 2001).
3. Motivational interviewing (aim: the enlargement of the intrinsic motivation) (Martino et al., 2002).
4. Individual and group counselling (Drake et al., 2001).
5. Pharmacological treatment (Dom, 2000).
6. Psychoeducation (Ryglewicz, 1991).
7. Long-term perspective (Mueser et al., 1997).
8. Stage-wise treatment (Department of health, 2002).
9. Social network (Nikkel & Coiner, 1991).

The research on the (superior) effectiveness of inpatient integrated treatment programs is very scarce.
Drake et al. (1997) took note of the fact that inpatient integrated treatments significantly enhance the intrinsic motivation of dually diagnosed patients. Herman et al. (2000) clearly demonstrated that inpatient integrated treatments result in a significantly higher increase in intrinsic motivation than inpatient standard treatments. Several researchers had to conclude that inpatient integrated treatments have no effect (DiNitto et al., 2002) or a (marginal) significant positive effect (Burnam et al., 1995; Moggi et al., 1999a; Moggi et al., 2002) on psychiatric symptoms . According to Blankertz & Cnaan (1994) and Moggi et al. (1999b) inpatient integrated treatments produce significantly better effects on psychiatric symptoms than inpatient standard treatments. Inpatient integrated treatments have no effect (Bartels & Drake, 1996; see Drake et al., 1998; Moggi et al., 1999a; DiNitto et al., 2002) or a significant positive effect (Ries & Ellingson, 1990; see Drake et al., 1998; Moggi et al., 2002) on substance use. Furthermore, several researchers argue that integrated treatments produce significantly better effects on substance use than inpatient standard treatments (Blankertz & Cnaan, 1994; Drake et al., 1997; Herman et al., 2000; Brunette et al., 2001). Inpatient integrated treatments result in an equal (Bartels & Drake, 1996; see Drake et al., 1998; DiNitto et al., 2002) or smaller number (Moggi et al., 1999b; Moggi et al., 2002) of hospitalisations at follow-up. Patients who were treated in inpatient integrated services are less frequent homeless (Drake et al., 1997; Moggi et al., 1999a; Brunette et al., 2001; Moggi et al., 2002) and without income (Moggi et al., 1999a; Moggi et al., 1999b).

Based upon the above-mentioned findings, several researchers argue that dually diagnosed patients can be effectively treated in inpatient integrated services. These researchers also believe that inpatient integrated treatment programs are significantly more effective than inpatient standard treatment programs (e.g., Drake et al., 1998). According to Ley et al. (2002), these conclusions are incorrect since most studies have important hiatuses (e.g., non-experimental designs, non-representative samples). These researchers also mention that the above-mentioned findings are seldom replicated. This scientific discussion calls for further research .

Since the present research team needs to evaluate the functioning of treated dually diagnosed patients, they selected a non-equivalent comparison group design (el-Guebaly et al., 1999). This means that all patients participate in four successive interviews in which their psychotic symptoms, substance use, readiness to change, quality of life, global functioning and forensic comorbidity will be examined. The variable choice is based upon the patients profile and upon the above-mentioned research results. Each variable will be judged by different persons (patients, staff, family). Each six months the work stress and satisfaction of the staff will be examined by means of three different questionnaires. Finally, the treatment cost will be evaluated. The different treatment interventions will be explored by means of a process evaluation.

A treatment is successful if the patient experiences an important improvement on one or more variables (within-subject comparison). The comparison between different treatments helps us to find out which treatment is best (between-subject comparison).


(1) The positive, depressive and anxiety symptoms are best investigated.
(2) The call for further research seems justified because of the following facts:
a. Negative treatment effects were never found.
b. The variance in research results might be an artefact of the variance in methodology.
c. The effectiveness of treatment components on the one hand and outpatient integrated treatments on the other hand could be demonstrated (e.g., Barrowclough et al., 2001; Martino et al., 2003).
d. The ecological validity of the research results is unknown (e.g.: are there differences between the American and the European population samples? Are there differences between patients with severe and less severe mental illnesses?).


Documentation :

Onderzoek naar de effectiviteit van de residentieel geïntegreerde behandeling voor patiënten met een dubbeldiagnose : eindrapport  Van Ham, Sophie - Sabbe, Bernard - De Wilde, Bieke  Gent : Academia Press, 2006 (PB6175)
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Onderzoek naar de effectiviteit van behandelingsprogramma’s, specifiek voor patiënten met een dubbele diagnose : tussentijdsrapport    Brussel : Federaal Wetenschapsbeleid, 2004 (SP1394)
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Onderzoek naar de effectiviteit van behandelingsprogramma’s, specifiek voor patiënten met een dubbele diagnose : samenvatting    Brussel : Federaal Wetenschapsbeleid, 2004 (SP1395)
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Etude sur l’efficacité des programmes de traitement de patients présentant un double diagnostic : résumé    Bruxelles : Politique scientifique fédérale, 2004 (SP1396)
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Effectiveness of inpatient treatment programs for dually diagnosed patients : summary    Brussels : Federale Science Policy, 2004 (SP1397)
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