Summary of literature and systematic reviews for comorbidity treatmentThe table below provides a summary of the review literature including systematic reviews around aspects of comorbidity service delivery and treatment. Many authors cited lack of methodological consistency as a limitation to their findings, diminishing the validity of the research and the comparability of studies. However, Kavanagh and Mueser (2007) noted that the scientific rigour of studies on the treatment of comorbidity has been steadily improving over time, with the growing recognition of the methodological requirements of this sort of research. They also noted that 'the variability of studies is so great that no standardized intervention has yet been examined, much less replicated, in more than one published study' (Kavanagh & Mueser, 2007, p.633).
The majority of the reviews focused on comorbidity from the perspective of the MH sector, with the majority of these focusing on co-occurring serious or severe mental illness (e.g. psychotic disorders, schizophrenia) with substance misuse, and psychosocial treatment interventions. When the focus was on mental health, the type and level of substance use was rarely described. Service types (residential or nonresidential), participant population groups, and settings (urban or rural) were not found to be defining factors in the review papers.
Table 34: Summary of literature and systematic reviews for comorbidity treatment
|Publication||Review description||Primary sector*||Comorbidity type*||Review findings / Recommendations||Treatment type*|
|Cleary et al. 2008||Cochrane systematic review of 25 RCT of psychosocial interventions to reduce substance use|
|Serious mental illness and substance misuse||25 articles reviewed. No compelling evidence to support any one psychosocial treatment over treatment as usual. Some support for motivational interviewing to reduce substance use. Suggestion that motivational interviewing is a crucial component in the effectiveness of treatment with cognitive behavioural therapy. Limitation: variation between studies, use of non-validated scales.|
|Drake et al. 2008||Systematic review of 45 controlled trials of psychosocial interventions|
|Severe mental illness and substance use as defined by DSM||Group counselling, contingency management and residential dual diagnosis treatment showed consistent positive effects on substance use disorder. No interventions showed consistent results for mental health outcome, although legal interventions improved treatment attendence.|
Limitations: Lack of methodological consistency.
|Reedy and Hall 2008||Literature review of studies that evaluate treatment or services for clients with substance use and mood or anxiety disorders|
|More severe substance use and less severe mental health problems||Findings supported concurrent or integrated treatment for clients with co-occurring substance use and mood or anxiety disorders. Recommended that all clients in the AOD sector should be screened for co-occurring disorders and service plans should provide comprehensive treatment.|
|Kavanah and Mueser 2007||Review of 17 randomised controlled trials of integrated treatment programs|
|Psychosis and substance misuse||Researchers found that the scientific rigour of studies on treatment of comorbidity is steadily improving. The following tentative conclusions were drawn: There is limited impact of brief interventions; there is little added impact from greater intensity of case management; better outcomes are achieved from extended cognitive behavioural therapy; integrated treatment appears superior to non-integrated controls.|
|Laker 2007||Review of articles looking at harm reduction (HR) and motivational interviewing (MI)|
|Not stated||13 articles reviewed that discussed both HR and MI, 4 RCTs provided main focus for appraisal and discussion. Short-term studies showed MI effective in reducing substance misuse. Long-term studies showed effectiveness of both MI and HR. There may be cost benefit in an HR approach compared with MI and no significant difference in long-term effect.|
|Mueser 2005||Review of effects of specific psychosocial interventions|
|Severe mental illness and substance misuse||Group interventions most extensively studied, with findings indicating that a vareity of different treatment approaches specifically designed for dual disorder clients are more effective at improving substance abuse outcomes compared with no group treatment or standard 12-Step approaches|
|Brunette et al. 2005||Pharmacological treatments for co-occurring substance use disorders in patients with schizophrenia: a research review|
|Severe mental illness, i.e. Schizophrenia - and substance misuse||Clozapine, despite potential side effects, showed the most promise. Further controlled trials are needed to assess the impact of atypical antipsychotics, mood stabilisers, and other agents on substance abuse in patients with schizophrenia. Until more data becomes available, it was recommended that clinicians follow established principles of pharmacotherapy for patients with dual disorders, in addition to psychosocial treatment for dual disorders|
|Donald et al. 2005||Qualitative systematic review of 10 RCTs. Integrated versus non-integrated management and care|
|Measurement of mental illness measured by DSM||Equivocal with regard to the superior efficacy of integrated approaches in either MH or AOD settings. Limitations: Lack of available evidence. Complexity and variability of participants presents challenges for undertaking controlled trials. This review has been evaluated by Cochrane Collaboration and assessed as potentially meeting its quality criteria|
|Drake et al. 2004||Review of 26 controlled trials|
|Severe mental illness and substance misuse||Cumulative evidence supported integrating outpatient MH and AOD treatments into a single package. Small number of motivational counselling sessions reduced substance use.|
Most studies reported to have methodological weaknesses
|Brunette et al. 2004||Review of 10 controlled studies of residential programs of comorbidity|
|Severe mental illness and substance misuse||Concluded that residential comorbidity programs that integrate and modify MH and AOD treatment approaches can be effective for the homeless or treatment non-responders. Research suggested that residential programs should be flexible, supportive, low-intensity and offered for long periods of time. Further research needed to establish the effectiveness of residential programs. Limitations: Methodological problems|
|Siggins Miller Consultants 2003||Review of 51 RCTs to identify best practice in management & care in tertiary settings.|
|Any||MH services more commonly saw clients with schizophrenia and co-occurring substance use disorder, while AOD services more commonly managed clients with affective, anxiety and personality disorders with co-occurring substance use disorder.|
|Crawford et. al 2003||Review of 10 years of literature of comorbidity, summarised by key findings in different themed areas|
|Any||Literature organised into themes: assessment and screening; substance-specific research; specific comorbid psychiatric conditions; childhood, women, violence and suicide; and treatment. Treatment organised as follows: Treatment models; psychological interventions; pharmacological interventions; treatment for specific types of substance use; treatment for specific psychiatric disorders; women and treatment.|
|Jeffery et al. 2000||Cochrane systematic review of interventions to reduce substance use|
|Severe mental health and substance use||6 studies identified. No clear advantage found in supporting any type of substance misuse program over psychiatric treatment as usual. No supporting evidence for integrated programs|
|Drake et al. 1998||Review of 36 integrated treatment models, 23 uncontrolled and 13 controlled studies|
|Severe mental health and substance use||Overall, comprehensive integrated dual diagnosis treatment programs were promising for attracting and retaining participants in intervention programs, with clinically meaningful reduction and remission of substance use disorders over time. Need for more controlled research|
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