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. 1998 Dec;33(5 Pt 1):1285–1308.

Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders.

R E Clark 1, G B Teague 1, S K Ricketts 1, P W Bush 1, H Xie 1, T G McGuire 1, R E Drake 1, G J McHugo 1, A M Keller 1, M Zubkoff 1
PMCID: PMC1070317  PMID: 9865221

Abstract

OBJECTIVE: To determine the cost-effectiveness of Assertive Community Treatment (ACT) in comparison to Standard Case Management (SCM) for persons with severe mental illness and substance use disorders. DATA SOURCES AND STUDY SETTING: Original data on the effectiveness and social costs of ACT and SCM that were collected between 1989 and 1995. Seven community mental health centers in New Hampshire provided both types of treatment. STUDY DESIGN: Persons with schizophrenia, schizoaffective disorder, or bipolar disorder and a concurrent substance use disorder were randomly assigned to ACT or SCM and followed for three years. The primary variables assessed were substance use, psychiatric symptoms, functioning, quality of life, and social costs. DATA COLLECTION METHODS: Effectiveness data were obtained from interviews at six-month intervals with persons enrolled in treatment and with their service providers. Social cost and service utilization data came from client reports; interviews with informal caregivers; provider information systems and Medicaid claims; law enforcement agencies; courts; and community service providers. PRINCIPAL FINDINGS: Participants in both groups showed significant reductions in substance use over time. Focusing on quality of life and substance use outcomes, ACT and SCM were not significantly different in cost-effectiveness over the entire three-year study period. Longitudinal analyses showed that SCM tended to be more efficient during the first two years but that ACT was significantly more efficient than SCM during the final year of the study. CONCLUSIONS: In an adequately funded system, ACT is not more cost-effective than SCM. However, ACT efficiency appears to improve over time.

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Selected References

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  1. Abram K. M., Teplin L. A. Co-occurring disorders among mentally ill jail detainees. Implications for public policy. Am Psychol. 1991 Oct;46(10):1036–1045. doi: 10.1037//0003-066x.46.10.1036. [DOI] [PubMed] [Google Scholar]
  2. Ananth J., Vandewater S., Kamal M., Brodsky A., Gamal R., Miller M. Missed diagnosis of substance abuse in psychiatric patients. Hosp Community Psychiatry. 1989 Mar;40(3):297–299. doi: 10.1176/ps.40.3.297. [DOI] [PubMed] [Google Scholar]
  3. Atkinson M., Zibin S., Chuang H. Characterizing quality of life among patients with chronic mental illness: a critical examination of the self-report methodology. Am J Psychiatry. 1997 Jan;154(1):99–105. doi: 10.1176/ajp.154.1.99. [DOI] [PubMed] [Google Scholar]
  4. Bartels S. J., Drake R. E., McHugo G. J. Alcohol abuse, depression, and suicidal behavior in schizophrenia. Am J Psychiatry. 1992 Mar;149(3):394–395. doi: 10.1176/ajp.149.3.394. [DOI] [PubMed] [Google Scholar]
  5. Bartels S. J., Teague G. B., Drake R. E., Clark R. E., Bush P. W., Noordsy D. L. Substance abuse in schizophrenia: service utilization and costs. J Nerv Ment Dis. 1993 Apr;181(4):227–232. doi: 10.1097/00005053-199304000-00003. [DOI] [PubMed] [Google Scholar]
  6. Bond G. R., Miller L. D., Krumwied R. D., Ward R. S. Assertive case management in three CMHCs: a controlled study. Hosp Community Psychiatry. 1988 Apr;39(4):411–418. doi: 10.1176/ps.39.4.411. [DOI] [PubMed] [Google Scholar]
  7. Bond G. R., Witheridge T. F., Dincin J., Wasmer D., Webb J., De Graaf-Kaser R. Assertive community treatment for frequent users of psychiatric hospitals in a large city: a controlled study. Am J Community Psychol. 1990 Dec;18(6):865–891. doi: 10.1007/BF00938068. [DOI] [PubMed] [Google Scholar]
  8. Borland A., McRae J., Lycan C. Outcomes of five years of continuous intensive case management. Hosp Community Psychiatry. 1989 Apr;40(4):369–376. doi: 10.1176/ps.40.4.369. [DOI] [PubMed] [Google Scholar]
  9. Bush C. T., Langford M. W., Rosen P., Gott W. Operation outreach: intensive case management for severely psychiatrically disabled adults. Hosp Community Psychiatry. 1990 Jun;41(6):647–651. doi: 10.1176/ps.41.6.647. [DOI] [PubMed] [Google Scholar]
  10. Carey M. P., Carey K. B., Meisler A. W. Psychiatric symptoms in mentally ill chemical abusers. J Nerv Ment Dis. 1991 Mar;179(3):136–138. doi: 10.1097/00005053-199103000-00004. [DOI] [PubMed] [Google Scholar]
  11. Caton C. L., Shrout P. E., Eagle P. F., Opler L. A., Felix A., Dominguez B. Risk factors for homelessness among schizophrenic men: a case-control study. Am J Public Health. 1994 Feb;84(2):265–270. doi: 10.2105/ajph.84.2.265. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Clark R. E., Drake R. E. Expenditures of time and money by families of people with severe mental illness and substance use disorders. Community Ment Health J. 1994 Apr;30(2):145–163. doi: 10.1007/BF02188626. [DOI] [PubMed] [Google Scholar]
  13. Clark R. E. Family costs associated with severe mental illness and substance use. Hosp Community Psychiatry. 1994 Aug;45(8):808–813. doi: 10.1176/ps.45.8.808. [DOI] [PubMed] [Google Scholar]
  14. Clark R. E., Ricketts S. K., McHugo G. J. Measuring hospital use without claims: a comparison of patient and provider reports. Health Serv Res. 1996 Jun;31(2):153–169. [PMC free article] [PubMed] [Google Scholar]
  15. Clark R. E., Teague G. B., Ricketts S. K., Bush P. W., Keller A. M., Zubkoff M., Drake R. E. Measuring resource use in economic evaluations: determining the social costs of mental illness. J Ment Health Adm. 1994 Winter;21(1):32–41. doi: 10.1007/BF02521343. [DOI] [PubMed] [Google Scholar]
  16. Cuffel B. J., Shumway M., Chouljian T. L., MacDonald T. A longitudinal study of substance use and community violence in schizophrenia. J Nerv Ment Dis. 1994 Dec;182(12):704–708. doi: 10.1097/00005053-199412000-00005. [DOI] [PubMed] [Google Scholar]
  17. Dickey B., Azeni H. Persons with dual diagnoses of substance abuse and major mental illness: their excess costs of psychiatric care. Am J Public Health. 1996 Jul;86(7):973–977. doi: 10.2105/ajph.86.7.973. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Dickey B., McGuire T. G., Cannon N. L., Gudeman J. E. Mental health cost models. Refinements and applications. Med Care. 1986 Sep;24(9):857–867. doi: 10.1097/00005650-198609000-00007. [DOI] [PubMed] [Google Scholar]
  19. Drake R. E., Osher F. C., Noordsy D. L., Hurlbut S. C., Teague G. B., Beaudett M. S. Diagnosis of alcohol use disorders in schizophrenia. Schizophr Bull. 1990;16(1):57–67. doi: 10.1093/schbul/16.1.57. [DOI] [PubMed] [Google Scholar]
  20. Drake R. E., Rosenberg S. D., Mueser K. T. Assessing substance use disorder in persons with severe mental illness. New Dir Ment Health Serv. 1996 Summer;(70):3–17. doi: 10.1002/yd.23319960203. [DOI] [PubMed] [Google Scholar]
  21. Gibbons R. D., Hedeker D., Waternaux C., Davis J. M. Random regression models: a comprehensive approach to the analysis of longitudinal psychiatric data. Psychopharmacol Bull. 1988;24(3):438–443. [PubMed] [Google Scholar]
  22. Gray A. M., Marshall M., Lockwood A., Morris J. Problems in conducting economic evaluations alongside clinical trials. Lessons from a study of case management for people with mental disorders. Br J Psychiatry. 1997 Jan;170:47–52. doi: 10.1192/bjp.170.1.47. [DOI] [PubMed] [Google Scholar]
  23. Jerrell J. M., Hu T. W., Ridgely M. S. Cost-effectiveness of substance disorder interventions for people with severe mental illness. J Ment Health Adm. 1994 Summer;21(3):283–297. doi: 10.1007/BF02521335. [DOI] [PubMed] [Google Scholar]
  24. Kivlahan D. R., Heiman J. R., Wright R. C., Mundt J. W., Shupe J. A. Treatment cost and rehospitalization rate in schizophrenic outpatients with a history of substance abuse. Hosp Community Psychiatry. 1991 Jun;42(6):609–614. doi: 10.1176/ps.42.6.609. [DOI] [PubMed] [Google Scholar]
  25. Laird N. M., Ware J. H. Random-effects models for longitudinal data. Biometrics. 1982 Dec;38(4):963–974. [PubMed] [Google Scholar]
  26. McHugo G. J., Drake R. E., Burton H. L., Ackerson T. H. A scale for assessing the stage of substance abuse treatment in persons with severe mental illness. J Nerv Ment Dis. 1995 Dec;183(12):762–767. doi: 10.1097/00005053-199512000-00006. [DOI] [PubMed] [Google Scholar]
  27. McHugo G. J., Hargreaves W., Drake R. E., Clark R. E., Xie H., Bond G. R., Burns B. J. Methodological issues in assertive community treatment studies. Am J Orthopsychiatry. 1998 Apr;68(2):246–260. doi: 10.1037/h0080333. [DOI] [PubMed] [Google Scholar]
  28. Minkoff K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hosp Community Psychiatry. 1989 Oct;40(10):1031–1036. doi: 10.1176/ps.40.10.1031. [DOI] [PubMed] [Google Scholar]
  29. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. L., Goodwin F. K. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264(19):2511–2518. [PubMed] [Google Scholar]
  30. Ridgely M. S., Goldman H. H., Willenbring M. Barriers to the care of persons with dual diagnoses: organizational and financing issues. Schizophr Bull. 1990;16(1):123–132. doi: 10.1093/schbul/16.1.123. [DOI] [PubMed] [Google Scholar]
  31. Rosenberg S. D., Drake R. E., Wolford G. L., Mueser K. T., Oxman T. E., Vidaver R. M., Carrieri K. L., Luckoor R. Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness. Am J Psychiatry. 1998 Feb;155(2):232–238. doi: 10.1176/ajp.155.2.232. [DOI] [PubMed] [Google Scholar]
  32. Siegel C., Laska E., Meisner M. Statistical methods for cost-effectiveness analyses. Control Clin Trials. 1996 Oct;17(5):387–406. doi: 10.1016/s0197-2456(95)00259-6. [DOI] [PubMed] [Google Scholar]
  33. Teague G. B., Drake R. E., Ackerson T. H. Evaluating use of continuous treatment teams for persons with mental illness and substance abuse. Psychiatr Serv. 1995 Jul;46(7):689–695. doi: 10.1176/ps.46.7.689. [DOI] [PubMed] [Google Scholar]
  34. Weisbrod B. A. A guide to benefit-cost analysis, as seen through a controlled experiment in treating the mentally ill. J Health Polit Policy Law. 1983 Winter;7(4):808–845. doi: 10.1215/03616878-7-4-808. [DOI] [PubMed] [Google Scholar]
  35. Wolff N., Helminiak T. W., Diamond R. J. Estimated societal costs of assertive community mental health care. Psychiatr Serv. 1995 Sep;46(9):898–906. doi: 10.1176/ps.46.9.898. [DOI] [PubMed] [Google Scholar]

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