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Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 4 - Evidence-Based practices for Co-Occurring Disorders - Understanding Evidence-Based Practices


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When she arrived at St. Elizabeth's Hospital in Washington, D.C., Janice Grady heard what sounded like a death sentence. "They suggested drug treatment and I said, `If you send me there I'm dead,' because I had been through drug treatment before. I knew that something else was wrong with me," Ms. Grady says.

Over 12 years, Ms. Grady was treated several times. During periods of recovery, she attended Federal City College and worked as a nurse and as an assistant director of a drug rehabilitation center. She wanted to stay off drugs, but other problems lurked. She was suicidal before the age of 13. At 14 she was raped and became a teenage mother. "Drugs were a way of dealing with those feelings," she says.

So in 1990 when a doctor from the St. Elizabeth's dual diagnosis program diagnosed her with depression, Ms. Grady says, "I cried, because someone said that there might be something else wrong with me." Now she understood why treatment of addiction, alone, was not enough. She subsequently was diagnosed with bi-polar disorder.

After 9 months of treatment, Ms. Grady entered an apartment at a women's residence, and received care at a mental health agency, including a weekly group for women with trauma and other co-occurring disorders, case management, and psychiatric help. She later earned a college degree and works at a treatment agency helping others with co-occurring disorders. Ms. Grady was in the stands cheering at her granddaughter's recent high school graduation. "I have never felt better," she says.

Understanding Evidence-Based Practices


Definition of Evidence-Based Practice

Just as treatments for other chronic illnesses change based on new advances in research and science, so, too, do treatments for substance abuse and mental disorders, whether occurring separately or co-occurring in a single individual. The challenge to mental and substance abuse professionals - and to the field as a whole - is to ensure that the services being provided, in fact, are the most appropriate for the individual and are the best possible from the perspectives of effectiveness and appropriateness. Those principles undergird the concept of evidence-based services and evidence-based practice.

The evidentiary yardstick against which the effectiveness of services is measured, itself, can vary in precision. Today's "gold standard" evidence-based practice to determine whether a treatment intervention does more good than harm is the assessment of research findings from randomized controlled clinical trials, constituting a rigorous research design (Ley et al., 2000; Sackett et al., 1996). Slightly lower on the scale - the next best evidentiary base - is the quasi-experimental study, in which comparison groups are assigned by randomization (Drake, Goldman et al., 2001). Some researchers believe that findings from open clinical trials (those lacking independent comparison groups) coupled with expert-based clinical observations are insufficient findings on which to determine the effectiveness and rigor of a particular practice. Such researchers believe that only the "gold standard" ensures against the adoption of practices as evidence-based that are contradicted by later findings of controlled research (Drake, Goldman et al., 2001).

It is not surprising that many approaches to care for people with co-occurring substance abuse disorders and mental disorders do not reach the high bar set by the research community's "gold standard." For that reason, the Institute of Medicine has adopted a more pragmatic approach. In its report, Crossing the Quality Chasm: A New Health System for the 21st Century (2000), IOM embraced a less stringent definition of what constitutes an evidence-based practice, suggesting it is the integration of three critical elements:

Best research evidence: clinically relevant research, often from the basic health and medical sciences, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination); the power of prognostic markers; and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

Clinical expertise: the ability to use clinical skills and past experience to identify and treat each patient's unique state and diagnosis, to assess the individual risks and benefits of potential interventions, and to do so within the context of the patient's personal values and expectations.

Patient values: the preferences, concerns, and expectations each patient brings to a clinical encounter that must be integrated into clinical decisions if they are to serve the patient.

The meaning and interpretation of evidence, no matter what kind, is an essential

and probably continual task. All forms of evidence must be weighed to determine whether efficacy (evidence of an effect under ideal conditions) or effectiveness (assessed/evaluated in actual practice) is achieved, and to delineate the particular conditions under which the approach can reasonably be expected to produce favorable outcomes (Peterson, 2001).

Many approaches to treating co-occurring disorders that do not meet strict standards of evidence are nevertheless commonly accepted and believed to be effective based on the best available research, clinical expertise, individual values, common sense, and a belief in human dignity. It is incumbent on practitioners to use the best available approaches. Whatever the definition adopted, some general cautions must be borne in mind. First, not every clinical condition has generated a corpus of research knowledge (Drake et al., 2001). Not every problem has an evidence-based answer (Goldman et al., 2001). Evidence-based medicine cannot be all things to all people (Davidoff, 1999). Finally, some clinical questions cannot wait for an evidence-based solution (Goldman et al., 2001; Davidoff, 1999).

With these cautions in mind, the evidence-based practices included in this chapter reflect this broad IOM-adopted definition, and represent the state-of-the-science in treatment for individuals with co-occurring substance abuse disorders and mental disorders. The strength and level of evidence for each will be noted, along with acknowledgment of the limitations of the research that supports a particular intervention or practice. In several areas - especially reimbursements and costs, access and effectiveness and quality - SAMHSA will collaborate with the Agency for Healthcare Research and Quality and its National Guidelines Clearinghouse to continue to work toward development of guideline criteria for evidence-based practices.

Evidence-Based Integrated Treatment is Multifaceted.

Current research attributes effectiveness to programs of integrated treatment for co-occurring disorders that include certain critical components as described in detail in this chapter (see "Interventions for Adults with Co-Occurring Disorders" section). Each of the individual interventions described has a body of research evidence supporting its effectiveness for individuals with co-occurring disorders. However, it is not simply the use of individual interventions that constitutes an integrated treatment program. Rather, it is the constellation of coordinated interventions - generally several evidence-based interventions used in combination to meet individual client needs, and delivered by the same clinicians working in one setting - that constitutes the evidence-based practice known as integrated treatment for co-occurring disorders.

Evidenced-based integrated treatment approaches combine or integrate mental health and substance abuse treatment and services at the level of the clinical intervention. Hence, integrated treatment programs mean that the same clinicians or teams of clinicians, working in one setting, provide appropriate mental health and substance abuse interventions in a coordinated fashion, whereby the agency or direct providers take responsibility for combining the treatment and service interventions into one coherent package (Drake el al, 1998; Drake et al, 2001). Integrated treatment programs can take place in either the mental health or substance abuse treatment systems, requiring only that treatment and services for both the mental health and substance abuse conditions are delivered by appropriately trained staff and occur within the same setting.


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