Outpatient mental health and the dual-diagnosis patient: Utilization of services and community...

Evaluation and Program Planning, Vol. 14, pp. 291-298, 1991 Printed in the USA. All rights reserved.

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OUTPATIENT MENTAL HEALTH AND THE DUAL-DIAGNOSIS PATIENT:

UTILIZATION OF SERVICES AND COMMUNITY ADJUSTMENT

LUCY FORD

Highland Hospital, Oakland, California

LONNIE R. SNOWDEN

University of California, Berkeley, and Institute for Mental Health Services Research

ELIZABETH J. WALSER

Oakland, California

ABSTRACT

The present study analyzed differences in utilization patterns and community adjustment between clients in community mental health with and without substance abuse disorders. Of a sample of 144 patients from an outpatient mental health clinic, 37% or 53 subjects were found to have dual disorders; this level of dual diagnosis occurred despite policies excluding dual disorder clients. The dual-diagnosis group had higher missed-appointment rates, spent fewer months in treatment, and had higher dropout rates. The dual-diagnosis group also fared worse in terms of community adjustment: They were more likely to be arrested, hospitalized, or placed on conservatorship during the two-year follow-up period. When multiple regressions were used to assess the relative impact of various factors on utilization and adjustment, dual-diagnosis status was the strongest predictor of subsequent hospitalizations and also was the best indica- tor, along with affective diagnosis, of missed-appointment rates. Even within community mental health clinics attempting to screen out substance abuse disorders, such disorders are a common occurrence and are associated with problematic patterns of service utilization and community adjustment.

The high prevalence of substance abuse disorders among psychiatrically impaired populations has become a major concern for service providers, program planners, and policy makers in the mental health field. Nu- merous studies have documented the extent of this phenomenon, with varying results: Crowley, Chesluk, Dilts, and Hart (1974) found over one third of psychiatric hospital admissions to be associated with drug abuse; other investigators report rates of substance abuse ranging from 37% for psychiatric inpatients (O’Farrell, Connors, & Upper, 1983) to 50% for users of psychiatric emergency services (Atkinson, 1973;

Menicucci et al., 1988) to 73% for a population of young adult, chronic mental patients (Safer, 1987). Among drug-abusing populations, substantial numbers have also been found to have coexisting psychopathol- ogies (Helzer & Pryzbeck, 1988; Mirin, Weiss, 8~ Mi- chael, 1988; Ross, Glaser, & Germanson, 1988).

Substance abuse tends to have a variable course (Haskin, Endicott, & Keller, 1989) and detrimental ef- fect on the psychosocial functioning of the mentally ill. A study by Robyak and colleagues (Robyak, Donham, Roy, & Ludenia, 1984) found more severe symptomatology and more negative social consequences result-

Requests for reprints should be sent to Lonnie R. Snowden, 120 Harvard Hall, University of California, Berkeley, CA 94720.

291

292 LUCY FORD, LONNIE R. SNOWDEN, and ELIZABETH J. WALSER

ing from substance abuse by their mentally disordered service hours than dual-diagnosis patients. In contrast, subjects; this group also tended to resort more often to others have found no significant relationship between the use of external controls, such as treatment facilities substance abuse and drop-out rates (Greenspan & Kul- and hospitals, in an effort to control their substance ish, 1985; O’Brien, Holton, Hurren, Watt, & Hassan- use. yeh, 1987; Persons, Burns, & Perloff, 1988).

The dual-diagnosis patient’s heavy reliance on external agencies has been substantiated by a number of studies. The younger members of this population, in particular, tend to be overrepresented in psychiatric emergency and inpatient services (Bergman & Harris, 1985; Caton, 1981; Solomon, 1986-87). Safer (1987) found this group to be hospitalized two to three times as often as other psychiatric patients. Kastrup (1987) found substance abuse to be a significant factor in the “revolving door” patient who is repeatedly rehospital- ized. Other researchers note that the substance-abusing psychiatric patient has longer hospital stays and is more likely to discharge against medical advice (Hall, Stick- ney, Gardner, Perl, & LeCann, 1979).

The dual-diagnosis patient is also over-represented in the criminal justice system (Caton, 1981), and may in fact be utilizing the criminal justice system in lieu of the mental health system in many cases (Bachrach, 1986). Holcomb and Ahr (1988) found higher arrest rates among the mentally ill population as a whole than among the general population; they also reported the dual-diagnosis patient to have significantly more arrests than psychiatric patients without coexisting substance abuse disorders.

Purposes of the present study were several. One was to identify the prevalence of dual diagnosis in outpatient community mental health agencies, intending to divert such clients rather than to treat them. Another purpose was to examine the association of dual-diagnosis status (i.e., dual diagnosis versus single diagnosis/psychiatric) among clients not screened out with drop-out rates, as well as on other utilization factors, such as appointment compliance rates and length of time in treatment. The investigation arose out of a concern by clinicians at the study site over what appeared to be a disproportionately large number of missed appointments by dual-diagnosis patients. We initially under- took the study to see if, in fact, dual-diagnosis patients had significantly higher failed-appointment rates than single-diagnosis patients. Other authors have noted that

substance abuse appears to have a significant negative impact on appointment-keeping behavior (e.g., Ananth, Vandewater, Kamal, Brodsky, Carnal, & Miller, 1989; Deyo & Inui, 1980).

The style of participation of the dual-diagnosis client in general outpatient care may be problematic. A review of the literature by Baekeland and Lundwall (1975) indicates that alcoholism and drug dependence, alone or

with co-existing psychopathology, contribute to drop- out rates of up to 75% by the fourth visit. Paolillo and

Moore (1984) found substance abuse to be associated with high rates of drop-out for users of community mental health services. Kofoed, Kania, Walsh, and At- kinson (1986) report two thirds of their dual-diagnosis sample dropped out of treatment by six months. Solo- mon (1986-87) compared dual diagnosis with single diagnosis: Psychiatric outpatients and single diagnosis patients stayed in treatment longer and received more

An additional goal of our study was to examine differences in community adjustment between dual-diagnosis and single-diagnosis psychiatric patients. Although many investigators have noted the poor functioning levels of dual-diagnosis individuals in general, few have addressed the functioning of those participating in outpatient treatment or compared their functioning with that of a comparable group of single-diagnosis psychiatric patients.

Nor have previous investigators considered programs in which active and deliberate attempts are made to exclude clients with co-occurring substance abuse problems. It is intended that clients in such programs have relatively minor levels of substance-related disability and that any residual impairment interferes little with their use of services and community functioning. Whether or not that objective is achieved remains an empirical question that was addressed in the present study.

METHOD

Setting come from the private sector and through word of

The study took place at a public, outpatient, mental mouth. The majority of the clinic’s clientele are Medi- health clinic serving several communities on the out- Cal recipients (California’s supplemented Medicaid pro- skirts of Oakland, California, As a part of the Alameda gram of financing care for the poor and disabled); how- County Mental Health System, the clinic serves a catch- ever, some patients pay for services on a sliding-scale ment area of approximately 300,000 people and pro- basis. vides services at any one time to about 600 clients. The The clinic is staffed by an interdisciplinary team of

clinic receives referrals primarily from Highland Gen- ten clinicians representing such diverse backgrounds as

era1 Hospital, which is the county’s only public inpa- psychiatry, psychology, social work, and psychiatric tient and emergency psychiatric facility. Referrals also nursing. After an initial assessment interview, the patient

Utilization and Adjustment by Dual-Diagnosis Patients 293

is assigned to a primary therapist and a psychiatrist, if needed for supervision of medication. A patient nor- mally sees the therapist for one hour biweekly, which is the maximum reimbursable by Medi-Cal, for a time period prescribed by the patient’s treatment plan. The treatment approach used varies from clinician to clinician, but generally consists of a blend of supportive, be- havioral, and psychodynamic techniques.

The clinic screens patients for alcohol and other drug problems at both the initial telephone contact and during the assessment interview. Those with significant problems are referred elsewhere for treatment, because Medi-Cal does not reimburse providers for treatment of patients with a primary diagnosis of substance abuse. Despite these precautions, a sizeable number of patients with substance abuse disorders are still inadvertently admitted for services, as the sample for the current study demonstrates.

Procedure To obtain the study sample a retrospective chart review was conducted of patients who received services between 1978 and 1988. Every fifth chart in the files was reviewed for inclusion in the sample. Criteria for exclu- sion from the study were: (a) Non-English speaking patients who required an interpreter, (b) patients who received only one therapy session, (c) those admitted less than nine months before the date of the chart review, unless they were deceased by the chart review date, (d) patients receiving medication supervision only, and (e) those receiving group instead of individual therapy. Charts were reviewed from both open and closed files.

Case records were examined for data on clinical factors and on various demographic and historical variables. Information on utilization patterns was collected for the year following admission to the clinic. Data were obtained on the following utilization variables: total number of appointments, number of appointments missed, visits per month, and total consecutive months in treatment. Data on community adjustment were collected for a follow-up period of two years after the index clinic admission. Information on three adjustment variables was obtained: occurrence and number of sub-

sequent arrests and psychiatric hospitalizations, and occurrence of subsequent conservatorships. Data gleaned from the outpatient charts was supplemented by a review of the county hospital’s psychiatric inpatient records. In- formation on private hospitalizations was available by client report.

The sample of 144 subjects was divided into two groups according to dual-diagnosis status, that is, whether or not the subject had a coexisting substance- abuse disorder. Dual-diagnosis category was not readily apparent from the patient’s official diagnosis, mainly because of the Medi-Cal limitations on funding of substance-abuse treatment mentioned above. This re- striction applies to clinics throughout California, and similar ones may apply elsewhere. Thus a thorough chart review was necessary to determine the presence of a dual disorder.

In order to check the validity of this method for the determination of dual-diagnosis status, a subsample of 3 1 cases was selected for cross-validation by the primary therapist. Three clinicians, blind to the dual-diagnosis category established by chart review, classified these subjects according to their clinical assessment. There was a 93% concordance rate with the chart review classification.

Analysis The two subsamples were compared by means of Stu- dent’s t-tests and chi-square analysis to determine between-group differences in demographic, clinical, and utilization variables and in community adjustment indicators before and for two years after the index clinic admission. As an additional measure of pretreatment adjustment, an impairment scale was devised in which subjects were rated according to the presence or absence of prior mental health service contact, prison experience, evictions, job losses, and homelessness. Positive values for these factors were totaled to produce initial impairment scores. The final step in the data analysis was to carry out multiple regressions to test the predictive value of dual-diagnosis status on utilization and community adjustment variables controlling for other clinical, demographic, and historical factors.

RESULTS

Description of the Sample Table 1 describes the characteristics of the sample The sample consisted of 68 subjects currently receiving according to subgroup. The two groups were similar services (47%) and 71 subjects who were no longer re- on all variables except for gender and age. The dual- ceiving services (49%) at the time of the chart review; diagnosis group was predominately male (57%), while five subjects had an indeterminate status. Of a total of the single-diagnosis/psychiatric group was mostly fe- 144 subjects, 91 (63%) were categorized as single diag- male (66%). The dual-diagnosis group was also younger, nosis, or psychiatric only, while 53 (37%) were found with an average age of 34 years, compared to the single- to have co-occurring substance abuse disorders and diagnosis group’s mean age of 37 years. Both of these were thus assigned to the dual-diagnosis category. findings are consistent with descriptions in the literature


TABLE 1 CHARACTERISTICS OF THE SAMPLE (N = 144)

Single Diagnosis

(n = 91) Dual Diagnosis

(n = 53)

Sex Female Male

Age

Ethnic

Black White

Latin0

Other

Marital status Single

Married

Sep. div. or widowed

Household composition

Alone With family

Non-relatives Board & care

Employment status Full/part time

Sheltered Unemployed

Education level

Diagnosis Schizophrenic

Affective

Anxiety Personality

Monthly income

Annual liabili~

Impairment rating at index admission (Range l-9, Mean 1.6)

65.9% (60) 34.1% (31)

37.1 yrs.

17.4% (15)

65.1% (56) 14.0% (12)

3.5% (03)

37.4% (34) 16.5% (15) 46.2% (42)

23.3% (21) 61.1% (55) 11.1% (IO)

4.4% (04)

13.6% (12)

3.4% (03) 83.0% (73)

12.3 yrs.

38.5% (35)

48.4% (44) 9.9% (09) 3.3% (03)

43.4% (23) 56.6% (30)* *

33.6 yrs. *

3.8% (02) 84.9% (45) 11.3% (06)

0

37.7% 120) 13.2% (07) 49.1% (26)

(11) (36) (07) (63)

(11)

(42)

21.6% 58.8% 13.7%

5 .9 %

20.8%

0 79.2%

t 2.4 yrs

54.7%

32.1% 13.2%

0

(29)

(17) (67)

$500.86 $664.32

$9.25 $54.18

However, the two groups differed significantly with respect to prior arrest histories: Although only 3.3% of the single-diagnosis/psychiatric subgroup had been arrested, close to 19% of the dual-diagnosis group had been arrested prior to the index admission (x2 = 9.89, df = 1, p < .Ol). Excluding prior arrests and hospitalizations, however, the two subgroups were comparable in terms of initial impairment level: When rated on a nine-point scale based on prior social functioning in various categories, the psychiatric group had mean scores similar to those of the dual-diagnosis group.

1.48 1.92 Utilization Patterns

*p < .05

=-p < .Ol

of the typical dual-diagnosis patient (e.g., Goldfinger, Hopkin, & Surber, 1984; Hall et al., 1979; Pepper, Kirshner, & Ryglewicz, 1981).

Apart from these differences, the profile of the typical subject is that of a single, white, unemployed high school graduate living with family members, with a primary diagnosis of either affective or schizophrenic disorder. Monthly incomes were fairly low, with an average of six hundred dollars per month, primarily in the form of public assistance. About 46010 of the subjects paid no fee for services.

The two subgroups also proved similar on most pretreatment variables (see Table 2). A high percentage of the sample had previous contact with the mental health system: About 6470 of the total sample had received some type of mental health service prior to the index

TABLE 2 PRE-TREATMENT CHARACTERISTICS

(PERCENT OF SAMPLE AND AVERAGE NUMBER)

Single Diagnosis . Dual Diagnosis

Average Average % (n) Number % (n) Number

Prior hospitalizations 46.2 (42) 1.02 52.8 (28) 1.96

Prior arrests 3.3 (3) .04 f8.9* (IO) .33

Prior conservatorships 13.3 (12) N/A 15.1 (8) nlA

l p < .Ol

clinic admission. Fewer subjects (22%) had received outpatient services specifically, prior to admission. The two groups were also similar as to proportion with prior hospitalizations; 49% had been hospitalized previously. No significant differences were found between groups on average number of prior hospitalizations or on proportion of subjects placed on conservatorships.

Table 3 describes the between-group differences in outpatient treatment utilization patterns for the year following the index admission, as well as differences in community adjustment described in the following sec- tion. The data presented reflect the average number of visits, number of months in treatment, and number of visits per month for one full year following admission into outpatient treatment, or until the first lapse of contact lasting three or more months, whichever came first. Three or more consecutive months without patient contact was defined as a treatment termination for the purpose of this study. The table also shows the missed- appointment or “no-show” rates for the two groups for the year following admission, as well as the drop-out rates for the two categories. A treatment drop-out was considered to be a unilateral termination on the part of the patient before significant improvement was made, as assessed by the primary therapist.

As Table 3 indicates, the psychiatric group parallefed the dual-diagnosis group in terms of average number of visits (20.8 and 17.7 visits, respectively) and visits per


TABLE 3

TREATMENT UTILIZATION PATTERNS AND COMMUNITY ADJUSTMENT DURING THE TWO YEARS FOLLOWING

ADMISSION TO OUTPATIENT TREATMENT

Single Diagnosis

(n)

Dual Diagnosis

(n)

Treatment utilization Average number of visits

Average missed-appointment rate

Average number of months

in treatment Average number of visits

per month

Drop-out rate

Community adjustment (percent of subgroups)

Arrests Hospitalizations Conservatorships

20.85 (91) 17.74 (53)

.I6 (86) .28 (51)”

10.49 (91)

1.95 (83) 4.4% (4)

0

7.7% (7) 2.2% (2)

9.19 (53)’

1.92 (53) 13.2% (7)”

15.1% (8)“’ 39.6% (21)’ l

11.3% (6)’

‘p < .05 * l p < .Ol Note: For continuous variables, n = sample size for calculation of mean; for categorical variables, n = subjects in cells describing joint

occurrence of variables in question.

month (approximately 1.9 visits per month for both groups). The two groups differed significantly, however, in terms of number of months in treatment, “no- show” rates, and drop-out rates. The dual-diagnosis group spent little over nine months in treatment, in contrast to the psychiatric group, which spent an average

of 10.5 months in treatment (t = 2.41 separate variance estimate, df = 84.6, p < .05). The dual-diagnosis group had almost twice as many missed appointments, failing to keep 27.5% of scheduled appointments, compared to the psychiatric group’s “no-show” rate of just 15.8% (t = 5.68, df = 135, p > .Ol). In addition, the dual- diagnosis group had drop-out rates almost three times higher than the single-diagnosis group (~2 = 3.69, p < .05).

In order to assess the predictive value of dual-diagnosis status on treatment utilization patterns with other factors held constant, a multiple regression model was cre- ated to evaluate the relative contributions of various demographic, historical, and clinical factors to each utilization variable identified above. Fourteen factors were entered into the regression analysis: ethnicity (coded as two dummy variables), education level, age, sex, family income, marital status, payment for services (coded as a dichotomous variable, “fee” or “no fee”), number of previous arrests, number of previous hospitalizations, impairment rating as of the index admission, psychiatric diagnosis (also coded as two “dummy” variables), and dual-diagnosis status (a dichotomous variable indicating presence or absence of a substance- abuse diagnosis in addition to a psychiatric diagnosis).

The results, as depicted in Table 4, demonstrate that dual-diagnosis status is the strongest predictor of missed-appointment rates, even after all other factors are held constant. Other factors predicting a high “no- show” rate are the presence of a concomitant affective disorder and a higher level of impairment at the index admission.

Dual-diagnosis status also proved to be a significant

TABLE 4

MULTIPLE REGRESSION ANALYSIS OF FACTORS PREDICTING UTILIZATION PATTERNS AND SUBSEQUENT HOSPITALIZATION AND CONSERVATORSHIP RATES

Missed-Appt. Rate l l

Beta

Total Months in Treatment*

Beta

No. of Times Hospitalized l l

Beta

No. of Times

Conserved’ l

Beta

Psychotic disorder Affective disorder Dual disorder

Age Education

Sex Income

No fee Black Latin0 Impairment at intake Marital status # prior hospital admissions # prior arrests

-.16 .14 .23’ * -.05

.4a** -.19’ -.02 .28’ l

-.14 .04 -.02 -.04 -.ll .09

-.04 -.Ol

.17 .03

.07 -.04

.20* -.14

.Ol .21

.03 -.03 -.05 .ll

.oa

.09

.31+ l

-.09

-.03 -.08 -.02

.I2 -.16

.30’

.14

.Ol

.02 -.I5

.I3 -.04

.13 -.Ol

-.06 -.I3

.07

.12 -.17

.26*

.19’

.04

.36” -.26’ l

l p < .05 **p < .Ol

predictor of number of months spent in outpatient treatment after the index admission, with dual-diagnosis subjects spending less time in treatment. Age was the only other significant predictor of time in treatment; older subjects stayed in treatment for longer periods of time. When total number of visits and frequency of visits were evaluated as dependent variables, no significant predictive variables were found.

Post-Admission Functioning The two groups differed dramatically with regard to post-admission indicators of community adjustment (see Table 3). Chi-square analysis of arrest, hospitalization, and conservatorship rates for the two-year follow- up period revealed that the dual-diagnosis group was much more likely to be arrested (~2 = 14.54, df = 1, p < .Ol). This group was also five times more likely to be hospitalized (~2 = 21.8, df = 1, p < .Ol), or conserved (~2 = 5.23, df = 1, p < .05) during this period than the nonsubstance-abusing psychiatric group.

To determine the impact of dual-diagnosis status on post-treatment functioning with other factors held con-


stant, a multiple regression model was evaluated similar to the one used to analyze predictors of utilization patterns. The model contained the 14 independent variables entered into the utilization model. The dependent variables evaluated were number of subsequent hospitalizations and number of subsequent conservatorships. Number of follow-up arrests was not introduced as a dependent variable at this stage of analysis because of restricted variation in this variable in the present sample.

As Table 4 shows, dual-diagnosis status proved to be a signi~cant predictor of number of hospitalizations but not of conservatorships. Unexpectedly, the results also demonstrated that those subjects of Latin0 origin were at higher risk for both hospitalizations and conservatorships. No other factors predictive of hospitalization emerged from the analysis. However, the analysis of subsequent ~onservatorship predictors yielded two risk factors: The number of prior hospitalizations and impairment level at intake were both found to be predictors of a higher number of conservatorships.

DISCUSSION

The dual-diagnosis patient escaping exclusionary policies and finding his or her way into the traditional outpatient setting appears to fare worse than does the single-diagnosis: psychiatric patient, both in utilization of services and in subsequent community adjustment. With respect to utilization patterns, our data show that the dually diagnosed individual has a higher missed- appointment rate and spends fewer months in treatment before dropping out. Moreover, dual-diagnosis status is the strongest predictor of high “no-show” rates, even when all other factors are held constant. In addition, when considering total time spent in treatment, dual- diagnosis status is second only to age in predicting length of stay; older patients tend to stay in treatment longer. These findings corroborate those of other studies Iink- ing substance abuse to poor utilization of outpatient services (e.g., Paolillo & Moore, 1984; Solomon, 1986 87). They also extend such findings to settings seeking to exclude dual disorders, indicating that associated problems are widespread and difficult to avoid.

Dual-diagnosis status is also associated with greater patient disability. In terms of community adjustment, the dual-diagnosis patient fares much worse than the single-diagnosis/psychiatric patient. This was found to be true despite similar levels of initial impairment for the two groups in our study. The former group was over five times as Iikely to be placed on conservatorship or hospitahzed within the two-year follow-up period than was the latter group. The dual-diagnosis group was also much more likely to experience subsequent arrests. Moreover, the presence of a dual diagnosis was

found to be the most significant factor in predicting future hospital admissions.

A closer look at the dual-diagnosis subject’s involvement with the criminal justice system yields further ev- idence for this claim. Although similar in terms of initial impairment levels and prior hospitalization rates, the dual-diagnosis group was almost six times more likely to have arrest histories as the single-diagnosis/ psychiatric group. Furthermore, although none of the single-diagnosis group was arrested during the follow-up period, over 15% of the dual-diagnosis group experi- enced subsequent arrests. It appears that dual-diagnosis patients in many instances use the criminal justice system in lieu of the mental health system to get their needs met, as others (e.g., Bachrach, 1986) have proposed. Thus it is not just the outpatient setting per se, but the service system as a whole that may be failing to meet the needs of the dual-diagnosis patient. Further research is needed that tracks these patients through a broad range of service systems in order to evaluate this con- cept better.

Despite the higher arrest and hospitalization rates of dual-diagnosis subjects, dual-diagnosis status proved not to be a strong predictor of subsequent conservatorship. However, impairment level and prior history of arrest or hospitalization were found to increase the like- lihood of being conserved. Two possible explanations come to mind: (a) The symptomatoIogy displayed by the dually diagnosed, being in large part drug-induced, may be more transitory and thus less likely to result in a conservatorship, or (b) the symptomatology of this

group may be of a more violent nature, producing more “criminal” behavior and thus leading to more chronic involvement with the criminal justice system than the mental health system. At any rate, it appears that the two groups may follow somewhat different paths through the human service sector; further investigation is needed to document this trend more thoroughly.

One unexpected finding was that the Latin0 ethnic group was at higher risk for both hospitalizations and conservatorships during the follow-up period. This factor was found to be significant even with all other factors held constant. This may suggest that the outpatient services provided were not entirely culturally sensitive or appropriate.

The findings reported here can be considered only preliminary for several reasons. First of all, hospital- based information on subsequent hospitalizations was limited to episodes occurring at the county hospital. This facility serves the great preponderance of hospital clients using the public mental health system, and hospitalization data from other facilities was available through self-report. Nevertheless, a complete file of data from hospital records would have been preferable. Data on arrest rates are based on self-report as well, unless subjects utilized the criminal justice psychiatric unit of the county hospital while incarcerated. Further study of this population would benefit from a broader database, which would include access to criminal justice system


data and hospital utilization data from a wider range of providers, in order to permit a more comprehensive tracking of subjects.

The dually diagnosed individual also fares worse in terms of post-admission adjustment, as the higher rates of arrests, hospitalizations, and conservatorships indi- cate. One explanation is that the outpatient services currently available were designed with the single-diagnosis: psychiatric patient in mind, and thus are more respon- sive to their needs than to those of the less compliant, crisis-oriented, dual-diagnosis patient. Also, the tradi- tionally trained clinician often considers drug abuse to be but a symptom of underlying psychological problems; thus he or she may see a patient in therapy for years without adequately addressing the drug abuse is- sue (Zweben, 1987). Specialized training may be necessary for successful intervention.

Several theorists have suggested the need for programs tailored to the outpatient treatment of the dual-diagnosis patient (e.g., Paolillo & Moore, 1984; Solomon & Gordon, 1987; Toseland, 1987). However, even with programs specifically designed for these patients, high dropout rates have been reported (e.g., Kofoed et al., 1986). It appears that the search for successful treatment approaches for this problematic population will continue to challenge practitioners, program planners, and researchers for some time to come.

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Outpatient mental health and the dual-diagnosis patient: Utilization of services and community...

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