Feasibility of a computerized intervention for offenders with substance use disorders: a research note.

OBJECTIVES: Despite evidence that treatment is effective in reducing recidivism among inmates with substance use problems, scarce resources mean that few of those in need of treatment actually receive it. Computerized substance abuse interventions could be used to expand access to treatment in prisons without placing an undue burden on resources. The major aim of the study was to compare treatment conditions in terms of their service utilization, skills acquisition, and treatment satisfaction. METHODS: The study recruited men and women with substance use disorders from 10 prisons in 4 states. In an open label clinical trial, 494 subjects were randomly assigned either to the Experimental condition, a computerized drug treatment intervention, the Therapeutic Education System (TES; n = 249), or to the Control condition, Standard Care (n = 245). Chi-square tests compared groups on categorical variables and independent samples t tests were used for interval level continuous variables. RESULTS: Initial evidence demonstrated: (1) comparable group rates of session attendance and high rates of TES module completion for experimental subjects; (2) comparable group gains in the development of coping skills; and (3) a more favorable view of TES than of Standard Care. CONCLUSIONS: Collectively, these results show that a computerized intervention, such as TES, can be implemented successfully in prison. Given the barriers to the delivery of substance abuse treatment typically encountered in correctional settings, computerized interventions have the potential to fill a significant treatment gap and are particularly well suited to inmates with mild to moderate substance use disorders who often are not treated.

Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions.

Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.

Modified therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use disorders.

This clinical trial evaluated a modified therapeutic community aftercare (MTC-A) program for a population triply diagnosed with HIV/AIDS, a substance use disorder, and a mental disorder. After six months of MTC residential treatment (MTC-R), subjects were randomly assigned to MTC-A (n=42) or to standard aftercare (C; n=34). Follow-up interviews at six and 12 months assessed eight outcome domains and adherence to prescribed HIV medication. A propensity model was used to re-balance the retrieved sample. At the six-month follow-up, High stratum MTC-A clients (those with greater psychological functioning and stable physical health at baseline) had greater improvement overall and for substance use and mental health than C clients in the same stratum. In contrast, C clients in the Low/Medium stratum (those with poorer psychological functioning and improved physical health) had more favorable outcomes overall and for substance use than their MTC-A counterparts; however, this stratum was not re-balanced effectively. Differences in HIV medication adherence were not detected. Clients with greater psychological functioning and stable health at treatment entry benefit more from the MTC-A program. In view of the potentially progressive nature of HIV, measuring physical and mental health during treatment and controlling for changes could be important in future research.

Modified therapeutic community for co-occurring disorders: single investigator meta analysis.

This paper presents the results of a meta-analysis for a single investigator examining the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring substance use and mental disorders (COD). The flexibility and utility of meta-analytic tools are described, although their application in this context is atypical. The analysis includes 4 comparisons from 3 studies (retrieved N = 569) for various groups of clients with COD (homeless persons, offenders, and outpatients) in substance abuse treatment, comparing clients assigned either to an MTC or a control condition of standard services. An additional study is included in a series of sensitivity tests. The overall findings increase the research base of support for the MTC program for clients with COD, as results of the meta-analysis indicate significant MTC treatment effects for 5 of the 6 outcome domains across the 4 comparisons. Limitations of the approach are discussed. Independent replications, clinical trials, multiple outcome domains, and additional meta-analyses should be emphasized in future research. Given the need for research-based approaches, program and policy planners should consider the MTC when designing programs for co-occurring disorders.

Violent offenses associated with co-occurring substance use and mental health problems: evidence from CJDATS.

The present study examines the relationship between substance use, mental health problems, and violence in a sample of offenders released from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,349) in a federally funded cooperative, the Criminal Justice Drug Abuse Treatment Studies (CJDATS), were analyzed. Among parolees referred to substance abuse treatment, self-reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. For most offenders with substance use problems, the quantity of alcohol consumed and the frequency of drug use were associated with a greater probability of self-reported violence. Mental health problems were not indicative of increases in violent behavior, with the exception of antisocial personality problems, which were associated with violence. The paper emphasizes the importance of providing substance abuse treatment in relation to violent behavior among offenders with mental health problems being discharged to the community.

Responding to the challenge of co-occurring disorders: suggestions for future research.

This special issue consolidates some recent research findings and scientific thought on co-occurring disorders from both the substance abuse and mental health fields. This summary article recaps and synthesizes the main findings and themes, then considers additional issues in the field today to arrive at an agenda for future co-occurring disorders research. Plans must: (1) encourage and assist further development of treatment programs that respond to an array of types and severities of co-occurring disorders while taking into account the limited resources typically available; (2) continue the development and testing of continuing care models by exploring strategies that will sustain the recovery of treated individuals who remain vulnerable to relapse; and (3) contribute to our understanding of the mechanisms and processes that enable new interventions and practices to be adopted, implemented, and sustained. "Co-occurring disorders" is a relatively new area of research; this special issue illustrates the productivity of work to date and indicates the potential for advances to come.

Modified therapeutic community for co-occurring disorders: a summary of four studies.

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.

Enhanced outpatient treatment for co-occurring disorders: main outcomes.

This study, which was conducted in an outpatient substance abuse treatment program, randomly assigned clients with mental health symptoms to either a control group, which received basic program services, or an experimental group, which was configured as a modified therapeutic community (TC) track, with the addition of modified TC features and three specific elements-psychoeducational seminar, trauma-informed addictions treatment, and case management. The experimental group had significantly better outcomes as compared with the control group on measures of psychiatric severity and on the key measure of housing stability; no difference was observed for substance use, crime, and employment. The findings must be qualified because (a) only 3 of 34 representative measures (<10%) showed significant differential treatment effects and (b) analysis revealed partial implementation of the enhancements. The study provides modest support for the effectiveness, on specific outcomes, of outpatient substance abuse treatment programs that add modified TC features and targeted interventions to strengthen their capacity to treat co-occurring disorders.

Synthesis of studies of co-occurring disorder(s) in criminal justice and a research agenda.

The studies reported in this special issue were designed to take advantage of the unique opportunity that the Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative provides to the systematic study of several key issues in programming for co-occurring disorder(s) (COD) in the criminal justice system. These papers present findings from CJDATS studies pertaining to co-occurring disorder(s), identify clinical initiatives to strengthen efforts to treat the population with co-occurring disorder(s), and point to a direction for the elaboration of a future research agenda. Four key areas of investigation are presented: Screening and Diagnosis; the Relationship of Co-Occurring Disorder(s) to Violence; Gender Differences; and the Delivery of Services for Co-Occurring Disorder(s). The first section of this article summarizes the studies included in this special issue within the context of the research literature already available. The second section suggests a future research agenda for the study of offender populations with co-occurring disorder(s), and concludes with a broad statement of clinical advancements to date.

Community-based co-occurring disorder (COD) intermediate and advanced treatment for offenders.

Against a backdrop of increasing concern about the adequacy of treatment for co-occurring substance use and mental disorders (typically known as "co-occurring disorders," or COD) in the criminal justice system, this article attempts to provide empirical evidence for a typology of levels of COD treatment for offenders in both prison and community settings. The paper investigates two levels of treatment programs for COD; "intermediate" programs, in which treatment programming has been designed primarily for offenders with a single disorder, and "advanced" programs, in which programming has been designed to provide integrated substance abuse treatment and mental health services. Findings from a national survey of program directors indicated that both intermediate and advanced COD treatment programs were similar in their general approach to substance abuse treatment, but differed considerably in their treatment of mental disorders, where the advanced programs employed significantly more evidence- and consensus-based practices. Results provide support for the distinction between intermediate- and advanced-level services for offenders with COD and support a typology that defines advanced programs as integrating a range of evidence- and consensus-based practices so as to modify treatment sufficiently to address both diseases.

Diagnostic profiles of offenders in substance abuse treatment programs.

This study examined the association of Axis I and Axis II disorders among offenders who were in prison-based substance abuse treatment in a national multi-site study. Participants (N = 280) received a psychosocial assessment and a structured diagnostic interview in two separate sessions. Logistic regression models examined the association between lifetime mood and anxiety disorders with two personality disorders, and the relationship of Axis I and Axis II disorders (alone and in combination) to pre-treatment psychosocial functioning. Over two-thirds of the sample met criteria for at least one mental disorder. Borderline personality disorder was strongly associated with having a lifetime mood disorder (odds ratio = 7.5) or lifetime anxiety disorder (odds ratio = 8.7). Individuals with only an Axis II disorder, or who had both Axis I and Axis II disorders, had more severe problems in psychosocial functioning than those without any disorder. Clinical treatment approaches need to address this heterogeneity in diagnostic profiles, symptom severity, and psychosocial functioning.

Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs.

This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.

Performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSIs) among minority offenders.

Previous research has shown the performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSI-MD and SMD)--six- and three-item instruments to screen for any mental disorder (CODSI-MD) and for severe mental disorders (CODSI-SMD), respectively--to be comparable or superior to other, longer instruments. This study tested the stability of the performance of the CODSI-MD and SMD across three racial/ethnic groups of offenders entering prison substance abuse treatment programs (n = 353), consisting of 96 African American, 120 Latino, and 137 White admissions. The Structured Clinical Interview (SCID) was used to obtain DSM-IV Axis I and II diagnoses; a lifetime SCID diagnosis of a mental disorder or a severe mental disorder was the criterion against which the CODSI-MD and SMD were validated. Results showed no statistical differences in sensitivity or specificity for either the CODSI-MD or SMD across the African American, Latino, and White prisoner groups. The value of the CODSI-MD and SMD as brief screens for mental disorders among offenders with diverse racial/ethnic backgrounds is discussed.

CJDATS CO-OCCURRING DISORDERS SCREENING INSTRUMENT (CODSI) FOR MENTAL DISORDERS (MD): A Validation Study.

Three standardized screening instruments-the Global Appraisal of Individual Needs Short Screener (GSS), the Mini-International Neuropsychiatric Interview-Modified (MINI-M), and the Mental Health Screening Form (MHSF)-were compared to two shorter instruments, the 6-item Co-Occurring Disorders Screening Instrument for Mental Disorders (CODSI-MD) and the 3-item CODSI for Severe Mental Disorders (CODSI-SMD) for use with offenders in prison substance-abuse treatment programs. Results showed that the CODSI screening instruments were comparable to the longer instruments in overall accuracy and that all of the instruments performed reasonably well. The CODSI instruments showed sufficient value to justify their use in prison substance-abuse treatment programs and to warrant validation testing in other criminal justice populations and settings.

CJDATS Co-Occurring Disorders Screening Instrument for Mental Disorders (CODSI-MD): A Pilot Study.

This article describes the development of an instrument to screen male and female offenders for co-occurring substance use and mental disorders. This phase developed and pilot tested (N = 100) the Criminal Justice Drug Abuse Treatment Studies (CJDATS) Co-occurring Disorders Screening Instrument for Mental Disorders (CODSI-MD), a 6-item instrument derived from three standard mental health screeners. The overall accuracy of the CODSI-MD (81%) compared favorably with the three standard instruments. A second 3-item instrument, developed to screen for severe mental disorders (the CODSI-SMD), had an overall accuracy of 82%. The results of this pilot study must be viewed cautiously, pending validation of the findings with a larger sample.

Cohort profile: seek, test, treat and retain United States criminal justice cohort.

BACKGROUND: The STTR treatment cascade provides a framework for research aimed at improving the delivery of services, care and outcomes of PLWH. The development of effective approaches to increase HIV diagnoses and engage PLWH in subsequent steps of the treatment cascade could lead to earlier and sustained ART treatment resulting in viral suppression. There is an unmet need for research applying the treatment cascade to improve outcomes for those with criminal justice involvement. METHODS: The Seek, Test, Treat, and Retain (STTR) criminal justice (CJ) cohort combines data from 11 studies across the HIV treatment cascade that focused on persons involved in the criminal justice system, often but not exclusively for reasons related to substance use. The studies were conducted in a variety of CJ settings and collected information across 11 pre-selected domains: demographic characteristics, CJ involvement, HIV risk behaviors, HIV and/or Hepatitis C infections, laboratory measures of CD4 T-cell count (CD4) and HIV RNA viral load (VL), mental illness, health related quality of life (QoL), socioeconomic status, health care access, substance use, and social support. RESULTS: The STTR CJ cohort includes data on 11,070 individuals with and without HIV infection who range in age from 18 to 77 years, with a median age at baseline of 37 years. The cohort reflects racial, ethnic and gender distributions in the U.S. CJ system, and 64% of participants are African-American, 12% are Hispanic and 83% are men. Cohort members reported a wide range of HIV risk behaviors including history of injection drug use and, among those who reported on pre-incarceration sexual behaviors, the prevalence of unprotected sexual intercourse ranged across studies from 4% to 79%. Across all studies, 53% percent of the STTR CJ cohort reported recent polysubstance use. CONCLUSIONS: The STTR CJ cohort is comprised of participants from a wide range of CJ settings including jail, prison, and community supervision who report considerable diversity in their characteristics and behavioral practices. We have developed harmonized measures, where feasible, to improve the integration of these studies together to answer questions that cannot otherwise be addressed.

The Impact of Technical Assistance and Implementation Support on Program Capacity to Deliver Integrated Services.

This study assessed gains that New York State mental health and addiction outpatient clinics achieved in their capacity to provide integrated mental health and substance abuse services for persons with co-occurring disorders. The investigators used two Dual Diagnosis Capability (DDC) indices-one for Addiction Treatment (DDCAT) and one for Mental Health Treatment (DDCMHT)-to measure integration capability at baseline (n = 603) and at follow-up (n = 150), an average of 2 years post-baseline, during which time programs received technical assistance and implementation support. At baseline, the average program score was 2.68, below the "Capable" level (3.0 on a 5-point scale). At follow-up, the average score was 3.04, and the percent of programs rated Capable more than doubled (from 22 to 52%). Programs with lower baseline scores and those with more time to follow-up (2-3 years) had the greatest increases, but 12 to 18 months were sufficient to realize sizeable and significant improvements.

A Technical Assistance Framework to Facilitate the Delivery of Integrated Behavioral Health Services in Federally Qualified Health Centers (FQHCs).

An implementation approach, featuring direct, onsite technical assistance is described, and findings from a pilot study assessing the capability of Federally Qualified Health Centers to provide integrated behavioral health services are presented. Investigators used the Behavioral Health Integration in Medical Care (BHIMC) index to measure integration at baseline and follow-up at four FQHCs in New Jersey. Results indicate that the average baseline capability score of 1.95 increased to 2.44 at follow-up, almost one-half point on the five-point BHIMC index. This pilot project demonstrates that co-occurring capability can be assessed, and system-wide technical assistance can be delivered to assist FQHCs in integrating behavioral health services. Future research should test technical assistance as an implementation strategy to promote the integration of medical care and behavioral health treatment on a wider scale.

TC-oriented supported housing for homeless MICAs.

This article describes a TC-oriented aftercare program for homeless mentally ill chemical abusers (MICAs) in a supported housing facility, and presents some preliminary data on program effectiveness. The study divided the clients who had completed a residential modified TC program into two groups--those who participated in the TC-oriented supported housing program and those who did not. The data show similarities in the profile of the two groups. Improvement in negative behaviors (e.g., drug use and crime) occurred during the residential program and stabilized during the supported housing program, while improvement in prosocial behaviors (e.g., psychological functioning and employment) was incremental and continuous over the course of both programs. Those who participated in the TC-oriented supported housing program demonstrated significantly better outcomes than those who did not. These findings provide preliminary evidence for the effectiveness of a TC-oriented supported housing program as an aftercare strategy for homeless MICA clients following residential treatment.