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Enhanced case management versus substance abuse treatment alone among substance abusers with depression.


This pilot study evaluated the effectiveness of enhanced case management for substance abusers with comorbid major depression, which was an integrated approach to care. One hundred and 20 participants admitted to drug treatment who also met Computerized Diagnostic Interview Schedule criteria for major depression at baseline were randomized to enhanced case management (ECM) (n = 64) or treatment as usual (TAU) (n = 56). Both groups were followed up at six and 12 months. Participants' current clinical status across a broad range of domains in the past 90 days was assessed using the Global Appraisal of Individual Needs and included their Depressive Symptom Scale, Homicidal-Suicidal Thought Index, and Mental Health Treatment Index scores. The findings did not reveal any statistically significant effects of ECM on outcome measures. However, in view of the high rates of adverse treatment outcomes among comorbid groups, including suicide, the finding of a clinically significant reduction in homicidal and suicidal thoughts warrants further research; the comprehensive approach to treatment tested may be especially helpful to depressed substance abusers with such ideations.

KEY WORDS: case management; comorbidity; depression; integrated care; suicide

Substance use disorders and depression often coexist; in the United States, about 15% of individuals meeting criteria for past-12-month substance use disorder also met criteria for major depressive disorder (Grant et al., 2004). Comorbid substance use with depression tends to worsen clinical course and outcomes (Bums & Teesson, 2002; Bums, Teesson, & O'Neill, 2005; Hasin et al., 2002), and those with such comorbidity are at a high risk of suicide (Davis, Uezato, Newell, & Frazier, 2008; Davis et al., 2006; Yaldizli, Kuhl, Graf, Wiesbeck, & Wurst, 2010). Appropriate interventions that have been empirically tested and that take into consideration the additional treatment needs of this population are needed.

In the past 10 years, integrated treatment for comorbid groups has been advocated to avoid a fragmentary approach to care and to facilitate coordinated, comprehensive, and efficient treatment (Chi, Satre, & Weisner, 2006; Nunes & Levin, 2004; Substance Abuse and Mental Health Services Administration, 2002). A meta-analysis of integrated treatment for coexisting depression and substance use disorders (Hesse, 2009) showed that integrated psychosocial treatment targeting both conditions (as compared with single-focus treatments) was related positively to improved outcomes in temas of percentage of days abstinent, depressive symptoms, and retention in treatment. Hesse concluded that although integrated treatment seems to be promising, more trials are needed to replicate such findings.

In the current study, we compared an enhanced case management (ECM) model with treatment as usual (TAU) at a substance abuse treatment facility. ECM was based on motivational interviewing, an integrated approach to address both substance abuse and comorbid depression. The focus was on providing information from standardized psychiatric assessments to the case managers to improve detection of the comorbid psychiatric disorder, to actively engage patients in depression treatment, to educate them about the relationship between the substance use and depressive symptoms, to identify and overcome barriers to care, and to increase retention in the treatment program. We hypothesized that compared with TAU participants, participants who received ECM would show increased involvement with mental health treatment services for continued management of substance use and coexisting depression, a decrease in depressive symptoms, and a decrease in homicidal or suicidal thoughts.



The study was a collaborative project between Washington University School of Medicine (WUSM) and six adult treatment units (three intensive outpatient and three regular outpatient treatment units) within the facilities of the Madison County, Illinois, Chestnut Health Systems (CHS) drug abuse treatment system. A two-group (ECM versus TAU) experimental approach with measurement of outcomes at six and 12 months following the intervention was adopted to evaluate the effectiveness of ECM.

Participants were recruited over a 12-month baseline field period. In all, 822 potential participants were referred to the study through entrance into mandated drug or alcohol treatment from 2001 to 2004. Of these, 10 were duplicates, 112 refused enrollment, eight could not be located, and 295 never returned to the treatment provider to be included. This left 397 subjects who were eligible for inclusion in the study. To be eligible, they needed to provide written inforuled consent to be randomized to ECM or TAU if they met criteria for major depression on the Computerized Diagnostic Interview Schedule-IV (CDIS-IV) (Robins et al., 2000), be willing and able to provide validated locator information for follow-up, and be at least 18 years old.

At each facility, subjects were approached by the study coordinator, and the study was briefly described. If a subject agreed to participate, the informed consent was administered by WUSM stale no one refused at this point. Subjects were then interviewed, and those who screened positive for depression (N= 120) were randomized into the ECM (n = 64) or the TAU (n = 56) group. Randomization was completed by the research statistician; assignment was placed in a sealed envelope by assigned ID and opened after the baseline, in front of the participant.

Six- and 12-month follow-up interviews were completed; out of the 120 participants enrolled, 107 were interviewed at six months (92% follow-up rate), and 109 were interviewed at 12 months (94% follow-up rate). For their time and effort in the research, participants were paid $20 at the completion of the baseline interview, $30 at the six-month follow-up interview, and $50 at the 12-month follow-up interview.


The Global Appraisal of Individual Needs (GAIN) (Dennis, Titus, White, Unsicker, & Hodgkins, 2003) was used to measure substance use disorders (alcohol, amphetamines, marijuana, cocaine, opiates, and other drags) on the basis of Diajlnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) criteria (American Psychiatric Association, 1994). GAIN assesses current (past-90-day) clinical status, health service use, and functional status across an array of domains. It is used to guide clinical decision making at intake and for monitoring and follow-up (information on the GAIN manual and GAIN instruments and publications is available at For this analysis, the following information was derived from GAIN: use, abuse, and dependence on all separate DSM-IV substance categories; current symptoms of depression; homicidal--suicidal thoughts; and use of mental health treatment services for comorbid depression. These sections of GAIN are described in the Outcomes Measures section.


TAU. This included the treatment routinely offered at the treatment facility for the substance abuse problem and consisted of drug education, individual and group counseling, and relapse prevention efforts. Participants randomized to this arm did not receive feedback on the results of their CDIS-IV diagnoses.

ECM. The central component of the study design was providing (versus not providing) psychiatric case management services. ECM was administered according to a manual that was conceptually based on the Medical Outcomes Study (Wells, Burnam, Rogers, Hays, & Camp, 1992) and the Arkansas/Aspen Primary Care intervention for depression (Rost, Pyne, Dickinson, & LoSasso, 2005). ECM included eight in-person sessions lasting about 30 minutes each during a 20-week period. Basic information was provided on the importance of treatment for depression as well as substance abuse treatment; patients were acquainted with their disorders, and specific symptoms, on the basis of CDIS-IV results, were carefully discussed in the light of their effects on an individual's life. The participants were also given a handbook that included information on depression, treatment, and expected outcomes.

Using the ECM manual, the therapists were extensively trained by the WUSM staff in the detection of coexisting depression; reports from the CDIS-IV used to diagnose depression were discussed so that they knew how to interpret and verify the diagnostic and symptom profiles. Training procedures included review of materials provided by the U. S. Department of Health and Human Services (United States Depression Guideline Panel, 1993). The following six actions were emphasized: (1) assessing current symptoms, (2) providing information, (3) exploring patient concems, (4) identifying barriers to care, (5) encouraging patient successes, and (6) helping patients figure out "what's next."

Forms documenting the content of each session-including time spent with each participant, specific topics covered, and services provided--were kept by the therapists. This helped to ensure that the entire manual was covered over the eight sessions. Fidelity to case management was monitored by WUSM staff throughout the study through review of audiotapes of the sessions and session documentation. In-person feedback to therapist was provided each week.

Outcome Measures

The following measures of effectiveness were used: Depressive Symptom Scale (DSS). The DSS is the count of DSM-IV symptoms of depression, assessed by six items from GAIN. At intake, this is for the past 12 months; at follow-up, it is for the past 90 days. Scores range from 0 to 6, with higher scores indicating higher levels of depressive symptoms. The mean DSS score among an adult clinical population used to norm the GAIN was 3.08 (SD--2.89) (Modisette, Hunter, Ives, Funk, & Dennis, 2010).

Homicidal-Suicidal Thought Index (HSTI). The HSTI is the count of endorsed items related to killing or hurting someone else (for example, "During the past year, have you had significant problems with thoughts about killing or hurting someone else?") (Conrad et al., 2010; Conrad, Conrad, Dennis & Riley, 2008; Pdley, Dennis, & Conrad, 2010) or thoughts of, plans for action toward, or attempted suicide in the past year, with higher scores indicating increased risk of suicide or homicide (score range: 0 to 5). Only one item was related to homicide; the remaining four were about increasing suicide risk. The mean HSTI score among an adult clinical population used to norm GAIN was 0.33 (SD = 0.88) (Modisette et al., 2010).

Mental Health Treatment Index (MHTI). The MHTI is the summative index of four items from GAIN that assessed the nights or times of visiting the emergency room, staying in the hospital, or visiting an outpatient facility for mental health problems divided by the range of 90 days. Higher scores indicated increasing involvement in mental health treatment in the past 90 days. The mean MHTI score among an adult clinical population used to norm GAIN was 0.01 (SD = 0.03) (Modisette et al., 2010).

Statistical Analysis

Chi-square and independent t tests were used to assess differences between the groups on baseline characteristics. Two-way analyses of variance (ANOVAs) with repeated measures on one factor (time) were computed to test for between-group differences on the study variables. Post-hoc tests were conducted to test for differences on the variables between the follow-up assessment points: baseline, six months, and 12 months. Because the distributions of the dependent variables were not normal, we created rank-order variables for each and reexamined differences by group and time for each dependent variable. To add the random effect of individual differences, mixed models were also analyzed. All statistical analyses were conducted using SAS version 9.2.


Baseline Measures

The mean age of the participants (N= 120) was 33 years (SD =9). Fifty-six percent of the sample was female; 81% was white, and 15% was black (of the remaining, 1% was Alaskan Native, 1% was Hispanic, and 2% was mixed race); and 40% were never married. The TAU group members were not different from the ECM group members at baseline, except that they were less likely to be married or cohabitating at baseline (see Table 1).

Participants' mean baseline scores on the outcome measures were as follows--DSS: 4.1 (SD= 1.9); HSTI: 0.98 (SD = 1.35); and MHTI: 0.01 (SD= 0.02)--indicating that the sample scored high on depression but had made, on average, less than one treatment visit for mental health care. Compared with the adult clinical samples used to norm the GAIN, this depressed sample of individuals mandated to substance abuse treatment was significantly more depressed and had significantly more homicidal or suicidal ideation (given a total sample size of at least 100 or 60, respectively). Although there were differences in mean scores between the two groups at baseline, they were not statistically significant. The clinical significance of differences between the two groups was explored using effect size calculations. These ranged from 0.24 for the HSTI and the MHTI to 0.15 for the DSS. The 0.24 effect size represents a small but potentially important difference (Valentine & Cooper, 2003) given the potential results of homicidal or suicidal ideation.


Mean values for the DSS across time are displayed in Table 2. Results were analyzed using one-way repeated measures ANOVAs. For each model, the effect of the enhanced treatment was not significant; rather, time significantly lowered mean scores on the DSS [F(2, 93)= 7.29, p = .0009]. The reduction in depression symptoms between baseline and 12-month follow-up by group using the equation minimal important difference divided by root mean square error (0.204/2.137) provided an observed effect size, or Cohen's d, of 0.14. The interaction effect between time and group was not significant (see Table 2). Mixed effects analysis using SAS Proc Mixed was also completed, accounting for the random individual variation in scores. Mean DSS scores between groups did not significantly vary (data are not shown).

Mean values for the HSTI across time are displayed in Table 2. Using one-way repeated measures ANOVAs, the effect of the enhanced treatment was not significant, whereas time significantly reduced mean scores on the HSTI [F(2, 93) = 12.48, p < .0001]. The reduction in homicidal or suicidal thoughts between baseline and 12-month follow-up by group using the equation minimal important difference divided by root mean square error (0.151/0.651) provided an observed effect size of 0.23, a small but potentially very significant difference. The interaction effect between time and group was not significant (see Table 2).

Mean values for the MHTI across time are shown in Table 2. Results were analyzed using a repeated measures, one-way ANOVA design. Neither time nor group assignment, nor an interaction between the two, affected receipt of additional mental health treatment, the outcome sought through ECM (see Table 2).


In this study, we aimed to examine the relative effectiveness of an ECM model in improving outcomes for substance abusers with comorbid depression. The ECM group members received more intensive, targeted assistance to increase their likelihood of seeking care for their comorbid depression; for this variable (MHTI), there was no difference between groups. Statistically, mandated alcohol/drug abuse treatment (TAU) appears to have been as effective as ECM at improving health care use for depressive symptoms. In terms of reducing symptoms of comorbid depression and homicidal-suicidal ideation, differences between groups could be considered clinically significant at follow-up; however, some differences existed at baseline. The ECM group was clinically less depressed, but clinically they had more homicidal and suicidal ideation at baseline. Thus, their change to reduced ideation at six- and 12-month followups appears even more clinically significant.

We lacked the power to detect significant statistical differences between the groups, given the small differences between the means in the dependent variables and the large variation in responses within the groups. For instance, using the DSS, with an observed difference in the means of 0.304 and a root mean square error of 2.137, a sample of 1,554 would have been needed to have 80% power to detect a significant difference between the two groups.

Increased treatment seeking, specifically for depression, was expected for the ECM group. Indeed, that was the purpose of the intervention. One possible reason for the lack of referrals for additional treatment among those in the ECM group was that they preferred to see their case manager for their problems rather than being referred to another therapist, a preference that was often conmmnicated to the case manager and recorded in session notes. Because participants were court mandated to receive treatment for their substance abuse disorders, they may have had little desire to receive additional, and different, treatment for depression, even with the targeted intervention. Participants may have believed that the mandated services would provide the help they needed, or they may have simply been overwhelmed with other needs that seemed to be more critical, such as those related to employment or housing. In addition, they may not have believed that their depression would be best resolved through therapy. A review of studies that included the "patient perspective" on help seeking for depression found that the majority of people believe depression is caused by situations rather than by biological or psychological factors (Prins, Verhaak, Bensing, & van der Meer, 2008). Thus, the ideal solution would be to resolve the situational factors leading to depression. Other studies among those with depression have found that most respondents prefer to manage their own depression (for example, van Beljouw et al., 2010).

Our findings provide only weak support for the importance of targeting depression through additional therapeutic attention beyond that provided by the drug abuse treatment counselor in a TAU group. It is possible that the substance abuse treatment professionals in the present study were directly targeting depression symptoms as a part of their treatment; this would explain the lack of difference between groups at follow-up. We did not include documentation of TAU in this study. Regression in symptoms toward the mean is an alternative explanation. The null statistical findings for the ECM group should be interpreted with caution, balanced with the clinically significant reduction in homicidal and suicidal ideation. Prior research has shown that compared with standard care, integrated treatment for co-occumng severe mental illness and substance abuse provided by trained case managers produces significant improvements in symptoms and level of satisfaction with care (Craig et al., 2008) and is an important improvement in services (Burns & Teesson, 2002). This is especially important in light of existing research documenting the higher risk of adverse outcomes such as suicide in individuals with comorbid depression and substance abuse (Borges, Walters, & Kessler, 2000; Davis et al., 2008). For instance, although in our sample it might appear that the average HSTI score at baseline was low (0.74 for the TAU group, 1.19 for ECM participants), the presence of even one individual who discloses such ideations to a therapist would be significant enough to warrant immediate attention and appropriate intervention to prevent any possible attempts at self-harm. Our finding of a clinically significant reduction in homicidal and suicidal thoughts warrants further research. The comprehensive approach to treatment tested may be especially helpful to depressed substance abusers with such ideation.

doi: 10.1093/swr/svs019

Original manuscript received June 7, 2010 Final revision received May 23, 2011 Accepted June 6, 2011 Advance Access Publication February 8, 2013


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Catherine IV. Striley, PhD, MSW, MPE, is an assistant professor at the University of Florida, Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions. Prasanthi Nattala, PhD, MPE, is an assistant professor, Department of Nursing, National Institute for Mental Health and Neuro Science (NIMHANS), Bangalore, India. Arbi Ben AbdaUah, PhD, is a research assistant professor, Institute of Quality Improvement, Research and Informatics (INQUIRI), Department of Anesthesiology, Washington University School of Medicine. Michael L. Dennis, PhD, is the senior research psychologist and director, GAIN Coordinating Center, Chestnut Health Systems, Normal, IL. Linda B. Cottler, PhD, MPH, is associate dean of research and planning, College of Pvblic Health and Health Professions and Dean's professor and chair, Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida. Address correspondence to Catherine W. Striley, University of Florida, 1225 Center Drive, Box 100231, Gainesville, FL 32610; e-mail:
(Table 1: Demographics and Characteristics)
of the ECM and TAU Groups at Baseline

Variable                             ECM              TAU

Mean age in years (SD)          30.68   (8.6)    30.82   (10.5)
Male                            25               19
White                           75               88
Married/cohabitating            36 *             11 *
High school diploma or above    95               94
Mean Depressive Symptom
  Scale score (a) (SD)          4.33    (1.81)   3.91    (1.96)
Mean Homicidal-Suicidal
  Thought Index scoreb (SD)     0.74    (1.15)   1.19    (1.49)
Mean Mental Health Treatment
  Index score (c) (SD)          0.01    (0.03)   0.008   (0.02)

Note: ECM =enhanced case management (n=64); TAU=treatment as
usual (n=56).

(a) Scores ranged from 0 to 6, with higher scores indicating higher
levels of depressive symptoms. (b) Scores ranged from 0 to 5, with
higher scores indicating increased risk of suicide or homicide.
(c) Scores ranged from 0 to 0.11 at baseline for this index variable
calculated as noted in the text, with higher scores indicated
increasing involvement in mental health treatment in the past 90 days.
* p=.04.

Table 2: Postintervention Outcomes, by Group: Results of Repeated
Measures ANOVAs (N = 120)

Measure and Score        TAU: M (SD)    ECM: M (SD)     SS

Depressive Symptom Scale (a)                           13.35

  Baseline               4.33 (1.81)   3.91 (1.96)     39.09
  Six-month follow-up    3.85 (2.04)   3.21 (2.36)      2.09
  12-month follow-up     3.35 (2.25)   3.13 (2.04)

Homicidal-Suicidal Thought Index (b)                    1.56

  Baseline               0.74 (1.15)   1.19 (1.49)     20.17
  Six-month follow-up    0.51 (1.01)   0.53 (0.85)      3.15
  12-month follow-up     0.34 (0.75)   0.32 (0.81)

Mental Health Treatment Index (c)                       0.00

  Baseline               0.01 (0.03)   0.008 (0.020)    0.01
  Six-month follow-up    0.02 (0.04)   0.01 (0.04)      0.01
  12-month follow-up     0.01 (0.03)   0.02 (0.07)

Measure and Score        df     MS          F          p

Depressive Symptom Scale 1     13.35   G: 1.67       .19

  Baseline               2     19.55   T: 7.29       .0009
  Six-month follow-up    2     1.05    T x G: 0.39   .67
  12-month follow-up

Homicidal-Suicidal Though1     1.56    G: 0.96       .32

  Baseline               2     10.09   T: 12.48      <.0001
  Six-month follow-up    2     1.57    T x G: 1.95   .15
  12-month follow-up

Mental Health Treatment II     0.00    G: 0.08       .78

  Baseline                     0.00    T: 1.75       .17
  Six-month follow-up          0.00    T x G: 1.63   .19
  12-month follow-up

Note: ANOVA=analysis of variance; ECM = enhanced case management
(n=69); TAU = treatment as usual (n=56); G = group; T = time.
(a) Scores ranged from 0 to 6, with higher scores indicating higher
levels of depressive symptoms. (b) Scores ranged from 0 to 5, with
higher scores indicating increased risk of suicide or homicide.
(c) Scores ranged from 0 to 0.11 at baseline for this index variable
as noted in the text, with higher scores indicated increasing
involvement in mental health treatment in the past 90 days.
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Author:Striley, Catherine W.; Nattala, Prasanthi; Abdallah, Arbi Ben; Dennis, Michael L.; Cottler, Linda B.
Publication:Social Work Research
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2013
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