Running head: THE EFFECTIVENESS OF INTEGRATED CARE

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The Effectiveness of Integrated Treatment for Co-Occurring Substance Use Disorder and Other
Mental Disorders: A Meta-Analysis
Jasmine G. Naccarato
California University of Pennsylvania

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Abstract
The comorbidity of Substance Use Disorder (SUD) and other mental disorders is common, with
estimated 50-75% of patients entering SUD treatment presenting other psychiatric disorders as
well (Bergman, Greene, Slaymaker, Hoeppner, & Kelly, 2014). These individuals typically
require more extensive treatment, and have a poorer prognosis than individuals with only one
disorder. There has been research that demonstrates that integrated treatment is more effective
for this population (Drake, Mueser, Brunette, and McHugo, 2004), but the feasibility is
questionable and many facilities do not implement it, thus these patients receive inadequate care.
There continues to be research on the effectiveness of integrated care, and this paper reviews 18
studies that were published or reported from 2004 to 2016. It includes randomized controlled
studies, quasi-experimental, as well as repeated measure and pilot studies. Significant results
published in these studies were analyzed with a meta-analysis calculator to determine effect sizes
using Cohen’s d, where .2 is small, .5 is medium, and .8 is a large effect size. (Cohen, 1988).
Although these studies have methodological weaknesses, this meta-analysis demonstrates
cumulative evidence supporting the effectiveness of integrated care for comorbid SUD and
mental illness. With this continued support of integrated care, research is moving on to
combinations of therapies for combinations of disorders, as well as studying the feasibility of
implementation.
Keywords: comorbidity, co-occurring, substance use disorder, mental illness,
integrated care

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Introduction
Effective care for individuals with comorbid Substance Use Disorder (SUD) and other
mental health disorders is essential, as these individuals typically have a poorer outcome posttreatment, have poor social and emotional functioning, more hospitalizations and relapses, as
well as a higher risk for suicidal actions. However, many of these individuals are either only
being treated for one of their disorders at a given time, or they are receiving ineffective parallel
care in separate facilities by non-cooperative teams. This is problematic since Kessler, Chiu,
Demler, Merikangas, and Walters (2005) estimate that “27% of people have at least one
psychiatric disorder, and 45% of people with a psychiatric condition actually have two or more
disorders.” Sheidow, McCart, Zajac, and Davis (2012) report that “36% of young adults with a
serious mental condition or young adults seeking treatment meet criteria for a SUD”. As research
began demonstrating the effectiveness of treating both disorders simultaneously, what is known
as the Integrated Treatment (IT) approach was developed in the United States in the late 1980’s.
With this method, either the same therapist or a collaborating therapeutic team would treat the
patient at a single site simultaneously. Many integrated treatments utilize different therapeutic
techniques, such as Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT),
contingency management, family interventions, as well as others that are specifically tailored to
individual disorders (McKee, Harris, & Cormier, 2013).
Despite growing research demonstrating the superiority of integrated treatment in
comparison to treatment as usual, many facilities are still not equipped to treat patients with cooccurring SUD and mental illness. One meta-analysis of research for the effectiveness of this
treatment, A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring
Substance Use Disorders was created to cohesively demonstrate the treatment results over a ten-

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year span (1994-2003 by Drake, Mueser, Brunette, and McHugo 2005). With this analysis,
including 26 experimental and quasi-experimental studies, Drake and colleagues (2005)
demonstrated how integrated treatment yielded better results across various factors in
comparison to treatment as usual, in areas such as fewer substance relapses post-discharge,
abstinence at follow-up, and improved mental health symptoms. These studies utilized
interventions such as stage-wise treatment, active treatment interventions, engagement
interventions, motivational interviewing, relapse prevention, and comprehensive services.
Drake’s meta analysis aids in the conclusion that recent research does offer evidence that
integrated dual disorder treatment can be effective, but commented that future research is needed
for more specific disorders and treatment combinations, as well as the issues of disseminating
and implementation for this treatment to the public in a cost-effective manner.
The current meta-analysis serves as a continuation of Drake and colleagues’ analysis
(2005), utilizing research conducted post 2003 to further demonstrate effectiveness of integrated
treatment for co-occurring Substance Use Disorder and other mental illnesses. These studies
include integrated care for the combinations of SUD with depression, anxiety, Posttraumatic
Stress Disorder (PTSD), Schizophrenia, and other psychotic disorders, in both adolescent and
adult populations. There are several articles included in discussion for the cost-effectiveness and
implementation of integrated care. Within this paper, “substance abuse” is used interchangeably
with “substance use disorder”, to refer to the abuse or dependence on alcohol or other drugs. This
is done to remain consistent to the articles being discussed, which also utilize the terms
interchangeably. “Comorbidity” and “Co-occurrence” are also used interchangeably to refer to
clients having more than one diagnosable disorder simultaneously. The description of severe
and/or persistent mental illness may refer to a variety of diagnoses, but typically to the diagnoses

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of Schizophrenia, Schizoaffective, Schizophreniform, Bipolar Disorder, and other psychotic or
personality disorders. The studies utilized in this meta-analysis were in Ebscohost, and are all
peer reviewed journal articles. The publication dates range from 2004 to 2016. Keywords used
to locate these articles include co-occurring, comorbidity, substance abuse, substance use
disorder, and mental disorder. In regards to the synonyms co-occurring and comorbidity, most
of articles utilized the word ‘co-occurring.’
There are various reasons this meta-analysis was not strictly limited to controlled studies.
Firstly, various articles that were originally found had to be excluded from the final evaluation of
this meta-analysis. This occurred for various reasons, ranging from inadequate statistical
postings (stating that results were significant but giving no actual data) to articles utilizing
certain statistics that could not be translated into Cohen’s d and properly analyzed with other
results. Secondly, as Drake and colleagues (2005) stated in their study, more research needs to
be completed on minority populations (including women with PTSD), and on specific treatment
combinations for specific combinations of disorders. Many uncontrolled or repeated measures
designs included in this review are just that, analyzing the effectiveness on different populations
and using new treatments, thus they are still in their beginning stages. Since research is still
needed on these topics, these preliminary studies were included. However, it is noted that the
results found in uncontrolled studies are not often exactly replicated by controlled studies, so
they should be interpreted with caution.
It is important to note that the studies included in this analysis include those comparing
integrated treatment to standard care or treatment as usual (TAU), which clients would typically
obtain in treatment that would focus on only SUD, and those comparing integrated treatment to
no treatment. Since the current meta-analysis analyses the effectiveness of integrated treatment

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overall, these studies are analyzed separately as to not skew results. The data reported regarding
integrated care compared to TAU demonstrates how much more effective it is than TAU, while
the data reported for integrated care compared to no treatment demonstrates its effectiveness in
general. Since most studies do not include their own reliability data, the calculator utilized for
the overall statistical analysis allows for partial reporting of reliabilities and constructs an
artificial distribution from there.
Results of Initial Meta-Analysis
As previously stated, this meta-analysis serves as a continuation of the analysis
completed by Drake and colleagues (2005). Thus, it is important to discuss the results found in
the initial study. It was noted that there were several trends emerging in the treatment literature,
such as the utilization of brief or time-limited interventions intermittent with standard care. One
common therapeutic technique being utilized was motivational interviewing, either within
standard care or as its own individual intervention. Various studies included in that analysis
yielded positive results with the inclusion of motivational counseling, whether it was
independent or not, including increased abstinence, better general functioning, fewer drinking
days, greater reductions in psychopathology, and reduced substance abuse (Drake et al., 2005).
It was also noted that various studies demonstrated that residential treatment with integrated
treatment often yielded better results than residential treatments that focused only on substance
abuse treatment. Overall, the meta-analysis reported sufficient data supporting the claim that
integrated care for comorbid SUD and other mental illness tends to be effective, although it was
noted that high fidelity is important and results are better if the critical components of integrated
care are utilized.

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Recent Studies, 2004-2016
A search of current literature identified 18 studies of integrated care interventions for
SUD and comorbid mental disorders that have been published between 2004 and 2016. These
studies and their significant results are summarized in Tables 1 and 3. These studies have
various methodological limitations such as self-selection, small sample sizes, non-equivalence of
groups, lack of control group and randomization, and so forth. The interventions, although all
considered ‘integrated’ vary across the studies in which therapeutic methods they utilize, ranging
from motivational interviewing, cognitive behavioral therapy (CBT), Behavioral Treatment for
Substance Abuse in Severe and Persistent Mental Illness (BTSAS), psychoeducation, Seeking
Safety (SS), and exposure therapy, in various combinations. When determining the effectiveness
of integrated care, the effectiveness is measured across a variety of different factors, since there
is no specific measure. These measures range from items related to substance use, psychiatric
symptoms, general functioning, suicidality, arrests, hospitalizations, quality of life. In regards to
measures utilized in the studies included, qualitative and quantitative methods such as
assessments, surveys, and interviews were typically employed. Some of the assessment tools
primarily utilized include: The Symptom Check List-90 (SDL-90-R) which evaluate a range of
psychopathology, Structured clinical interviews of the DSM-IV, Brief Symptom Inventory,
Addiction Severity Index (ASI), Timeline Follow Back (TLFB) which assesses alcohol and drug
use, Beck Depression Inventory, the University of California at Los Angeles PTSD Reaction
Index (UCLA), the Cohesion and Conflict subscales of the Family Environment Scale (FES), the
drug abuse screening test (DAST-d), the short Michigan screening test (SMAST-d) for
alcoholism, the Hamilton Depression and Anxiety scales (HAM-D, HAM-A), the Mood and
Anxiety Questionnaire (MASQ) Global Assessment of Functioning Scale (GAF), The Clinician

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Administered PTSD Scale (CAPS), The Children’s Depression Inventory (CDI), The Perceived
Stress Model (PSS) and others. The organization of the studies and the results reflects the
decision to separately analyze integrated treatment compared to treatment as usual and integrated
treatment compared to no treatment, studies are then separated further by grouping studies
relating to the same or similar mental illness co-occurring with substance use disorder.
Study Results
Integrated Care vs. Treatment as Usual
There is available research that demonstrates the effectiveness of integrated care, but
when it comes to demonstrating its effectiveness, it must be shown that it is more effective or
superior to the standard treatment that is currently being utilized in facilities. Implementation
and dissemination may be hindered if this treatment is not shown to be better than standard
treatment, as it involves facilities to retrain their workers and implement new strategies regarding
integrated care. Various studies included in this analysis demonstrate that integrated care can
yield better results than standard care alone, and this study analyzes these results to determine
how large of an effect size the results generate, as to show in a quantitative manner exactly how
much better integrated care can be considered in various situations. Any measures that are not
listed as being superior to the standard care were measured as being equally successful to the
typical treatment (refer to table 1).
Substance Use with Psychotic Disorders
Various studies included focus on comorbid substance use disorder with psychotic
disorders or psychosis, including Schizophrenia, Schizoaffective, Major effective, Bipolar, or
other Axis I diagnosis. A large amount of past research has focused on integrated care with these

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more severe mental illnesses and demonstrated positive results. Baker and colleagues (2006),
utilized a combination of ten sessions including motivational interviewing and CBT in
combination with standard care and the results were compared to clients receiving standard care
alone. The therapy group yielded statistically significant results when compared to the control
group in various aspects, including short term depression (6 month mark) (d=.5, p<.001), general
functioning (as measured with the GAF;(d=.58, p<.01), in terms of their overall BDI-II
Depression scores (d=.78, p<.001). In Barrowclough and colleagues’ study (2010) motivational
interviewing and CBT was also utilized alongside standard care and compared to the typical
treatment, although the treatment lasted up to a year with a maximum of 26 sessions. This study
demonstrated positive results in regards to substance use (abstinence on primary drug d=.35,
p=.02; decrease in all substances d=.39, p=.017) and readiness to change (d=.43, p=.004).
Bellack and colleagues’ (2006) study utilized a specific treatment known as BTSAS as an
integrated treatment for SUD and psychotic disorders. BTSAS includes contingency contracts,
motivational interviewing, a harm reduction model, drug abuse education, skills training and
relapse prevention. This was compared to a standard treatment known as STAR, which only
includes a supportive and encouraging group environment for SUD with some psychoeducation.
This study demonstrated positive results favoring the treatment group in aspects such as
attendance (d=.64, p<.03), better urinanalysis outcome (d=.78, p<.03), and survival of treatment
(d=.71, p<.03).
Substance Use Disorder with Posttraumatic Stress Disorder
As of recent years, more studies have begun to focus on the comorbidity of SUD and
PTSD. Drake and colleagues (2005) noted that “many dual disorders programs have identified
high rates of trauma histories and post-traumatic symptoms among women and suggested

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interventions to address trauma, but few data on outcomes are yet available.” Various studies
included focus on women with PTSD or complex traumas as their population, providing some
preliminary evidence for a group and disorder that was not previously available. A new
therapeutic model known as Seeking Safety (SS) is utilized in some of these studies. SS is a
highly flexible evidence-based model that addresses both trauma and addiction. Positive results
were found when SS replaced twice weekly recovery groups in standard treatment in a study
completed by Boden and colleagues (2012), in comparison to standard treatment alone. The
experimental group had greater attendance (d=.69, p<.01), had greater client satisfaction (d=.53,
p<.01), and had greater active coping skills than the control group post-treatment (d=.59, p<.01).
In Gatz and colleagues’ study (2007), Seeking Safety was also utilized and yielded positive
results in favor of the experimental group, which did not receive any trauma specific treatment.
The population for this group was women with co-occurring disorders who have experienced
trauma. Those who received SS had better improvement on their PTSD (d=.23, p<.05), and on
their coping skills (d=.23, p<.05). However, those who did improve on their coping, regardless
of the group, had significantly better PSS scores (d=.28, p<.05), GSI scores, (d=.41, p<.001) and
drug scores (d=.29, p<.05). Although not utilizing SS, Danielson and colleagues (2012) studied
the effect of a therapy known as RRFT, which incorporates psychoeducation, coping, family
counseling, communication, substance use counseling, PTSD counseling, healthy dating and
sexual decision making, and revictimization risk reduction on a group of sexually assaulted
adolescents with SUD and their caregivers. This was a pilot study but it did utilize
randomization and a comparison group. Results in favor of the RRFT group were found with
significant improvements on the UCLA-A (d=.74, p=.42), UCLA-P (d=1.47, p=.02), CDI
(d=.65, p=.03), TLFB (d=.6, p=.04), Cohesion-A (d=1.95, p=.02), Cohesion-P (d=.87, p=.003),

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Conflict-A (d=1.41, p=.02), and Conflict-P (d=.61, p=.10). In the study completed by
McGovern and colleagues (2015), results of a group receiving I-CBT alongside standard care
was compared to standard care alone, and the I-CBT group was found to have greater reduction
in substance use (d=.31, p<.05).
Substance Use Disorders with Other Mental Illness
There are various studies included in this analysis that observe integrated treatment
utilized for comorbid SUD and less severe mental illness such as depression and anxiety, as well
as other aspects such as suicidality and integrated on-site or off-site comparison. Wustoff, Waal,
and Grawe (2014) analyzed the outcomes of integrated care for comorbid SUD and
depression/anxiety, and although they found that the experimental group had significantly higher
motivation (d=.36, p=.003), this was the only factor that was significantly better than the control
group. Although various diagnoses were identified in the study completed by Esposito-Smythers
and colleagues (2011), the focus was on the comorbidity and the presence of suicidality. The
experimental group received I-CBT, compared to the control group receiving treatment as usual.
In comparison, the experimental group had less suicide attempts (d=.82, p=.023), inpatient
hospitalizations (d=.81, p=.02), partial hospitalization (d=.57, p=.11), emergency department
visits (d=.93, p=.007), arrests (d=.94, p=.01) and client run aways (d=.69, p=.05). In terms of
analyzing whether on-site integration is superior too off-site, Brooner and colleagues (2013)
compared results for psychiatric and SUD comorbidity within versus outside of a methadone
treatment center. Clients in the onsite group had lower SCL-90-R scores (d=.31, p=.006), larger
reductions in GSI (d=.34, p=.003), were more likely to remain in treatment (d=.7, p<.001), and
were more likely to initiate psychiatric care (d=.76, p<.001) when compared to clients receiving
off-site psychiatric treatment with a methadone clinic.

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Overall Analysis for Integrated Care vs. Standard Care
When significant statistics from the studies regarding integrated care in comparison to
standard care were entered in the meta-analysis calculator (Lyons & Morris, 1997), which
weights the studies per their sample size, a result of d=.46 was found in regards to integrated
care being superior to standard care. This analysis included 39 effect sizes on multiple factors
from 11 of the 18 studies included. There was a standard deviation of .23, and a variance of .06,
using Brannick-Hall (2001) Variance corrections for small K sizes. The mean N for these
included studies was 170. Full summary results are listed on table 2.
Table 1— Compared to Standard Treatment

Study
Baker et al.,
2006

Design
Randomized
Controlled
Trial

Participants
N = 130 dual
diagnosis clients

Interventions
10 sessions
of integrated
MI and CBT
vs. Standard
Care

Barrowclough Randomized
et al., 2010
Controlled
Trial

N= 327 dual
diagnosis clients

Bellack,
Bennett,
Gearon,
Brown, &
Yang, 2006

N = 110 dual
diagnosis clients

BTSAS vs.
STAR

N= 98 male
veterans with

Seeking
Safety plus

Randomized
Clinical Trial

Boden et al., Randomized
2012
Controlled

Combination

of MI and
CBT with
Standard
Care vs. TAU

Outcomes
Greater
improvements
in depression,
general
functioning,
and BDI-II
scores.
Greater
decrease in
main substance
use, greater
decrease in all
substance use,
and greater
increase in
readiness to
change.
Significantly
more clean
urine tests, as
well as better
attendance and
survival rates.
Significantly
greater

Effect Size
Cohen’s
d=.5, .58,
and .78
respectively

Cohen’s d=
.35, .39, .43
respectively

Cohen’s
d=.64, .78,
.71
respectively

Cohen’s
d=.69, .53,

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Trial

comorbid SUD
and PTSD

TAU vs. TAU
alone.

Brooner et
al., 2013

Randomized
Controlled
Trial

N=360 dual
diagnosis clients

Integrated
treatment
outside a
Methadone
clinic vs. TAU
within.

EspositoSmythers,
Spirito,
Kahler,
Hunt, &
Monti, 2011

Randomized
Controlled
Study

N = 40
adolescents
with SUD and
suicidality.

I-CBT vs. TAU

McGovern
et al., 2015

Randomized
Controlled
Trial

N= 221 clients
with SUD and
PTSD

Wusthoff,
Randomized
Waal &
Controlled
Grawe, 2014 Trial

N= 76 clients
with SUD and
depression/
anxiety
N = 300 dual
diagnoses and
SUD clients.

I-CBT plus
standard
care, IAC plus
standard
care, SC only.
Combination
MI/CBT vs.
TAU

Bergman et
al., 2014

Repeated
Measures
Design

CBT/MI

attendance,
satisfaction,
and active
coping skills.
Significantly
lower follow-up
SCL-90-R
scores, larger
reductions in
GSI scores,
more likely to
remain in
treatment, and
more likely to
initiate
psychiatric care.
Significantly
fewer suicide
attempts,
inpatient
hospitalizations,
partial
hospitalizations,
emergency
department
visits, arrests,
and run aways
Significantly
less substance
use in I-CBT
group than
both.
Significant
increase in
motivation.

.59
respectively

Comorbid
patients
showed greater
symptom
decrease than
SUD only
counterparts.

Cohen’s
d=.3

Cohen’s d=
.31, .34, .7,
.76
respectively

Cohen’s d=
.82, .81,
.57, .93,
.94, .69
respectively

Cohen’s d =
.31

Cohen’s d=
.36

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Uncontrolled
Cook,
Pilot Study
Walser,
Kane, Ruzek,
and Woof,
2006

N = 25 veterans
with PTSD and
SUD

Seeking
Safety

Danielson,
2012

Pilot
Randomized
Study

N = 30
adolescents
with PTSD and
SUD with their
caregivers

RRFT vs. TAU

Gatz et al.,
2007

QuasiN = 402 women
experimental with PTSD and
SUD

Seeking
Safety vs.
TAU

Significant
reduction in
PTSD
symptoms,
significant
increase in
quality of life.
Significantly
better UCLA
PTSD-A and P
scores, CDI
scores, TLFB
scores,
Cohesion A and
P scores, and
Conflict A and P
scores.
Significantly
better
improvement
on PTSD
symptoms and
coping skills,
and those who
increased in
these had
significantly
better PSS, GSI,
and drug
scores.

Cohen’s d=
1.32, .5
respectively

Cohen’s d =
.74, 1.47,
.7, .6, 1.95,
.87, 1.41,
.61
respectively

Cohen’s d =
.23, .23,
.28, .41, .29
respectively

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Table 2: Summary Results Integrated Treatment vs. Standard Treatment
Sample
Brannick-Hall (2001) Variance Corrections for Small
Weight
K Sizes
Mean FX
(http://luna.cas.usf.edu/~mbrannic/files/conf/siok.htm)
Size & Std
Dev
Mean Std
Variance
Std Dev
Dev
.22
.1
0.01
0.10
r
.46 .24
0.06
0.24
d
.23 .11
0.01
0.11
z
Mean N
K

Unweighted
Mean Fx Size
& Std Dev

Mean

Std
Dev
.30
0.13
0.65
0.35
0.32
0.16
170.05 145.89
(# of
39
effects)
Sampling Error Variance
0.006
Corrected Variance
0.004

Integrated Care vs. No Treatment
When determining the effectiveness for integrated care, various studies included in this
analysis did not utilize a control group that was receiving the standard care giving for SUD.
Instead, some of these studies either did repeated measures to analyze the overall improvement
post-treatment, or compared results to a control group that was waitlisted and served as a ‘notreatment’ group. These studies have been analyzed separately in this meta-analysis, because the
effect sizes calculated represent the overall effectiveness in comparison to no treatment, rather
than treatment as usual, thus it is expected for these effect sizes to be larger. The separation was
completed for this to avoid skewing.
Substance Use and Posttraumatic Stress Disorder
In addition to other studies that focused on minority groups such as women who have
experienced trauma, Cohen and Hien (2006) observed the results of CBT on women with

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comorbid PTSD and SUD who have experienced complex traumas in comparison to a group
receiving no treatment. The experimental group yielded positive results in regards to ASI
alcohol scores (d=.33, p=.005) and CAPS score (d=.59, p=.006) that were significantly better
than the no treatment group. Lynch, Heath, Mathews, and Cepeda (2012) analyzed the
difference in results of Seeking Safety vs. waitlisted trauma-exposed incarcerated women, after
the need for treatment of the comorbidity of SUD and PTSD was identified in this population.
The women in the treatment group obtained significant decreases in their PTSD (d=.56, p=.034),
depression scores (d=.67, p<.0001), and maladaptive coping (d=.66, p=.002), while
experiencing increases in interpersonal functioning (d=.42, p=.009) and better adaptive coping
(d=.34, p=.024). In regards to populations typically observed for PTSD treatment, Cook and
colleagues (2006) analyzed the effect of CBT for comorbid SUD and PTSD in the Veteran’s
population with a repeated measures design. With this study, it was found that the veterans had
significantly decreased PTSD symptoms (d=1.32, p<.001) and an increased quality of life
(d=.49, p<.05) when compared to pre-treatment. Although this study has a very small sample
size (n = 5), the results were recorded statistically allowing for comparison in the study
completed by Najavits, Schmitz, Gotthardt, and Weiss (2005). This study utilized Seeking
Safety with the addition of Exposure therapy, which is not something that many other studies
have attempted to incorporate due to the fear of exposure causing a relapse in drug use (Najavits,
Schmitz, Gotthardt, & Weiss, 2005). With this combination of treatments, the dually diagnosed
men with comorbid PTSD and SUD yielded various significant results: reductions in drug use
(d=1.29, p=.05), improvements in family social functioning (d=1.24, p=.05), improvements in
psychiatric problems (d=.96, p=.1), reductions in trauma symptom checklist score (d=1.45,
p=.03), reductions in anxiety (d=1.3, p=.04), reductions in dissociation (d=1.46, p=.03),

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reductions in sexual abuse trauma index (d=1.28, p=.04), reductions in depression scores
(d=1.14, p=.06), improvements in sleep problems (d=1.09, p=.07), and improvements on GAF
scores (d=1.8, p<.02). Since this was a preliminary study with a very small sample size, these
very large effect sizes need to be interpreted with caution since a controlled study would likely
not yield such superior results. However, since the results were overly positive (so much that
even if a controlled study yielded only half as significant results, it would still have moderate
effects) and this study includes a new aspect of treatment, it was included.
Substance Use Disorder and Other Mental Illness
The remainder of the studies included focused on either a variety of mental illnesses or
less severe illness such as depression. Within the study completed by Cooper and colleagues
(2010), the population was focused on the homeless with comorbid SUD and the following
disorders: somatization, obsessive compulsive, depression, anxiety, phobias, and psychotic
disorders. This study utilized repeated measures design to analyze the effect of I-ACT on this
population. By the end of the study, significant results were found for reduction of substance use
(d=1.12, p<.001) and psychiatric symptoms (d=.76, p<.001) compared to pre-treatment
statistics. Another study observed the effect of integrated CBT therapy for co-occurring
depression and SUD in young adults (Hides et al., 2010). This study demonstrated various
significant results including better HAM-D scores (d=1.35, p<.001), HAM-A scores (d=.91,
p<.001), MASQ anxious scores (d=.67, p<.001), MASQ depressive scores (d=.8, p<.001),
MASQ anxious arousal scores (d=.61, p<.001), MASQ anhedonic depression scores (d=.76,
p<.001), and CGI-S scores (d=1.05, p<.001). Finally, Grawe, Hagen, Espeland, and Mueser
(2007) utilized a specific treatment in their study known as the Better Life Program. With this,
individuals receive weekly sessions in closed-ended groups for 4-6 months, with

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psychoeducation, MI, social skills training, peer support, establishing healthy relationships and
leisure activities incorporated. This pilot study demonstrated significant results in comparison to
pre-treatment on DAST-d scores (d=.34, p<.01), SMAST-d scores (d=.36, p<.01), and GAF
scores (d=.78, p<.001).
Overall Analysis of Integrated Care vs. No Treatment
When significant statistics from the studies regarding integrated care in comparison to no
treatment were entered in the meta-analysis calculator (Lyons & Morris, 1997), which weights
the studies per their sample size, a result of d=.70 was found in regards to integrated care being
superior to no treatment. This analysis included 31 effect sizes on multiple factors from 7 of the
18 studies included. There was a standard deviation of .29, and a variance of .09, using
Brannick-Hall (2001) variance corrections for small K sizes. The mean N for these included
studies was 57.83. Full summary results are listed on table 4.
Table 3 – Compared to no Treatment
Study
Cohen &
Hien, 2006

Design

Cooper et
al., 2010

Repeated
Measures
Design

Grawe,
Hagen,
Espeland &
Mueser,
2007
Hides et
al., 2010

Pilot Study

N = 63 dual
diagnosis
patients.

Repeated
Measures

N = 60 young
adults with SUD

QuasiExperimental

Participants
N = 107 women
with SUD and
PTSD with
complex
trauma
N = 152
homeless dual
diagnosis
clients

Interventions

Outcomes
CBT
Significantly
compared to better ASI
no treatment alcohol scores
group
and CAPS
score.
I-ACT
Significant
reduction in
substance use
and psychiatric
symptoms
Better Life
Significantly
Program
better DAST,
SMAST, and
GAF scores.

Effect Size
Cohen’s d=
.33, .59
respectively

10 sessions of
CBT with case

Cohen’s d =
1.35, .91,

Significantly
better Ham-D

Cohen’s d=
1.12, .76
respectively

Cohen’s d=
.34, .36, and
.78
respectively

THE EFFECTIVENESS OF INTEGRATED CARE

19

Design

and depression.

management

Lynch,
Heath,
Mathews
& Cepeda,
2012

Quasiexperimental

N= 114
incarcerated
women with
PTSD and SUD

Seeking
Safety vs.
waitlist

Najavits,
Schmitz,
Gotthardt
and Weiss,
2005

Repeated
Measures
Pilot Trial

N = 5 men with
PTSD and SUD

Seeking
Safety and
Exposure
therapy

and A scores,
MASQ anxious,
depressive,
anxious
arousal, and
anhedonic
depression
scores, and
CGI-S scores.
Greater
decrease in
PTSD,
depression
scores, and
maladaptive
coping.
Greater
increases in
interpersonal
functioning
and adaptive
coping.
Significant
reductions in
drug use,
trauma
symptoms,
anxiety,
dissociation,
sexual abuse
trauma index,
and
depression
scores with
improvements
on family
social
functioning,
psychiatric
symptoms,
sleep
problems and
GAF scores.

.67, .8, .61,
.76, 1.05
respectively

Cohen’s
d=.56, .67,
.42, .34, .66
respectively

Cohen’s d =
1.29, 1.24,
.96, 1.45,
1.3, 1.46,
1.28, 1.14,
1.09, 1.8
respectively

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20

Table 4: Summary Results Integrated Treatment vs. No Treatment
Sample
Brannick-Hall (2001) Variance Corrections for Small
Weight
K Sizes
Mean FX
(http://luna.cas.usf.edu/~mbrannic/files/conf/siok.htm)
Size & Std
Dev
Mean Std
Variance
Std Dev
Dev
.32 .12
.01
.12
r
.7
.3
.09
.3
d
.34 .14
.02
.13
z
Mean N
K

Unweighted
Mean Fx Size
& Std Dev

Mean

Std
Dev
.4
.15
.9
.4
.43
.18
57.84 47.95
(# of
31
effects)
Sampling Error Variance
.02
Corrected Variance
.003

Principals of Integrated Treatment
There are various principals and themes within Integrated Care that are deemed as
necessary for the treatment to be effective in a population of dually diagnosed individuals. Since
this study includes randomized controlled studies, and quasi-experimental studies, as well as
uncontrolled, repeated measures, and pilot studies, the inclusion of evidence rating is vital to
demonstrate that the principals of this treatment are well supported. The level of evidence is
rated in accordance with the Texas Psychosocial Rehabilitation Conference Criteria (Carmichael
et al., 1998). The levels of evidence range from 1 to 5, with level 1 requiring at least 5 controlled
studies with meaningful outcomes, level 2 indicates fewer than 5 studies and/or studies with less
meaningful outcomes, level 3 refers to uncontrolled empirical studies, level 4 is based on
multiple studies, and level 5 denotes expert panel recommendations (Carmichael et al., 1998).
The principals of care for integrated treatment in which evidence is demonstrated are: taking a
low stress or harm reduction approach, motivation based treatment (including a stage-wise

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21

approach), Cognitive-Behavioral Therapy, supporting functional recovery, and engaging the
individual’s social network (Mueser and Gengerich, 2013).
Low Stress and Harm Reduction
For individuals with comorbid disorders, interpersonal stress caused by intense treatment
may cause an increase in symptoms, and be responsible for high drop-out rates. These
individuals may be more vulnerable to overly direct approaches or confrontations, including
raised voices or calling out of negative behaviors in the presence of others (such as in group
therapy). It is ideal for those administering treatment to this population to be empathetic and
understanding of the client, aiding in their progression and realizing what stage of change they
are in. In terms of harm reduction, the primary initial goal is to remove the most harmful aspects
of the individual’s life, such as those that cause immediate threat to safety of self or others,
threats to housing, etc. This is done without necessarily eliminating or reducing the use of
substance or engagement in other risky behaviors. It is typically accomplished in various ways,
such as providing clean needles to drug users or counseling individuals who trade sex for money
about protection and their options (Mueser and Gengerich, 2013). A total of 10 of the studies
included in this analysis are supportive of the low stress and harm reduction approach with three
of them being randomized controlled trials (Bellack et al., 2006; Boden et al., 2012; McGovern
et al., 2015), three being quasi-experimental (Cohen and Hien, 2006; Gatz et al., 2007; Lynch et
al., 2012), and four of them being repeated measures or pilot studies (Cook et al., 2006; Cooper
et al., 2010; Hides et al., 2010; Najavits et al., 2005). Due to the combination of RCT and quasiexperimental, the level of evidence rating for this principal is 1.

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22

Motivation Based Treatment
Motivation to change is often an issue for individuals suffering from SUD, with the
problem increasing if they also demonstrate comorbid mental illness. Motivation to change is an
important aspect of treatment and necessary for true progress to be made. In regards to stagewise approaches, it is important to recognize that there are stages of motivation, and each stage
requires different aspects of treatment. These can be divided into precontemplation, where the
person is not thinking about change, and contemplation, where the person is thinking about
change. The next is preparation, in which they make plans on how to change their behaviors.
Completion of this stage leads to the action stage, where the person is actively attempting to
make these changes (Mueser and Gengerich, 2013). Finally, the maintenance stage is achieved
and the individual is maintaining the desired changes in behavior that they have obtained.
Depending on the stage the client is currently in, aspects of therapy will vary such as motivation
to encourage change, interventions, awareness, psychoeducation, or a firmer focus on the
reduction of symptoms. Of the studies included, a total of 16 of 18 demonstrated motivation
based treatment, including a stage-wise approach. Of these studies, seven were RCT (Baker et
al., 2006; Barrowclough et al., 2010; Bellack et al., 2006; Boden et al., 2012; Brooner et al.,
2013; Esposito-Smythers et al., 2011; Wustoff, Waal, & Grawe, 2014), three were quasiexperimental experimental (Cohen and Hien, 2006; Gatz et al., 2007; Lynch et al., 2012), and six
were repeated measures or pilot studies (Bergman et al., 2014; Cook et al., 2006; Cooper et al.,
2010; Danielson et al., 2012; Hides et al., 2010; Najavits et al., 2014). The level of evidence for
this principal is 1.

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23

Cognitive-Behavioral Therapy
Cognitive-behavioral therapy has been utilized in treatment for various mental disorders,
including SUD (Mueser and Gengerich, 2013). Although there is a range of different techniques
and methods for CBT, it is primarily used to teach effective skills to individuals, cope with
symptomatology, and reframing negative thought processes. Some examples of CBT that are
known to be useful for treating co-occurring disorders include social skills training, coping skills
training, cognitive restructuring, and the development of new outside activities to replace the
previous dangerous acts (Mueser & Gengerich, 2013). Of the 18 studies included in this
analysis, a total of 16 supported the principal of inclusion of cognitive-behavioral therapy.
Seven of these studies had RCT designs (Baker et al., 2006; Barrowclough et al., 2010; Boden et
al., 2012; Brooner et al., 2013; Esposito-Smythers et al., 2011; McGovern et al., 2015) three of
them were quasi-experimental experimental (Cohen and Hien, 2006; Gatz et al., 2007; Lynch et
al., 2012), and six were either repeated measures or pilot studies (Bergman et al., 2014; Cook et
al., 2006; Cooper et al., 2010; Danielson et al., 2012; Hides et al., 2010; Najavits et al., 2014).
The level of evidence for this principal is 1.
Supporting Functional Recovery
Supporting functional recovery refers to progress that is made in life outside of the
psychiatric and SUD symptomatology. This may include a focus on employment, since many
individuals with severe mental illness do not currently work. This may be done using supportive
employment programs that do not enforce eligibility criteria on participants beyond the desire
and motivation to work. Functional recovery may also focus on peer relationships and
psychosocial functioning. These individuals typically have very strained relationships with their
families and friends, inhibiting their support system. Of the 18 studies included, only eight of

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24

them incorporated a specific focus on supporting functional recovery. Two of these studies had
an RCT design (Boden et al., 2012; Esposito-Smythers et al., 2011), two of them were quasiexperimental (Gatz et al., 2007; Lynch et al., 2012), and four were either repeated measures or
pilot studies (Cooper et al., 2010; Danielson et al., 2012; Grawe et al., 2007, Wustoff et al.,
2014). Due to the insufficient controlled results for this principal, the level of support is 3.
Engaging Social Networks
Having a family member or loved one with a mental illness can cause tension and stress.
When overwhelmed, family members may withdraw their support from the individual in care,
which can create more problems such as instable housing and financial situations. When
engaging the social network, the family is included in the treatment. This is important because
family support is associated with a faster rate of remission (Mueser & Gengerich, 2013). While
helping the family cope with their loved one’s illness, they also become involved in the
treatment. Psychoeducation is often used to properly inform them of the illness’s that they are
dealing with, creating a more understanding and empathetic atmosphere for the client. Of the 18
studies included, a total of 12 of them supported the principal of engaging the individual’s social
network. Of those included, four were of RCT design (Baker et al., 2006; Boden et al., 2012;
Esposito-Smythers et al., 2011; Wustoff et al., 2014), three were quasi-experimental (Cohen and
Hien, 2006; Gatz et al., 2007; Lynch et al., 2012), and five were either repeated measures or pilot
studies (Cook et al., 2006; Cooper et al., 2010; Danielson et al., 2012; Grawe et al., 2007;
Najavits et al., 2005). The level of evidence for this final principal of integrated care is 1.

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25

Discussion
Since the completion of the initial meta-analysis by Drake and colleagues (2005), recent
studies have continued to analyze the effectiveness of integrated care when treating comorbid
SUD and other mental illnesses. Although much of the initial research was aimed at the more
severe mental illnesses, current research is beginning to include the analysis of less severe
diagnosis comorbid with SUD such as depression and anxiety. Another trend is the focus on
PTSD in various populations, such as women, veterans, and incarcerated individuals, and the
utilization of more specific interventions for these populations. These specific integrated
interventions, such as Seeking Safety, BTSAS, RRFT, and the combination of SS and Exposure
Therapy, demonstrate a forward motion in comparison to the studies included in Drake et al.,
(2005), as this was listed as a future focus. However, many of these specific approaches are still
in their preliminary stages and controlled studies are still needed. Current studies are
demonstrating combinations of the principals of integrated care, with many implementing at least
four of the listed principals and achieving significant results. (Boden et al., 2012; Cohen & Hien,
2006; Cook et al., 2006; Cooper et al., 2010; Danielson et al., 2012; Esposito-Smythers et al.,
2011; Gatz et al., 2007; Lynch et al., 2012; Najavits et al., 2005; Wusthoff, Waal, & Grawe,
2014).
Although a continuation of more mature studies is necessary for specific treatments, the
issues of feasibility and dissemination are still pressing. The feasibility of implementing
integrated care for co-occurring Substance Use Disorders and other mental health disorders
presents a challenge. Although the implementation of these services would be difficult, there are
some studies that show that it can happen (Killeen, Back, & Brady, 2015; Padwa et al., 2016;
Mckee, Harris & Cormier, 2013). However, health-care reform in the United States of America,

THE EFFECTIVENESS OF INTEGRATED CARE

26

for example, would require changes in the workforce and delivery of substance abuse treatments.
They would need to include clinicians that can address disorders other than just Substance Use
Disorder in scientifically sound manners (Killeen, Back, & Brady, 2015). Care systems would
need to hire clinicians who have knowledge of their care but also are cross trained in addiction
and mental health. However, the cost that is associated with training and supervision may be
worth the positive outcomes associated with integrated care. Once implemented, facilities may
experience a decrease in staff turnover and readmission rates, as well as improved patient
outcome. Some studies have attempted the implementation of integrated services, such as
Mckee, Harris, and Cormier (2013) and Padwa and colleagues (2016). Although Padwa and
colleagues (2016) acknowledged the difficulty and unfeasibility for some centers to provide fully
integrated behavioral health services, the authors did state that is was possible in many facilities.
They also offered the solution of “enhancing primary care clinic capacities related to SU
medications” to help close the gap between services. Mckee, Harris & Cormier (2013), however,
conducted a successful study of implementing integrated care. With this, a 28-day addiction
service was transformed into a 3-month integrated treatment program. With 155 individuals
participating in the study, it demonstrated significant improvement in mental health symptoms,
acquisition of knowledge and skill, and improvement in self-esteem. This entire study was
completed with positive results while maintaining the lowest per in patient cost of all hospital
inpatient units, despite having to have a completely new manualized service, training for
clinicians, and formal measurements. One of the studies previously mentioned in this review
involving the Better Life Program (Grawe et al., 2007) also measured their feasibility during the
experiment and found that they could effectively give treatment and maintain positive results.
With the current research supporting the superiority and effectiveness of integrated care, and

THE EFFECTIVENESS OF INTEGRATED CARE

27

future research verifying specific techniques for specific combinations of disorders, it is likely
that research will put more of a focus on implementation in the future.
The results of this meta-analysis lend support for the implementation of integrated care
for this high-risk population. Future research focusing on specific combinations of disorders
would help with the establishment of evidence-based practices, which is necessary in the field
and when dealing with managed cared. The data from this analysis demonstrates that this is a
more appropriate treatment for this population than what is currently being utilized. These
integrated treatments may be more effective in various situations and significantly improve
quality of life for patients. Although implementation may be a costly endeavor, there is evidence
that it can be done in a cost-effective manner. Research on implementation and comorbid
specific treatments would be the necessary next step in expanding knowledge and understanding
of this field.
Conclusions
Comorbidity of Substance Use Disorder with other mental illnesses typically leads to a
poorer prognosis and increased risk of negative outcomes. Recent research has demonstrated the
effectiveness of integrated treatments for this population, and also offers some evidence of its
possible superiority over standard care for SUD, primarily when the treatment incorporates
multiple principals of integrated care. Although this meta-analysis offers continued evidence of
its effectiveness, statistical results should be interpreted with caution due to some
methodological weaknesses. Despite these positive results, further research is still necessary to
identify specific intervention combinations for specific comorbid diagnoses and analyze the
effectiveness in a randomized, controlled environment. Research has begun to analyze the

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28

process of feasibility of dissemination, but continued research is still necessary to identify costeffective mechanisms.

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29

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