Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

By Ivn D. Montoya, M.D., M.P.H.
| January 1, 2006

Dr. Montoya is clinical director of Pharmacotherapies and Medical Consequences Grants in the Division of Pharmacotherapies and Medical Consequences of Drug Abuse, National Institute on Drug Abuse.

Successful interventions to improve treatment compliance can be labor-intensive but ultimately cost-effective (Haynes et al., 2002). They should address factors such as the characteristics of the therapist, the service, the nature of the treatment and the patient.

Interventions to enhance treatment compliance have been categorized into the affective, behavioral and cognitive (ABC) domains (Schaffer and Yoon, 2001). They require an understanding of the therapeutic regimen; counseling about the importance of adherence; organizing medication-taking; rewarding and recognizing the patient's efforts to follow the regimen; and enlisting social support from family and friends (Haynes et al., 2002)

Some of the most promising strategies for improving treatment compliance are based on cognitive/motivational interviewing and behavioral techniques such as reinforcement (Carroll et al., 2005; Zygmunt et al., 2002). A review of the literature of measures to enhance treatment adherence among patients with BD showed that cognitive-behavioral therapy, interpersonal group therapy, group sessions for partners and education about the illness are effective in improving treatment adherence (Owen et al., 1996; Sajatovic et al., 2004).

Contingency management interventions that reinforce treatment compliance have been shown to improve SUD treatment outcome. These interventions can reinforce one or multiple aspects of the treatment plan such as therapeutic activities, counseling, attendance at Alcohol(Drug information on alcohol)ic Anonymous meetings or simply compliance with prescribed medications (Petry et al., 2001). Good attendance to individual standardized interpersonal cognitive psychotherapy has been positively correlated with objective measures of treatment outcome (e.g., urine drug testing) in patients with comorbid cocaine and heroin dependence (Montoya et al., 2005). Given that poor compliance is likely to recur, booster interventions are needed to reinforce and consolidate gains (Zygmunt et al., 2002).

Patients with comorbid mental illness and SUD can benefit from the simultaneous treatment of both disorders. A study of substance abusers dually diagnosed with obsessive-compulsive disorder showed that those who received a combined intervention that addressed their obsessive-compulsive symptoms and substance abuse stayed longer in treatment than a second group that received only substance abuse treatment (Fals-Stewart and Schafer, 1992b).

Clinicians, services, patients and treatment regimens should work in tandem to meet the particular clinical needs of patients with comorbid disorders. Patients need to be supported and not blamed or punished with administrative discharges for poor treatment compliance. Innovative approaches to improve treatment compliance for patients with comorbid mental illness and SUD can be cost-effective and make a significant public health contribution.

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Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

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