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
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