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Objective: The authors outline a minimal set of outcome indicators to assess the effects of specialized treatment for people with severe mental illness and substance use disorders and report on use of these indicators in a longitudinal study of such treatments., Methods: A total of 147 clients with dual disorders participated in a controlled clinical trial of three interventions--behavioral skills training, case management, and 12-step recovery--in a county mental health program. The clients were assessed every six months over a two-year period using multidimensional self-report and observer-rated outcome measures encompassing psychosocial functioning, psychiatric and substance abuse symptoms, and service utilization., Results: Client self-reports showed changes in psychosocial functioning, especially increased functioning in residential stability and work, and reductions in alcohol and drug symptoms and usage. Data on service utilization showed decreased use of acute and subacute mental health services and increased use of outpatient and case management services over time. Ratings by trained observers of psychiatric symptoms and psychosocial functioning improved dramatically., Conclusions: A minimal set of outcome indicators for clinical trials and demonstrations of interventions for clients with dual disorders should include client self-reports of social adjustment, life satisfaction, psychiatric and substance abuse symptoms, and current substance use; interviewers' ratings of psychosocial functioning and psychiatric symptoms; data on utilization of mental health treatment and support services; and data on clients' personal income, use of medical services, and contact with the criminal justice system.

In a national evaluation, we assessed the implementation and outcomes of a multisite demonstration program for homeless persons with alcohol and other drug problems. We developed comprehensive case studies from data on client characteristics, utilization of services, implementation of interventions, and community systems of care at nine project sites. Client-level outcome data were analyzed to estimate the effectiveness of the interventions in a subset of projects with experimental or quasi-experimental evaluation designs. After controlling for baseline predictors, treatment clients in the majority of sites were significantly more likely than comparison clients to report improvement on one or more outcome dimensions. On alcohol use, for example, under conservative assumptions the average treatment client was drinking less at follow-up than were 57 percent of comparison clients. Analyses of predictor-by-treatment interactions suggested that clients with fewer problems benefited most from the interventions. The implementation analysis yielded a number of lessons for policymakers and program planners.

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact that knowing what to do (by way of special programming) is insufficient to address the problem. The system problems are at least as intractable as the chronic illnesses themselves. Organizing and financing care of patients with comorbities is complicated. At issue are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, and administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment.