BACKGROUND: Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes. OBJECTIVE: The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious. DESIGN: A literature review was conducted and randomized clinical trials describing ACT’s impact on substance use were reviewed. RESULTS: Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better. CONCLUSION: Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.
Bellack, A.S., Bennett, M.E., Gearon, J.S., Brown, C.H., & Yang, Y. ( 2006). A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness . Archives of General Psychiatry, 63, 426-432.
2.
Bond, G.R., & McDonel, E.C. ( 1991). Assertive community treatment and reference groups: An evaluation of their effectiveness for young adults with serious mental illness and substance abuse problems. Psychosocial Rehabilitation Journal, 15, 31-44.
3.
Burns, B.J., & Santos, A.B. ( 1995). Assertive community treatment: An update of randomized trials. Psychiatric Services, 46, 669-675.
4.
Clarke, G.N., Herinckx, H.A., Kinney, R.F., Paulson, R.I., Cutler, D.L., Lewis, K., & Oxman, E. ( 2000). Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: Findings from a randomized trial of two ACT programs vs. usual care. Mental Health Services Research, 2, 155-164.
5.
Coldwell, C.M., & Bender, W.S. ( 2007). The effectiveness of assertive community treatment for homeless populations with severe mental illness: A meta-analysis. American Journal of Psychiatry, 164, 393-399.
6.
Conrad, K.J., Lutz, G., Matters, M.D., Donner, L., Clark, E., & Lynch, P. ( 2006). Randomized trial of psychiatric care with representative payeeship for persons with serious mental illness. Psychiatric Services, 57, 197-204.
7.
Dixon, L., Turner, J., Krauss, N., Scott, J., & McNary, S. (1999). Case managers’ and clients’ perspectives on a representative payee program. Psychiatric Services, 50, 781-786.
8.
Dixon, L., Weiden, P., Torres, M., & Lehman, A. ( 1997). Assertive community treatment and medication compliance in the homeless mentally ill. American Journal of Psychiatry , 154, 1302-1304.
9.
Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M., Dickinson, D., Goldberg, R.W., . . . Kreyenbuhl, J. (2010). The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and summary statements. Schizophrenia Bulletin, 36, 48-70.
10.
Drake, R.E. ( 1998). Brief history, current status, and future place of assertive community treatment. American Journal of Orthopsychiatry , 68, 172-175.
11.
Drake, R.E., Bartels, S.J., Teague, G.B., Noordsy, D.L., & Clark, R.E. ( 1993). Treatment of substance abuse in severely mentally ill patients. Journal of Nervous and Mental Disease, 181, 606-611.
12.
Drake, R.E., McHugo, G.J., Clark, R.E., Teague, G.B., Xie, H., Miles, K., & Ackerson, T.H. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorders: A clinical trial. American Journal of Orthopsychiatry, 68, 201-215.
13.
Drake, R.E., O’Neal, E.L., & Wallach, M.A. ( 2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment , 34, 123-138.
14.
Essock, S.M., Mueser, K.T., Drake, R.E., Covell, N.H., McHugo, G.J., Frisman, L.K., . . . Swain, K. ( 2006). Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric Services, 57, 185-196.
Green, A.I., Drake, R.E., Brunette, M.F., & Noordsy, D.L. ( 2007). Schizophrenia and co-occurring substance use disorder . American Journal of Psychiatry, 164, 402-408.
17.
Hanrahan, P., Luchins, D.J., Savage, C., Patrick, G., Roberts, D., & Conrad, K.J. ( 2002). Representative payee programs for persons with mental illness in Illinois. Psychiatric Services, 53, 190-194.
18.
Hurlburt, M.S., Hough, R.L., & Wood, P.A. ( 1996). Effects of substance abuse on housing: Stability of homeless mentally ill persons in supported housing. Psychiatric Services , 47, 731-736.
19.
Jerrell, J.M. ( 1999). Skill, symptom, and satisfaction changes in three service models for people with psychiatric disability. Psychiatric Rehabilitation Journal, 22, 342-347.
20.
Kertesz, S.G., Crouch, K., Milby, J.B., Cusimano, R.E., & Schumacher, J. E. (2009). Housing first for homeless persons with active addiction: Are we overreaching?Milbank Quarterly, 87, 495-534.
21.
Lehman, A.F. ( 1999). Improving treatment for persons with schizophrenia . Psychiatric Quarterly, 70, 259-272.
22.
Lehman, A.F., Dixon, L.B., Kernan, E., DeForge, B.R., & Postrado, L.T. (1997). A randomized trial of assertive community treatment for homeless persons with severe mental illness . Archives of General Psychiatry, 54, 1038-1043.
23.
Milby, J.B., Schumacher, J.E., McNamara, C., Wallace, D., Usdan, S., & McGill, T. (2000). Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug and Alcohol Dependence, 60, 55-67.
24.
Milby, J.B., Schumacher, J.E., Wallace, D., Freedman, M.J., & Vuchinich, R.E. (2005). To house or not to house: The effects of housing to homeless substance abusers in treatment. American Journal of Public Health, 95, 1259-1265.
25.
Morse, G.A., Calsyn, R.J., Klinkenberg, W.D., Trusty, M.L., Gerber, F., Smith, R., . . . Ahmad, L. ( 1997). An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services, 48, 497-503.
26.
Moser, L.L., & Bond, G.R. ( 2009). Scope of agency control: Assertive community treatment teams’ supervision of consumers. Psychiatric Services , 60, 922-928.
27.
O’campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. ( 2009). Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: A realist approach for synthesizing evidence. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 86, 965-989.
28.
Ries, R.K., & Comtois, K.A. ( 1997). Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders . A comparative study of payee and non-payee participants. American Journal on Addictions, 6, 330-338.
29.
Rosen, M., Desai, R., Bailey, M., Davidson, L., & Rosenheck, R. ( 2001). Consumer experience with payeeship provided by a community mental health center. Psychiatric Rehabilitation Journal, 25, 190-195.
30.
Rosen, M.I., McMahan, T.J., & Rosenheck, R. ( 2007). Does assigning a representative payee reduce substance abuse? Drug and Alcohol Dependence, 86, 115-122.
Rosenberg, S.D., Goodman, L.A., Osher, F.C., Swartz, M.S., Essock, S.M., Butterfield, M.I., . . . Salyers, M.P. ( 2001). Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. American Journal of Public Health , 91, 31-37.
33.
Stein, L.I., & Test, M.A. ( 1980). Alternative to mental hospital treatment I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37, 392-397.
34.
Swartz, J.A., Hsieh, C.M., & Baumohl, J. ( 2003). Disability payments, drug use and representative payees: An analysis of the relationships. Addiction, 98, 965-975.
35.
Tidey, J., & Ries, R. ( 2007). People with Mental Illness. In S. T. Higgins, K. Silverman, S. H. Heil (Eds.), Contingency management in the treatment of substance use disorders: A science-based treatment innovation. New York, NY: Guilford Press.
36.
Tsemberis, S., Gulcur, L., & Nakae, M. ( 2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94, 651-656.
37.
Vanderplasschen, W., Wolf, J., Rapp, R.C., & Broekaert, E. ( 2007). Effectiveness of different models of case management for substance-abusing populations. Journal of Psycho-active Drugs, 39, 81-95.
38.
Wasmer, D., & Pinkerton, M. ( 1999). Impact of flexible duration assertive community treatment program utilization patterns and state hospital use. Journal of Rehabilitation, 65, 25-30.
39.
Ziedonis, D.M., Smelson, D., Rosenthal, R.N., Batki, S.L., Green, A.I., Henry, R.J., . . . Weiss, R.D. ( 2005). Improving the care of individuals with schizophrenia and substance use disorders: Consensus recommendations. Journal of Psychiatric Practice, 11, 315-339.
