Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems. This combination results in increased risk for frequent psychiatric relapses, poor medication compliance, violence, suicide, legal problems, and high utilization of the emergency room or inpatient services. Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to clinical interventions, programs, and system flaws that have not addressed the individual's needs. Integrated treatment requires both an understanding of mental illness and addiction and the means to integrate and modify the traditional treatment approaches in both the mental health and addiction treatment fields. There is strong evidence to support the efficacy and effectiveness of integrated treatment in this population. All mental health clinicians should become experienced and skilled in the core psychotherapy approaches to treating substance use disorders, including motivational enhancement therapy, relapse prevention (cognitive-behavioral therapy), and 12-step facilitation. In addition, integrated treatment includes integrating medications for both addiction and mental illness with the behavioral therapies and other psychosocial interventions. This article reviews the clinical intervention, program, and system components of integrated treatment and specific clinical interventions for this population.

Family psychoeducation programs have emerged as a strongly supported evidence-based practice in the treatment of schizophrenia and bipolar disorder. Over 30 randomized clinical trials demonstrated that psychoeducation programs reduce relapse, improve symptomatic recovery, and enhance psychosocial and family outcomes. Recent work supports family psychoeducation strategies for other disorders, including major depression, obsessive-compulsive disorder, and borderline personality disorder. This review summarizes the research evidence supporting prominent models of family psychoeducation. Professional and peer-led family education programs are also reviewed and differentiated from family psychoeducation. Directions for future research studies to enhance the evidence base and inform treatment recommendations are proposed. Finally, strategies for implementation of family psychoeducation in routine clinical practice are discussed.

The cholinergic system is a major neuromodulatory neurotransmitter system, interacting with core regions of the brain and affecting learning and memory function. Cholinergic function is severely reduced in patients with pathologic conditions, such as Alzheimer's disease. Muscarinic receptors M1–M5 are located at the postsynaptic level of the central cholinergic synapse. Blockage of certain muscarinic receptors has been shown to affect cognitive functioning. The roles of the individual receptor subtypes has implications for pharmacotherapy; eg, nonselective antimuscarinic/anticholinergic medications may block muscarinic neurotransmission, causing deficits in recall and new learning, while M1-receptor agonists and M2-receptor antagonists may not interfere with cognitive functioning. Studies investigating central nervous system (CNS) depressant effects of drugs have shown that antimuscarinic agents have the potential to cause impairment of CNS functioning. CNS dysfunction may be manifested as changes in memory, disruption of sleep, hallucinations, confusion, and delirium.

Anticholinergic load refers to the cumulative effect of taking multiple drugs with anticholinergic activity. The extent to which a particular drug affects the cholinergic system can be determined by its ability to cross the blood-brain barrier, the integrity of which decreases with age. Elderly individuals are also at high risk for increased anticholinergic load due to reductions in metabolism and elimination as well as pharmacokinetic drug interactions. In addition, elderly people are often prescribed several medications that have direct anticholinergic properties and take over-the-counter medications which may also carry substantial anticholinergic burden. The cumulative effect of these medications in vulnerable elderly patients may precipitate early cognitive declines or further exacerbate cognitive deficits in those already suffering from dementia. Risk of cognitive impairment in patients with overactive bladder can thus be reduced through use of M3-selective antagonists, such as darifenacin, and via alternatives to pharmacotherapy, such as behavioral modification, pelvic floor strengthening, and bladder-retraining exercises.

At least 80% of urology patients are taking several medications for any variety of other medical conditions. However, regarding treatment of overactive bladder (OAB) specifically, there are several antimuscarinic drugs available. Tolterodine and trospium chloride are, in essence, nonspecific in terms of muscarinic receptor selectivity. Solifenacin and oxybutynin show selectivity for the M1, and darifenacin is significantly M3 receptor specific (Slide 17).

The potential benefit for selective antimuscarinic agents is that they might target the bladder more specifically and avoid anticholinergic side effects in other organ systems, specifically the brain and heart. We do know that M3 receptors are also present in the intestines and in the salivary glands; thus, we might not expect organ selectivity with an M3-specific receptor because that receptor would also potentially affect the salivary gland and the intestinal tract as well.

There is a growing body of data regarding M3 activity specificity and decreased cognitive impairment in patients of various ages. This, as well as the reduction of cardiac side effects, are the major benefits of using an M3-selective anticholinergic medication rather than a nonselective agent for the treatment of OAB.

Objective: To evaluate whether posttraumatic stress disorder (PTSD) is related to outcomes in persons with severe mental illness (SMI) participating in a study of vocatinal rehabilitation programs

Background: PTSD is a common comorbid disorder in people with SMI, but it is unknown whether PTSD interferes with the ability to benefit from rehabilitation programs such as supported employment.

Methods: The relationships between PTSD and symptoms, health, quality of life, and work outcomes was examined in 176 clients with SMI participating in a 2-year randomized controlled trial of three vocational rehabilitation programs: supported employment based on the Individual Placement and Support model, a psychosocial rehabilitation program based on transitional employment, and standard services.

Results: The overall rate of current PTSD in the sample was 16%. Compared with clients without PTSD, clients with PTSD had more severe psychiatric symptoms, worse reported health, lower self-esteem, and lower subjective quality of life. Clients with PTSD who participated in the Individual Placement and Support model (the most effective vocational model of the three studied) also had worse employment outcomes over the 2-year study period than clients without PTSD, with lower rates of compeitive work, fewer hours worked, and fewer wages earned. Employment outcomes did not differ between clients with PTSD versus without PTSD in the other two vocational rehabilitation approaches.

Conclusion: The findings suggest that PTSD may contribute to worse work outcomes in clients participating in supported employment programs. Effective treatment of these clients with PTSD may improve their ability to benefit from supported employment.

Objective: As part of this national project, we examined barriers and strategies to implementation of two evidence-based practices (EBPs) in Indiana.

Background: Despite many advances in the knowledge base regarding mental health treatment, the implementation of EBPs in real-world setting remains poorly understood. The National EBP Project is a multi-state study of factors influencing implementation of EBPs.

Methods: Over a 15-month period we observed eight assertive community treatment (ACT) programs and six integrated dual disorders treatment (IDDT) programs and noted pertinent actions taken by the state mental health agency influencing implementation. We created a database containing summaries of monthly visits to each program and interviews with key leaders. Using this database and clinical impressions, we rated barriers and strategies at each site on seven factors: Attitudes, Mastery, Leadership, Staffing, Policies, Workflow, and Program Monitoring.

Results: At the site level, the most frequently observed barriers were in the areas of leadership, staffing and policies for ACT, and mastery and leadership for IDDT. Overall, barriers were more evident for IDDT than for ACT. Strategies were less frequently noted but generally paralleled the areas noted for barriers. However, our central finding was that ACT was generally more successfully implemented than IDDT throughout the state, and that this difference could be traced in large part to state-level factors relating to historical preparation for the practice, establishment of standards, formation of a technical assistance center, and funding.

Conclusion: In this case study, both state-level and site-specific factors influenced success of implementation of EBPs. To address these factors, the field needs systematic strategies to anticipate and overcome these barriers if full implementation is to be realized.

Background: Assertive community treatment (ACT) is an intensive and comprehensive treatment for clients with severe mental illness (SMI) who do not readily benefit from clinic-based services. Monitoring the implementation of such programs is critical, because better-implemented programs have been found to be effective in improving client outcomes.

Objective: We tested the hypothesis that fidelity to the ACT model would be positively correlated with improved client outcomes, as measured by reduction in psychiatric hospital use.

Methods: A scale measuring fidelity of program implementation, the Dartmouth ACT Scale, was examined in 10 newly formed ACT teams. Using the team as the unit of measure, the mean reduction in state hospital days for a 1-year period before and after program admission was calculated. Mean effect size in reduction in hospital days was used as the outcome measure in a correlational design.

Results: Pre/post comparisons showed a 43% reduction in hospital days for 317 clients (t=8.61, P<.001). The Pearson correlation between DACTS fidelity and reduction of state hospitaldays was .49, P=.08, one-tailed.

Conclusion: Several possible reasons are offered for why the study hypothesis was not confirmed. However, even if predictive validity of the Dartmouth ACT Scale is limited, it continues to be a useful tool for program monitoring and for providing corrective feedback.