Improving Compliance with the Initial Outpatient Session among Discharged Inpatient Dual Diagnosis Clients

Introduction Although poor compliance with treatment is common across a wide range of mental health, medical, and substance use disorders (Meichenbaum & Turk, 1987), it is particularly high among clients with psychiatric and comorbid substance use disorders (Booth, Cook, & Blow, 1992; Carey & Carey, 1990; Matas, Staley, & Griffin, 1992). In a quality assurance study involving 38 inpatients with major depression and a substance use disorder (MD+) and 104 inpatients with major depression without a coexisting substance use disorder (MD-), we found a significant difference [[X.sup.2] (1) = 20.52; p [less than] .001] between the rates of compliance with the initial outpatient session: MD-clients entered outpatient care at double the rate of MD+ clients (86 percent versus 43.5 percent). In reviewing data from several hundred referrals to our outpatient dual diagnosis clinic, we also found that inpatients successfully enter treatment at about half the rate of clients who come directly from the community or are referred from other outpatient programs in our medical center. Thus, dual diagnosis inpatients, who have greater symptomology and impairment compared with outpatients, are at much greater risk of outpatient treatment entry failure. Dual diagnosis clients' failure to enter, comply with, or complete treatment is associated with many adverse effects. Poorly compliant clients are more likely to experience clinical deterioration of their psychiatric condition, relapse to alcohol or other drug use, and return to the hospital as a result of severe depression, suicidality, homicidality, mania, or psychotic decompensation. Missing outpatient appointments often leads to failure to renew medication prescriptions, which in turn contributes to exacerbations of psychiatric and substance use symptoms. In addition, poor treatment compliance causes the loss of supportive relationships and contributes to frustration among family members and professionals, who find themselves watching helplessly as the client deteriorates. Moreover, because of the increased risk of rehospitalization, poor outpatient compliance leads to increased costs of care as a result of more days spent in expensive inpatient treatment facilities. Strategies to Enhance Treatment Entry, Adherence, and Completion Numerous reports suggest that a variety of strategies can enhance treatment entry, adherence, and completion rates. These include using telephone or mail reminders of the initial treatment appointment, providing reinforcers for appropriate participation in treatment activities, increasing the frequency and intensity of services offered in the early phase of outpatient care, collaborating with outpatient staff when referring a client from inpatient care, offering outpatient appointments within several days of the request for help, using specialty dual diagnosis programs for psychiatric clients who have additional substance use disorders, and using case managers (Agosti, Nunes, Stewart, & Quitkin, 1991; Hochstadt & Trybula, 1980; Kadden & Mauriello, 1991; Matas, Staley, & Griffin, 1992; Meichenbaum & Turk, 1987; Stark, Campbell, & Brinkerhoff, 1990). Even a modest improvement in treatment compliance can have a significant positive impact in addressing the costly public health problem of comorbid psychiatric and substance use disorders. Brief Motivational Session prior to Psychiatric Hospital Discharge In our open treatment outpatient dual diagnosis clinic, we have been able to increase steadily the compliance rate among recently discharged inpatients for the initial outpatient appointment by offering a single motivational therapy (MT) session several days prior to hospital discharge. This MT approach, implemented by the second author, integrates strategies from motivational enhancement therapy (MET) (Miller, Zweben, DiClemente, & Rychtarik, 1995) and dual disorders recovery counseling (DDRC) (Daley & Thase, 1994). …