Article

Randomized Controlled Trial of Motivational

Interviewing, Cognitive Behavior Therapy, and Family
Intervention for Patients With Comorbid Schizophrenia
and Substance Use Disorders
Christine Barrowclough, Ph.D.
Gillian Haddock, Ph.D.
Nicholas Tarrier, F.B.Ps.S.
Shn W. Lewis, F.R.C.Psych.
Jan Moring, Ph.D.
Rob OBrien
Nichola Schofield, B.Sc.
John McGovern, M.Sc.

Objective: Comorbidity of substance

abuse disorders with schizophrenia is associated with a greater risk for serious illness
complications and poorer outcome. Methodologically sound studies investigating
treatment approaches for patients with
these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This
study investigates the relative benefit of
adding an integrated psychological and
psychosocial treatment program to routine
psychiatric care for patients with schizophrenia and substance use disorders.
Method: The authors conducted a randomized, single-blind controlled comparison of routine care with a program of
routine care integrated with motivational
interviewing, cognitive behavior therapy,
and family or caregiver intervention.

Results: The integrated treatment program resulted in significantly greater improvement in patients general functioning than routine care alone at the end of
treatment and 12 months after the beginning of the study. Other benefits of the
program included a reduction in positive
symptoms and in symptom exacerbations and an increase in the percent of
days of abstinence from drugs or alcohol
over the 12-month period from baseline
to follow-up.
Conclusions: T he se findin gs d em on strate the effectiveness of a program of
routine care integrated with motivational
interviewing, cognitive behavior therapy,
and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or
drug abuse or dependence.
(Am J Psychiatry 2001; 158:17061713)

any studies have shown that the rate of substance

use in subjects with severe mental illness is high; estimates of recent or current abuse for community samples
range from 20% to 40% (1). These rates are higher than
those for the general population (2), and patients with comorbid mental illness and substance abuse disorders
(dually diagnosed patients) have been a cause for concern because even low levels of substance abuse or dependence represent a risk factor for serious complications, including suicide, poor compliance with treatment, more
inpatient stays, violence, and a poor overall prognosis (3,
4). In the United States, difficulties arising from treating
individuals with dual diagnoses in either the substance
use system or the mental health system or from excluding
such patients from both systems have been described (5).
This has led to recommendations for the integration of
treatments for substance abuse or dependence and mental illness. However, reviews of integrated programs for patients with dual diagnoses (6, 7) suggest that the methodological weaknesses of studies to date prevent drawing
any conclusions about the efficacy of treatments.
With these issues in mind, we designed a randomized
controlled trial to evaluate the effectiveness of a treatment

1706

program for patients with schizophrenia and either drug

or alcohol use problems. The program integrated three intervention approaches with routine care: 1) motivational
interviewing, 2) individual cognitive behavior therapy,
and 3) family or caregiver intervention. The value of the
latter two approaches has been evaluated for patients with
schizophrenia and no identified substance use problems
(811). In our current study, these approaches were integrated with an intervention designed to enhance motivation to reduce substance use (12, 13). The rationale for this
treatment synthesis has been detailed elsewhere (14).
Briefly, the expectations were 1) that the majority of patients would be unmotivated to change their substance
use at the outset, 2) that patients symptoms might be a
factor in the maintenance of substance use but that the
drug and alcohol use might exacerbate symptoms, and
3) that family stress might have a particularly detrimental
effect on outcomes of patients with dual diagnoses. The
aim of this study was to investigate whether the program
of interventions had a beneficial effect on illness and
substance use outcomes over and above that achieved by
routine care.
Am J Psychiatry 158:10, October 2001

BARROWCLOUGH, HADDOCK, TARRIER, ET AL.

Method
Design
This was a randomized, controlled, single-blind clinical trial.
Patient-caregiver dyads were allocated to either the experimental
intervention program plus routine care or routine care alone.

Patient and Caregiver Selection and Allocation

Subjects were entered into the trial as patient-caregiver dyads
(for patients with more than one relative or caregiver, the person
with the major care role was selected). Inclusion criteria for patients were as follows: 1) a nonaffective psychotic disorder
(schizophrenia or schizoaffective disorder according to ICD-10
and DSM-IV criteria), 2) meeting DSM-IV criteria for substance
abuse or dependence, 3) in current contact with mental health
services, 4) age=1865 years, 5) a minimum of 10 hours of face-toface contact with the caregiver per week, and 6) no evidence of organic brain disease, clinically significant concurrent medical illness, or learning disability. Diagnoses were established by an experienced diagnostician (S.W.L.) on the basis of chart review and,
when indicated, consensus discussion. No systematic assessment
was made of axis II disorders.
Potential subjects were identified by first screening the hospital
admission records from the mental health units of three National
Health Service hospital trusts in the northwest of England (Tameside & Glossop, Stockport, and Oldham). Patients were approached first for consent, then caregivers of consenting patients
were approached for consent. Only when both patient and caregiver provided written informed consent were patients accepted
into the study. Patients and caregivers were assessed by using
multiple measures before random assignment to one of the two
arms in the controlled trial: 1) motivational interviewing, cognitive behavior intervention, and family intervention in addition to
routine care, and 2) routine care alone. Individual patients were
allocated to each condition by a third party with no affiliation to
the study who used a computer-generated randomization list
stratified for sex and three types of substance use (alcohol alone,
drugs alone, or drugs and alcohol) to ensure equal male-female
and substance use representation in each arm of the trial.

Interventions
Integrated intervention program. The planned intervention
period was 9 months; sessions took place in the caregivers and
patients homes, except when patients or caregivers expressed a
preference for a clinic-based appointment (one individual in the
integrated care group expressed this preference). All patients in
the study were allocated a family support worker from the voluntary organization Making Space. The services of this support
worker included providing information, giving advice on benefits, advocacy, emotional support, and practical help. The frequency and nature of contact with the support worker was decided by mutual agreement between caregiver and support
worker. The integrated treatment program attempted to combine
three treatment approaches: motivational interviewing, individual cognitive behavior therapy, and family or caregiver intervention. The interventions are described elsewhere (14), and only
brief details will be given here.
Motivational interviewing (12) was used to increase motivation
for change in those patients who were ambivalent. Key concepts
fostered in this style of interviewing are that responsibility for
problems and their consequences is left with the patient, and efforts to change are not started before the patient has committed
himself or herself to particular goals and strategies. The individual cognitive behavior therapy was modified from approaches
used to ameliorate delusions and hallucinations in patients with
chronic psychosis (15). The general approach to family intervention was as described elsewhere (16). For the purposes of this
Am J Psychiatry 158:10, October 2001

study, an emphasis was placed on promoting a family response

that was consistent with the motivational interviewing style.
The interventions began with the motivational interviewing
phase and five initial weekly sessions designed to assess and then
enhance the patients motivation to change. If the patients commitment was obtained, changes in substance use were negotiated
on an individual basis. With the introduction of the individual
cognitive behavior therapy at week 6 (or earlier if appropriate),
the motivational interviewing style was integrated into subsequent cognitive behavior therapy sessions. The individual cognitive behavior therapy took place over approximately 18 weekly
sessions, followed by six biweekly sessions (a total of 29 individual
sessions, including the motivational interviewing).
Following assessment of both patients and caregivers, shared
goals were generated that became the focus of conjoint patient/
family sessions. The family intervention consisted of 1016 sessions, some of which took the form of integrated family/patient
sessions, some of which involved family members alone.
All of the clinicians involved in the trial received training in
motivational interviewing style from an experienced interviewer
with extensive training in the techniques ( J.M.). Six clinicians
(five clinical psychologists [C.B., G.H., J.McG., N.T., and Ian Lowens] and one nurse therapist [R.O.]) conducted the cognitive behavior therapies (individual and family). All had experience in
cognitive behavior therapy work with psychotic patients and were
eligible for accreditation as cognitive behavior therapists with the
British Association for Behavioural and Cognitive Psychotherapy.
Therapy was detailed in a comprehensive treatment manual
(available from C.B.), and the therapists received weekly supervision based on audiotaped sessions to ensure treatment fidelity.
Routine care. Routine care in the context of the National Health
Service of Great Britain consists of psychiatric management by the
clinical team, coordinated through case management and including maintenance neuroleptic medication, monitoring through
outpatient and community follow-up, and access to communitybased rehabilitative activities, such as day centers and drop-in
clinics. All of the patients in the integrated treatment program also
received routine care.

Assessment Procedures and Instruments

Primary and secondary outcomes. Selection of the primary
outcome was influenced by the fact that no single measure encompasses both substance use and symptom outcomes for patients with dual diagnoses. To reflect the multicomponent nature
of the interventions, the primary outcome selected was change in
the Global Assessment of Functioning Scale (DSM-IV, p. 32), a
measure that assesses the individuals overall functioning on a
rating scale that ranges from 0 to 100. Multiple secondary outcomes were also employed, including measures of patient symptoms and patient substance use. Caregiver outcomes were also
assessed but will not be reported on here. Demographic details of
patients and caregivers were collected by using a short checklist
at the first interview.
The outcome assessment measures were administered at three
time points: before random assignment to the two treatment conditions, immediately after treatment (9 months after the beginning of the study), and 3 months after the end of treatment (12
months after the beginning of the study). Additionally, detailed
patient interviews to assess substance use were conducted every
3 months throughout the intervention. The assessments were
conducted by independent assessors (two psychology graduate
research assistants [N.S. and Joanne Quinn]). The assessors were
blind to treatment allocation; attempts to maintain their blindness included use of separate rooms and administrative procedures for project staff, multiple coding of treatment allocations,
and requesting subjects not to disclose information about the
treatment.

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COMORBID SCHIZOPHRENIA AND SUBSTANCE USE

TABLE 1. Correlations Between Nonspecific Measures of Substance Use at Baseline in 36 Patients With Comorbid Schizophrenia and Substance Use Disorders
Leeds Dependence
Questionnaire:
Most Frequently
Used Substance
Measure
Leeds Dependence Questionnaire: most
frequently used substance
Addiction Severity Index: drug and
alcohol subscales combined
Timeline follow-back: percent of days of
abstinence from most frequently used
substance
Timeline follow-back: percent of days of
abstinence from all substances
Clinician Rating Scales: most frequently
used substance

rs

Timeline Follow-Back:
Timeline Follow-Back:
Percent of Days of
Percent of Days of
Addiction Severity Index:
Abstinence From All
Abstinence From
Drug and Alcohol
Substances
Frequently Used Substance
Subscales Combined

rs

0.43

<0.01

0.26

n.s.

0.18

n.s.

0.29

n.s.

0.30

n.s.

0.65

<0.01

0.29

n.s.

0.11

n.s.

0.56

<0.01

Assessment of patients symptoms and functioning. The

Global Assessment of Functioning Scale (DSM-IV, p. 32), Positive
and Negative Syndrome Scale (17), and Social Functioning Scale
(18) were used to assess patients symptoms and functioning. Interrater reliability was assessed for the clinician-rated assessments. The two research assistants independently rated a set of
10 randomly selected patients on the Global Assessment of Functioning Scale. Good reliability was found; the intraclass correlation coefficient (ICC) was 0.93. The interrater reliability of the
assessors on the Positive and Negative Syndrome Scale was established before the study by computing ICCs for the ratings of 14
videotaped interviews by the assessors and an experienced research psychiatrist external to the study. For the Positive and Negative Syndrome Scale positive subscale, ICC=0.83; for the negative subscale, ICC=0.88; and for total score, ICC=0.95.
Medication compliance. The Drugs Attitude Inventory (19), a
self-report scale shown to be highly predictive of compliance, was
used to measure medication compliance.
Patient relapse outcomes. Two methods of assessing the frequency and duration of relapse were used for relapses in the 2
years before the study and during the study period: 1) number
and duration of hospital admissions, identified from hospital
record systems, and 2) number and duration of exacerbations of
symptoms lasting longer than 2 weeks and requiring a change in
patient management (increased observation and/or medication
change by the clinical team), assessed from hospital case notes.
When symptom exacerbation preceded hospitalization, only one
relapse was recorded. Reliability for number and duration of exacerbations was checked by comparing ratings for 10 randomly
selected patients. No differences were found between the two independent assessors for these variables.
Patients substance use. Timeline follow-back interviewing
techniques (20) were used to collect data on substance use behavior. Briefly, the technique involves asking individuals to reconstruct their drug use/drinking behavior over a specified interval.
For the purposes of the current study 3-month intervals were
used: 1) patient timeline follow-back interviews were conducted
before patients were randomly assigned to the two treatments
and collected data for the 3 months before the start of the study,
2) they were conducted at 3 and 6 months during treatment, and
3) they were conducted 9 months and 12 months after the beginning of treatment. At all assessment points, details of behavior for
all substance use (alcohol and nonprescribed drugs) were sought,
irrespective of specific use at baseline. Two variables were computed for evaluating outcomes: percent of days of abstinence
from the most frequently used substance (identified from the Ad-

1708

rs

rs

0.22

n.s.

diction Severity Index [21]) and percent of days of abstinence

from all substances.
The drug and alcohol subscales of the Addiction Severity Index
(21) were used. The scores used for analyses were the composite
scores for responses to a set of items based on the last 30 days
(thus capable of showing change). Composite scale scores range
from 0 to 1. Adequate psychometric properties for use with patients with dual diagnoses have been published (22, 23). In order
to compare scores between individuals who differed in type of
substance use, the two composite scores (drug and alcohol) were
summed.
The Leeds Dependence Questionnaire (24) is a 10-item questionnaire used to measure psychological dependence across a
wide range of substances. In order to compare individuals using
different substances, Leeds Dependence Questionnaires completed for the patients most frequently used substance were
selected for outcome assessments. The alpha coefficient for
patients completing the most frequently used substance scale
at baseline was 0.85, showing that the scale has good internal
consistency.
The Alcohol Use Scale and the Drug Use Scale of the Clinician
Rating Scales (25) were employed at the start of the study to permit comparison between patient and clinician reports of substance use. These scales were completed by the patients key
worker. Each scale consists of five points (1=abstinence to 5=dependence with institutionalization), and the rater is encouraged
to use all available information sources in making a judgment. In
comparing the Clinician Rating Scales with self-report measures,
the scale appropriate to the patients most frequently used substance was selected (the Alcohol Use Scale or the Drug Use Scale).

Concurrent Validity of Substance Use Measures

Spearmans correlation coefficient (rs) (26) was used to create a
correlation matrix of self-report and clinician-rated substance
use measures taken at baseline (Table 1). There was a significant
correlation between the two questionnaire measures of substance use (the Addiction Severity Index drug and alcohol subscales combined and the Leeds Dependence Questionnaire).
Scores on the Clinician Rating Scales showed good association
with the data from the timeline follow-back interviews; greater
substance use rated by clinicians was associated with a smaller
percent of days of abstinence for the most frequently used substances. As would be expected, there was greater association between self-report measures that examined all substance use. In
summary, there was substantial concurrent validity for the measures employed in the study.
Am J Psychiatry 158:10, October 2001

BARROWCLOUGH, HADDOCK, TARRIER, ET AL.

TABLE 2. Functioning and Symptom Outcomes of 36 Patients With Comorbid Schizophrenia and Substance Use Disorders
Before and After Treatment With Routine Care Alone or an Integrated Program of Routine Care Plus Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention
Integrated Care Group

Routine Care Group

After Treatment

Measure

Baseline
(N=18)

9 Months
After Start of
Treatment
(N=17)

12 Months
After Start of
Treatment
(N=17)

After Treatment

Baseline
(N=18)

9 Months
After Start of
Treatment
(N=15)

12 Months
After Start of
Treatment
(N=15)

Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Positive and Negative Syndrome Scale score
Positive symptoms subscale
16.50 5.74 15.29 4.69 13.35 4.57 15.22 5.12 16.40 4.29 16.07 5.54
Negative symptoms subscale
13.22 3.21 12.47 4.12 12.65 4.97 13.72 3.69 16.20 4.87 14.67 6.02
Total
61.33 10.04 58.94 11.44 56.88 14.23 62.39 15.89 65.53 15.28 63.40 17.96
Global Assessment of Functioning Scale score 49.67 11.96 55.94 10.67 58.41 13.56 53.33 13.53 47.50 12.11 48.13 15.26
Social Functioning Scale score
103.93 6.52 105.02 6.42 108.41 8.35 101.90 10.19 100.01 9.18 101.14 9.94

Analyses
All analyses were conducted on an intent-to-treat basis. Patient
deaths were treated as relapses, and subject attrition did not affect the analyses of relapse outcomes because relapse was assessed from service records. When scores from assessment measures deviated significantly from a normal distribution, logtransformed scores were used, and when distributions remained
skewed or there was significant kurtosis, nonparametric statistics
were used. Nonparametric analyses used included the MannWhitney test (U), the Wilcoxon matched-pairs signed-ranks test
(z), and Spearmans correlation coefficient for ranked data (rs)
(26). Two-tailed tests of significance were used in all analyses.

Results
Participant Flow and Follow-Up
From the 66 eligible patient-caregiver pairs invited to
participate in the study, 23 (35%) patients and a further
seven (11%) caregivers refused, making a total 30 (45%) refusers.
Using information from hospital records, we compared refusers and participants on a number of patient
variables, including household composition, age, sex,
employment, type of substance, and illness history characteristics. Patients who refused were significantly older
(median=35.0 years, range=2157, versus median=30.50
years, range=1762) (U=299.0, p<0.03); had a longer duration of illness dated from their first admission (median=7.50 years, range=123, versus median=4.00 years,
range=119) (U=273.0, p<0.05); and had fewer admissions in the last 3 years (median=1, range=04, versus
median=2, range=07) (U=286.5, p<0.05). No other differences were found between the two groups.
The final study group consisted of 36 patient-caregiver
dyads. Thirty-three (92%) of the patients were male; the
mean age of the patients was 31.1 years (SD=9.69); mean
illness duration was 8.4 years (SD=8.44); mean number of
hospitalizations was 4.9 (SD=4.08); and all were of white
European ethnic origin. Eighteen patients lived with their
caregiver. There were no differences between the patients
who participated in the integrated program and those
given routine care on any of the demographic or illness
history variables.
Am J Psychiatry 158:10, October 2001

Nineteen of the patients used both drugs and alcohol,

11 used alcohol only, and six used drugs only. There was
no difference between groups in the distribution of drug
and alcohol use. Fifteen patients used only one substance:
11 used alcohol only, three cannabis only, and one amphetamines only. Ten patients used only cannabis with alcohol, and one used only heroin and alcohol. Ten patients
used multiple drugs. The drug used by most patients was
cannabis (22 patients), followed by amphetamines (N=
10), cocaine (N=4), and heroin (N=4).
At baseline, all patients scored above the cutoff score of
5 for a clinically significant substance use problem in psychiatric populations on either the Drug Abuse Screening
Test (27) or the Michigan Alcoholism Screening Test (28).
From the timeline follow-back data, the mean number of
days per week of use (for all substances) was 5.2 (SD=1.8).
There was no difference in Drugs Attitude Inventory
scores between patients participating in the integrated
program (median=15.0, range=22 to 24) and those given
routine care (median=11, range=10 to 26) (U=157.0, n.s.).
Of the caregivers, 27 were women and nine were men;
their mean age was 51 (SD=12.12). In terms of relationships, the majority (N=24, 66.7%) were parents, six (16.7%)
were partners, and the remainder were one sibling, one
grandparent, two landladies, and two ex-partners. For all
caregiver variables assessed, including expressed emotion
status (29), there were no statistical or clinical differences
between the groups at baseline.
There were three deaths during the 9-month intervention period: one in the integrated care group (heart attack)
and two in the routine care group (one drug overdose and
one fall from a high bridge). One additional patient in the
routine care group refused to complete assessments at the
end of 9 months of treatment and at the 3-month followup, and one patient in the integrated care group refused to
complete the assessment at the end of 9 months of treatment. Thus the final numbers of patients after treatment
were 17 in the integrated care group and 15 in the routine
care group at 9 months and 17 in the integrated care group
and 15 in the routine care group at 12 months.

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COMORBID SCHIZOPHRENIA AND SUBSTANCE USE

TABLE 3. Percent of Days of Abstinence for 36 Patients With Comorbid Schizophrenia and Substance Use Disorders Before,
During, and After Treatment With Routine Care Alone or an Integrated Program of Routine Care Plus Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention
Change From Baseline During Treatment
Baseline
Measure
Percent of days of abstinence from most frequently used substancea
Integrated care group
Routine care group
Percent of days of abstinence from all substancesb
Integrated care group
Routine care group

Median Range

3 Months After Start of

Treatment

6 Months After Start of

Treatment

Median

Range

Median

Range

18
18

27.50
34.24

0 to 89 17
0 to 71 18

26.96
3.16

22 to 67 17
55 to 55 15

15.22
8.08

35 to 98
25 to 50

18
18

19.14
21.74

0 to 89 17
0 to 71 18

26.26
1.09

43 to 62 17
63 to 55 15

20.62
1.10

35 to 98
39 to 80

Mann-Whitney test results of comparisons between groups were U=162.00, n.s., baseline; U=119.00, n.s., at 3 months; U=125.00, n.s., at 6
months; U=81.00, p=0.08, at 9 months; and U=90.50, n.s., at 12 months.
b Mann-Whitney test results of comparisons between groups were U=149.50, n.s., baseline; U=104.00, n.s., at 3 months; U=94.00, n.s., at 6
months; U=85.00, n.s., at 9 months; and U=97.50, n.s., at 12 months.

Participation in the Integrated Program

The median number of family intervention sessions was
11 (range=120). For individual cognitive behavior therapy intervention, the median number of sessions was 22
(range=029). The number of support worker contacts
with patients was significantly higher for the patients receiving routine care (median=7.5, range=021) than for
those in the integrated program (median=4, range=010)
(U=78.5, N=36, p<0.008); however, there were no differences in number of contacts with caregivers in the two
groups (routine care group median=4.5, range=022, integrated care group median=5.5, range=117).

Patient Outcomes
Symptoms and functioning. Table 2 gives the scores
for the two groups of patients on measures of global functioning, symptoms, and social functioning. Actual means
and standard deviations are given in this table, but in the
text we report adjusted means and standard errors. To
compare the effects between the groups on the outcome
measures from baseline to just after the 9-month treatment period and from baseline to 12 months after the beginning of treatment, analyses of covariance were used
with the baseline scores entered as the covariate.
For the primary outcome of interest, patients level of
functioning, there was a superior result for the group
given integrated treatment according to Global Assessment of Functioning Scale scores at both 9 months (adjusted mean=57.2, SE=2.11, versus adjusted mean=46.16,
SE=2.17) (F=13.11, df=1, 30, p<0.001) and 12 months (adjusted mean=60.14, SE=2.47, versus adjusted mean=46.28,
SE=2.54) (F=15.06, df=1, 30, p=0.001).
For the Positive and Negative Syndrome Scale, the integrated care group had lower scores on the positive symptoms subscale over time, and the routine care group had
slightly higher scores. This difference was not significant
at 9 months (adjusted mean=14.8, SE=0.8, versus adjusted
mean=17.0, SE=0.8) (F=3.43, df=1, 29, p<0.07) but was significant at 12 months (adjusted mean=12.85, SE=0.94, versus adjusted mean=16.63, SE=1.00) (F=7.43, df=1, 29,

1710

p<0.01). Although there was a statistical difference in the

negative symptoms subscale of the Positive and Negative
Syndrome Scale in favor of the integrated care group at 9
months (adjusted mean=12.50, SE=0.97, versus adjusted
mean=16.17, SE=1.04) (F=6.67, df=1, 29, p<0.02), this difference was not maintained at 12 months (adjusted
mean=12.68, SE=1.19, versus adjusted mean=14.63, SE=
1.27) (F=1.25, df=1, 29, n.s.). There was no difference between the two groups for Positive and Negative Syndrome
Scale total scores at 9 months (integrated care group adjusted mean=58.97, SE=2.69, versus routine care group adjusted mean=65.50, SE=2.88) (F=2.76, df=1, 29, n.s.) or 12
months (integrated care group adjusted mean=56.91, SE=
3.21, versus routine care group adjusted mean=63.36, SE=
3.42) (F=1.89, df=1, 29, n.s.).
Regarding social functioning, there was no difference between the groups in Social Functioning Scale total scores at
9 months (integrated care group adjusted mean=104.20,
SE=1.51, versus routine care group adjusted mean=100.94,
SE=1.60) (F=2.15, df=1, 29, n.s.) or at 12 months (integrated
care group adjusted mean=107.06, SE=1.53, versus routine
care group adjusted mean=102.78, SE=1.68) (F=3.42, df=1,
28, p<0.08).
Relapse. At the end of the 9-month treatment, 10 (55.5%)
of 18 patients in the routine care group had at least one relapse, compared with five (27.8%) of 18 patients in the integrated care group (2=2.86, df=1, p<0.09). At 12 months
the difference in relapse rate was significant: six patients
(33.3%) in the integrated care group relapsed, compared
with 12 patients (66.7%) in the routine care group (2 =
4.00, df=1, p<0.05). The difference between groups in the
total number of days spent in relapse was not significant at
9 months (integrated care group median=0, range=079,
versus routine care group median=13, range=098) (U=
117.0, N=33, n.s.) or at 12 months (integrated care group
median=0, range=0112, routine care group median=26,
range=0106) (U=98.0, N=33, p<0.06). Looking at the
mirror images of days spent in relapse before and after
treatment according to the relapse history obtained from
case notes, we found that the number of days was signifiAm J Psychiatry 158:10, October 2001

BARROWCLOUGH, HADDOCK, TARRIER, ET AL.

differences in change scores between groups at the posttreatment assessments.

Discussion

Change From Baseline After Treatment

9 Months After Start of
Treatment

12 Months After Start of

Treatment

Median

Range

Median

Range

17
15

8.77
3.00

20 to 99
32 to 84

17
15

10.00
14.13

27 to 89
41 to 100

17
15

8.77
3.33

37 to 99
27 to 96

17
15

18.68
1.09

27 to 89
27 to 100

cantly smaller for the integrated care group at 9 months

but not for the routine care group (z=2.19, N=17, p<0.03,
versus z=1.02, N=16, n.s.). This advantage for the integrated care group was maintained at 12 months (z=1.99,
N=17, p<0.05, versus z=0.53, N=15, n.s.).
Substance use disorders. Table 3 gives the baseline values and the change in these values at the four assessment
points (3, 6, 9, and 12 months after the beginning of the
study) on the two outcomes of interest for the timeline follow-back: percent of days of abstinence for the most frequently used substance and percent of days of abstinence
from all substances. Table 3 shows that the integrated care
group had a greater increase in percent of days of abstinence over baseline values than the routine care group at
all assessment points during and after treatment, although the differences were not significant at any single
time point. When the mean change in percent of days of
abstinence relative to baseline values over the four time
points during and after treatment were compared between the two groups (sum of the percent of days of abstinence at 3, 6, 9, and 12 months subtracted from the baseline value), the percent of days of abstinence from all
substances was greater for the integrated care group (median=19.99, range=25.6 to 83.4, versus median=6.52,
range=67.9 to 53.2) (U=86.5, p<0.03). However, the difference between groups in the mean percent of days of abstinence relative to baseline for the most frequently used
substance was not significant (integrated care group median=17.76, range=25.6 to 83.4, versus routine care group
median=3.11, range=46.2 to 54.6) (U=103.0, n.s.).
Leeds Dependence Questionnaire and Addiction
Severity Index scores. For the integrated care group,
the median baseline score on the Leeds Dependence
Questionnaire was 4.5 (range=015); for the routine care
group, it was 6.0 (range=013). The median baseline score
of the integrated care group on the Addiction Severity Index was 0.37 (range=0.180.60); for the routine care group
it was 0.34 (range=0.120.77). There were no significant
Am J Psychiatry 158:10, October 2001

This study demonstrates that an intensive treatment

program integrating routine care with motivational interviewing, cognitive behavior therapy, and family intervention resulted in significant improvement in the main outcome of patients general functioning when compared
with routine care alone. There were also significant benefits to patients in terms of some secondary outcomes, including a significant reduction in positive symptoms, a reduction in symptom exacerbations, and an increase in
percent of days of abstinence from drugs and alcohol averaged over the 12-month period. Thus, the advantage of
the integrated treatment was evident in terms of both
symptom improvement and reduction in substance use.
The acceptability of treatment to patients was also good,
demonstrated by the finding that 94% (N=17) of the 18 patients completed the program. Other studies have found
the rate of treatment completion to be low (30, 31), and it
has been suggested (7) that treatments taking into account
a persons readiness to change may be more effective in
engaging people in treatment.
The relatively small number of subjects in this study is a
limitation, and a key issue concerns the potential generalizability of the findings to other patients with comorbid
schizophrenia and substance use disorders. Certainly, the
demographic characteristics of our study group would
seem to be in accord with sex and age biases found in
larger studies: substance use in schizophrenia (as in the
general population) is more likely to be found in young
men (e.g., reference 32). Similarly, the substance use profile of the study group matches the type of substance use
most prominent in patients with schizophrenia. A recent
review of prevalence studies for substance use in schizophrenia (33) reported that cannabis is the most frequently
used drug, that alcohol use frequently occurs with drug
use; and that multiple substance use is common. Alcohol
is also the most frequently found substance of abuse in
this patient population (3).
Little information is available to indicate what percent of
patients with comorbid schizophrenia and substance use
disorders have contact with their families, or whether patients with family contacts have a different profile of substance use from those without such contacts. However, the
poor outcomes for the routine care patients in our study
are consistent with reports in the literature for those who
have comorbid substance use disorders and severe mental
illness. Two-thirds of the patients receiving routine psychiatric care relapsed within 12 months. These patients also
experienced a deterioration in general functioning and an
increase in positive symptoms of schizophrenia, and there
is some indication that they increased their substance use.
Therefore, there is some evidence that our patient group

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COMORBID SCHIZOPHRENIA AND SUBSTANCE USE

was representative of other patients with comorbid schizophrenia and substance use disorders.
Bellack and DiClemente (34) noted that despite the absence of definitive data on specific intervention techniques, researchers appear to have broad agreement
about some general requirements for treatment. First,
they agree that patients with dual diagnoses need a special
program that integrates and coordinates elements of both
psychiatric treatment and substance abuse treatment.
Second, they agree that treatment needs to match the patients stage of change and that the persons motivation to
change is likely to wax and wane. We took these factors
into account in designing the treatments used in the study
reported here, which gives some empirical support to the
efficacy of such integrated treatments for patients with
dual diagnoses. However, studies with larger numbers of
subjects are required before definitive conclusions can be
made about treatment options for this patient group. Additionally, since the integrated care group received considerably more therapy time than did the routine care group,
a further limitation of the study design is that we are unable to rule out the possibility that the superior outcomes
for the integrated care group were due to the additional attention rather than the specific cognitive behavior therapy
interventions that they received.
A related issue is that although the indications are that
multifaceted treatments may be required to have an impact on the complex and challenging problems of this patient group, in the longer term, research is needed to examine the relative efficacy of different components of
integrated interventions. More work is also required to examine the long-term outcomes and cost benefits of such
treatment programs.
Received April 25, 2000; revisions received Oct. 31, 2000, and Feb.
22, 2001; accepted March 6, 2001. From the Academic Division of
Clinical Psychology and the Academic Division of Psychiatry, School
of Psychiatry and Behavioural Sciences, University of Manchester,
UK; and Tameside & Glossop Community & Priority National Health
Service Trust, UK. Address reprint requests to Dr. Barrowclough, Academic Unit of Clinical Psychology, Mental Health Unit, Tameside General Hospital, Fountain Street, Ashton-under-Lyne, Lancashire, OL6
9RW, UK; [email protected] (e-mail).
Supported by West Pennine, Manchester, and Stockport Health Authorities and Tameside & Glossop National Health Service Trust Research and Development Support funds and by Making Space, the
organization for supporting caregivers and sufferers of mental illness.
The authors thank Joanne Quinn, Julie Morris, Gina Evans, and Ian
Lowens for their help.

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