Expansion and Enhancement of Davidson County Dual Diagnosis Service Capabilities

Contract Information

Dates of Service: October 1, 2001 through September 30, 2004

Grantee Federal
Identification Number: T1-12720

Project Name: Expansion and Enhancement of Davidson County Dual Diagnosis Service Capabilities

Principal Investigator: Scott Orman

Project Location: Foundations Associates; Nashville, Tennessee
Dual Diagnosis Management; Nashville, Tennessee
Michael Cartwright, Executive Director

Project Purpose

Foundations Associates (FA) responded to Davidson County, TN’s growing service needs for integrated front end delivery services for adults with co-occurring disorders by embarking on a three year expansion and enhancement project based on its existing outpatient program. The purpose of the expansion component was to increase the capacity of FA’s American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC)-2 Level II.1 from 14 to 28 step-down and case management services slots. This represents a 100% program expansion, creating ASAM PPC-2 Level I outpatient services to accommodate 92 consumers annually. The purpose of the enhancement component was to modify FA’s existing outpatient program by replicating and adopting principle components based upon empirically supported findings from its residential model. FA’s intensive outpatient program alternative conscientiously responded to economic trends toward less restrictive, less costly and more responsive integrated community-based treatment. The Intensive Outpatient Program (IOP) fills a niche between traditional outpatient psychotherapy and residential programs and demonstrates a commitment to managed care objectives.

Over the three year time span, data were collected on FA’s newly designed Intensive Outpatient Program (IOP) and FA’s existing residential program. The stated goal of the project was to develop the least restrictive and resource intensive model of community-based dual diagnosis treatment, while yielding results comparable to those of FA’s residential model. The purpose of the present study was to compare longer-term, more intensive community-based services with sustained follow-ups to FA’s highly acclaimed residential program. The purpose of this comparison was to determine if the intensive outpatient services would produce comparable efficacy results as the residential program. Project enhancement goals included, but were not limited to, increasing periods of sobriety and behavioral stability, as evidenced through measures of reduced recidivism, decreased substance use/harm reduction, and enhanced familial and proximal natural and agency supports. In addition, we proposed to enhance key areas of service gaps currently missing in outpatient treatment models of integrated care by raising the scope and duration of service intensity to mirror that of the residential program.


Program Description

As our interdisciplinary teams worked more effectively to address specific consumer needs throughout the project, we moved well-beyond traditional service model programs and enhanced integrated care principles to incorporate a holistic recovery-oriented program strategy. Treatment integration and principle enhancement has been essential in responding to a multiple-needs population, like that of the dually diagnosed. In the following subsections, we describe a comprehensive assessment process, enhanced integrated case management and therapy strategies, and a family education training program. The enhanced IOP strategies were designed with long term perspectives to extend the duration of all services to the community-based consumer to decrease long-term societal cost and improve clinical outcomes.


Summary of Baseline Findings

Severity of Substance Use

This report details data collected on 816 research participants in Foundations Associates integrated treatment program for individuals with co-occurring disorders. Baseline findings for clients entering Foundations Associates consistently show substantial substance use along with a variety of symptoms typically associated with substance abuse and dependence.

Each participant was screened for alcohol and drug abuse or dependence using the TAAD interview, which is designed to identify symptoms of a possible current DSM-IV diagnosis for alcohol or other drugs. The TAAD has 16 items that address drug dependence and 19 that address alcohol dependence. The instrument assesses both dependence and abuse by establishing a pattern of behaviors or consequences rather than simply a pattern of use. According to TAAD scoring procedures (Hoffman, 2001), possible dependence is indicated if the individual endorses items from at least three of the DSM-IV categories for dependence. A more stringent dependence criterion requires positive responses on at least five different dependence items. Similarly, possible abuse is indicated if the individual endorses at least one item in any of the four DSM-IV abuse categories while the more stringent abuse criteria require at least two different indications of abuse in one or more of the categories. For our purposes, indications for abuse and dependence reflect the more stringent criteria.

As illustrated in Figure 1 on the following page, many participants reported behaviors and consequences indicative of multiple dependence and/or abuse patterns. More consumers reported behaviors and consequences of drug dependence and abuse compared to alcohol dependence and abuse. Far greater percentages met the criteria for possible dependence or abuse (see Figure 2), which do not require selecting multiple items within each DSM-IV category.



As a supplement for the TAAD substance abuse/dependence measure, GPRA items are included in this report to capture frequency of substance use in the 30 days prior to treatment. The results can be seen in Figure 3 below. Again, illegal drug use (61.3%) was reported more often than any use of alcohol (50.7%) or alcohol use to intoxication (38.2%). In terms of specific illegal drugs reported, cocaine (43.4%) and marijuana (26.8%) use were reported more than all other illegal drugs combined. It is somewhat surprising that cocaine use was reported more frequently than alcohol use to intoxication. However, this trend is consistent with findings from the TAAD assessment, which also indicated more drug abuse/dependence compared to alcohol.


While the TAAD instrument provides a more stable measure of substance use by focusing on symptoms associated with dependence and abuse, it also limits our understanding of the severity of substance use by type of substance. Figure 4 below details the frequency of substance use and provides a more detailed indication of substance use severity. It is important to note that the average number of days reflects only those individuals reporting use for that particular category.

Four substance use categories were not included because they represented far fewer cases (n<25, or 3.1%). Those reporting substance use at baseline typically indicated frequent use, which is consistent across all categories (i.e., approximately 12-13 days out of the last 30 for each substance use category).


In addition to frequent substance use in the last 30 days prior to enrollment at Foundations Associates, many consumers reported recent treatment for substance use problems. FA serves a population with extensive treatment histories, which is not unusual for a population with co-occurring disorders. Participants in the program were often referred from other treatment facilities where they were receiving treatment focusing on substance use. Of those:

  • 12% were referred from inpatient treatment facilities where they were receiving treatment for substance use
  • 8% were referred from outpatient treatment programs where they were receiving treatment for substance use
  • 17% were referred from residential treatment facilities where they were receiving treatment for substance use

Psychiatric Severity

Clients entering the treatment program at Foundations Associates consistently reported high levels of symptomatology across all major psychiatric domains. Using the Brief Sytmptom Inventory (BSI), which has well-established normative data, we can compare the psychiatric severity of participants to typical mental health consumers in outpatient settings. Relative to BSI normative data for psychiatric outpatient consumers, program participants tend to fall around the 60th to 70th percentile in psychiatric severity (i.e., the average Foundations consumer scores higher than 60 to 70 percent of typical psychiatric outpatients). Compared to general (i.e., non-psychiatric) population norms, the average FA consumer reported psychiatric symptom severity in the 95th to 99th percentile range. Table 2 below compares the BSI scores of FA program participants to BSI outpatient norms and BSI census norms.



BSI Outpatient Norms

BSI Census Norms







Interpersonal Sensitivity





















Global Severity




Figure 5 below helps illustrate that psychiatric severity is higher for program participants compared to mental health outpatient norms and census norms. Across all psychiatric domains, FA participants experience psychiatric symptomatology that is more severe than the majority (i.e. greater than 50%) of those in the outpatient and census normative groups. Although there is some fluctuation across domains, the global severity category indicates that the average FA participant reports higher symptom severity than almost 70% of psychiatric outpatients.


Consistent with BSI baseline scores, the Mental Component Summary from the SF-12 also suggests that participants face substantial psychiatric impairment compared to general population norms. The Mental Component score for the general population has a mean of 50 and a standard deviation of 10 points. The above graph shows that program participants have an average score that is almost two standard deviations lower than the norm, indicating psychiatric conditions that present a large burden on mental health status. BSI domain scores and SF-12 summary measures indicate that consumers served by Foundations Associates have greater psychiatric impairment than general psychiatric outpatient populations.

Associated Problems Medical, Family/Social, Economic, Housing, and Legal Problems

Subjective items from the Lehman’s Quality of Life Interview offer a general description of associated problems from the consumers’ perspective as they enter treatment (See Figure 6). All major categories are somewhat consistent except reported satisfaction with finances. Participants indicated considerably less satisfaction with finances on subjective items compared to the other categories.



Leave a Comment