The 10-year outcomes for participants with schizophrenia and co-occurring substance abuse were positive for large proportions. Despite severe and prolonged disability, many of these individuals were able to achieve control of both disorders, to reduce episodes of hospitalization and homelessness, to live independently, to achieve success in several aspects of community functioning, and to attain what they perceived as a better quality of life.
The 10-year results also document steady and significant improvements between 3 and 10 years. At 3-year follow-up, most participants had not achieved the clinical cutoffs taken as indicators of recovery in several areas,35
but by 10 years a majority had achieved these levels on at least 4 of 6 recovery outcomes. Not only did participants continue to improve in outcomes between 3 and 10 years in most areas, but they also improved in some areas (independent living and satisfaction with leisure activities) that had seemed static at 3 years. Thus, the evidence here suggests that improvements and recovery progress over many years, not just during the early stages of dual diagnosis treatment.
Amounts of activities, social contacts, and family contacts actually decreased as participants learned to manage mental illness and substance abuse and as they attained independent living, employment, and friendships with non–substance abusers. These findings are consistent with qualitative studies of the recovery process among persons with co-occurring disorders.50,51
The concept of mental health recovery continues to be difficult to define and measure. For the current analysis, we have taken the position that recovery outcomes should correspond to meaningful behaviors identified by dual diagnosis clients themselves. For example, people with co-occurring mental illness and substance abuse report that having regular contacts with friends who do not abuse substances, rather than increasing the size of their social networks or their overall amounts of social contact, is a meaningful social outcome. We used clients' advice to select recovery outcomes, but we readily acknowledge that the operational definitions used here were idiosyncratically determined by the clients who collaborated with us on this study and were limited by the variables available in our data. Since our recovery outcomes did not include sustained abstinence (a common standard in the substance abuse field), we analyzed abstinence separately and documented similar results—steady progress over time and minimal relationships with other domains.
The observed weak relationships between outcomes from multiple domains indicate that the domains are relatively independent. The only strong relationship was between high psychiatric symptoms and poor life satisfaction. Our findings regarding weak relationships between outcomes are consistent with many years of schizophrenia research. For example, Strauss and Carpenter52
and Gurel and Lorei53
documented similar weak relationships among outcome domains for schizophrenia clients many years ago. To these previous findings, we have added the observation that substance abuse (including sustained abstinence) and quality of life outcomes are also relatively independent of the other outcome domains.
The relationships between treatment and recovery are unclear in this study, other than that hospitalization declines steadily over time as recovery improves. Our 3-year follow-up data showed that nearly all participants were rapidly engaged in outpatient dual diagnosis services and that hospital use and homelessness were reduced over time as people increased their use of outpatient services.35
The data indicated, however, that these participants continued to require substantial outpatient treatments and supports to remain out of institutional settings over 3 years. Quality of services and specific services were also important. In centers where the assertive community treatment and integrated treatment model were implemented with high fidelity, substance abuse outcomes were much better than in centers with poor implementation.54
Further, schizophrenia clients who received clozapine during the early years of the study experienced highly significant improvements in substance abuse outcomes compared with those on other antipsychotic medications.55
We have not yet analyzed service data for years 3 to 10, but relationships between services during the first 3 years and 10-year outcomes reported here were not significant.
Including subjective measures of quality of life is somewhat controversial because these measures tend to be stable over time as people readjust their own expectations.56
However, we found improvements in reported overall life satisfaction and also in specific areas of quality of life. Other attitudinal concepts that are often identified by clients and could be considered to be indicators of recovery include hope, self-esteem, and empowerment.27
Several caveats deserve mention. This study group did not approximate a representative sample of people with schizophrenia and substance abuse, though it was representative of those in treatment in the New Hampshire state mental health system around 1990. Further, the New Hampshire mental health system was atypical in offering comprehensive integrated dual disorders treatment during the early 1990s. Many state systems are, however, currently implementing integrated treatment programs.57
The longitudinal improvements reported here cannot be attributed to integrated dual disorders treatment. Other possible explanations include regression to the mean, the natural course of dual disorders, and temporal changes. For example, the findings regarding competitive employment and regular contacts with non–substance abusers might be explained by the emphasis on supported employment and self-help that began during these years in New Hampshire. In fact, the increases in competitive employment for this study group were remarkably similar to the overall increases in New Hampshire for the population of persons with severe mental illness during the same years. Regression to the mean offers an unlikely explanation for changes that were steady over many years. On the other hand, it is certainly possible that improvements in recovery outcomes are characteristic of the natural course of co-occurring disorders since both schizophrenic and substance use disorders individually tend toward such a positive course with age.
Despite these caveats, the data presented here provide a hopeful long-term picture for clients with co-occurring schizophrenic and substance use disorders. The long-term course for most people with these disorders, at least in New Hampshire, appears to involve steady remission of symptoms of both disorders, steady improvements in key areas of independent role functioning, and steady gains in quality of life and overall life satisfaction.