The authors are affiliated with the Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road (MPD 152), Menlo Park, CA 94025 (e-mail: mark.ilgen@med.va.gov). Dr. Moos is also with Stanford University School of Medicine, Palo Alto, California. This article is part of a special section honoring the memory of three leaders in the psychosocial treatment of patients with severe and persistent mental disorders: Wayne S. Fenton, M.D., Gerard E. Hogarty, M.S.W., and Ian R. H. Falloon, M.D., D.Sc.

High rates of psychiatric disorders are common among patients seeking treatment for substance use disorders (1,2). Overall, researchers (3,4,5) and treatment providers (6) acknowledge the importance of attending to patients' psychiatric symptoms in treatment for substance use disorders. On average, one year after treatment patients with a psychiatric diagnosis who are treated for substance use disorders report significant decreases from baseline levels in substance use and psychiatric symptoms (3,7). However, despite these average improvements, some patients may experience an increase in psychiatric symptoms.

The occurrence of deterioration (that is, an increase in psychiatric symptoms) during or after psychiatric care was first described in 1938 by Masserman and Carmichael (8). Although a majority of psychotherapy outcome studies focus on symptom improvement, in a review of more than 40 articles describing deterioration, Mohr (9) reported that rates of deterioration ranged roughly from 3 to 80 percent.

Deterioration has only recently been investigated in the treatment of substance use disorders, with just six known studies on the topic (10,11,12,13,14,15). Within these studies, rates of deterioration ranged from 10 to 30 percent, probably because of variations in sample characteristics, type of treatment, and the definition of deterioration. In general, patient-related predictors of deterioration included more severe substance use, more severe psychiatric symptoms, and a history of prior psychiatric treatment and prior arrests (10,11).

With respect to treatment-related factors, poorer quality of the therapeutic alliance between the patient and treatment provider was linked to deterioration immediately after outpatient treatment for alcohol use disorder (15). In addition, shorter duration of treatment and fewer outpatient mental health visits predicted a higher likelihood of deterioration (10). Probable treatment-related predictors of deterioration include a lack of bonding within treatment, a lack of monitoring or supervision, low expectations and a lack of challenge, and an overemphasis on confrontation (16).

Research on treatment for substance use disorders has utilized indices of substance use and substance-related problems as the primary measure of deterioration. However, as indicated by Mohr (9), it is also important to attend to deterioration in psychiatric symptoms. Given that psychiatric symptoms have been tied to both negative (17) and positive responses to treatment for substance use disorders (for example, better retention) (18), it is important to examine how treatment response is related to changes in psychiatric symptoms. Monitoring patients for an exacerbation of psychiatric symptoms during treatment may be a way to identify patients at risk of poor prognosis after treatment.

Thus the study presented here utilized a naturalistic, prospective case-control design to examine the phenomenon of psychiatric symptom exacerbation during residential treatment for substance use disorders. Specifically, we asked the following four questions. What is the prevalence of worsening of psychiatric symptoms (or deterioration) during treatment for substance use disorders? Compared with patients whose psychiatric symptoms improve, do patients who show deterioration report poorer functioning at discharge and one-year after treatment entry? Do patients who show deterioration during treatment enter treatment with more psychiatric or substance-related problems and poorer coping skills? Is the prevalence of deterioration associated with the type of treatment orientation, and do patients whose symptoms deteriorated view the treatment environment as less helpful than those whose symptoms improved?

Patients were recruited for participation after presenting for treatment at one of 15 residential treatment programs for substance use disorders in the Department of Veterans Affairs (VA) health care system between 1992 and 1995 (14). The research project received approval from institutional review boards at each of the 15 sites, and participants provided informed consent before participation. Programs had a 21- to 28-day desired length of stay, used individual and group therapy to assist patients in meeting their treatment goals, and were multidisciplinary in staffing. The major elements of treatment included behavioral skills training, an examination of the process of relapse, and peer support for abstinence. Treatment was primarily focused on substance use disorders and did not have an explicit dual diagnosis focus. Women were excluded from the study because of the small number of female patients (N=64). Of the 3,699 male patients who completed a baseline assessment at treatment entry, 3,322 (90 percent) were reassessed upon discharge from treatment, and 3,018 (82 percent) were reassessed at the one-year follow-up.

Patients completed items from four subscales measuring depression, anxiety, psychotic, and paranoid symptoms on the Brief Symptom Inventory (BSI) (19) at treatment entry, discharge, and one year. The BSI is a self-report inventory designed to assess psychological symptoms in clinical and nonclinical samples. Psychiatric symptoms were measured by the sum of all 22 items rated on 5-point scales ranging from 0, not at all, to 4, extremely (α=.94). Possible scores range from 0 to 86, with higher scores indicating more psychiatric symptoms. Scores on the BSI are correlated with other measures of psychiatric distress (20).

In order to identify the deteriorated group, we focused on the 3,322 patients who completed assessments at both baseline and discharge from treatment. Discharge BSI scores were subtracted from baseline BSI scores to identify patients who experienced an increase in psychiatric symptoms during treatment. Of the 3,322 patients, 426 patients (13 percent) showed an increase in psychiatric symptoms during treatment (deteriorated group), 71 (2 percent) showed no change in symptoms, and 2,825 (85 percent) showed a decrease in psychiatric symptoms (improved group).

Baseline BSI scores were used to match patients in the improved group (N=2,825) with patients in the deteriorated group (N=426). Specifically, the frequency of each baseline BSI score was determined for patients in the deteriorated group. Then, for each baseline BSI score, a number of patients in the improved group were randomly selected to match the number of patients in the deteriorated group with the same score. At baseline, patients in the deteriorated and improved groups had average BSI scores of 22.2±16.8 and 22.1±16.6, respectively. At discharge the average BSI score for patients in the deteriorated group was 30.0±19.0, an increase of 7.8±7.6 during treatment. In contrast, the average discharge BSI score for patients in the improved group was 9.4±9.9, a decline of 12.7±12.1. This process of matching patients on the basis of baseline psychiatric symptoms was undertaken to ensure that the designations of improved and deteriorated reflected changes in psychiatric symptoms during treatment with minimal baseline differences in psychiatric symptoms between groups.

Measures

Substance use. Estimates of quantity and frequency of alcohol use were obtained by using questions adapted from the Health and Daily Living Form (21). To measure the quantity of alcohol consumption, patients reported the average number of drinks that they had consumed per day over the past three months. To measure the frequency of alcohol and drug consumption, patients estimated the average number of days per week that they consumed alcohol or drugs over the past three months.

Self-efficacy for abstinence. This item was adapted from scales developed for cigarette smokers (22,23). The question asks participants to rate how confident they are that they will be completely abstinent from all substances in one year (1, not at all confident, to 10, extremely confident).

Approach and avoidance coping. Approach and avoidance coping were measured at discharge by using four six-item subscales from the Coping Responses Inventory (CRI) (24). Coping by cognitive avoidance (α=.75) assesses an individual's attempts to avoid realistic thinking about a stressor, and coping by emotional discharge (α=.63) assesses an individual's attempts to manage responses to a stressor by expressing emotions (for example, yelling or crying). Coping by positive reappraisal (α=.75) assesses an individual's attempts to reappraise the stressor in a positive manner. Coping by problem solving (α=.78) reflects an individual's attempts to behaviorally manage a stressful situation.

Length of treatment, treatment dropout, psychiatric diagnoses, and number of individual sessions. Information was obtained from treatment providers about the length of treatment (measured in days from intake to discharge) and whether the patient dropped out of treatment against the advice of the treatment team. Patients who dropped out of treatment were contacted to provide follow-up data and were included in the analyses presented here. Additionally, patient records were examined to obtain psychiatric diagnoses, which were based on clinical interviews conducted by experienced treatment providers during intake interviews. At discharge, patients reported the number of individual sessions that they received during treatment.

Treatment environment. Patients described the treatment environment by using the Community Oriented Programs Environment Scale (COPES) (25). The COPES taps the bonding or quality of relationships between patients and staff (involvement, support, and spontaneity), the extent of monitoring or supervision (organization, clarity, and control), performance expectations (autonomy and practical and personal problem orientation), and the emphasis on confrontation (anger and aggression). Each of the subscales includes ten dichotomously scored items (alphas range from .58 to .78) (26). Patients also rated their satisfaction with the program by using the Client Satisfaction Questionnaire (CSQ-8) (27). The CSQ-8 asks clients to rate their level of satisfaction with the treatment program on 11 items, each scored with a 4-point scale ranging from 0, not satisfied, to 3, satisfied (α=.88).

Program orientation. Designation of the treatment orientation of each program was based on direct observation of the program and data gathered during semistructured interviews with each program director and the Drug and Alcohol Program Treatment Inventory (DAPTI) (28,29). Program directors provided information on treatment, including percentage of time spent in 12-step and cognitive-behavioral treatment and goals and activities relevant to such treatment. On the basis of this information, five programs were categorized as 12 step, five programs were categorized as cognitive-behavioral, and five programs were categorized as eclectic (14).

Data analyses

All analyses were conducted with SPSS version 11.5 (30) on data pooled from all 15 treatment programs. All programs were examined because all were drawn from the same national treatment system. They were targeted toward patients with substance use disorders in order to maximize power to detect differences between groups and aid in hypothesis development. We compared the deteriorated and improved groups on discharge and one-year outcomes by using analyses of variance (ANOVAs) for continuous outcomes and chi square tests for categorical outcomes. Then, ANOVAs and chi square tests were used to compare patients in the deteriorated and improved groups on baseline personal characteristics and treatment experiences.

Rates of deterioration and differences between groups

A total of 426 of 3,322 patients (13 percent) experienced a worsening of psychiatric symptoms during the course of residential treatment for substance use disorders. As shown in Table 1, compared with patients in the improved group, those in the deteriorated group were more likely to use substances during treatment and to drop out of treatment. Patients in the deteriorated group also reported lower levels of self-efficacy at discharge. With regard to one-year outcomes, patients in the deteriorated group continued to report elevated psychiatric symptoms and were less likely to be abstinent, consumed more alcohol, and used drugs more frequently than patients in the improved group.

Differences between groups on baseline personal characteristics

As shown in Table 2, patients in the deteriorated and improved groups did not differ on any baseline demographic characteristic or measure of substance use. Patients in the deteriorated group were no more likely than those in the improved group to be given a diagnosis of major depressive disorder, an anxiety disorder (including posttraumatic stress disorder), or a personality disorder. However, a higher proportion of patients in the deteriorated group than in the improved group were given a diagnosis of either a substance-induced or nonsubstance-induced psychotic disorder. At baseline, compared with patients in the improved group, those in the deteriorated group reported lower self-efficacy and more reliance on emotional discharge coping.

Differences between treatment experiences in the two groups

Patients in both groups received similar types of treatment, and both groups received treatment for similar lengths of time (Table 3). However, compared with patients in the improved group, those in the deteriorated group reported that treatment involved less bonding with the treatment staff (lower involvement, support, and spontaneity), less monitoring and supervision (poorer organization and clarity), lower performance expectations (less autonomy and less practical orientation and personal problem orientation), and more confrontation (open expression of anger). Additionally, patients in the deteriorated group were less satisfied with their overall treatment experience.

A sizable minority of patients with substance use disorders experienced a worsening of psychiatric symptoms during the course of residential treatment for these disorders. Patients who experienced an exacerbation of psychiatric symptoms were more likely to use substances during residential treatment and to drop out of treatment. They also reported poorer psychiatric and substance-related outcomes at one-year follow-up. At treatment entry, patients in the deteriorated group were more likely to have a psychotic diagnosis, to have low self-efficacy, and to rely on avoidance coping. Moreover, patients in the deteriorated group experienced the treatment environment less favorably and were less satisfied with treatment.

The prevalence of psychiatric symptom exacerbation in the sample presented here was broadly similar to the prevalence of substance-related deterioration reported previously (10 to 30 percent) (10,11,12,13,14,15). These rather substantial rates of exacerbation of substance use and psychiatric symptoms during, or shortly after, treatment highlight the importance of identifying personal and treatment-related risk factors for deterioration.

Although prior research has yielded mixed results as to whether psychiatric symptoms are associated with poorer substance use disorder treatment outcomes (3,4,5,18), much of this work has focused on elevated baseline psychiatric symptoms. We controlled for baseline psychiatric severity and focused on the exacerbation of psychiatric symptoms, which was associated with a poorer experience during treatment, higher likelihood of dropout, and worse psychiatric and substance-related outcomes at one year. Accordingly, treatment providers should monitor psychiatric symptoms not only at baseline but also during treatment to look for indications of deterioration.

The presence of a psychotic diagnosis, whether or not substance induced, was associated with a heightened risk of deterioration. This is consistent with past research indicating that, even when compared with other patients with psychiatric and substance use disorders, patients with psychotic disorders may show an unusually poor response to substance abuse treatment if it lacks a specific focus on psychiatric symptoms (3). Thus these patients may be especially appropriate for more integrated dual diagnosis treatment, which involves ongoing management of both mental health and substance-related problems and comprehensive planning for continued support following discharge (31). Our findings showed comparable rates of deterioration in three types of treatment (12-step programs and eclectic and cognitive-behavioral therapy). Similarly, within Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), rates of deterioration were roughly equivalent in each of three distinctly different outpatient treatments for alcohol use disorders (15).

A unique contribution of the study presented here was examination of the role of the treatment environment in psychiatric deterioration. In general, compared with patients in the improved group, those in the deteriorated group experienced the treatment environment as being less cohesive and well structured and more confrontational. Similarly, a poorer therapeutic alliance predicted deterioration in Project MATCH (15). The findings indicate that even though patients in the both groups obtained a comparable amount of treatment, those in the deteriorated group did not integrate fully into the treatment and were less satisfied with their treatment experiences.

Several limitations are important when interpreting the findings presented here. Women were excluded from the sample, which limits the generalizability of the findings. Additionally, we studied residential treatment; thus generalizations to other treatment settings should be made with caution. Another point is that our use of a matched sample may have limited the variability in baseline factors, especially those correlated with the BSI, and thus decreased the likelihood that they would predict deterioration.

Also, because information about patients' treatment experiences was obtained at discharge, it was not possible to tell if negative experiences preceded or were an outcome of deterioration. More work is needed to establish the temporal progression of treatment factors and their precise relationship to deterioration. Additionally, increased reliability of measures of coping and treatment environment could strengthen predictions of deterioration in future research.

Although our findings indicate that, on average, patients in the deteriorated group consumed more alcohol and drugs at follow-up, it is clear that variation exists within both of the groups and that some individuals may have experienced a worsening of psychiatric symptoms without an increase in substance use. Future research would benefit from more comprehensive measures of deterioration during treatment that may be more closely associated with future substance use.

The study presented here is the only research that we are aware of that assessed the exacerbation of psychiatric symptoms during treatment for substance use disorders. Because a return to substance use is rare in residential treatment settings (roughly 4 percent in the sample presented here), measures of deterioration based on psychiatric symptoms may be a useful way to detect deterioration in this setting. The exacerbation of psychiatric symptoms is associated with patient dissatisfaction with the treatment experience and with poorer proximal and long-term outcomes.

The study presented here was designed to document the rates of deterioration and help develop hypotheses about potential consequences and causes of deterioration. Thirteen percent of patients reported a deterioration of psychiatric symptoms during treatment, and these patients reported poorer psychiatric and substance-related functioning up to one year after treatment. At baseline, patients in the deteriorated group were more likely to have a diagnosis of a psychotic disorder as well as lower self-efficacy and more emotional-discharge coping. Additionally, patients in the deteriorated group reported poorer ratings of the treatment environment and lower treatment satisfaction than those in the improved group.

Because a substantial proportion of patients experienced an exacerbation of psychiatric symptoms between entry into and discharge from treatment, treatment providers should be more vigilant about identifying and preventing psychiatric deterioration. Regular assessments with clinical interviews or self-report measures, such as the Brief Symptom Inventory, could help to detect changes in psychiatric symptoms during treatment. Attending to changes in psychiatric symptoms during treatment and tailoring interventions to patients at greatest risk could help reduce the likelihood of psychiatric deterioration and other complications associated with in-treatment increases in psychiatric symptoms.