The Moderating Impact of Posttraumatic Stress Disorder On the Effectiveness of Intensive Case Management with Substance Dependent Women Receiving Temporary Assistance for Needy Families

BACKGROUND/PURPOSE: In the early 1990s, studies emerged indicating substance use as a significant factor preventing welfare recipients from achieving employment and subsequent self-sufficiency (Office of Inspector General, 1992). Some states experimented with supplemental social service interventions, including case management (CM), to facilitate the engagement of the “hard to employ” into substance abuse treatment (Besharov & Germanis, 2004; Morgenstern et al., 2006). Intensive case management (ICM) has been utilized by public and private social service sectors to increase outpatient substance abuse treatment retention (OSAT), as well as increase abstinence outcomes (Hesse, Vanderplasschen, Rapp, Broekaert, & Fridell, 2007; Morgenstern et al., 2006; Siegal, Rapp, Li, & Saha, 2001). ICM has been found effective for facilitating entry into, retention in, and completion of OSAT for low-income substance dependent women. Few studies have specifically examined the moderating impact of additional mental health disorders on ICM's effectiveness with this population. Building on a previous study that examined the moderating impact of depressive symptoms, this study investigated how either symptoms of posttraumatic stress disorder (PTSD) or a diagnosis of PTSD, according to DSM-IV criteria, moderated ICM's impact on OSAT attendance and outcomes for substance dependent women on TANF. METHOD: Substance dependent women on TANF (N=302) were recruited from local welfare offices in Essex County, NJ; assessed after screening; and randomly assigned to ICM or usual care (UC). Participants were re-assessed at 3, 9, 15, and 24 months. UC consisted of a health assessment at the local welfare office and referral to OSAT services. Clients in ICM, a manual guided intervention, received extensive outreach, assessment, and direct provision of services. Appropriate to the longitudinal, repeated measures nature of the data, generalized estimating equations modeling was used to assess the predictive value of ICM in facilitating OSAT attendance and abstinence (percent days abstinent) for women with a PTSD diagnosis or a continuous range of symptoms of PTSD (measured by the Posttraumatic Diagnostic Scale). Data were modeled using negative binomial regression models with log link function, which provided the best model fit. FINDINGS: Moderation of ICM was found only in regards to attendance. When controlling for baseline differences and depression, attendance rates for women with higher levels of PTSD symptoms in ICM were 10% higher compared to the other three groups through 24 months of follow-up (Incidence Rate Ratio, IRR = 1.10, 95% CI = 1.02-1.19). A significant main effect was found for PTSD diagnosis on percent days abstinent (p < .01), even when controlling for depression, but no moderation effect was demonstrated. Findings indicate overall that substance dependent women with higher levels of PTSD symptoms or a diagnosis of PTSD attend more days of OSAT and have higher rates of abstinence in the context of ICM. CONCLUSION: Findings further confirm that ICM is an effective intervention for managing the chronic nature of co-morbid disorders and substance dependence for TANF women. ICM improves the rates of OSAT attendance and performs equally well for both women with and without PTSD in facilitating abstinence rates.