CPG for Psychosocial Interventions in Severe Mental ... - GuíaSalud

5.4. Interventions with specific subpopulations
5.4.1. SMI with dual diagnosis
Substance abuse is, for different reasons, a frequent comorbility in people with SMI and entails a
worsening of the clinical condition, of their clinical management and prognosis. One of the consequences
of dual diagnosis is an increase in non-treatment adherence and abandonment, more
relapses, suicides, contagion of viric diseases via parenteral way, home abandonment, disruptive
behaviour with aggression, legal problems, less economic resources and less social support 52 .
Psychiatric and drug-dependent treatments have traditionally been separate and may differ
in theoretic cases and implementation methods. In those places where the Mental Health and Drug
Dependent networks have been or are administratively separate, the psychiatric or psychosocial
treatment of SMI and treatment programmes for drug dependences have been offered separately,
in parallel or in sequence, with the possibility of neither being optimised on having to negotiate
the patient with two separate teams. On other occasions, the presence of both diagnoses compromised
the parallel care, requiring the tempering or control of the “other problem” by a network,
to incorporate it to the second (control of drug addiction to be able to be incorporated into specific
psychosocial rehabilitation programmes “without” the handicap of active drug addition; or,
on the contrary, rejection in treatment for drug dependency units until clinical stability has been
achieved).
Thus, the efficacy of integrated programmes for the treatment or reduction of substance
abuse in patients with SMI is being questioned. The objective is to know the evidence of the
importance of providing addiction treatment programmes and psychosocial rehabilitation programmes
by one single coordinated team to achieve the objectives of both programmes.
In this question, no difference has been established between the studies aimed at diagnostic
groups that, a priori, may have different characteristics (for example, bipolar disorder). For that
SMI subgroup, RCT have been found included in selected reviews such as Weiss et al 209 and
Schmitz et al 210 , whose data have been treated globally.
The evidence review rejected the study of the use of other psychosocial techniques that
patients with SMI and dual diagnosis may receive on specific occasions, such as cognitive-behavioural
therapies, social skills training or motivational interview, whose efficacy will be assessed
in other sections.
Question to be answered
• What type of treatment has proven to be mos t effective in people with SMI and substance
abuse: integral or parallel treatment?
Cleary et al 52 developed a SR that included 25 RCTs which assesses the effect of psychosocial
interventions in the reduction of the consumption of substances in patients with SMI.
Likewise, Morse et al 211 performed a RCT (n = 149) with 24-month follow-up on people
with SMI and substance abuse, as well as “homeless”. They were randomised either to an integrated
ACT or standard ACT programme or to standard treatment. This study has an important
bias risk as it does not specify the losses in the groups.
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