CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 44MANAGEMENT OFCO-OCCURRING SUBSTANCEUSE DISORDERSDAVID J. KAVANAGHNATURE OF THE ISSUES IN COMORBID POPULATIONSIn recent years there has been increasing interest in effective ways to manage people withboth psychoses and co-occurring substance use disorders (SUDs). Despite the importanceof these problems, treatment research in this area remains at a relatively early stage, withfew well-controlled trials and outcomes that are often quite weak. However, we nowhave a substantial body of research on the nature, incidence, and correlates of SUDs inpsychoses, and on the nature and perceived limitations of existing services. This researchhas clear implications for interventions.SUDs Are Very Frequent in People with PsychosesAbout half of people with schizophrenia spectrum disorders have an SUD at some time intheir lives. In treatment settings, rates can be even higher—especially in acute or crisis services,or in services for people with high needs for ongoing support, because the combinationof problems increases problem severity and risk of relapse.There are important implications for clinical practice that arise from this observation.First, because comorbidity is so common, screening for substance use should be universaland routine in initial assessments and status reviews of people with psychosis. Second,routinely offering more intensive or prolonged treatment than that available atpresent to everyone with schizophrenia and an SUD would have substantial resourceimplications. Unless budgets and staffing receive a substantial boost, or other consumersreceive less intervention, there will be severe limitations on the extent to which such additionaltreatment can be contemplated. Exporting the problem to another service (e.g., analcohol and other drug service) just shifts rather than solves the resource problem.459