CLINICAL HANDBOOK OF SCHIZOPHRENIA

44. Management of Co-Occurring Substance Use Disorders 461TABLE 44.1. Treatment Recommendations on Co-Occurring Mental Disorders and SUDsRecommendations from epidemiological research1. Universally screen for SUDs in people with psychosis.2. To maximize access and restrict cost:• Integrate comorbidity work in standard treatment.• Routinely apply brief interventions.• Restrict high-cost interventions to those who will benefit only from those treatments.3. Have treatments that are suitable for the following, while ensuring that less common groups arealso addressed:• High-risk groups (e.g., young men).• Substances currently in common use among the service’s consumers (e.g., nicotine, alcohol,cannabis, cocaine/amphetamines).• Use of multiple substances.4. Ensure that treatments can deal with initial instability in substance control, and that optimismabout recovery is expressed. Even in low-intensity treatments, some ongoing, assertive contactmay be required.5. Intervene early to help preserve prospects of functional recovery.6. Present comorbidity interventions in the context of maintaining optimal physical and mentalhealth to reduce stigma and maximize engagement. Nicotine smoking should be an importantfocus.7. Any problematic responses by others should be addressed (e.g., in family intervention) andhighly confrontational approaches to clients should be avoided.8. Any responses by the service to substance-related infractions should be proportional andexpected, and minimize threats to engagement or relapse.9. Treatments should offer more opportunities for pleasure and mood enhancement than are takenaway.10. Treatments for complex problems should sequentially focus on the single behavioral change withthe greatest potential impact on the current problems.Recommendations based on treatment outcome research1. Mental health and SUD treatments for people with serious mental disorders should be fullyintegrated and routinely offered by the mental health service, with consultative support fromalcohol or other drug services where required.2. People with serious mental disorders and severe substance dependence may require input frommultiple services.3. Current trials do not offer strong support for any specific treatment component or set ofcomponents. Approaches used with each disorder have some effect.4. A staged approach to treatment intensity should be considered, with higher intensity treatmentsreserved for consumers who do not respond to lower intensity treatments.impact or leave people at risk of relapse, if it ignores potential relationships with othersubstances. Examples are people’s difficulties resisting consumption when intoxicatedwith another drug; ongoing contact with suppliers, users, or usage contexts for otherdrugs; use of the same mode of administration, such as smoking or injection for multipledrugs; and strategic consumption to deal with effects of other drugs. Both clients andtreatments may productively target one substance at a particular time, but this focusshould not become myopic and miss cross-substance influences.The high levels of service contact and poor response to previous treatment commonlyseen in this group lead many therapeutic staff to be doubtful of success or to lackself-efficacy about being able to provide effective treatment. It is important to remindourselves that recovery from a substance-related problem often requires several attempts,