CLINICAL HANDBOOK OF SCHIZOPHRENIA

44. Management of Co-Occurring Substance Use Disorders 465DESCRIPTION OF TREATMENT APPROACHES,AND EVIDENCE FOR THEMThere are three main approaches to multiple disorders. One is to address them sequentially.This may be especially useful when clearly there is one primary problem, and otherproblems simply flow from it. A second approach is to treat the disorders in parallel. Thisimplies that they are independent disorders that co-occur by chance, and also that treatmentsfor the disorders will not interfere with each other. A third approach is integratedtreatment for both disorders by a single treatment agent. Each aspect of the treatmenttakes the full set of issues into account and is tailored to have maximum impact on multipleareas. A single, coherent treatment plan attempts to address the disorders and the associationsbetween them. This does not, of course, require that all treatment componentsare applied simultaneously—just that all elements take account of the total context.A body of research has attempted to determine which of these models is best for peoplewith psychosis and SUDs. Although there are few randomized controlled trials andsignificant methodological limitations to the current research, the current evidence ismore in favor of an integrated treatment by a single agent than treatment with othermodels. There are several possible reasons for this observation: Integrated treatment, bydefinition, ensures some treatment for both conditions, and communication is ensured.There is more likely to be consistency in advice and objectives, and each aspect is morelikely to be tailored and timed to take into account other comorbid conditions. Consistencyis also present in the therapeutic relationship. Each of these features could conceivablybe obtained in a model involving more than one treatment agent, and with parallelor sequential aspects, but it would be much more difficult.In many countries, services for mental health problems and SUDs are offered by separateagencies, with a very different mix of professional backgrounds, inclusion criteria,treatment foci and objectives, methods, and degree of assertive follow-up. Frequentlythey are in separate locations, and intersectoral communication is often problematic.Gaps are commonly reported in perceived ability to manage problems that are seen as theprovince of the companion sector. These structural features create significant difficultiesfor individuals with multiple, complex problems. Historically, often they have been excludedfrom one or both services altogether, or left to negotiate treatments with multipleagencies themselves. This has sometimes meant that only the most motivated and resourcefulconsumers and families have been able to obtain an acceptable standard oftreatment for comorbidity. Sequential treatments often become sequential culs-de-sac;parallel treatments may take diverging or conflicting paths, and integrated treatment maybe extremely difficult if not impossible.How then do we resolve this problem? Even if services are combined, attitudes, practicesand professional specialities may still carry over. Should specialist comorbidityteams be established? Such teams can be very useful in promoting cross-sectoral trainingand offering supervision or specialist consultation, but a risk is that other staff membersmay attempt to slough off all relevant consumers to that team, so that it is soon overwhelmedby the caseload. A set of service criteria and priorities would inevitably have tobe established, and there would be a new basis for service exclusion.There is a practical alternative. If the regular treatment staff from each service takesresponsibility for the assessment and management of the kinds of comorbidity that routinelypresent in its service, an integrated model of treatment can be delivered. Consumerswith serious mental disorders could be assured of treatment by the mental health servicefor a comorbid SUD. Conversely, individuals presenting to a specialist SUD service couldexpect to have comorbid anxiety or depression treated. Some services already run on this