CLINICAL HANDBOOK OF SCHIZOPHRENIA

466 VI. SPECIAL POPULATIONS AND PROBLEMSmodel, although some others remain stuck in a less flexible or encompassing role. A corollaryof the recommended approach is that staff members acquire competence in managingthe commonly presenting comorbidities in their service, and that quality control andaccreditation encompass management of comorbidity as a core function. Comanagementof comorbid disorders across services, or management by specialist comorbidity trainersor consultants, could then be limited to individuals with particularly severe or apparentlyintractable problems.EVIDENCE ON TREATMENT EFFECTSCurrent evidence suggests that some atypical antipsychotic medications may reduce othersubstance use, and that most medications for substance misuse may (with some provisos)be safely applied in people with serious mental disorders. However, there are few data asyet on the specific efficacy of the latter drugs for people with psychosis.There are still very few randomized controlled trials on psychological interventionsfor comorbidity in the literature. They often obtain relatively weak, short-lived, or patchyresults across different substances, and many positive results are not subsequently replicated.This is the case even when the intervention is much more substantial and intensivethan would be practical in a standard service. On the one hand, in common with the generalliterature on the treatment of SUDs, initial changes by individual participants areoften unstable, and multiple attempts at control are often needed. Extended treatmentmay often be required.On the other hand, evidence on interventions for risky alcohol consumption in thegeneral population suggests that opportunistic brief interventions can be remarkably effective.These interventions typically involve feedback of results from screening and assessment,and advice to stop or reduce substance use, sometimes with specific suggestionson how to do it. The number and duration of treatment sessions differ widely, but singlesessioninterventions of 5 minutes or less still have significantly better effects than notreatment, and brief interventions give the same average impact as longer ones.Motivation enhancement, ormotivational interviewing (Miller & Rollnick, 2002), isa style of intervention that can be used in either a brief format or as the precursor to longertreatment. It encourages clients to express ambivalence about their current substanceuse, and how it fits with their self-concept and goals. There is no attempt to persuade orargue with clients—instead, they are encouraged to develop awareness of their own motivationsfor change. Both brief interventions in general and motivation enhancement haveparticularly strong supportive evidence for change in alcohol consumption (Miller &Wilbourne, 2002), but they have also been applied to other behavior targets.There is some evidence that motivation enhancement can be effectively adapted tocomorbid populations, generating engagement in subsequent extended treatment, andserving as a relatively brief, stand-alone intervention. However, as in the case of longertreatments, evidence on substance-related changes is inconsistent. At least some of thedifficulty that is experienced in controlled trials may reflect the fact that some clients successfullymake significant and sustained changes in their substance use after having an inpatientadmission, with little or no specific intervention. Perhaps their reaction to an admissionand their awareness (whether preexisting, or triggered by staff comments) thatsubstances may have triggered it is as much intervention as this group needs. Or it may bejust a matter of regression to the mean: Their substance use before admission was morethan usual, triggering an episode, but they then returned to more usual consumption. Weneed to find out more about natural recovery processes in this population to understandhow we can increase the proportion of people who fall into this group.