Expert answers from
Psychosis, drugs and alcohol
- ‘Dual diagnosis’
- Psychosis, drugs and alcohol
- Treatment and care for two problems
- What NICE says
- Antipsychotic medication
- Treatment for drug and alcohol misuse
- Physical tests
- Treatment for physical health problems
- Support for family members
Someone who has a ‘dual diagnosis’ has been given two different diagnoses because they have two different, co-existing illnesses or conditions.
However, in mental health services, the term ‘dual diagnosis’ often refers to people who have experienced psychosis who also use drugs and/or alcohol in a way that is detrimental to their health. The harmful use of drugs and/or alcohol is called ‘substance misuse’ by health professionals.
An estimated 40 per cent of people who have experienced psychosis ‘misuse substances’ at some time in their lives: more than twice the number of people who have no experience of psychosis.
‘Substances’ include street drugs (cannabis, cocaine, crack cocaine and heroin, for example), prescribed drugs (diazepam [Valium], for example) or medicines that can be bought ‘over the counter’, liked codeine. Cannabis is the street drug most commonly used by people who have experienced psychosis.
People who have a diagnosis of a mental illness such as schizophrenia say that they take drugs or drink alcohol often to help cope with some of the symptoms of the illness, or counter some of the side effects of the medication. However, even a small amount of drugs and alcohol can make the symptoms of psychosis worse, and make treatment less effective – the drugs or alcohol may stop antipsychotic medication from working properly.
Research has shown that people who have a mental illness like schizophrenia who misuse drugs and/or alcohol are more likely to relapse and spend time on hospital wards. They are less likely to take prescribed medication and more likely to ‘drop out’ of treatment and lose touch with mental health services. They are more likely to take their own lives, more likely to get involved in illegal activities and more likely to be violent.
One study in Sweden showed that people who had a diagnosis of schizophrenia who misused substances were four times more likely to be convicted of a violent crime than members of the general public and than people who had a diagnosis of schizophrenia who did not misuse drugs and/or alcohol.
People who have a mental illness who misuse drugs and/or alcohol are more likely to have housing problems or be homeless, and less likely to have a good relationship with their family. People who have a mental illness like schizophrenia and coexisting substance misuse problems are often socially excluded.
They may also have serious physical health problems as a result of the alcohol and drugs they use. Drinking excessive amounts of alcohol regularly can cause pancreatitis (inflammation of the pancreas), high blood pressure, cirrhoisis of the liver, heart disease and some sorts of cancer. Drug misuse can cause lung problems and people are at far greater risk of contracting blood borne viruses such as hepatitis and HIV, and are at risk of accidentally overdosing.
People who have experienced psychosis and use drugs or drink alcohol in a hazardous way may need help for a number of different problems. However, the different types of service that could help are often run by different organisations, which means people may not get a comprehensive package of support.
There is no treatment specifically for people who have experienced psychosis who also misuse drugs or alcohol – and to date, there has been little research into effective treatments for people who have a mental illness like schizophrenia who also misuse drugs and/or alcohol.
Most research about treatments focuses on just one condition at a time, so research into the treatment of psychosis has typically excluded people who also have a substance misuse problem. Most research about treatments for people who misuse drugs and/or alcohol have excluded people who have a co-existing mental illness.
Health professionals should therefore offer National Institute for Health and Care Excellence (NICE)-recommended treatment for bipolar disorder or schizophrenia as well as NICE-recommended treatment for drug and/or alcohol misuse.
Mental health services and substance misuse services, however, are often run by different organisations, or sometimes by separate parts of the same organisation. This means people are sometimes ‘bounced’ between services, or do not get the care they need. Professionals working in mental health services may not have the skills to support people who misuse drugs and alcohol and professionals working in substance misuse services may not have the skills to support people who have a mental illness such as schizophrenia.
NICE recommends the two types of services should work closely together to make sure care and treatment is properly coordinated. Mental health professionals who are supporting people who have experienced psychosis should take specialist advice from drug and alcohol workers and arrange to collaborate with these specialist services. Professionals working in drug and alcohol services should be involved in the planning of care for people who have a mental illness – they should, for example, attend Care Programme Approach meetings.
Some people who have a mental illness do not think their use of drugs and alcohol causes any problems, so may not want to access specialist services geared to helping them stop. There are some services that actively try to encourage people to have treatment for both their mental health problems and substance misuse – assertive outreach teams, for example (though these teams are being disbanded in some areas).
In addition, teams of researchers around the world are developing and testing treatments and services specifically for people who have experienced psychosis and also misuse drugs and/or alcohol. One research trial in England, for example, looked at whether a combination of cognitive behaviour therapy and motivational interviewing helped people who had a diagnosis of schizophrenia reduce the amount of drugs and/or alcohol they used. Studies in America are testing 'family therapy for dual diagnosis'. Research teams are also trying to understand more about why people who have experienced psychosis use drugs or drink alcohol in a hazardous manner in order to inform the design of new treatments.
The National Institute for Health and Care Excellence has produced guidance about the treatment and care people should receive when they have both a mental illness like schizophrenia and a drug or alcohol problem.
The guideline is called: Psychosis with coexisting substance misuse: assessment and management in adults and young people. It was published in March 2011. You can read a summary written for people who use services and their family members at the NICE website: Treatment and support for people with psychosis who use drugs and/or alcohol.
The guideline stresses that people who misuse drugs and/or alcohol should not be excluded from mental health services offering support to people who have experienced psychosis. Neither should they be excluded from substance misuse services because they have a diagnosis of schizophrenia or bipolar disorder. They should be given access to evidence-based treatment for both psychosis and drug and alcohol misuse.
It also recommends health professionals work with people who have co-existing mental illness and substance misuse problems to develop advance decisions and advance statements (see People who have experienced psychosis before page) to say what sort of treatment they would like if they become unwell again – and that family members should be involved in that process, unless the individual does not want them to be.
There has been no research that conclusively shows whether a particular antipsychotic medication works better than any other for people who have co-existing substance misuse problems.
Alcohol and drugs may decrease the effectiveness of antipsychotic drugs or increase the risk of side effects. The NICE guideline on treatment for co-existing psychosis and substance misuse says health professionals should consider what effect alcohol or drugs might have when prescribing antipsychotics, and take into account which substance is being misused.
Most treatments for substance misuse are provided by community-based services so people don’t have to be admitted to hospital. However, sometimes people may need treatment in hospital for drug and/or alcohol use.
The treatment given for drug misuse depends on the kind of drug people are using. It may include detoxification, taking a drug substitute (such as methadone if people are dependent on heroin), or an incentives programme (to encourage people to stop using drugs by giving them a voucher, for example). It may include medication to help people manage withdrawal symptoms if they have developed a physical dependency, and talking therapies like motivational interviewing or cognitive behaviour therapy. Treatments aim not just to help people stop, but also to help them deal with withdrawal symptoms and prevent relapse.
You can read a summary that explains treatments recommended in both guidelines in a booklet: Treatments for drug misuse.
The booklet also explains how family members might be able to support a person who has a drug problem and get help for themselves.
Treatments for alcohol misuse may include detoxification to help people stop drinking safely, talking therapies and medication to help people manage withdrawal symptoms when they have developed a physical dependency. People may also be offered treatment for physical health problems caused by alcohol.
There are two NICE guidelines about the treatment of alcohol misuse. The first is Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
You can read a summary of the guideline written for the public – Treating harmful drinking and alcohol dependence.
The other guideline is Alcohol use disorders: physical complications.
You can read a summary of the guideline written for the public – Physical health problems caused by drinking alcohol.
The NICE guidance on psychosis and co-existing substance misuse says people should be properly assessed to help professionals plan the treatment they need.
Biological or physical tests for substance use – such as blood and urine tests, or hair analysis – can be used to help assessment and treatment of substance misuse. However, the individual must give consent for these tests to happen, and they should be agreed as part of the treatment plan.
The NICE guidance says biological and physical tests should not be used to routinely screen for substance misuse in adults who have a mental illness such as schizophrenia.
People who have a mental illness llike schizophrenia and a co-existing substance misuse problem may also need treatment for physical health problems.
The physical well-being of people who have a mental illness should be monitored by their GP at least once a year. If people also use alcohol or drugs heavily, they should have more frequent physical check-ups.
It can be very difficult to live with or support someone who has a mental illness such as schizophrenia and a drug or alcohol problem. Family members can help their relative to tackle their substance misuse problems, but need support and information from health professionals in order to do that.
NICE guidance says family members should be given information about psychosis and substance misuse and information about different treatments.
If an individual agrees that family members can be being involved in his or her treatment, relatives should be given information about the care plan and how best to offer support. Health professionals should involve family members in the assessment, as they may be able to give crucial information. Family members could also be involved in developing advance decisions and advance statements that express their relative’s wishes about treatment, if they become seriously unwell in future. Health professionals should also offer support to family members – putting them in touch with carers’ groups, for example.
This page was updated on 10 June 2012 (NICE name change incorporated 25 April 2013).
There are no plans to update the page because funding for mentalhealthcare.org.uk ended in April 2013.
We will, however, continue to regularly check that all links are working.
Links on this page last checked: 4 December 2013
Next links check due: Aoril 2014
Other useful websites
is a health and social care organisation that provides services for people with complex needs, including people who have mental health problems and misuse drugs and alcohol. It is the largest provider of substance misuse services in England and Wales.