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Best practice portal:
Treatment options for dual-diagnosis patients

This page refers to the current evidence on the effectiveness of the available treatment options for dual-diagnosis patients. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 05.2017     Next update: 10.2017

Effects of available treatments for dual-diagnosis patients

Beneficial

No interventions met the criteria for this category.

Likely to be beneficial

Antipsychotic treatment for schizophrenia and substance use disorders

Antipsychotic (Clozapine) was found in a comprehensive review (EMCDDA 2015) to be effective in:

  • controlling both psychotic symptoms and reducing substance use

Behavioural therapy for eating and substance use disorders

Dialectical behavioural therapy was found in a comprehensive review (EMCDDA 2015) to be effective in:

  • reducing both eating disorders and substance use disorders

Integrated treatment for anxiety and opioid disorders

Combining CBT with antidepressants was found in a comprehensive review (EMCDDA 2015) to be effective in:

  • improving outcomes for comorbid opioid and anxiety disorders patients

Integrated treatment for psychosis and substance use disorders

Integrated treatment of psychosis and substance use disorders (i.e. combining psychological and antipsychotic treatments) was found in a comprehensive review (EMCDDA 2015) to be effective in:

  • significantly improving psychotic symptoms and substance use

Therapeutic communities in prison and aftercare to reduce re-incarceration rates drug-using offenders with co-occurring mental illness

Therapeutic communities and aftercare were found in a narrative systematic review (Perry et al., 2015, 8 RTCs, N = 2 058) to have a moderate effect in:

  • reducing re-incarceration rates of drug-using offenders with co-occurring mental illness

Trade-off between benefits and harms

No interventions met the criteria for this category.

Unknown effectiveness

Interventions for drug-using offenders with co-occurring mental illness to reduce drug use and re-arrest

Different interventions targeting drug-using offenders with co-occurring mental illness (including therapeutic communities in prison, mental health drug court, motivational interviewing and cognitive skills and interpersonal psychotherapy) were found in a narrative systematic review (Perry et al., 2015, 8 studies, N =2 058) to have no effect in:

  • reducing drug use
  • reducing re-arrest rates

Pharmacological treatment of attention deficit hyperactivity disorder (ADHD) and substance use disorders

Pharmacological treatment of attention deficit hyperactivity disorder (ADHA) was found in a systematic review with meta-analysis (Cunill et al., 2015, 13 studies, N = 1271) to have no effect in:

  • reducing substance use or improving retention in treatment, although the results found a small to moderate reduction of ADHD symptoms

Pharmacological and psychosocial treatments for depression and substance use disorders

Antidepressant and psychosocial treatments were analysed in a comprehensive review (EMCDDA 2015) which found that:

  • antidepressants have little effect on the maintenance of abstinence. When an antidepressant is effective in treating acute depression, there is only a relative reduction in the use of the psychoactive substance
  • different psychotherapies, such as CBT, Twelve-Step Facilitation and motivational interviewing on major depression or on substance use disorders alone has been investigated without reaching a conclusive result

Pharmacological treatments for personality and substance use disorders

A comprehensive review (EMCDDA 2015) found that:

  • there is no evidence that any pharmacotherapy is particularly beneficial in the comorbidity of personality disorders with substance use disorders

Evidence of ineffectiveness

No interventions met the criteria for this category.

References and definitions

References

 Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

 

 

About dual-diagnosis

Case definition

The EMCDDA has defined ‘comorbidity’, in the context of drug users, as a ‘temporal coexistence of two or more psychiatric disorders as defined by the International Classification of Diseases, one of which is problematic substance use’. The World Health Organization (WHO) defines ‘dual diagnosis’ as ‘the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder’ (WHO, 2010). Since 2012, the World Psychiatric Association (WPA) has had a new Section for this issue, and has chosen to use the term ‘dual disorders/pathology’ for this Section (WPA, 2014).

Aetiology

There is evidence for the association between several mental disorders and substance use disorders, but the nature of this relationship is complex and may vary depending on the particular mental disorder (e.g. depression, psychosis, post-traumatic stress disorder) and the substance in question (e.g. alcohol, cannabis, opioids, cocaine).

Prevalence

Data on psychiatric symproms among people in treatment for drug dependence are sparse and results varied . For instance, prevalence figures for mood disorders vary from 5 % in an Italian sample of polydrug users (Di Furia et al., 2006) to 90 % in a sample of 150 patients from therapeutic communities in nine European countries (De Wilde et al., 2007).

Interventions

Treatment options for co-morbid substance and psychiatric problems are based on combination of cognitive therapy and pharmacological interventions.

Primary outcomes

  • Retention in treatment
  • Reduction of psychiatric symptoms
  • Reduction of substance use

References

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Thursday, 18 May 2017