Dual diagnosis describes a condition when a person with both a mental health diagnosis such as PTSD and a substance use disorder. This comorbidity is associated with poorer treatment outcomes than for either condition alone. Several psychological therapies are successful at treating each disorder individually, however when occurring together, they may be harder to treat.

What is the evidence for psychotherapy for dual diagnosis?

Moderate to low quality evidence found a small improvement in PTSD symptoms in people with a dual diagnosis following individual psychological treatments that have a trauma focus when compared to treatment as usual. This effect remained for up to seven months. There was also a small reduction in substance use with individual psychological therapy with a trauma-focus at 5 to 7 months follow-up, but not immediately following treatment. The only other significant improvement in substance use was with a full dose of a group therapy called Seeking Safety. This was found immediately post-treatment but not at follow-up. There were no significant benefits for PTSD symptoms or substance use with non-trauma-based treatments or with other group treatments.

August 2021

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Substance use is a concern for people with a mental illness due to the association with poor clinical and social outcomes. Substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse.

Substance abuse leads to risk-taking behaviour, illegal activity, interpersonal problems and a loss of interest in usual activities. Abuse jeopardises physical health and neglect of important commitments at home, school or work.

Substance dependence involves having a strong physical or psychological need for the substance. Not taking it leads to withdrawal symptoms within a few hours of stopping, such as nausea, vomiting, tremors, chills, sweating, low blood pressure, irritability, depression, anxiety or confused thinking.

What is the evidence for substance use in people with bipolar disorder?

Moderate to low quality evidence finds a medium to large increased risk of any substance use disorder in people with bipolar disorder compared to people without a mood disorder. Moderate to high quality evidence shows people with a comorbid substance use disorder have more manic episodes, and are more likely to have a diagnosis of bipolar I rather than bipolar II disorder. They are also more likely to be male, have a history of suicidal behaviour, and have an early age of onset of bipolar disorder (<18 years). Having a substance use disorder was also associated with a greater risk of hospitalisation, high levels of alcohol intake, increased the risk of a mood recurrence and rapid-cycling.

For cannabis use in particular, moderate quality evidence found around one-quarter of people with bipolar disorder reported using cannabis. Cannabis use was associated with more depression, anxiety, and mania symptom severity, more mood episodes, more suicide attempts, and more insomnia or hypersomnia. Cannabis use was also associated with younger age, male gender, single marital status, having fewer years of education, an earlier onset of affective symptoms, psychotic symptoms, and use of other substances.

In children and youth with bipolar disorder, moderate to low quality evidence finds the risk of having a substance use disorder is around 31%. Rates were significantly higher in youth than in children, and in youth with comorbid PTSD or disruptive behaviour disorder.

November 2021

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Dual diagnosis is a term that refers to having both a mental illness such as bipolar disorder and a substance use problem. Studies of dual diagnosis investigate the effectiveness and availability of treatments for improving outcomes relating to either diagnosis, such as symptoms, functioning, quality of life, substance use, or cognitive problems.

What is the evidence for treatments for dual diagnosis?

Moderate to low quality evidence finds some improvement in symptoms and substance use with cognitive behavioural therapy plus medication. However, these results were not consistently found using different measures of substance use and symptoms.

November 2021

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Several treatments have been targeted to people with ‘dual diagnosis’, which is having both a psychiatric disorder and a substance use disorder. Studies investigate the availability and effectiveness of treatments for either diagnosis, including symptom severity, substance use, social functioning, quality of life, and also, cognition.

What is the evidence for treatments for dual diagnosis?

Moderate to high quality evidence quetiapine significantly improved manic symptoms, but not depression symptoms compared to placebo. There were no effects for mania or depression of mood stabilisers, citicoline, or acamprosate compared to placebo. Lower quality evidence from small trials suggests the anticonvulsants valproate and lamotrigine may also improve mood and reduce substance use.

November 2021

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Dual diagnosis is the term used for people with both a mental illness like schizophrenia and substance use disorders. Studies targeting this population often investigate outcomes relating to both diagnoses, such as symptoms, substance use, social function, quality of life, and cognitive outcomes.

What is the evidence for medications for dual diagnosis?

Moderate to low quality evidence suggests olanzapine was superior to perphenazine, quetiapine, risperidone, and ziprasidone for overall symptoms in people with a dual diagnosis. Olanzapine was superior to perphenazine, quetiapine, and ziprasidone for positive symptoms, and olanzapine was superior to perphenazine, risperidone, and ziprasidone for negative symptoms.

The remaining evidence on antipsychotics and other agents (e.g. mazindol, lamotrigine, antidepressants, anti-craving agents, or disulfiram) for symptoms, substance use or other outcomes was based on small sample sizes, so no conclusions can be drawn.

October 2020

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Drug and alcohol misuse, abuse or dependence are concerns for people with schizophrenia due to the association with poor clinical and social outcomes, including high rates of suicide, HIV, homelessness, aggression and incarceration. Moreover, substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse. This topic covers outcomes for people with schizophrenia and comorbid substance use (termed ‘dual diagnosis’). Please also see the topic on rates of comorbid substance use, as well as substance use as a risk factor for schizophrenia.

What is the evidence on outcomes for people with schizophrenia and comorbid drug and alcohol use?

High quality evidence shows a small increase in positive symptoms, but a medium-sized reduction in negative symptoms in people with schizophrenia and any current substance use disorder compared to people with schizophrenia without a current substance use disorder. Moderate to high quality evidence finds patients with any current substance use are also more likely to have depressive symptoms.

Moderate to low quality evidence finds an increased risk of treatment non-adherence, relapse and re-hospitalisation in people with first-episode psychosis and cocaine, opiates, or ecstasy use. Patients with a mixed psychoactive substance use disorder or a cocaine use disorder also show increased extrapyramidal (movement) symptoms, particularly akathisia and tardive dyskinesia compared to patients without a substance use disorder.

For cannabis use, high quality evidence found a small to medium-sized decrease in negative symptoms in people with schizophrenia who recently abstained from cannabis use compared to people with schizophrenia with no cannabis use. There was a small increase in positive symptoms and hospital stay duration in people who continued cannabis use after the first onset of psychosis compared to non-users of cannabis. There were also higher rates of relapse in people who continued cannabis use compared to people who discontinued cannabis use after the first onset of psychosis. Cannabis use was also associated with and earlier age of onset of the disorder, more suspiciousness and unusual thought content in people at risk of psychosis.

For cognition, high quality evidence shows a small effect of lower current IQ, and a medium-sized effect of lower premorbid IQ in people with psychosis and current cannabis use compared to people with psychosis without current cannabis use. Moderate quality evidence also finds poorer verbal working memory in those currently using cannabis. For people with schizophrenia specifically, moderate to high quality evidence finds a medium-sized effect of better global cognition, processing speed, planning, and visual and working memory in those with any history of cannabis use, but not in those with current cannabis use. Similarly, high quality evidence shows a small to medium-sized increase in global cognition, processing speed, planning, visual and working memory, attention, and psychomotor skills in people with psychosis and a polysubstance or cannabis use disorder compared to people with psychosis with no substance use disorder. For people with psychosis and an alcohol use disorder, moderate quality evidence finds more impaired working memory compared to people with psychosis and no substance use disorder.

March 2022

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