Drug and alcohol use, abuse, or dependence are concerns for people with mental disorders due to their association with poor clinical and social outcomes such as high rates of suicide, HIV, homelessness, aggression, and incarceration. Comorbid substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse.

Tobacco smoking is also very common and poses considerable health risks, potential interference with the metabolism of psychotropic medications, and financial burden. Heavy cigarette use may contribute to the increased mortality and reduced life expectancy reported within the mental illness population.

What is the evidence for substance use in people with PTSD?

Moderate to high quality evidence finds a medium-sized increased rate of current smoking in people with PTSD, with the effect largest in males aged 20-30 years. Higher rates of drug and alcohol misuse were found in people with more severe PTSD symptoms compared to people with less severe PTSD symptoms. PTSD symptoms include intrusions, avoidance, hyperarousal, and negative thoughts and mood.

In prisoners with PTSD, there was a small to medium-sized increased rate of substance use disorders when compared to prisoners without PTSD. Rates were highest in male prisoners, in adult prisoners, and in prisoners with any lifetime rather than current PTSD diagnosis.

August 2021

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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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Tobacco smoking is very common among people with schizophrenia, who often show particularly heavy usage. This poses considerable health risks, may interfere with antipsychotic medications and may place a financial burden on the individual. Heavy cigarette use may contribute to the increased mortality and reduced life expectancy reported within the schizophrenia population.

What is the evidence for medications for smoking cessation?

Moderate quality evidence finds medium-sized effects of more smoking cessation with bupropion or varenicline than with placebo, assessed at 3-month follow-up. Varenicline also reduced the number of cigarettes smoked per day and resulted in more abstaining smoking behaviour.

October 2020

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Various lines of evidence suggest an association between substance use and psychiatric disorders. In particular, use during adolescence or early adult life is now thought to be one of a number of environmental stressors that interact with genetic factors to predispose an individual to later bipolar disorder.

What is the evidence for substance use as a risk factor for bipolar disorder?

Moderate quality evidence suggests a medium to large effect of increased risk of bipolar disorder with prior cannabis use and a small to medium-sized effect of increased risk of bipolar disorder with prior opioid use.

Moderate to low quality evidence suggests medium-sized to large effects of increased risk of bipolar disorder with prior cocaine or tranquiliser use.

October 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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Drug and alcohol use, abuse or dependence are concerns due to the association with high rates of suicide, HIV, homelessness, aggression and incarceration. Moreover, comorbid 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 presents the rates of drug and alcohol use in people with schizophrenia spectrum disorders. Please also see the topic on the effects of drug and alcohol use on the course and outcomes of these disorders.

What is the evidence for comorbid drug and alcohol use?

Moderate quality evidence shows the lifetime prevalence of any illicit drug misuse, abuse or dependence in people with schizophrenia ranges between 17% for those in rehabilitation and long-term settings, to 70% in community health settings.

The lifetime prevalence rates of alcohol misuse, abuse or dependence ranges between 29% for those in rehabilitation and long-term settings to 75% in community health settings. Prevalence of alcohol use is higher in studies using the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-revised diagnostic criteria compared to studies using DSM-IV, or the International Classification of Diseases (ICD) 9 or 10. Prevalence is also higher in samples aged 30 to 40 years and in studies published between 1990 and 1995.

The lifetime prevalence of cannabis use disorders in people with schizophrenia is around 27%, with current prevalence around 16%. The prevalence of any cannabis use in first episode psychosis patients is around 33-38%, and around 50% for those at ultra high-risk for psychosis. Prevalence is higher in males and in people under 30 years of age. The initiation of cannabis use is usually around 6-7 years prior to onset of psychosis, and continuation of cannabis use declines after treatment.

The rate of stimulant use disorders in people with psychosis is around 9%. Studies including patients with affective psychosis as well as patients with schizophrenia, studies of inpatients, cannabis users, and studies from USA and Australia report the highest rates of stimulant use.

Any lifetime substance use, particularly cannabis, is associated with an earlier age of onset of psychosis.

March 2022

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