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Treatment of substance use disorders with co-occurring severe mental health disorders

Murthy, Pratima; Mahadevan, Jayant; Chand, Prabhat K.

Current Opinion in Psychiatry: July 2019 - Volume 32 - Issue 4 - p 293–299
doi: 10.1097/YCO.0000000000000510
ADDICTIVE DISORDERS: Edited by John B. Saunders and Linda B. Cottler

Purpose of review To provide an update of treatment for substance use in patients with co-occurring substance use disorders (SUD) and mental health disorders (dual diagnosis) with a focus on both pharmacological and psychosocial interventions.

Recent findings A total of 1435 abstracts were identified, of which we selectively reviewed 43 for this narrative review. There is emerging evidence, both clinical and neurobiological, that clozapine is a more efficacious antipsychotic in treatment of individuals with schizophrenia and SUD. The use of depot atypical antipsychotic paliperidone palmitate in this population is also promising. Although valproate remains the treatment of choice in individuals with bipolar disorder and SUD, present evidence suggests that lithium and quetiapine may not be effective in this population. Naltrexone is the most effective anticraving agent in individuals with severe mental illness (SMI) and comorbid alcohol use disorders. The use of opioid substitution therapy in individuals with SMI and comorbid opioid use disorders is also associated with favorable outcomes. Varenicline shows promise in patients with SMI who smoke tobacco. Psychosocial interventions should be instituted early in the course of treatment. They should ideally be high intensity and based on established therapies used for SUD.

Summary The paucity of systematic studies in individuals with co-occurring mental health disorders and SUD remains a concern, given the enormous burden that they pose. However, there are a number of studies which have evaluated interventions, both psychosocial and pharmacological, which show promise and can guide clinical practice.

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Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India

Correspondence to Dr Pratima Murthy, Professor of Psychiatry and Head, Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, India. Tel: +91 8026995274; e-mail:

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