If the patient is actively dependent upon substances, detoxification is necessary as a first or simultaneous step during initial treatment of the psychosis. The use of medication in patients who are actively dependent or currently intoxicated with substances requires a different algorithm for use of psychosis pharmacotherapy. An algorithm for this is currently under development. At least some of the patient's symptoms may be due to the direct physiological effects of the substance, and may improve after detoxification. Non-specific behavioral tranquilization may be necessary during this process, often with the same medications used to treat the primary psychotic disorders, but this must be done with care so as to avoid toxic interactions with the particular substance(s) of abuse that are on board. For example, prescribed benzodiazepines are ideally avoided.¹
A "Dual-Diagnosis" treatment approach is usually advised as the next step for these patients. Relapse-prevention counseling, 12 step programs, and/or cognitive-behavioral interventions are recommended. Patients may need structured living situations that emphasize abstinence and contain the necessary supervision, while accepting the patients' need for psychotropic medication for their psychotic disorder. Despite prevalence estimates ranging from 40 to75%, screening and treatment for this problem is frequently not occurring in public care systems, and this may account for some of the poor outcome and treatment resistance of these patients.
Systems of care that integrate substance abuse rehabilitation and recovery, with mental illness treatment and rehabilitation appear to be the ideal.² After acute stabilization, patients should be engaged in an ongoing education process for both disorders, and there should be clear-cut policies on responses to problematic behaviors.²
