Table 4.
Consideration of treatment adjustments
| Guideline | Does the recommendation address the management of coexisting disorders? | What treatment adjustment should be considered? (such as a change of antipsychotic medication in patients who have alcohol use disorder) | Recommendation for monitoring of physical health | Recommendation about drug interactions | Psychological and psychosocial interventions |
|---|---|---|---|---|---|
|
NICE 2011 (coexisting disorders) [37] |
No recommendations regarding the benefits of one antipsychotic over another are given. Refers the reader to the NICE guidelines for related disorders. | Mentioned. Use of long-acting injectable antipsychotic medication | Mentioned | Mentioned. Substance misuse practically alcohol may affect the metabolism of medication | Mentioned |
|
NICE 2016 (coexisting disorders) [38] |
Not mentioned. Refers the reader to a NICE guideline for the management of coexisting disorders. | Not mentioned | Mentioned | Not included | Not mentioned |
| Australian government 2016 [39] | Mentioned. Detailed treatment plan for both psychosis and bipolar disorder are provided | Not mentioned | Mentioned | Included | mentioned |
| SIGN 2013 [47] | Mentioned. The treatment of both disorders requires a joint consultative approach between the services provided from both mental health and substance use settings. | Not mentioned | Mentioned | Not included | Mentioned |
| NICE 2014 [48] | Mentioned. Monitoring for coexisting conditions particularly in the early phases of treatment. | Not mentioned | Mentioned | Not included | Mentioned |
| WFSBP 2015 [49] | Mentioned. Consider the addition of clozapine for coexisting disorder. | Mentioned. Patients with a history of non-adherence to their medication should be treated with long-acting depot formulations of antipsychotic medications. | Not mentioned | Not included | Mentioned |
| RANZCP 2016 [50] | Mentioned. Treatment of comorbid substance use. Urine or saliva drug testing for the presence of substance misuse should also be employed. | Not mentioned | Mentioned | Not included | Mentioned |
| BAP 2019 [51] | Mentioned. Optimization of antipsychotic medication and one should consider the addition of clozapine for the patients with dual diagnosis. | Not mentioned | Mentioned | Included | Mentioned |
| APA 2020 [52] | Mentioned. Treatment for both disorders should be provided by the same clinician team. However, if an integrated treatment is unavailable, the treatment plan should address both disorders with communication and collaboration among the clinicians treating the patient. | Not mentioned | Mentioned | Included | Mentioned |
| VA/DoD 2010 [53] | For the management of substance misuse, the reader should refer to the VA/DoD guideline for other related disorders. Treatment of bipolar disorder should be based on this guideline. | Not mentioned | Mentioned | Included | Mentioned |
| Singapore MOH 2011 [54] | Mentioned. Patients with both addiction and bipolar disorders should be treated. | Not mentioned | Not mentioned | Not included | Mentioned |
| NICE 2014 [55] | The reader should refer to the NICE guideline for other related disorders. Moreover, bipolar disorder treatment should be in accordance with this guideline. | Not mentioned | Mentioned | Included | Mentioned |
| BAP 2016 [56] | For alcohol use disorder, this guideline refers the reader to another BAP guideline. The practitioner should assess to what extent substance misuse contributes to bipolar disorder symptom. | Not mentioned | Mentioned | Included | Mentioned |
| CANMAT and ISBD 2018 [57] | Mentioned. For patients with both bipolar disorder and substance misuse, lithium can reduce using of substance. Patients with both bipolar disorder and substance misuse may benefit from the use of N-acetylcysteine. | Mentioned. Reduce bipolar disorder symptoms with olanzapine. Reduce cravings for alcohol and cocaine use with aripiprazole. | Mentioned | Not included | Mentioned |
| BAP 2012 [40] | Treatment of bipolar disorder as recommended in other guidelines and the impact of harmful substance use should be assessed. | Mentioned. Add sodium valproate for bipolar disorder patients who are on lithium only, and limit alcohol drinking with Naltrexone. Clozapine should be considered in patients with both schizophrenia and substance misuse. | Mentioned | Not included | Not mentioned |
| WFSBP 2017 [41] | It is difficult to provide treatment recommendations for managing patients with both schizophrenia and coexisting alcohol use disorder. |
Mentioned. Suggest the use of second generation antipsychotics for managing patients with both schizophrenia and coexisting alcohol use disorder. However, evidence recommends the use of clozapine. |
Not mentioned | Not included | Mentioned |
| gov.uk 2017 [42] | Mentioned. Dual focused treatments | Not mentioned | Mentioned | Included | Mentioned |
| DGPPN and DG-Sucht 2017 [43] | Mentioned. Pharmacological treatment should be based on schizophrenia guidelines. | Mentioned. Treatment of patients with schizophrenia and comorbid alcohol use disorder with atypical antipsychotics (AAP). | Not mentioned | Not included | Mentioned |
| NICE 2011 [44] | Mentioned. For the treatment of comorbid mental health disorders, the reader is referred to the other related disorder’s NICE guideline. | Not mentioned | Mentioned | Included | Mentioned |
| APA 2018 [45] | Not mentioned. | Not mentioned | Not mentioned | Not included | Not mentioned |
| ASAM 2015 [46] | Mentioned. Use of mood stabilizers for the treatment of patients with bipolar disorder. Patients with schizophrenia should be treated with suitable antipsychotic therapy along with treatment of opioid use disorder. Patients with a history of non-adherence to their medication should be treated with long-acting depot formulations of antipsychotic medications. Methadone, buprenorphine, or naltrexone for mental status stabilization. | Not mentioned | Mentioned | Included | Mentioned |
AOD Alcohol and other drug, APA American Psychiatric Association, ASAM American society of addiction medicine, AUD alcohol use disorder, BAP British Association of psychopharmacology, CANMAT and ISBD Canadian Network for Mood and Anxiety Treatments and International Society for Bipolar Disorders, gov.UK United Kingdom guidelines on clinical management, DGPPN and DG-Sucht German Association for Psychiatry, Psychotherapy, and Psychosomatics and the German Association for Addiction Research and Therapy, NICE National Institute for Health and Care Excellence, RANZCP Royal Australian and New Zealand College of Psychiatrists, SIGN Scottish Intercollegiate Guidelines Network, Singapore MOH Singapore Ministry of Health, SMI Severe mental illness, SUD Substance use disorder, UK United Kingdom, US United States, VA/DoD Department of Veterans Affairs and The Department of Defense, WFSBP World Federation of Societies of Biological Psychiatry