Trans-Sector Integrated Treatment in Psychosis and Addiction

Patients with schizophrenic psychosis and a comorbid addiction disorder account for about 50% (lifetime prevalence) and 25–30% (6-month prevalence) of all patients with psychosis (1– 3). These cases are referred to as dual diagnosis patients. Often, young men of a low educational status are affected and the disease course tends to be unfavorable with a poor prognosis (2– 5): dual diagnosis patients experience psychotic relapses and emergency admissions more frequently, and their disorder is more prone to becoming chronic. Such patients often display aggressive behaviors directed towards themselves and others, and they have poorer sociorehabilitative results in the long term than other patients with psychosis (3, 5). Primarily because of their relatively poor compliance, dual diagnosis patients are regarded as difficult to treat. They often encounter therapeutic nihilism from health professionals (6). On the basis of model projects and controlled studies, integrated therapeutic programs have been favored since the 1990s, in which the treatment is administered in an integrative setting and by a team that has experience and competence in treating both disorders (2, 3, 7– 9). Measures that have been described as successful in the long term are motivational, low-threshold programs that were conceived for a longer period and include psychoeducational, behavioral therapeutic, and occasionally family therapy elements. Although the 2006 S3 guideline for schizophrenia recommended implementing these programs in standard care (10), progress since then has been slow. Recent randomized studies and meta-analyses have taken a more critical view of the effectiveness of integrated treatment programs: success seems low and only partial, so that the cost–benefit ratio is regarded with some skepticism (11– 15). In spite of indications of the clinical relevance of even small effects that may be stronger in subgroups, no indicators of the preconditions for the observed therapeutic responses have been identified thus far. Accordingly, the 2011 guideline from the UK National Institute for Health and Care Excellence (NICE, National Institute for Health and Clinical Excellence at the time) recommends offering therapeutic measures for both disorders but does not recommend any particular program and neither does it demand an integrated approach (16). Most randomized studies are from the US or European countries, whose healthcare systems differ from Germany’s. From Germany, only one randomized study has been reported that evaluated a brief inpatient motivational intervention (MI) and showed that, subsequent to inpatient treatment, the MI group used the outpatient therapeutic services to a greater degree than controls. No benefits were observed regarding substance use (17). The present study evaluated a long-term, trans-sector, integrated treatment program for dual diagnosis patients with a follow-up period of 12 months under standard treatment conditions.