Ten-year outcomes for patients with dual diagnoses of schizophrenia and
substance abuse appear to be remarkably good across several measures of
A naturalistic, longitudinal study of 130 patients with co-occurring
schizophrenia and substance use disorders found that participants improved
steadily over 10 years in the outcome domains of symptoms, substance abuse,
institutionalization, functional status, and quality of life, pointed out a
report in the July Schizophrenia Bulletin.
Moreover, at 10-year follow-up, many had achieved "recovery"
according to measures selected by the dual-diagnosis patients themselves:
controlling symptoms of schizophrenia, remission from substance abuse, living
independently, being competitively employed, having regular social contacts
with nonsubstance abusers, and expressing overall life satisfaction.
Importantly, these six outcomes were only weakly interrelated over time,
suggesting that recovery, as defined by patients, is a multidimensional
"The long-term prognosis is good, so we need to bring hope to people
with dual disorders and their families," lead author Robert Drake, M.D.,
told Psychiatric News. "Further, people move toward recovery
through many different paths, suggesting that we need to provide multiple
options for them such as dual-diagnosis groups and self-help groups. That
there are multiple dimensions of recovery, which are only weakly linked, means
that we should start working clinically with clients where they have interest
and understand that improvements in different areas of adjustment will occur
over time in different patterns."
Drake is a professor of psychiatry and of community and family medicine at
Dartmouth Medical School.
The study examines the 10-year course of 130 patients in the New Hampshire
Dual Diagnosis Study, a prospective, longitudinal study of patients with
severe and persistent mental illness (chronic schizophrenia, schizoaffective
disorder, or bipolar disorder) and co-occurring substance use disorder.
As part of that study, participants had previously entered a three-year,
randomized, controlled trial of two forms of care management between 1989 and
1992, in which they received integrated treatment for their two diagnoses from
their respective mental health centers for three years.
After the three-year study, participants who remained in treatment were
released from their experimental conditions and received treatment as usual
during the subsequent years.
To assess changes at the 10-year mark, recovery outcomes and cutoffs for
the current study were defined as follows:
Results showed that participants' substance abuse improved dramatically at
the 10-year follow-up: 65 percent had no signs of abuse or dependence, and 39
percent had been abstinent for at least six months.
Moreover, substantial proportions were above cutoffs selected by
dual-diagnosis patients as indicators of recovery: 62.7 percent were
controlling symptoms of schizophrenia, 62.5 percent were actively maintaining
remission from substance abuse, 56.8 percent were in independent-living
situations, 41.4 percent were competitively employed, 48.9 percent had regular
social contacts with nonsubstance abusers, and 58.3 percent expressed overall
Drake said that defining and refining measures of "recovery"
continues to be a challenge for researchers.
"The difficulty in defining and measuring recovery is more conceptual
than empirical," Drake said. "People with mental illness often
define recovery in terms of an intrapsychic process, such as moving away from
preoccupation with illness to a satisfying life. There is no consensus on
these concepts, and there are, therefore, no valid measures of the process.
When we conceptualize recovery as a set of objective outcomes, as we did in
our paper, it is relatively easy to measure."
As a naturalistic study, the relationship between treatment and recovery is
correlational only. However, study data show that nearly all participants were
rapidly engaged in outpatient dual-diagnosis services during the original
three-year study, and hospital use and homelessness were reduced over time as
people increased their use of outpatient services.
Schizophrenia patients who received clozapine during the early years of the
study experienced highly significant improvements in substance abuse outcomes
compared with those on other antipsychotic medications.
"The biggest problem for individuals with co-occurring disorders in
our current health care nonsystem is that people do not have access to good
services," Drake said.
He added that the study findings extend what much research has already
shown— that patients with severe mental illness can recover over
time—flying in the face of conventional, and some professional,
"The natural course of schizophrenia is that most people improve,
often dramatically, over time," Drake told Psychiatric News."
This has always been true, at least for the last 100 years or so while
researchers have been studying [the illness] course carefully. The same is
true for substance use disorders—most people recover over time. What we
haven't known until now is that the prognosis is also good for people with
co-occurring severe mental illness and substance use disorders.
"I'm not sure why the general public's view of these illnesses is so
pessimistic, but stigma is surely one factor," he said. "I believe
that psychiatry has an obligation to bring more accurate information to public
"Ten-Year Recovery Outcomes for Clients With Co-Occurring
Schizophrenia and Substance Use Disorders" is posted at<http://schizophreniabulletin.oxfordjournals.org/cgi/content/full/32/3/464>.▪