The search and selection of guidelines
In total, 12,644 records were identified through the searching of various databases. After the exclusion of data de-duplication and both title and abstract screening, 32 guidelines were screened for eligibility. Twenty-one guidelines were included in this study (Fig. 1).
General Characteristics Of The Included Guidelines
Of the 21 included, three guidelines related to coexisting disorders, seven guidelines related to SUD including alcohol use disorder and opioid disorder (Table 1). Eleven guidelines related to SMI (six of them were related to schizophrenia, and five of them were related to bipolar disorder). The aim of each guideline is illustrated in Table 1.
Table 1
General characteristic of the guidelines
Guideline title
|
Organization
|
Country
|
Publication
year
|
Target disorders
|
Aim
|
For which patient population is this guideline intended for?
|
For which healthcare provider is this guideline intended for?
|
Clinical setting for which this is applicable
|
Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (39)
|
NICE
|
UK
|
2011
|
Psychosis + SUD
|
To provide diagnosis and treatment recommendations for both disorders.
|
For all patients above 14 years old with both disorders.
|
For professionals who provide care in all clinical settings.
|
All clinical settings and medical services that commissioned by NHS
|
Coexisting severe mental illness and substance misuse: community health and social care services overview (40)
|
NICE
|
UK
|
2016
|
Psychosis + SUD
|
To offer a number of integrated services to meet people’s requirements and solve other related problems, such as lack of housing and joblessness.
|
For patients above 14 years old with both disorders.
|
All professionals and commissioners, Workers who have direct contact with patients, The criminal justice system, Voluntary organizations and other third-party sectors, Targeted patients and their families and carers.
|
Community settings
|
Guidelines on the management of cooccurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (33)
|
Australian government
|
Australia
|
2016
|
Co-occurring alcohol and other drug and mental health conditions
|
To provide directives in relation to the management of AOD and co-occurring mental health conditions.
|
Patients with AOD and co-occurring mental health conditions.
|
AOD workers, including nurses, medical practitioners, psychiatrists, psychologists, counsellors, social workers, and other AOD workers.
|
AOD treatment settings
|
Management of schizophrenia (30)
|
SIGN
|
UK
|
2013
|
Schizophrenia
|
To provide recommendations for managing schizophrenia.
|
Adults with schizophrenia
|
Healthcare providers
|
Not mentioned specifically
|
Psychosis and schizophrenia in adults: prevention and management (41)
|
NICE
|
UK
|
2014
|
Psychosis and schizophrenia
|
To provide diagnosis and treatment recommendations psychosis and schizophrenia.
|
Adults with psychosis and schizophrenia
|
Health care providers who provide services in primary, community, secondary and tertiary clinical settings.
|
All clinical settings and medical services that commissioned by NHS
|
Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation (45)
|
WFSBP
|
International
|
2015
|
Schizophrenia
|
To issue guidelines relating to the management of schizophrenia and the assessment of pharmacological agents.
|
Patients with schizophrenia.
|
Physicians
|
Not mentioned specifically
|
Clinical practice guidelines for the management of schizophrenia and related disorders (32)
|
RANZCP
|
Australia and New Zealand
|
2016
|
Schizophrenia and related disorders
|
To provide guidance for the treatment of schizophrenia and to provide care for schizophrenic patients.
|
For patients with schizophrenia and related disorders.
|
Clinicians such as psychiatrists and GPs, psychiatry trainees, mental health nurses, clinicians who have contact with this patient group, and policymakers.
|
Not mentioned specifically
|
Evidence-based guidelines for the pharmacological treatment of schizophrenia (47)
|
BAP
|
UK
|
2019
|
Schizophrenia
|
To provide recommendations for the management of schizophrenia.
|
Patients with schizophrenia
|
Clinicians
|
Not mentioned specifically
|
Practice guideline for the treatment of patients with schizophrenia (43)
|
APA
|
US
|
2020
|
Schizophrenia
|
To help clinicians optimize care for their patients and improve quality of care.
|
Patients with schizophrenia
|
Clinicians
|
Not mentioned specifically
|
Management of Bipolar Disorder in Adults (BD) (28)
|
VA/DoD
|
US
|
2010
|
Bipolar disorder
|
To manage patients with bipolar disorder.
|
People aged 18 years old and older with bipolar disorder.
|
Healthcare professionals
|
Not mentioned specifically
|
Bipolar disorder (29)
|
Singapore MOH
|
Singapore
|
2011
|
Bipolar disorder
|
To manage patients with bipolar disorder.
|
Older patients with bipolar disorder
|
GP and clinicians
|
Not mentioned specifically
|
The assessment and management of bipolar disorder in adults, children and young people in primary and secondary care (38)
|
NICE
|
UK
|
2014
|
Bipolar disorders
|
To manage patients with bipolar disorder.
|
Children, young adults (aged above 13 years old), and adults.
|
Professionals who provide care in all clinical settings.
|
All clinical settings and medical services that commissioned by NHS
|
Evidence-based guidelines for treating bipolar disorder (48)
|
BAP
|
UK
|
2016
|
Bipolar disorder
|
To assess and manage patients with bipolar disorder.
|
Patients with bipolar disorder.
|
Practitioners
|
Not mentioned specifically
|
Guidelines for the management of patients with bipolar disorder (36)
|
CANMAT and ISBD
|
Canada
|
2018
|
Bipolar disorder
|
To manage patients with bipolar disorder.
|
Patients with bipolar disorder
|
Psychiatrists and primary care providers
|
Not mentioned specifically
|
Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity (46)
|
BAP
|
UK
|
2012
|
SUD
|
To provide treatment recommendations in order to help clinicians in prescribing medication for patients with SUD alone and those with psychiatric comorbidities.
|
Young adults and adults with SUD.
|
Clinicians such as psychiatrists and GPs, professionals in this field, non-specialists, patients and their families.
|
Not mentioned specifically
|
Guidelines for biological treatment of substance use and related disorders, part 1: Alcoholism, first revision (42)
|
WFSBP
|
International
|
2017
|
Substance use and related disorders
|
To provide recommendations for the treatment of AUD that help clinicians in clinical decision making and subsequently improvement of care
|
Adult with AUD
|
Professionals who provide care for patients with AUD.
|
Not mentioned specifically
|
Drug misuse and dependence UK guidelines on clinical management (34)
|
gov.uk
|
UK
|
2017
|
Substance misuse
|
To provide guidance on managing drug abuse and dependency in the UK.
|
Drug misusers
|
Healthcare professionals, Regulatory bodies, Targeted patients, and their families and carers.
|
Drug misuse services
|
German Guidelines on Screening, Diagnosis and Treatment of Alcohol Use Disorders (35)
|
DGPPN and DG-Sucht
|
Germany
|
2017
|
Alcohol use disorder
|
To provide screening, diagnosis, and treatment recommendations for patients with alcohol misuse disorder.
|
Patients with alcohol misuse disorder and comorbidity psychiatric disorders.
|
Clinicians
|
In- and outpatient settings
|
Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (37)
|
NICE
|
UK
|
2011
|
Alcohol use disorder
|
To provide recommendations for managing patients with alcohol misuse disorder.
|
Younger children and young adults 10–17 years old with alcohol use disorder.
|
Professionals who provide care in all clinical settings.
|
All clinical settings and medical services that commissioned by NHS
|
Practice guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder (44)
|
APA
|
US
|
2018
|
Alcohol use disorder
|
To provide recommendations that help in improving the quality of care and quality of life for patients with AUD.
|
Patients with AUD
|
Clinicians
|
Not mentioned specifically
|
National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (31)
|
ASAM
|
US
|
2015
|
Opioid use disorder
|
To provide recommendations for managing patients with opioid use disorder.
|
Patients with opioid use disorder
|
Physicians; other healthcare providers, medical educators, trainee; and clinical care managers.
|
Not mentioned specifically
|
(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; (DGPPN and DG-Sucht) German Association for Psychiatry, Psychotherapy, and Psychosomatics and the German Association for Addiction Research and Therapy; (gov.UK) United Kingdom guidelines on clinical management; (NICE) National Institute for Health and Care Excellence; (NIH) National health service; (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
|
Most of the included guidelines were produced by NICE in England (n = 5), followed by guidelines produced by British Association of Psychopharmacology in the UK (n = 3). Two of the included guidelines were published by APA in the USA, two of them were produced by the World Federation of Societies of Biological Psychiatry (WFSBP) which developed by a group of experts from different countries, and nine guidelines were published by government departments of health (28–36) (Table 1).
Quality Assessment Of Guidelines
The scores of each guideline against the criteria of the AGREE II tool are displayed in Table 2. In terms of ‘scope and purpose’, first domain had the highest domain score. Only four guidelines scored below 80% (29,31,33,36) (Table 2). In the second domain, ‘stakeholder involvement’, the guidelines that were developed by NICE and Scottish Intercollegiate Guidelines Network (SIGN) demonstrated the highest score; 84% and 83%, respectively (30,37–41) (Table 2).The ‘Rigour of development’ domain scores were generally low (Fig. 2). Fifteen out of 21 included guidelines rated below 70% (Table 2). Most of the guidelines scored higher in ‘Clarity of presentation’ domain (Fig. 2). The guidelines that were developed by NICE and SIGN obtained the highest scores (30,37–41) (Table 2). Figure 2 shows that the ‘Applicability’ domain has the lowest domain score. Fifteen guidelines were graded below 50% (Table 2).With regard to the ‘Editorial independence’ domain, the highest score was reported with the NICE guidelines, this being 83%. The rest of the included guidelines were graded below 80% (Table 2) (Fig. 2).
Table 2
Quality assessment of guidelines
Guideline
|
Domain1: SCOPE AND PURPOSE
|
Domain2: STAKEHOLDER INVOLVEMENT
|
Domain 3: RIGOUR OF DEVELOPMENT
|
Domain 4: CLARITY OF PRESENTATION
|
Domain 5: APPLICABILITY
|
Domain 6 : EDITORIAL INDEPENDENCE
|
Overall quality
|
Recommendation of use
|
NICE 2011 (39)
|
100.00%
|
84.00%
|
73.00%
|
95.00%
|
67.00%
|
83.00%
|
7
|
Recommended
|
NICE 2014 (40)
|
100.00%
|
84.00%
|
73.00%
|
95.00%
|
67.00%
|
83.00%
|
7
|
Recommended
|
RANZCP 2016 (32)
|
83.00%
|
72.00%
|
35.00%
|
83.00%
|
33.00%
|
42.00%
|
4
|
Recommended with modification
|
BAP 2012 (46)
|
83.00%
|
61.00%
|
54.00%
|
83.00%
|
42.00%
|
42.00%
|
5
|
Recommended with modification
|
WFSBP 2017 (42)
|
83.00%
|
50.00%
|
60.00%
|
67.00%
|
25.00%
|
42.00%
|
4
|
Recommended with modification
|
gov.uk 2017 (34)
|
94.00%
|
67.00%
|
60.00%
|
72.00%
|
33.00%
|
33.00%
|
7
|
Recommended
|
DGPPN and DG-Sucht 2017 (35)
|
83.00%
|
56.00%
|
63.00%
|
78.00%
|
33.00%
|
50.00%
|
4
|
Recommended with modification
|
NICE 2011 (37)
|
100.00%
|
84.00%
|
73.00%
|
95.00%
|
67.00%
|
83.00%
|
7
|
Recommended
|
ASAM 2015 (31)
|
67.00%
|
72.00%
|
52.00%
|
83.00%
|
38.00%
|
58.00%
|
5
|
Recommended with modification
|
APA 2018 (44)
|
89.00%
|
56.00%
|
65.00%
|
83.00%
|
42.00%
|
75.00%
|
6
|
Recommended
|
Singapore MOH 2011 (29)
|
67.00%
|
56.00%
|
25.00%
|
89.00%
|
38.00%
|
17.00%
|
3
|
Not recommended
|
VA/DoD 2010 (28)
|
83.00%
|
56.00%
|
58.00%
|
83.00%
|
38.00%
|
17.00%
|
4
|
Recommended with modification
|
CANMAT & ISBD 2018 (36)
|
67.00%
|
61.00%
|
31.00%
|
61.00%
|
29.00%
|
42.00%
|
3
|
Not recommended
|
SIGN 2013 (30)
|
94.00%
|
83.00%
|
71.00%
|
95.00%
|
50.00%
|
50.00%
|
7
|
Recommended
|
WFSBP 2015 (45)
|
83.00%
|
50.00%
|
60.00%
|
67.00%
|
25.00%
|
42.00%
|
4
|
Recommended with modification
|
NICE 2016 (40)
|
100.00%
|
84.00%
|
73.00%
|
95.00%
|
67.00%
|
83.00%
|
7
|
Recommended
|
NICE 2014 (41)
|
100.00%
|
84.00%
|
73.00%
|
95.00%
|
67.00%
|
83.00%
|
7
|
Recommended
|
BAP 2019 (47)
|
83.00%
|
61.00%
|
54.00%
|
83.00%
|
33.00%
|
42.00%
|
5
|
Recommended with modification
|
BAP 2016 (48)
|
83.00%
|
61.00%
|
54.00%
|
83.00%
|
33.00%
|
42.00%
|
5
|
Recommended with modification
|
APA 2020 (43)
|
89.00%
|
56.00%
|
65.00%
|
83.00%
|
42.00%
|
75.00%
|
6
|
Recommended
|
Australian government 2016 (33)
|
78.00%
|
56.00%
|
21.00%
|
89.00%
|
38.00%
|
25.00%
|
3
|
Not recommended
|
(APA) American Psychiatric Association; (ASAM) American society of addiction medicine; (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; (VA/DoD) Department of Veterans Affairs and The Department of Defense; (WFSBP) World Federation of Societies of Biological Psychiatry
|
Assessment Of Concurrent Problems
All of the included coexisting disorders guidelines emphasized that a comprehensive assessment should be carried out for patients with either SMI or SUD for dual diagnoses (33,39,40). However, five out of eleven SMI guidelines did not highlight the assessment of coexisting disorders (29,30,36,38,41). In addition, one SUD guidelines did not highlight the assessment of coexisting disorders (42) (Table 3).
Table 3
Consideration of concurrent problems
Guideline
|
Is the link between mental health and misuse of substances mentioned as part of the background?
|
Does the guideline mention that either SMI or SUD can worsen the outcome of another?
|
Does the guideline provide recommendations about Screening/Assessment for coexisting disorders?
|
Does the guideline mention the competence of healthcare professionals in recognition the existence of the other comorbidity (i.e. either substance misuse or mental health problems)?
|
Does the guideline requests healthcare professionals to seek advice or training from the other service i.e. training from substance misuse service staff to staff in mental health services?
|
Does the guideline specifically mention not to exclude patients who misuse substance from age-appropriate treatment settings of mental illness due to use of substances?
|
Does the guideline specifically mention not to exclude patients who have mental illness from age-appropriate treatment setting of substance misuse due to mental health problems?
|
Who refers patients to a mental health setting or to the substance misuse/alcohol misuse services?
|
If a guideline is for mental health, does it mention not to discharge patients from inpatient services because of their substance misuse?
|
NICE 2011
(coexisting disorders) (39)
|
Yes
|
Yes
|
Mentioned. Suspected patients should be asked about any drugs and alcohol drinking including: its type, quantity, frequency, route of administration, and duration of use.
|
Yes
|
Yes
|
Yes
|
Yes
|
Mentioned. All staff who have direct contact with patients, including professionals in primary care and educational settings.
|
Yes
|
NICE 2016
(coexisting disorders) (40)
|
Yes
|
Yes
|
Mentioned. A Full evaluation for suspected patients.
|
No
|
Yes
|
Yes
|
No
|
Mentioned. All staff who have direct contact with patients, including professionals in primary care and educational settings.
|
No
|
Australian government 2016 (33)
|
Yes
|
Yes
|
Mentioned. After abstinence, a full assessment of the patient should ideally occur.
|
Yes
|
Yes
|
No
|
No
|
Not mentioned
|
Not applicable
|
SIGN 2013 (30)
|
Yes
|
Yes
|
Not mentioned
|
Yes
|
Yes
|
Yes
|
No
|
Not mentioned
|
No
|
NICE 2014
(41)
|
Yes
|
Yes
|
Not mentioned
|
No
|
Yes
|
No
|
No
|
Mentioned. Primary healthcare professionals
|
No
|
WFSBP 2015 (45)
|
Yes
|
Yes
|
Mentioned. Detailed assessment of substance use disorder should be obtained.
|
No
|
No
|
No
|
No
|
Not mentioned
|
No
|
RANZCP 2016 (32)
|
Yes
|
Yes
|
Mentioned. Any suspicions regarding the use of stimulant drugs should be raised if there are recurrent episodes of psychosis.
|
Yes
|
Yes
|
No
|
No
|
Mentioned. Health care professionals and any other professionals involved in providing care for patients, such as GPs and social counsellors.
|
No
|
BAP 2019 (47)
|
Yes
|
Yes
|
Mentioned. A detailed assessment of substance use disorder should be obtained.
|
No
|
No
|
No
|
No
|
Not mentioned
|
No
|
APA 2020 (43)
|
Yes
|
Yes
|
Mentioned. Any initial assessment of a patients with a possible psychotic disorder should include an assessment of their tobacco use and other substance misuse.
|
Yes
|
Yes
|
No
|
No
|
Not mentioned
|
No
|
VA/DoD 2010 (28)
|
Yes
|
Yes
|
Mentioned. A complete clinical assessment should be obtained.
|
No
|
No
|
No
|
No
|
Not mentioned
|
Yes
|
Singapore MOH 2011 (29)
|
Yes
|
Yes
|
Not mentioned
|
No
|
No
|
No
|
No
|
Not mentioned
|
No
|
NICE 2014 (38)
|
Yes
|
Yes
|
Not mentioned
|
No
|
Yes
|
No
|
No
|
Mentioned. Primary healthcare professionals
|
No
|
BAP 2016 (48)
|
No
|
Yes
|
Mentioned. The clinician should assess to what extent does substance misuse contribute to bipolar symptoms.
|
No
|
Yes
|
No
|
No
|
Not mentioned
|
No
|
CANMAT and ISBD 2018 (36)
|
Yes
|
Yes
|
Not mentioned
|
Yes
|
No
|
No
|
No
|
Not mentioned
|
No
|
BAP 2012 (46)
|
Yes
|
Yes
|
Mentioned. Substance history, family history, urinalysis and blood tests, as well as an assessment of psychiatric disorder onset, and the misuse of substances should be carried out.
|
No
|
No
|
No
|
No
|
Not mentioned
|
Not applicable
|
WFSBP 2017 (42)
|
Yes
|
Yes
|
Not mentioned
|
No
|
No
|
No
|
No
|
Not mentioned
|
Not applicable
|
gov.uk 2017 (34)
|
Yes
|
Yes
|
Mentioned. Identifying any current or previous psychological problems
|
Yes
|
Yes
|
Yes
|
No
|
Mentioned. GPs
|
Not applicable
|
DGPPN and DG-Sucht 2017 (35)
|
Yes
|
Yes
|
Mentioned. The assessment process derived from alcohol use disorder identification test guidelines
|
No
|
No
|
No
|
No
|
Not mentioned
|
Yes
|
NICE 2011 (37)
|
Yes
|
Yes
|
Mentioned. Patients should be referred to a psychiatrist for effective assessment and treatment.
|
Yes
|
Yes
|
No
|
No
|
Mentioned. Whole range of healthcare such as a GP.
|
Not applicable
|
APA 2018 (44)
|
Yes
|
Yes
|
Mentioned. Patients should be assessed for alcohol use disorder and comorbid mental health disorder.
|
No
|
No
|
No
|
No
|
Not mentioned
|
No
|
ASAM 2015 (31)
|
Yes
|
Yes
|
Mentioned. A comprehensive assessment of the patient and any ideas related to suicide should be evaluated. The patient’s full medical history and a physical
examination should also be obtained.
|
Yes
|
Yes
|
No
|
No
|
Not mentioned
|
Not applicable
|
(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; (GPs) General practitioners
(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
|
Three guidelines mentioned that patients with SMI with coexisting SUD who completed their SMI treatment course should not be discharged from a healthcare setting due to their substance misuse (28,35,39). Of the SMI guidelines, four guidelines highlighted the competency need of healthcare providers in each health care setting to consider for the co-existing disorders (30,32,36,43).Three out of seven SUD guidelines similarly covered competency aspects (31,34,37). All coexisting disorder guidelines requested healthcare providers to gain training and expertise from other specialist staff (33,39,40) (Table 3).
Treatment Of Coexisting Disorders
All of the guidelines related to SMI or coexisting disorders described the importance of screening and/or treatment for both problems simultaneously (33,39,40). The SMI guidelines often stipulated SUD clinical guidelines and vice versa when recommending treatment of the other co-existing disorder (Table 4). One SUD guideline (44) however, did not explicitly provide recommendation regarding treatment of both disorders.
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) (39)
|
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) (40)
|
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 (33)
|
Mentioned. Detailed treatment plan for both psychosis and bipolar disorder are provided
|
Not mentioned
|
Mentioned
|
Included
|
mentioned
|
SIGN 2013 (30)
|
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
(41)
|
Mentioned. Monitoring for coexisting conditions particularly in the early phases of treatment.
|
Not mentioned
|
Mentioned
|
Not included
|
Mentioned
|
WFSBP 2015 (45)
|
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 (32)
|
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 (47)
|
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 (43)
|
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 (28)
|
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 (29)
|
Mentioned. Patients with both addiction and bipolar disorders should be treated.
|
Not mentioned
|
Not mentioned
|
Not included
|
Mentioned
|
NICE 2014 (38)
|
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 (48)
|
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 (36)
|
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 (46)
|
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 (42)
|
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 (34)
|
Mentioned. Dual focused treatments
|
Not mentioned
|
Mentioned
|
Included
|
Mentioned
|
DGPPN and DG-Sucht 2017 (35)
|
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 (37)
|
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 (44)
|
Not mentioned.
|
Not mentioned
|
Not mentioned
|
Not included
|
Not mentioned
|
ASAM 2015 (31)
|
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
|
Only two out of the eleven SMI guidelines mentioned recommendation about treatment adjustments when considering dual diagnoses and treatment (36,45). Similarly, only three of the seven SUD guidelines mentioned recommendation about treatment adjustment (35,42,46) (Table 4). Examples of treatment adjustments included recommendation for the use of long-acting injectable antipsychotic medication in cases where there was a history of non-adherence to medication in place of regular antipsychotic medication (39). In addition, two of the guidelines related to coexisting disorders (33,39), five of SMI guidelines (28,38,43,47,48) and three of the SUD guidelines (34,37,49) considered potential drug interaction in patients with SMI and coexisting SUD (33,39). For example, the NICE (2011) guideline recommends that caution be exercised during the prescribing of medication for patients demonstrating substance misuse particularly that of alcohol, since alcohol will affect the metabolism of other medications and either diminish their efficacy or increase the risk of side effects (39) (Table 4).
Importance of physical health monitoring were described by all guidelines related to coexisting disorders, nine SMI guidelines, and four of the seven SUD guidelines. These included monitoring and management of diabetes mellitus and hyperlipidemia (Table 4).
Care Pathway And Integrated Care Provision
All of the coexisting disorders guidelines, seven of the SMI guidelines, and three of SUD guidelines mentioned the importance of continuity of care. For example, the Australian government guideline advised that it is important to develop systems in order to facilitate the transition of patients with coexisting disorders by providing them with much-needed services and helping them to address their complex needs (33) (Table 5).
Table 5
Care pathway and integrated care provision
Guideline
|
Does the guideline mention continuity of care i.e. importance of same health or key worker in managing the substance misuse or mental health/ continuity of care?
|
Where should integrated services be provided
|
Is there a mention of the role of emergency department or A&E and what they should do if patients present there?
|
NICE 2011
(coexisting disorders) (39)
|
Yes
|
Secondary care mental health services,
CAMHS
|
Yes
|
NICE 2016
(coexisting disorders) (40)
|
Yes
|
Mental health services
|
No
|
Australian government 2016 (33)
|
Yes
|
AOD settings
|
No
|
SIGN 2013 (30)
|
No
|
Not mentioned
|
No
|
NICE 2014
(41)
|
Yes
|
secondary care settings
|
No
|
WFSBP 2015 (45)
|
No
|
Not mentioned
|
No
|
RANZCP 2016 (32)
|
Mentions continuity but not link key worker
|
Dual diagnosis service
|
No
|
BAP 2019 (47)
|
No
|
Not mentioned
|
No
|
APA 2020 (43)
|
Yes
|
Not mentioned
|
No
|
VA/DoD 2010 (28)
|
Yes
|
Urgent/emergent mental health settings
|
No
|
Singapore MOH 2011 (29)
|
Yes
|
In an integrated specialist treatment centre.
|
No
|
NICE 2014 (38)
|
Yes
|
Not mentioned
|
No
|
BAP 2016 (48)
|
No
|
Not mentioned
|
No
|
CANMAT and ISBD 2018 (36)
|
Yes
|
inpatient hospital or community residential treatment
|
No
|
BAP 2012 (46)
|
No
|
Not mentioned
|
No
|
WFSBP 2017 (42)
|
No
|
Not mentioned
|
No
|
gov.uk 2017 (34)
|
Yes
|
In drug misuse services and mental health services
|
Yes
|
DGPPN and DG-Sucht 2017 (35)
|
No
|
Inpatient treatment
|
No
|
NICE 2011 (37)
|
Yes
|
Not mentioned
|
Yes
|
APA 2018 (44)
|
Yes
|
Not mentioned
|
No
|
ASAM 2015 (31)
|
No
|
Hospitals
|
Yes
|
(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
|
Only one of the guidelines pertaining to coexisting disorders mentioned that healthcare providers in the emergency department should regularly ask patients about any potential drug misuse (39). Three of the guidelines related to SUD mentioned the role of the emergency department (31,34,37). Such consideration was missing from SMI guidelines. (Table 5).
Equity Consideration And Person-centered Care
Three guidelines pertaining to coexisting disorders, ten SMI guidelines, and six SUD guidelines described the essential role played by ‘significant others’ such as families and carers and encouraged their involvement along with any integrated care plans provided to patients (Table 6). All of the three guidelines pertaining to coexisting disorders were explicit in reporting the need for assessment of any children cared for by patients with both disorders, according to safeguarding procedures. However, only three of the SMI guidelines and two of the SUD guidelines provided recommendations about children cared for by patients with both disorders (Table 6).
Table 6
Equity considerations and person-centered care
Guideline
|
Does the guideline mention the importance of involving family and carers?
|
Dose the guideline mention children cared for by patient with mental health conditions or substance misuse?
|
Does the guideline mention the importance of engaging with various ethnicities and cultural needs?
|
Does the guideline mention allaying patient fear about being detained or forcefully put into care or rehabilitation?
|
Is there consideration for people with physical, sensory or learning disabilities in the guideline?
|
NICE 2011
(coexisting disorders) (39)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
NICE 2016
(coexisting disorders) (40)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Australian government 2016 (33)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
SIGN 2013 (30)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
NICE 2014
(41)
|
Yes
|
No
|
Yes
|
No
|
Yes
|
WFSBP 2015 (45)
|
Yes
|
No
|
No
|
No
|
No
|
RANZCP 2016 (32)
|
Yes
|
No
|
Yes
|
No
|
No
|
BAP 2019 (47)
|
Yes
|
No
|
No
|
No
|
Yes
|
APA 2020 (43)
|
Yes
|
No
|
Yes
|
No
|
Yes
|
VA/DoD 2010 (28)
|
Yes
|
No
|
No
|
No
|
Yes
|
Singapore MOH 2011 (29)
|
No
|
No
|
No
|
No
|
No
|
NICE 2014 (38)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
BAP 2016 (48)
|
Yes
|
Yes
|
No
|
No
|
No
|
CANMAT and ISBD 2018 (36)
|
Yes
|
No
|
No
|
No
|
Yes
|
BAP 2012 (46)
|
Yes
|
No
|
No
|
No
|
No
|
WFSBP 2017 (42)
|
Yes
|
No
|
No
|
No
|
No
|
gov.uk 2017 (34)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
DGPPN and DG-Sucht 2017 (35)
|
No
|
No
|
No
|
No
|
No
|
NICE 2011 (37)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
APA 2018 (44)
|
Yes
|
No
|
No
|
No
|
Yes
|
ASAM 2015 (31)
|
Yes
|
No
|
No
|
No
|
Yes
|
(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
|
All of the guidelines pertaining to coexisting disorders, five of the SMI guidelines, and two of the SUD guidelines mentioned the importance of ensuring that healthcare providers who provide care to patients with coexisting disorders should engage with patients from different ethnicities and cultural backgrounds (Table 6). Only the NICE 2011 offered advice to healthcare providers to solve access to care issues in patients (39) (Table 6).
Consideration Of Multiple Social Disadvantage
All of the guidelines pertaining to coexisting disorders, nine of the SMI guidelines, and five of the SUD guidelines considered the assessment of risks of violence, suicide, and self-harm (Table 7). Two of the guidelines pertaining to coexisting disorders highlighted the risk of certain getting involved with criminal justice system and the importance of prevention actions (39,40). Only the SMI guideline by Royal Australian and New Zealand College of Psychiatrists (RANZCP) (32) and three of the SUD guidelines (31,34,37) highlighted the risk of patients being registered in the criminal justice system (Table 7).
Table 7
Inclusivity in relation to consideration of homelessness and contextual factors
Guideline
|
Does the guideline mention that concurrent problems can increase risk of self-harm, suicide, violence, injury or offending behaviour?
|
Is the risk of criminal justice system/offending/prison for those affected mentioned?
|
Does the guideline recommend providing health care for prison offender in rehabilitation centre
|
Is the risk of homelessness for those affected mentioned?
|
Does the guideline provide suggestions for healthcare professionals to refer patients to housing assistance or homelessness services if patients are found at risk of homelessness
|
Does the screening mentions patient history of sexual or other forms of abuse?
|
Is there mention of or consideration about stigma and discrimination in healthcare setting?
|
Does the guideline mention the importance of working with voluntary, charity or No?
|
NICE 2011
(coexisting disorders) (39)
|
Yes
|
Yes
|
Yes, in case of diverted treatment
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
NICE 2016
(coexisting disorders) (40)
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Australian government 2016 (33)
|
Yes
|
No
|
No
|
Yes
|
No
|
Yes
|
Yes
|
No
|
SIGN 2013 (30)
|
Yes
|
No
|
No
|
Yes
|
Yes
|
No
|
No
|
No
|
NICE 2014
(41)
|
No
|
No
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
WFSBP 2015 (45)
|
Yes
|
No
|
No
|
Yes
|
Yes
|
No
|
No
|
No
|
RANZCP 2016 (32)
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
BAP 2019 (47)
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
APA 2020 (43)
|
Yes
|
No
|
No
|
Yes
|
Yes
|
Yes
|
No
|
No
|
VA/DoD 2010 (28)
|
Yes
|
No
|
No
|
No
|
No
|
Yes, but as risk factor for suicide in patients with bipolar disorder
|
No
|
No
|
Singapore MOH 2011 (29)
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
NICE 2014 (38)
|
Yes
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
No
|
BAP 2016 (48)
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
CANMAT and ISBD 2018 (36)
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
BAP 2012 (46)
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
WFSBP 2017 (42)
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
gov.uk 2017 (34)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
DGPPN and DG-Sucht 2017 (35)
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
NICE 2011 (37)
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
APA 2018 (44)
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
ASAM 2015 (31)
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
No
|
No
|
(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
|
All of the guidelines pertaining to coexisting disorders, four of the SMI guidelines (30,32,43,45), and two of the SUD guidelines (34,39) attempted to inform the healthcare providers about the risk of homelessness as being a negative social outcome for individuals affected by SMI or SUD. However, only the Australian government mentioned the risk of homelessness in patients with coexisting disorders, but did not provide further recommendations about how such patients could receive support (33) (Table 7). Assessment of the history of any kind of abuse suffered by the patient, including sexual abuse were only rarely considered (28,33,34,37,38,43) (Table 7).
Issue of stigma and discrimination from healthcare providers were covered well by guidelines for co-existing disorders but less so by either SMI or SUD guidelines (Table 7).
Two of the guidelines pertaining to coexisting disorders, two of the SMI guidelines, and two of the SUD guidelines seemed to encourage seeking support from voluntary organizations (32,34,37,39–41) (Table 7).