Intended for healthcare professionals

Practice Guidelines

Assessment and management of psychosis with coexisting substance misuse: summary of NICE guidance

BMJ 2011; 342 doi: (Published 23 March 2011) Cite this as: BMJ 2011;342:d1351
  1. Tim Kendall, director1, visiting professor2, consultant psychiatrist and medical director3,
  2. Peter Tyrer, professor of community psychiatry 4,
  3. Craig Whittington, senior systematic reviewer 5,
  4. Clare Taylor, editor1
  5. on behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA, UK
  2. 2University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
  3. 3Sheffield Health and Social Care NHS Foundation Trust, Sheffield S10 3TH, UK
  4. 4Imperial College London, London SW7 2AZ
  5. 5National Collaborating Centre for Mental Health, University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
  1. Correspondence to: T Kendall tim2.kendall{at}

Many people with mental health problems use substances (including illicit drugs and alcohol), and for people with psychosis (predominantly schizophrenia and bipolar disorder), substance misuse occurs more frequently than in the general population.1 2 For example, a 1990 study in the United States reported a 47% lifetime prevalence rate of substance misuse among people with schizophrenia and 60% among people with bipolar disorder; in the general population, the substance misuse rate was 16%.2 3

People with psychosis commonly take various non-prescribed substances to cope with their symptoms, and in about a third of people with psychosis, this amounts to hazardous, harmful, or dependent use.4 Among people with psychosis, those with coexisting substance misuse have a higher risk of relapse and admission to hospital,5 higher mortality,6 and higher levels of unmet needs. This is partly because the substances used may exacerbate the psychosis or interfere with pharmacological or psychological treatment.

This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the assessment and management of psychosis and coexisting substance misuse in adults and young people.7


NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice; this was often necessary for this guidance because there was evidence for the treatment of either psychosis or substance misuse but little evidence for treatment when both conditions were present. Evidence levels for the recommendations are given in italic in square brackets.

Working with people with psychosis and coexisting substance misuse

  • Engage the person from the start and build a respectful, trusting, non-judgmental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and …

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