There is an increasing recognition of the problems associated with alcohol and other drug misuse and mental illness (see Chapter.18.104.22.168). Often alcohol misuse is complicated by multiple substance misuse. For example, in the Epidemiologic Catchment Area Study half of all patients with schizophrenia also had a substance misuse disorder,(76> and a recent British survey of psychotic patients found that 36 per cent misused drugs or alcohol. (77) However, there is currently no consensus on the most appropriate treatment services for patients with comorbidity.(78) Substance misuse can be particularly problematic in the context of mental illness, and is associated with higher rates of violence and poor treatment outcome (see Chipie.L11...4.4). Such patients are often non-compliant and disruptive in mental health services, and typically do not engage in alcohol or drug services. Assertive community outreach and integrated service models, covering both mental illness and substance misuse, have been advocated, but evidence for the effectiveness of such services is currently limited. (7 79)
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