Imagine trying to manage the symptoms of schizophrenia while also struggling with substance use. It's a devastating combination that affects a huge number of people—nearly half of those with schizophrenia also have a substance use disorder. The big question is: do the talk therapies and support programs we currently offer actually help? A major review of 35 clinical trials, involving over 4,100 people, has given us a sobering answer. The analysis found that current psychological and psychosocial interventions have only a very small effect on reducing overall symptoms. More strikingly, they found no difference at all between therapy and control groups when it came to reducing the use of substances like alcohol, cannabis, or stimulants. It's important to note that the tiny benefit seen for symptoms was mainly driven by studies focused on nicotine use. The researchers have low confidence in the symptom reduction finding, meaning we can't be very sure of it. For the substance use result, they have moderate confidence. The bottom line is clear: the current standard of care is falling short for people facing this dual challenge, highlighting a critical gap that demands new solutions.
Psychological interventions show minimal symptom benefit, no substance use effect in schizophrenia with SUDDo current talk therapies help people with schizophrenia who also use substances?
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Key Takeaway
Consider that psychological interventions show minimal symptom benefit and no substance use effect in schizophrenia with SUD.
This systematic review and meta-analysis evaluated psychological and psychosocial interventions for adults with schizophrenia and co-occurring substance use disorders. The analysis included 35 randomized controlled trials with 4,136 total participants, of which 29 trials (3,831 participants) contributed to pairwise meta-analyses. The primary outcomes were overall symptom reduction and substance use reduction measured at posttreatment using validated scales.
For overall symptom reduction, interventions showed a very small effect favoring the intervention group (standardized mean difference -0.11, 95% CI -0.27 to 0.05). The confidence interval includes no effect, and the authors note low confidence in this estimate. For reducing all types of substance use, no difference was found between intervention and control groups (SMD -0.01, 95% CI -0.21 to 0.18), with moderate confidence in this estimate.
Safety and tolerability data were not reported in the included studies. The authors note that the small effect on overall symptoms was mainly driven by studies focusing on nicotine use. Results for alcohol, cannabis, amphetamines, and other stimulants showed similar no-effect patterns. Key limitations include the posttreatment-only assessment timeframe and lack of safety reporting.
For clinical practice, this evidence suggests current psychological and psychosocial interventions provide limited benefit in reducing symptoms and no effect in reducing substance use in individuals with schizophrenia and substance use disorders compared to control conditions. The exception appears to be nicotine use, which drove the small symptom benefit. These findings highlight the need for more effective treatment approaches for this challenging dual-diagnosis population.
What this means for you:
Current talk therapies show little benefit for people with both schizophrenia and substance use. More on Schizophrenia
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View Original Abstract ↓
IMPORTANCE: Substance use disorder (SUD) is commonly found in individuals with schizophrenia, with a high co-occurrence rate of approximately 41.7%. Despite this high prevalence, people with both schizophrenia and SUD are frequently excluded from clinical trials and systematic reviews; this special group is particularly challenging to treat and imposes a significant economic burden on health care systems.
OBJECTIVE: To evaluate the efficacy, acceptability, and tolerability of psychological and psychosocial interventions in patients with schizophrenia and co-occurring SUD.
DATA SOURCES: The Cochrane Schizophrenia Group registry was searched up to January 13, 2025. Data analysis was performed from March to April 2025.
STUDY SELECTION: Randomized clinical trials (RCTs) examining psychological and psychosocial interventions compared with control groups in adults with schizophrenia and concomitant SUD were identified. No restrictions were applied regarding the type of substance used, including alcohol, cannabis, nicotine, and stimulants, such as amphetamines.
DATA EXTRACTION AND SYNTHESIS: A systematic review and random-effect pairwise meta-analyses were conducted to estimate standardized mean differences (SMD) with 95% confidence intervals and were reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Confidence in the estimate was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
MAIN OUTCOMES AND MEASURES: The primary outcomes were overall symptoms and substance use reduction measured by validated scales at posttreatment.
RESULTS: A total of 35 RCTs were included (4136 participants), with 29 trials involving 3831 participants contributing to pairwise meta-analyses comparing psychological and psychosocial interventions with control conditions. Among the 3748 participants with reported sex, 951 (25.4%) were female, and mean (range) age was 37.2 (20.6-57.5) years. A very small effect favoring the intervention group was observed in reducing overall symptoms (SMD, -0.11; 95% CI, -0.27 to 0.05; 13 trials; low confidence in the estimate), mainly driven by nicotine studies. No difference was found between intervention and control groups in reducing all types of substance use (SMD, -0.01; 95% CI, -0.21 to 0.18; 8 trials; moderate confidence). When considered separately, alcohol, cannabis, amphetamines, and other stimulants showed similar no-effect results, while nicotine use indicated a small effect.
CONCLUSION AND RELEVANCE: The findings of this systematic review and meta-analysis suggest that current psychological and psychosocial interventions provide limited benefit in reducing symptoms and no effect in reducing substance use in individuals with schizophrenia and SUD compared to control conditions, with the exception of nicotine use, highlighting the urgent need to develop more effective treatment strategies.
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