This study reviewed the degree to which guidelines for SMIs and SUDs archived by the National Guidelines Clearinghouse addressed treatment for co-occurring disorders. Slightly more than half of the total guidelines retrieved included some type of recommendation for the treatment of co-occurring disorders. These recommendations included assessment, referrals, and collaboration with other professionals in the other sector of care. With the exception of two guidelines (described below), these recommendations contained minimal elaboration or specificity, leaving considerable room for interpretation on how the recommendations should actually be implemented in routine practice.
Two guidelines are particularly noteworthy with respect to their specificity regarding treatment for co-occurring disorders. This included the treatment guideline for schizophrenia, authored by the American Psychiatric Association (Guideline R). This guideline provided a comprehensive description of the major features of treatment (e.g., case management, family interventions, rehabilitation, pharmacotherapy, and housing) and noted the importance of the same clinicians treating both the SMI and SUD. Overall, these recommendations are consistent with the broader literature on comprehensive and integrated treatment for this population (Drake et al., 1998
). It should be noted that the treatment guideline for bipolar disorder, also authored by the American Psychiatric Association (Guideline J), did not contain any treatment recommendations regarding SUDs. This is a surprising finding, given the evidence suggesting that the rates of co-occurring alcohol and drug problems among persons with bipolar disorder are at least equal to or greater than the rates among persons with schizophrenia (Robins and Regier, 1991
The second guideline to address treatment targeted substance use disorders with co-occurring psychiatric disorders (Guideline B). This is a comprehensive treatment guideline that contains screening suggestions, essential components of treatment (e.g., psychoe-ducation, double trouble groups, and community-based dual recovery mutual self-help groups), and treatment strategies (e.g., motivational interviewing, contingency management, relapse prevention, and assertive community treatment). This guideline also corresponds to a larger treatment manual provided by the Center for Substance Abuse Treatment (2005)
The majority of the guidelines targeting co-occurring disorders were intended for a multidisciplinary audience of service providers. This reflects the wide recognition that treating SUDs, SMIs, and these conditions as they co-occur requires coordination with many different provider types. However, the outcomes targeted by the guidelines were generally restricted to the primary focus of the single disorder, even though the assessment and/or treatment issues addressed co-occurring disorders. This suggests that many of these guidelines have limited utility for addressing the full range of problems and needs that are commonly encountered among persons with co-occurring disorders.
Limitations and Generalizability
This systematic review was restricted to guidelines archived on the NGC. This excluded a potentially large number of proprietary and nonproprietary guidelines that are available in print and electronically. Thus, the generalizability of this study is limited. Additionally, it was beyond the scope of this study to examine the quality and consistency of the recommendations contained in the guidelines against the extant literature. Despite these limitations, it is important to emphasize that the NGC remains as one of the largest (or the largest) data base that provides readily obtainable guidelines from major organizations that are free.