As a general principle co-occurring mental and alcohol use disorders should be managed in parallel or in an integrated fashion with evidence-based treatments provided for both problems. Users of these guidelines should consult clinical practice guidelines for specific mental disorders, and in the absence of guidance or evidence to the contrary, apply those recommendations to the care of those with comorbid conditions. Care should be taken to coordinate treatments, so they are complementary rather than contradictory.

The Setting and Organisation of Care

As comorbidity is the norm rather than the exception in people seeking help for alcohol use disorders, services should plan for and anticipate comorbidity.  Experiences of trauma are very common in people attending alcohol and other drug services and it is good practice to consider trauma informed care in designing spaces, policies and procedures so as not to unnecessarily trigger traumatic memories.  Creating a safe space with sufficient privacy, free of violent or sexual material on TV screens or in magazines (e.g. in waiting areas), and sufficient staffing to monitor the behaviour of others who may be perceived as intrusive or harassing are some key features of trauma informed care. 

Alcohol use disorders can be chronic and impact on client motivation and this is even more pronounced in people who also have comorbid mental disorders thus it is a good practice point to consider that care be organised to provide integrated, co-ordinated, engaging care with minimal administrative barriers.  Consensus guidelines for the management of multimorbidity and the comorbidity guidelines lead to the following recommendations:

Chapter Recommendation Grade of recommendation
21.11 Trauma informed care can help the design of spaces, policies, and procedures to avoid unnecessarily triggering those with experiences of trauma GPP
21.12 Offer care that is tailored to the person’s personal goals and priorities GPP
21.13 Consider reducing interventions that have a high burden on the individual in case adherence may be compromised GPP
21.14 Develop and agree upon an individualised management plan with clear responsibilities for coordination of care GPP

E-Health & E-Therapy Interventions

Providing care face to face is the most common way for alcohol treatment to proceed. Since the last edition of these guidelines e-health and in-particular providing psychological interventions over the internet has become a more viable option. Such e-therapies can be effective and may improve access to care. These interventions provide information, describe the procedures of psychological therapies and provide individualised support in a variety of ways. They are not simply the switching of face to face contact with that provided by telephone or teleconferencing.

While e-therapies for common mental disorders are available (such as MindSpot, this way up, Beacon, eMHprac, HeadtoHealth) those specific to comorbid substance use and mental disorders are more difficult to access because they are often the subject of research trials without any mechanism for widespread dissemination. E-therapies are not a solution to workforce shortages. For drug and alcohol services without the staffing to provide intervention for comorbidity onsite e-therapies may provide a useful addition to treatment plans. However, care should be taken to coordinate the intervention so as to monitor progress, ensure continuity of care, and maximize engagement. 

Chapter Recommendation Grade of recommendation
21.15 e-therapy may provide timely and economical access to evidence based therapies for comorbid mental disorders as part of a broader treatment plan where progress is monitored, and engagement and continuity of care are maintained GPP