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Co-occurring schizophrenia and substance use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis

E Cabrina Campbell, MD
Stanley N Caroff, MD
Stephan C Mann, MD, DLFAPA
Section Editors
Andrew J Saxon, MD
Stephen Marder, MD
Deputy Editor
Richard Hermann, MD


Schizophrenia and addiction are both chronic disorders with serious complications, consequences, and costs for individuals and society. Both conditions are associated with poor adherence to treatment and poorer outcomes when the co-occurring disorder is present.

Some of the symptoms of schizophrenia overlap with symptoms of intoxication, chronic use, or withdrawal from alcohol or other drugs. Family history and the temporal relationship of symptoms can help to distinguish patients with a substance use disorder (SUD) alone from co-occurring schizophrenia and SUD.

The psychiatric diagnoses, substance abuse and substance dependence, in DSM-IV-TR were replaced by one diagnosis, substance use disorder, in DSM-5 [1]. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, substance dependence is approximately comparable to substance use disorder, moderate to severe subtype, while substance abuse is similar to the mild subtype.

The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of schizophrenia and substance use disorder are described here. Treatment of co-occurring schizophrenia and substance use disorder are described separately. The epidemiology, pathogenesis, clinical manifestations, course, assessment, diagnosis and treatment of schizophrenia occurring alone and substance use disorder occurring alone are also discussed separately. (See "Psychosocial interventions for co-occurring schizophrenia and substance use disorder" and "Schizophrenia in adults: Epidemiology and pathogenesis" and "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment" and "Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for schizophrenia: Side effect management" and "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Cannabis use and disorder: Epidemiology, comorbidity, health consequences, and medico-legal status" and "Cannabis use and disorder: Clinical manifestations, course, assessment, and diagnosis" and "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis".)


Prevalence — Epidemiologic studies have generally shown that the prevalence of substance use disorder (SUD) is elevated in persons with schizophrenia compared with the general population. As examples, in a study of substance use among 9142 individuals with severe psychotic disorders, including 5586 subjects with schizophrenia or schizoaffective disorder, the odds of nicotine (smoking), alcohol, marijuana, and other drug use were higher (odds ratios = 3.5 to 4.6) in patients with psychosis compared with 10,195 nonpsychiatric controls [2]. Rates of substance use varied among subgroups based on age, gender, and race or ethnicity. Having a psychotic disorder further increased the odds of substance use in each subgroup. The lifetime prevalence of the DSM-IV-TR disorders substance abuse and substance dependence among patients with schizophrenia has been estimated to range from 47 to 59 percent in the United States , compared with 16 percent in the general population [3-5]. Differences between schizophrenia patients and normal controls in substance use may be diminished when the effects of low socioeconomic status (common among schizophrenia patients) is taken into account [6-14]. High rates of co-occurrence have also been observed internationally (eg, in Australia, Switzerland, Italy, Germany, England, Turkey) [15-17]. Many with these co-occurring disorders used two or more substances.  

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Literature review current through: Oct 2017. | This topic last updated: Sep 15, 2017.
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