Alcohol use disorders are common comorbid conditions in schizophrenia, and their presence is associated with poor adjustment and poor treatment response. Standard alcohol assessment instruments have not been validated for use with schizophrenic patients, and several authors have questioned the validity of these patients' self-reports. A reliable and valid screening procedure for assessing alcohol use is needed. The present study used the following three methods to evaluate a rural sample of 75 outpatients with DSM-III-R schizophrenia or schizoaffective disorder: (1) clinical records; (2) research interviews using standard alcohol assessment instruments; and (3) case managers' ratings. In addition, consensus diagnoses, determined by combining information from all three methods with intensive case reviews, were used to determine the sensitivity and specificity of the other approaches. As expected, clinical evaluations frequently missed alcohol problems. Research interviews and case managers' ratings differentiated between alcoholic and nonalcoholic schizophrenic patients and were highly correlated. Case managers' ratings, which incorporated longitudinal observations of behavior and collateral reports as well as interview data, were more sensitive measures of current alcohol use disorders than research interviews. Subjects frequently manifested alcohol-related problems that interfered with community adjustment without the full dependence syndrome, suggesting that schizophrenic patients may be particularly vulnerable to negative effects of alcohol.

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Substance use disorder is common in patients with schizophrenia and dramatically worsens their outcome. The typical antipsychotic medications, introduced over 50 years ago, are effective for the treatment of psychosis but may have only limited efficacy in patients with these co-occurring disorders because patients continue to use substances while taking them. In preliminary studies, however, several of the atypical antipsychotic medications have shown promise for reducing alcohol and drug use in patients with schizophrenia. A neurobiologic formulation is discussed, suggesting that the use of substances in patients with schizophrenia may be based on a dysfunction within the dopamine-mediated brain reward circuitry, and that clozapine in particular, may potentially ameliorate this dysfunction and lessen the desire for substance use. Medications for the treatment of alcohol use disorders, such as disulfiram, naltrexone and acamprosate, as well as other adjunctive medications, may also be useful. Further studies are required to establish a solid evidence base of best practices for the use of medications in these patients.

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