Overview

Chronic substance use is associated with increased risk for many mental health conditions, listed below. One reason mental health problems contribute to developing substance use problems is that many individuals attempt to self-medicate their mental health symptoms through substance use. Conversely, chronic substance use can lead to mental health problems. In either event, it is important to discover mental health problems in people struggling with substance use problems through mental health screening.

Co-occurrence of substance use disorder(s) with mental disorder(s) is often called a "dual diagnosis." The incidence is high at around 7.9 million adults or around 45% of those seeking treatment for substance use disorder (CBHSQ, 2015).

For example, data from a classic study found the following prevalence for mental health disorders one year after the participants had been identified as alcohol dependent (the DSM diagnosis at the time) (Kessler et al., 1996; Regier et al., 1990).

  1. Mood Disorders: 29.2%
  2. Major Depressive Disorder: 27.9%
  3. Bipolar Disorder: 1.9%
  4. Anxiety Disorders: 36.9%
  5. Generalized Anxiety Disorder (GAD): 11.6%
  6. Panic Disorder: 3.9%
  7. Post Traumatic Stress disorder (PTSD): 7.7%
Depression

Depression is the most common mental health disorder co-occurring with substance use disorders (CBHSQ, 2015). The U.S. Preventive Services Task Force (USPSTF) has indicated that all adults should be screened for depression, even in the absence of a past history (USPSTF, 2016). It is particularly relevant in patients having substance use disorders, giving the frequency with which they are co-morbid. Screening tools suggested by the USPSTF include the Patient Health Questionnaire, the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale in postpartum and pregnant women. Noting the severity of each condition is also important.

Other Mental Health Disorders

Anxiety is also common in persons with substance use disorders. PTSD is particularly common. As many as 40% of patients who are drug dependent report symptoms of PTSD (Papastavrou et al, 2011).

Personality disorders, bipolar, Attention Deficit and Hyperactivity Disorder (ADHD), and psychosis are among the other mental health diagnoses with a relatively high incidence of substance use disorder.

View ReferencesHide References
Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. HHS Publication. 2015; SMA 15-4927, NSDUH Series H-50: . Available at: https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm
E Papastavrou , A Farmakas, G Karayiannis, E Kotrotsiou. Co morbidity of Post-Traumatic-Stress Disorders and Substance Use Disorder. Health Science Journal. 2011; 5(2): 107-17. Available at: http://www.hsj.gr/medicine/co-morbidity-of-posttraumaticstress-disorders-and-substance-use-disorder.pdf Accessed on: 2013-10-10.
Ismene L. Petrakis, et al. . Comorbidity of alcoholism and psychiatric disorders. National Institute on Alcohol Abuse and Alcoholism . 2002. Available at: http://pubs.niaaa.nih.gov/publications/arh26-2/81-89.htm Accessed on: 2016-02-09.
U.S. Preventative Services Task Force. Final Recommendation Statement - Depression in Adults: Screening. U.S. Preventative Services Task Force Website. 2016. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1 Accessed on: 2016-02-02.
Treatment Technology

Emerging technologies have made it possible to support patient treatment inside the office and expand the exchange of information outside of office visits:

  • Telehealth delivery systems, such as electronic health records (EHR), allow for the exchange of patient information between providers, creating a more coordinated care approach for total health.
  • Patient portals allow for web-based delivery of information.
  • Mobile apps that can be used for patient education are readily available wherever the patient uses a mobile device and can be used to provide patient education.
  • Telemedicine provides remote clinical services to patients through the use of two-way, real-time interactions, such as through video conference calling. It allows patients to receive diagnosis and care for a number of ailments when they are unable to physically get to the medical office.

(USDHHS, 2016)

Assessments

Electronic assessments can help aid in early intervention for substance abuse, and also help your patients with their overall addiction treatment needs. Studies show that patients are more likely to disclose substance use within an online/digital setting rather than in face-to-face assessments (USDHHS, 2016). Studies have also shown that web-based, evidence-based assessments are effective in determining levels of substance use and identifying those who may benefit from treatment (USDHHS, 2016). These types of assessments can be utilized for early interventions, which will, in turn, improve treatment outcomes for those who need addiction support. NIDA has developed one such online screening tool. See the resources on this page or at the end of this module.

Interventions

Electronic interventions can be utilized to support and extend care outside the office setting. Ongoing electronic interventions, such as automatic motivational calls to patients with substance use issues, may help them to decrease their substance use over time and be more encouraged to work towards continued overall abstinence (USDHHS, 2016).

To find one of the many apps available that support recovery, direct patients to search their mobile app store for terms such as "substance abuse recovery apps" or "addiction apps".

View ReferencesHide References
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.
Staff Role

Keep in mind that many of the SBIRT steps can be completed by multiple staff: medical assistant, physician assistant, nurse practitioner, social worker, or counselor. Throughout this activity, dialogue examples will be given for different medical staff. The various screening tools are designed for simple administration and scoring while the later steps simply require an understanding of the brief intervention steps and motivational interviewing.

Flow of Information

Each standardized screening tool includes instructions for administration and scoring so they can be administered and scored by staff with minimal training. If initial screening is completed via a self-administered, computer or paper, standardized health assessment or by staff interview, a system for flagging responses of concern, such as those that suggest unhealthy alcohol use, needs to be in place. "Flagging" of positive responses can be achieved by a note in the patient record or use of alerts in certain electronic medical records for this purpose. It can be a very quick, simple process once it is set up and becomes part of the routine.

Examples of Screening Results

Significant results on admission screening:

Blood pressure 160/90; CAGE-AID positive: 2 out of 4 questions

Vital signs and substance use

BP: 120/90, Pulse: 68, Temp. 98.0, Substance use: NIDA Quick Screen - Negative

Practice Tip

Use of Electronic Health Records (EHR). Select an electronic medical record that has an expectation to screen for all substances: tobacco, alcohol, illicit drugs, or misuse of drugs. Choose EHRs where the user must go through this step in admitting a new patient and in periodic updating of the medical history. Also, the electronic record should have some mechanism of reminding the provider of any positive screening results.

After scoring the screening tool, you can review or confirm with the patient his or her responses and use the opportunity to explain why their answers make you concerned about their health.

Note: It is important to let clients know the health risks associated with even low to moderate drinking. Current research suggests that even low to moderate drinking increases a person's risk for alcohol-related cancer by 38%. Heavy drinking increases the risk of developing these cancers by 51%. It is important to note that the most current research suggests that there are no net health benefits to drinking alcohol (Smyth et al., 2015).

 

I looked over the health assessment that you completed with our nurse and a few of your answers caught my attention. For instance, I am concerned about your drinking habits and how they may impact your health. Can we talk about that?

View ReferencesHide References
Smyth A, Teo KK, Rangarajan S, O'Donnell M, Zhang M, Rana P, Leong DP, Dagenais G, Seron P, Rosengren A, Schutte AE, Lopez-Jaramillo P, Oguz A, Chifamba J, Diaz R, Lear S, Avezum A, Kumar R, Mohan V, Szuba A, Wei L, Yang W, Jian B, McKee M, Yusuf S. Alcohol Consumption and Cardiovascular Disease, Cancer, Injury, Admission to Hospital, and Mortality: A Prospective Cohort Study. The Lancet. 2015. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00235-4/references Accessed on: 2015-09-28.
Communication to Build Patient Rapport

Effective communication skills can improve the effectiveness of screening. Patients who are abusing alcohol or drugs may be reluctant to tell the truth. The following techniques from motivational interviewing may help establish rapport and get the patient to open up:

Ask Open-Ended Questions
 

Tell me more about your marijuana use

 

This is more effective than asking the patient if their marijuana use is a problem, which is likely to be answered, "No."
 

Be Sensitive to the Patient's Own Perspective
 

Anything you say about your drinking stays between us and I only use to understand your needs and how I might help, so please feel free to be open and honest when answering my questions. 

 

 

Listen Reflectively

Paraphrase what you heard from them to let them know you are listening carefully.

 

I lost all my friends. It seems like no one wants to be close to me since I started using a lot of drugs.

 
 

It sounds like your drug use makes you feel pretty isolated.

 

 

Convey a Non-Judgmental Attitude
 

I am not here to judge you. Instead, I want to help you make the best possible decisions about your use of alcohol.

 

 

Empathize with the Patient
 

I know this is not the easiest topic to talk about, and I appreciate that you are willing to talk with me about it.

 

(Sobell & Sobell, 2008)

Note: Additional Motivational Interviewing skills are covered later in the training.

Practice Tip
Pauses are a powerful way to draw people out without asking further questions. After making a simple question or a reflective statement, pause and wait patiently. Most people will fill the pause.
View ReferencesHide References
Sobell, Sobell. Motivational interviewing strategies and techniques: Rationales and examples. Nova Southeastern University. 2008. Available at: http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf Accessed on: 2015-06-16.
Preparation

When trying a new screening instrument, read it aloud before administering it to patients. For example, try reading the sample script for the NIDA-Modified ASSIST:

 

 Hi, I’m ____. Nice to meet you. If it’s okay with you, I'd like to ask you a few questions that will help me give you better care. The questions relate to your experience with alcohol, tobacco, and other drugs.  By "drugs" I mean both "street drugs" and prescribed (like pain medications), if you have taken them for reasons or in doses other than being prescribed them. I ask these questions only to better diagnose and provide any treatments you might need.

 

 

Wording

Reading or repeating screening questions as they are written is important because these tests were validated using these words. Providers can repeat or clarify questions, but it is best not to modify them.

 

Have people annoyed you by criticizing your drinking or drug use?

 

Have they annoyed me or I annoyed them?

 

Have people annoyed you by criticizing your drinking or drug use?

 

The clinician patiently repeated the question, clarifying for the patient that the question asks about the patient's own annoyance with the reactions of others to the patient's substance use, not the annoyance of others with them. This question in the CAGE or CAGE-AID screening tools sometimes causes confustion, because providers and patients may misunderstand it to be about the annoyance of others.

Stage Description
Abstinence "No use" to "a few sips/puffs"
Experimentation First one or two times used
Limited use Use with friends in low risk situation without resulting problems at predictable times, such as weekends
Problematic use to Mild Substance Use Disorder Use in a high risk situation, e.g., driving or that results in problems, such as a fight or school suspension; use for emotional regulation. (1-3 of the criteria for substance use disorder)
Moderate substance use disorder Use associated with recurring problems or that interferes with functioning, such as school, personal care, etc. (4-5 criteria for substance use disorder)
Severe substance use disorder Compulsive use, dependence, loss of control (6 or more criteria for substance use disorder)

(AAP, 2011)

View ReferencesHide References
American Academy of Pediatrics. Policy statement. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011; 128(5): e1330-e1340. Available at: http://pediatrics.aappublications.org/content/128/5/e1330.full Accessed on: 2011-12-13.
Special Considerations for Children and Adolescents

There are several special considerations in screening adolescents for substance use (AAP, 2011):

  • Build rapport early so that trust is already established when discussions about substance use are needed.
  • At risk use is especially important in children and adolescents because
    • Even first use can result in unintentional injury or death with naive use and relatively higher level of risk-taking behavior on the average
    • Higher level of risk for developing addictions neurodevelopmentally
  • Any use of alcohol is considered at risk, unlike adults.
  • Use developmentally appropriate screening tools, such as the CRAFFT
  • Any use should be identified followed by assessment as to where the youth falls on the spectrum from early experimental use through severe substance use disorder.
CRAFFT

CRAFFT is a 6-question screening tool that takes 5 minutes. It is used for adolescents under the age of 21. It does not ask about tobacco or assess the severity of the problem (Knight et al., 2003; Knight et al., 1999).

It begins by asking the adolescent if they have used alcohol, marijuana, or anything to get "high" in the past 12 months. A positive response from the patient for use of any of these substances will advise the provider to begin with the series of 6 questions, ordered by the CRAFFT mnemonic. A positive response on 2 or more of the 6 questions indicates a need for further assessment.

Interview Example

(UMBC Tube, 2013)
Problems viewing videos? Click on View References below to access the video link to YouTube.

View ReferencesHide References
American Academy of Pediatrics (AAP). Alcohol use by youth and adolescents: a pediatric concern. Pediatrics. 2010; 125(5): 1078-1087. Available at: https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf Accessed on: 2010-10-29.
Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003; 27(1): 67-73.
Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Archives of Pediatric and Adolescent Medicine. 1999; 153(6): 591-596. Available at: http://jamanetwork.com/journals/jamapediatrics/fullarticle/347094 Accessed on: 2010-08-25.

Pages

Subscribe to SBIRT Training RSS