Screening for Co-occurring Disorders
Dr. Mark McGovern responds to questions from participants in his Web conference on screening and assessment and the Dartmouth Psychiatric Research Center-Hazelden Co-occurring Disorders Program.
Q.: Is length of abstinence considered in making diagnoses? What is the ideal time to actually diagnose a psychiatric disorder after evacuation of all substances? six months, nine months, one year?
A.: The 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides guidelines for determining the presence of an independent psychiatric disorder versus a “substance-induced” disorder. A psychiatric disorder can be established when the symptoms: 1) occur prior to the onset of the substance use, 2) exist during periods of abstinence, or 3) continue 30 days past the cessation of substance use or withdrawal. Although these three factors may seem relatively straightforward, they are far from it. Often substance use and mental health problems erupt at the same time or same period in life, typically during adolescence or emerging adulthood. It can be difficult to determine which disorder occurred first. Second, many patients entering addiction treatment, or any treatment, haven’t ever been abstinent. And the third criterion is, in reality, quite ambiguous. Withdrawal from some substances may happen in a matter of days (as is the case with alcohol). With others, like cocaine and marijuana, withdrawal may take weeks, and for other substances like opioids, withdrawal may last months.
In adhering strictly to the DSM-IV criteria and using 30 days from last substance use as the guideline, clinicians may be taking a more aggressive approach to diagnosis. On the other hand, if they consider the mechanisms of the specific substance in question and adjust the time frame for abstinence accordingly, they can take a more conservative approach. Neverthless, six months, nine months or one year of abstinence are unrealistically conservative time frames.
Q.: How do Post-Acute Withdrawal (PAW) symptoms play into establishing an independent psychiatric disorder?
A.: Post-Acute Withdrawal (PAW) symptoms make it particularly challenging for a clinician to establish the presence or absence of an independent psychiatric disorder. PAW symptoms are typically associated with chronic opioid use, including heroin and prescription narcotics. These substances have a severe impact on the brain, in particular on the neurotransmitter systems called endorphins. In addition, dopamine receptors and other systems are also likely to be profoundly affected. Opiate drugs can all but pulverize endorphin receptors. Methadone enables the endorphin receptors to work to restore some balance in neurochemistry. It helps these receptors work much like the way insulin enables a Type I diabetic’s diseased pancreas to function. This is why methadone is frequently call “opioid replacement therapy.” However, methadone and buprenorphine target the endorphin and not the dopamine receptors, so ongoing symptoms such as irritability, depression and anxiety may persist long after the cessation of opiate use, even when a patient uses methadone or buprenorphine medications. Unfortunately, the DSM-IV provides minimal guidance in this circumstance.
If, in the short term, it is not possible to make a clear diagnosis, clinicians are encouraged instead to consider the implications of treating or not treating the psychiatric disorder. Some psychotropic medications, such as anti-depressants, have a lag time before they are effective. In these instances, taking a more aggressive approach and treating for psychiatric symptoms may be indicated. Evidenced-based psychosocial treatments like cognitive behavioral therapy are indicated for either a substance use or psychiatric disorder. They are even indicated for psychiatric or substance-induced symptoms that do not meet diagnostic criteria. When it is difficult to make a definitive diagnosis of a psychiatric disorder, prescribing psychosocial treatment could still be appropriate. Of course, there are potential side effects to these medications. CBT, however, is widely regarded as safe and effective with no to minimal side effects.
Q.: I provide drug and alcohol counseling to high school kids. What is the best way to screen these kids for co-occurring illnesses?
A.: The Global Appraisal of Individual Needs (GAIN) short screen, called the GAIN SHORT SCREENER or GSS available from Chestnut Health Systems in Illinois is a reliable and valid screening measure for youth with co-occurring disorders. (See the website of Chestnut Health Systems for additional information.)
Q.: How do you recommend screening and treating persons with co-occurring disorders in the prison system?
A.: Correctional facilities have a unique culture, and this culture varies across prison systems as does the cultural background of the persons incarcerated within them. Nonetheless, research has consistently found high rates of co-occurring substance use and psychiatric disorders among this population—disorders that, for the most part, have gone untreated. The correctional system presents an excellent, if not first opportunity, for people with co-occurring disorders to receive appropriate care.
With respect to screening and assessment, one must consider what potential incentives and disincentives there are for people to accurately and truthfully report problems. In some instances, people may be given rewards for reporting problems. For instance, the reward might be obtaining certain medications or the opportunity to attend therapy sessions or Twelve Step meetings. Or there may be liabilities in reporting problems, such as being seen as “crazy” and suffering stigmatization and discrimination. For this reason, the recommended self-report measures (e.g., Modified MINI Screen or the Substance Severity Index) should be used along with interviews by trained clinicians as well as a review of toxicological, collateral, and historical record data on the client.
Q.: Which of the specific screening measures are in the public domain?
A.: The best screening measures in the public domain include four principal measures: the Modified MINI Screen, Mental Health Screening Form, the CAGE-AID, and the Substance Severity Index. The Screening and Assessment curriculum in the Hazelden Co-occurring Disorders Program reproduces these screens. The curriculum also provides other screening measures designed for specific disorders, such as depression, anxiety, PTSD, and social anxiety. All of these measures are in the public domain. You can also find public-domain screening tools on the Client Support area of the Behavioral Health Evolution website.
To learn more about Hazelden’s behavioral health webinars, visit our free webinars page .