Diagnosing Substance Use Disorders Among Patients Seeking Treatment For Psychiatric Disorders

Co-occurring SUDs are often overlooked in patients seeking treatment for psychiatric disorders. The first step in the accurate diagnosis of SUDs is to systematically ask the patient about the presence of substance use. Structured clinical assessments have been demonstrated to improve detection of SUDs compared to routine assessment in outpatient SPMI (Breakey, Calabrese, Rosenblatt, & Crum, 1998) and inpatient (Albanese, Bartel, Bruno, Morgenbesser, & Schatzberg, 1994) populations; they have also outperformed urine toxicology testing (Albanese et al., 1994). Unfortunately, the increasing acuity of patients on inpatient units and the demanding time constraints of outpatient psychiatric practice (Woodward, Fortgang, Sullivan-Trainor, Stojanov, &Mirin, 1991) may pose challenges to the systematic assessment of SUDs. In one outpatient study, adding the 4-item CAGE (Cut Down, Annoyed, Guilty, Eye-Opener; Ewing, 1984) questionnaire improved the sensitivity of detecting SUDs from 62% to 97% in an SPMI population (Breakey et al., 1998). However, self-report alone, without urine toxicology, can also lead to underdetection of substance use (Claassen et al., 1997; Shaner et al., 1993).

Finally, contingencies play an important role in patients' willingness to self-report substance use. If patients are repeatedly encouraged to be honest in their self-reports, and if they are told (and more importantly, if they believe) that there will be no negative consequences of reporting use (e.g., being discharged from a treatment program or reported to a probation officer or employer), then they are more likely to be forthcoming in reporting their use. If, however, they are concerned that there will be negative consequences, then they are less likely to do so. Thus, self-reports of substance use in an emergency room, where a patient is unlikely to know the clinician and will probably not believe (whether it is true or not) that there will be no negative consequences for disclosing use, are likely to be suspect. However, in an outpatient treatment setting, where a patient has an opportunity to build a relationship with a clinician or treatment team, and perhaps sees other patients self-disclosing and benefiting from that disclosure, self-reports are likely to be more valid (Weiss, 1998).

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