1. Sponsored by the University of Iowa
Screening, Brief Intervention, and Referral to Treatment (SBIRT): Mental Disorders and Health Considerations
Welcome! Today we’ll discuss some of the important relationships between mental and physical health that clinicians may encounter as they apply the SBIRT process in practice.
Sponsored by the University of Iowa
With funding from the Substance Abuse & Mental Health Services Administration (SAMHSA)

2. Goals for today . . .
Describe the relationships between mental illness and substance use.
Identify screening methods for depression and anxiety.
Describe health effects and interactions with substance use.
Identify symptoms suggesting the need for detoxification and referral to treatment.
We’ll start by considering some of the most common mental disorders that occur concurrently with substance use – both “risky” drinking that is the focus of the SBIRT process, and also substance use disorders.
In that context, we’ll review common screening tools for anxiety and depression – which are often valuable in planning more comprehensive assessment and treatment of concurrent conditions.
We’ll also review the health effects of alcohol and think about substance intoxication that may require medical attention and specialized treatment.

3. Mental Illness and Substance Use
Substance use can 
Be a form of self-medication related to psychiatric symptoms
Increase risks for onset of mental disorders
Worsen symptoms of mental disorders
Let’s start with the important relationship between substance use and psychiatric illness.
Alcohol and drugs may be used to deal with distressing symptoms of mental disorders, but they can also trigger the onset of mental illness and make existing symptoms worse.

4. Mental Illness and Substance Use
Concurrent treatment is essential
Thorough assessment of both conditions
Optimal treatment of both 
Primary care clinics
Specialty care referrals
Integrated, collaborative treatment preferred
People who have a mental disorder and also use substances are at high risk for having a downward spiral in their health. As a result, assessing and treating both conditions at the same time is essential.
Building a strong base of objective data to support symptom presentation – including standardized scale scores, lab values, and physical assessment findings – is essential to adequately treat both conditions. For most people with co-occurring substance and mental disorders, integrated treatment that offers health, mental health, and substance use treatment in the same clinic is optimal. That way they get the best of primary care and specialty treatments working as a team.

5. Clinical Depression
Depressive symptoms may lead to alcohol or drug use as a form of self-medication
AND
Substance use may precipitate depression by altering brain chemistry
Excessive drinking may also lead to bad decisions, which contribute to feeling down
Both clinical and sub-clinical depression is widely associated with substance use, particularly drinking. Of importance, the relationship goes both ways.
Drinking can lead to depression, and
Depression can lead to drinking.
And it’s not just drinking. Use of other substances, including both prescription and illicit drugs, may also be used to “self-medicate” the distressing thoughts and feelings that clinical depression can trigger.
If you suspect a client has depressive symptoms along with substance use, be sure to assess their depression symptoms using a standardized scale.
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Reference: Depression and the Connection to Substance Abuse (

6. Depression Screening Patient Health Questionnaire
PHQ-2: 2 items; hallmark symptoms of depression  anhedonia and prominent dysphoria
PHQ-9: 9 items; diagnostic criteria rated from 0 to 3 for total score of 0 to 27
The Patient Health Questionnaire 2-item and 9-item scales are widely used in clinical settings to assess depressive symptoms. Just like we use the 2-item Annual screen for substance use, the PHQ-2 can be used to detect clinical depression since it rates the two hallmark symptoms of clinical depression: loss of ability to experience pleasure in usual activities and prominent dysphoria or sadness, feeling blue and down. The PHQ-9 is equally easy to use and score, making it another popular alternative.

7. PHQ-9 Scoring
Score each item 0=Not at all 1=Several days 2=More than half the days 3=Nearly every day
Total each column
Add across columns to get a total score: 0 to 27
Apply cut-points
0 to 4 – depression is not significant
5 to 9 – mild depression
10 to 14 – moderate depression; any score 10 or greater is considered clinically significant;
15 or greater – severe depression
Each symptom is rated on a four-point scale. First you total the columns, then add the column totals to get a total score of 0 to 27. A score of 10 or greater indicates clinically significant depression – depression that deserves further assessment and treatment.
The PHQ-9 is just the first step toward a more comprehensive assessment and decisions about treatment. However, quantifying the number and intensity of depressive symptoms can help guide decision-making about possible treatments, which can include medications, psychosocial therapies, and increased physical activity for those with milder depressions.

8. Anxiety Disorders Commonly associated with  Social anxiety disorder
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Panic disorder/panic attacks
Alcohol/other substances + Anxiety 
Response to distressing symptoms
Intensify symptoms
Like depression, anxiety-related disorders can be the reason for substance use, but also worsens symptoms of anxiety-related disorders. For example, individuals with PTSD may experience temporary relief from distressing symptoms of the disorder when drinking alcohol, but ultimately alcohol will intensify their anxiety symptoms.

9. Anxiety Screening Generalized Anxiety Disorder (GAD) scale
GAD-7: 7 items; diagnostic criteria for GAD; scored 0 to 3 like PHQ-9
Nervous, anxious, on edge
Not able to control worrying
Worrying too much about different things
Trouble relaxing
So restless it’s hard to sit still
Easily annoyed, irritability
Feeing afraid; something awful might happen
When you detect anxiety-related symptoms in a client that is using a substance, we highly recommend that you quantify them using a standardized scale. A good starting point is the GAD-7, which will give you a foundation for understanding the frequency and intensity of anxiety-related symptoms.

10. GAD-7 Scoring
Score items like PHQ-9 0=Not at all 1=Several days 2=More than half the days 3=Nearly every day
Total each column
Add across columns to get a total score
Apply cut-points
0 to 4 – anxiety is not significant
5 to 9 – mild anxiety
10 to 14 – moderate anxiety; any score 10 or greater is considered clinically significant;
15 or greater – severe anxiety
The GAD-7 is scored just like the PHQ-9, and uses similar cut-points that can help direct treatment decisions.
There are many additional anxiety scales, including ones that are more targeted for specific syndromes. Which tool or tools you use in practice should be guided by the population you serve. The main point is to clarify the contributing roles of anxiety and depression in substance use – and make sure that both conditions are adequately treated.

11. Attention Deficit/Hyperactivity Disorder (ADHD)
Adolescents 
14% of children ages with ADHD had problems with alcohol use as adults (compared to peers without ADHD)
40% of children with ADHD began using alcohol by mean age of 14.9 years (compared to 22% of children without)
Several studies have shown a strong connection between ADHD and substance use. This evidence suggests that adolescents with ADHD are at a higher risk to start using alcohol during their teenage years. Of equal importance, ADHD is a predictor of alcohol and substance use as an adult. In short, there are many reasons to include substance use in discussions with youth who have ADHD.
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Reference: ADHD and Substance Abuse (

12. Attention Deficit/Hyperactivity Disorder (ADHD)
ADULTS 
Strong connections between ADHD, drug abuse, and alcoholism
ADHD is 5 to 10 times more common among adult alcoholics than those without the condition
About 25% of adults being treated for alcohol and substance use have ADHD
The risks of substance use continue into adulthood for individuals with ADHD. In adults, substances are often used to improve their mood or to sleep better. Of note, substance use is also common among individuals with undiagnosed ADHD or those who have not received treatment.
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Reference: ADHD and Substance Abuse (

13. Serious Mental Illness
Bipolar disorder – More likely to develop an addiction to drugs or alcohol
Schizophrenia
Symptoms similar to drug use
More likely to have substance use disorder (SUD)
Personality disorders
Use of alcohol and drugs can aggravate symptoms
More likely to engage in substance use
Individuals with serious and persistent mental disorders are also more likely to use alcohol and drugs. As noted earlier, alcohol or drugs may be used to reduce distressing symptoms, including psychotic symptoms like auditory hallucinations.
If you are treating individuals with existing mental disorders like ADHD, bipolar disorder, schizophrenia, and personality disorders, think carefully about the potential that they are also using one or more substances – and work toward concurrent treatment of both conditions.
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References:
Bipolar Disorder and Addiction (
Schizophrenia: What About Substance Abuse? (
Borderline Personality Disorder and Addiction (

14. Treatment and Recovery
Dual diagnosis: Mental disorder + Substance use disorder
More challenging than either alone
Treatment can be less effective
Collaborative, integrated treatment is most effective
With a dual diagnosis – substance use disorder and a mental disorder – treatment can be a challenge. As noted earlier, collaborative, integrated approaches to treatment are ideal. However, the starting point is first understanding that more than one illness is affecting your patient. Only then can you work toward developing an effective treatment plan.

15. Health Effects and Interactions
Let’s move ahead now and talk about substance-related health effects.
As we briefly reviewed in our introductory SBIRT program, substance use can have an impact on many parts of our bodies. For individuals with pre-existing health problems, and particularly for those with complex medical problems that are treated with a variety of different medications, substance use can really complicate the person’s health AND treatment of their medical problems.
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Reference: Beyond Hangovers – understanding alcohol’s impact on your health

16.  UI Branded Education Sheet for older adults
Anyone who is given the AUDIT should also be provided a copy of the Education Sheet
In the earlier training module, SBIRT for the Special Needs of Older Adults, we briefly reviewed some of the common health challenges older adults face, and how drinking – in particular – can complicate the course and outcome of treatment. Today we’ll take a little deeper look at some of those problems.

17. Many great resources!!
Beyond Hangovers: Understanding Alcohol’s Impact on Your Health ngovers.pdf Alcohol’s Effects on the Body Alcohol Facts and Statistics coholFacts&Stats.pdf Medical Consequences of Drug Abuse consequences-drug-abuse
Most of what is known today about health risks relates to excessive alcohol use. However, there is also a growing body of evidence about both illicit drugs and misuse of opioids. As listed on the slide, there are some great educational materials available at no cost, which can help with educating peers in health care settings and clients alike. We encourage you to take time to review these to supplement the content provided in this module.

18. Health Assessment Data
Keep substance use in mind 
Presenting problems/observations
Physical assessment findings
Lab results
Collateral interviews: What are others saying? Concerned about?
Health conditions may be the “signal” to explore substance use!
While it’s beyond the scope of this module to review common physical findings, lab values, or other data that may relate to substance use, we urge you to think carefully about health-related complications of alcohol and drug use as antecedents to discussion. The SBIRT annual screen is just one way that health care providers may detect substance use.

19. Brain
Alcohol and drugs interrupt communication pathways and change brain structure and chemistry
Disruptions in mood, behavior, cognition
Motor coordination, sleep, temperature regulation
Two special risks 
Prenatal alcohol exposure; fetal alcohol syndrome
Adolescent substance use; affects the brain while it is still in development
Alcohol-related disruptions to neurotransmitters can trigger mood and behavioral changes, including depression, agitation, memory loss, and even seizures. With long-term and heavy use, alterations in neurons lead to brain mass and structure changes that may affect a wide range of abilities.
And as we reviewed in the program for youth, there are special risks associated with substance use early in life, from pregnancy through adolescence.
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References:
Beyond Hangovers – understanding alcohol’s impact on your health
The Affects of Long Term Drug Use On The Brain (
The Effects of Drugs and Alcohol on the Adolescent Brain (

20. Heart/Vascular Strokes Hypertension
Cardiomyopathy: Long-term heavy drinking (anatomic function)
Arrhythmias (physiologic function)
Atrial fibrillation
Ventricular tachycardia
Strokes
Hypertension
Additional risks with illicit drugs; varies by drug type
While researchers now understand that drinking moderate amounts of alcohol can protect some individuals from the risks of coronary artery disease, they also know that excessive or long-term drinking and drug use cause a wide variety of cardiovascular risks. Evidence also indicates that drug use has considerable implications for cardiac health – from risks of myocardial infarction to arrhythmias.
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References:
Beyond Hangovers – understanding alcohol’s impact on your health
Addiction, Heart Disease, and Stroke (

21. Cancer
Alcohol and drug use are associated with increased risk for many types of cancer 
Mouth
Esophagus
Pharynx
Larynx
Liver
Breast
Colon
Rectal
The more a person drinks, the higher the risk for a variety of cancers.
The National Cancer Institute identifies alcohol as a risk factor for mouth, esophagus, pharynx, larynx, liver, and breast cancers. Heavy drinking can also increase the risk of developing other types of cancer, such as colon or rectal cancer. _________________________
References:
Beyond Hangovers – understanding alcohol’s impact on your health
Medical Consequences of Drug Abuse – Cancer (

22. Immune System
Chronic diseases are associated with impaired bone marrow function
Weakens the immune system
Impacts defense systems
Innate
Adaptive/acquired
Drinking too much alcohol can weaken the immune system, which makes it easier for diseases to overtake the body. It can suppress both the innate and acquired immune systems, creating vulnerability to illness and disease that the person would otherwise resist.
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References:
Beyond Hangovers – understanding alcohol’s impact on your health

23. Liver
Alcohol consumption increases the risk of liver damage; the amount of alcohol doesn’t correlate well with the amount of damage to the liver
Alcoholic hepatitis – inflammation due to excessive fat in the liver
Fibrosis – scar tissue
Cirrhosis – deterioration of the liver
Heroin, inhalants and steroids liver damage
Heavy drinking causes fat to build up in the liver, which can lead to dangerous inflammations and also development of scar tissue. Excessive scar tissue can lead to cirrhosis of the liver. Complications of cirrhosis may include jaundice, insulin resistance and type 2 diabetes, and liver cancer. Chronic use of some drugs – such as heroin, inhalants, and steroids – can also lead to significant liver damage.
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References:
Beyond Hangovers – understanding alcohol’s impact on your health
Liver Damage (

24. Pancreas Substance use can lead to pancreatic organ damage
Heavy, long-term drinking
Some drugs
Increases risks for 
Pancreatitis
Acute
Chronic
Pancreatic cancer
Long-time excessive alcohol consumption can lead to pancreatitis. Damage can also be caused by heroin, cocaine, and non-medical use of prescription drugs. Pancreatitis is a risk factor for the development of pancreatic cancer.
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References:
Beyond Hangovers – understanding alcohol’s impact on your health
The Effects of Drug Abuse on Your Pancreas (

25. Kidney Function Alcohol can worsen kidney disease
Binge drinking can lead to acute kidney failure
Drugs are also associated with damage or failure
Heroin
Inhalants
MDMA (ecstasy)
PCP
Certain drugs and the excessive use of alcohol can cause kidney damage or lead to kidney failure.
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References:
Alcohol and Your Kidneys (
Medical Consequences of Drug Abuse – Kidney Damage (
Of WATER, not alcohol!!!

26. Smoking, Tobacco, Nicotine
Alcohol and tobacco are often used together
Roughly 70% of people with an alcohol- related substance use disorder use tobacco products
Cigarette smoking is associated with drug use
Nearly 60 percent of new smokers were under the age of 18 (in 2010)
Smoking is a “gateway” to alcohol/drugs
Another important consideration is the relationship between tobacco use and substance use. As outlined on the slide, there’s a strong relationship between smoking and both alcohol and drug use. In turn, we urge thoughtful consideration of possible substance use among clients who may smoke, particularly youth.
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References:
Smoking and Adolescence (
Alcohol and Tobacco (
Substance Use and Tobacco (
The association between cigarette smoking and drug abuse in the United States (

27. Complex Medical Problems
Risky, harmful substance use makes it more difficult to treat underlying medical conditions, including:
Management of the medical condition itself
Heart failure
Diabetes
Kidney function
Hypothyroidism
Effective use of therapeutic medications
This is just a brief list of medical conditions that may become more complex when substance use is involved. Alcohol and drug use can make the medical condition worsen, or more difficult to manage. For those who use multiple drugs to treat their health conditions, alcohol use can interact with those medications and cause problems, particularly in older adults who have multiple medical conditions. In short, this is another important sub-population to carefully monitor for substance use!
_________________________
References:
Psychotropic drug use and alcohol consumption among older adults in Germany (
Alcohol, drugs and much more in later life (

28. Medical Detoxification
SBIRT focuses on identification of risky behaviors, but . . .
Clinicians also need to recognize intoxication that warrants medical attention
Recognize warning symptoms
Understand detoxification methods
Be PREPARED
Know who/what your resources are!
While you are not expected to use detoxification methods with your clients, it’s important to understand warning signs that a client may be using alcohol or drugs at a level that they need help to safely stop. Being prepared is really the main issue.

29. Signs & Symptoms of Withdrawal
Emotional symptoms
Anxiety
Restlessness
Irritability
Insomnia
Headaches
Poor concentration
Depression
Social isolation
Physical symptoms
Sweating
Racing heart
Palpitations
Muscle tension
Tightness in the chest
Difficulty breathing
Tremor
Nausea, vomiting, or diarrhea
The signs and symptoms of withdrawal from alcohol and drug use cover a wide range of both emotional and physical symptoms. Of equal importance, withdrawal symptoms vary from person to person.
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References: Withdrawal (

30. Signs & Symptoms of Withdrawal
Dangerous symptoms that require emergent medical treatment include 
Grand mal seizures
Heart attacks
Strokes
Hallucinations
Delirium tremens (DTs)
The most dangerous physical withdrawal symptoms come from suddenly stopping the use of alcohol and tranquilizers.
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Reference: Withdrawal (

31. Detoxification/ Referral
Detox alone isn’t enough 
Important first step in treatment
Necessary to reduce risks of relapse
Careful/thoughtful assessment is essential to guiding next steps
Work toward building relationships to support crisis intervention decisions!
Some individuals may present to you asking for help with detoxification from alcohol or drugs. Decisions about next steps should be guided by thorough evaluation, AND also what options are readily available.
For example, you may attempt to refer the patient for specialty treatment, but the service is already full and wait-listed. Having a working relationship with specialty services ahead of time will help in the decision-making process needed to keep the person safe. As discussed in SBIRT, a “warm handoff” that supports the person as they get to treatment is essential. Individuals with strong support systems are more likely to succeed.
In some cases, emergency services may be indicated, and clearly any dangerous symptoms of withdrawal will require immediate emergency care.
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Reference: Detox: Summary & Key Issues to Remember (

32. How Detox Works
Close supervision/continuous monitoring is necessary over the course of days to prevent delirium tremens (DTs)
“Cold turkey” is never recommended without medical supervision
Benzodiazepines are commonly used in withdrawal protocols
Good resource  Alcohol Withdrawal Treatment, Symptoms, and Timeline timelines-treatments/alcohol
While every individual’s experience with detox will be different, there are guidelines to assist in clinical decision-making. The one provided by the American Addiction Centers is a good example, but there are others that may provide better guidance based on your clinical setting and the primary population that you serve. As before, collaborating with substance use specialty care providers in advance of a crisis can ease the tension of knowing what is best for individual clients in your practice.
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Reference: Alcohol Withdrawal Treatment, Symptoms, and Timeline (

33. Summary
There is a close relationship between mental disorders and substance use
Treatment of concurrent substance use and mental disorders can be challenging, and is more successful when personalized to the individual
Understanding and identifying substance-related health effects and interactions is key to comprehensive care
Identifying signs of withdrawal can avert crises; referral to treatment is the preferred intervention to manage withdrawal
In summary, concurrent mental, medical, and substance use disorders demand thoughtful assessment and treatment. Using standardized scales and physical findings based on assessments help clinicians better gauge therapeutic next steps for care and treatment. While treatment can be challenging for those with dual diagnoses or co-occurring conditions, understanding the complexity of issues is an important first step in the provisions of comprehensive, competent care and treatment.