Download Screening, Brief Intervention, and Referral to

Screening, Brief Intervention,
and Referral to Treatment
(SBIRT):
Mental Disorders and Health
Considerations
Sponsored by the University of Iowa
With funding from the Substance Abuse & Mental
Health Services Administration (SAMHSA)
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Goals for today . . .
1. Describe the relationships between mental
illness and substance use.
2. Identify screening methods for depression
and anxiety.
3. Describe health effects and interactions
with substance use.
4. Identify symptoms suggesting the need for
detoxification and referral to treatment.
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
• 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
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
• 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
Attention Deficit/Hyperactivity
Disorder (ADHD)
ADOLESCENTS 
• 14% of children ages 15-17 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)
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Health Effects and Interactions
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
 UI Branded
Education Sheet
for older adults
Anyone who is
given the AUDIT
should also be
provided a copy of
the Education
Sheet
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Many great resources!!
Beyond Hangovers: Understanding Alcohol’s Impact on Your
Health
https://pubs.niaaa.nih.gov/publications/hangovers/beyondHa
ngovers.pdf
Alcohol’s Effects on the Body
https://www.niaaa.nih.gov/alcohol-health
Alcohol Facts and Statistics
https://pubs.niaaa.nih.gov/publications/alcoholfacts&stats/Al
coholFacts&Stats.pdf
Medical Consequences of Drug Abuse
https://www.drugabuse.gov/related-topics/medicalconsequences-drug-abuse
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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!
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Heart/Vascular
• 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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Cancer
Alcohol and drug use are associated with
increased risk for many types of cancer 
• Mouth
• Liver
• Esophagus
• Breast
• Pharynx
• Colon
• Larynx
• Rectal
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Immune System
• Chronic diseases are associated with
impaired bone marrow function
• Weakens the immune system
• Impacts defense systems
Innate
Adaptive/acquired
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Pancreas
• Substance use can lead to
pancreatic organ damage
Heavy, long-term drinking
Some drugs
• Increases risks for 
Pancreatitis
 Acute
 Chronic
Pancreatic cancer
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Of WATER, not alcohol!!!
Smoking, Tobacco, Nicotine
Alcohol and tobacco are often used together
• Roughly 70% of people with an alcoholrelated 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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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!
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
Signs & Symptoms of Withdrawal
• Emotional symptoms
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Anxiety
Restlessness
Irritability
Insomnia
Headaches
Poor concentration
Depression
Social isolation
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
• Physical symptoms
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Sweating
Racing heart
Palpitations
Muscle tension
Tightness in the chest
Difficulty breathing
Tremor
Nausea, vomiting, or
diarrhea
Signs & Symptoms of Withdrawal
• Dangerous symptoms that require emergent
medical treatment include 
Grand mal seizures
Heart attacks
Strokes
Hallucinations
Delirium tremens (DTs)
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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!
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
http://americanaddictioncenters.org/withdrawaltimelines-treatments/alcohol
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT
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
SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT