Subacute and Longer-Term Assessment

Settings for subacute assessment include the following:

  • Medical clinics
  • Mental health clinics
  • Sexually transmitted disease (STD) clinics
  • Hospitals
  • Emergency rooms
  • Welfare and social services offices
  • Other nontreatment settings
  • Doctors’ offices
  • Psychotherapists’ offices.

This section will focus on patients who likely have coexisting AOD use and mood disorders, are not imminently dangerous, and are candidates for treatment. Their functional levels, liabilities, and strengths should be assessed. The goal of subacute assessment is to develop treatment plans with less need for the focus on acute protection (as in the case of acute assessment). Treatment planning is based on a full assessment of treatment needs.

Assessments can be considered part of the treatment process since the assessment process often facilitates breaking through the addicted person’s denial mechanisms. By asking specific questions (about work, relationships, health, or legal problems), the clinician calls attention to the consequences of AOD use. Toxicology screens and/or abnormal liver function tests such as the GGT should be obtained when symptoms and AOD use reports don’t match. Such results can be identified as “consequences” of AOD use. Diagnostic and assessment sessions can be the first intervention. The boundary between assessment and treatment is fluid.

Medical Assessment

A plan should be developed to assess and treat medical conditions that can precipitate or complicate mood disturbances. Such conditions include endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection.

Some medical problems may have a heightened visibility because of their more obvious need for ongoing treatment. However, frequently the primary health care needs of patients with combined AOD and mood disorders are not pursued. For this reason, a plan to assess and meet these treatment needs should be developed.

Psychiatric and Addiction Screening

A subacute nonemergency setting is appropriate for screening and in depth diagnostic interviews for AOD and psychiatric disorders. The following sources can provide valuable information for screening and assessment: psychiatric history, previous medical and psychiatric records, and information from collateral sources such as employers, family members, and laboratory data.

A diagnostic interview, unlike a screening interview, can be done over the course of several sessions. Collateral sources, especially family members, can help clarify diagnostic issues and to help patients recognize the denial that may accompany their disorders.

A thorough history of AOD use, problems, patterns, and treatments should be obtained at this stage. Such information should be collected in a supportive nonjudgmental manner and over multiple interviews when possible. As with the psychiatric assessment, interviews with family and collateral sources are important.

Assessment Instruments

The diagnostic evaluation can include the clinical application of the DSM-III-R (or DSM-IV), perhaps in the form of the Structured Clinical Interview from DSM-III-R (SCID). The Brief Psychiatric Rating Scale, the Hamilton Scale, the Addiction Severity Index (ASI), and the Beck Scale can also be used to assess patients with dual disorders.

The SCID and the ASI are research instruments, but their demonstrated reliability and the advantages of consistent, standardized tools make it reasonable to administer them. Facilities that use these instruments should provide training in their use.
Psychosocial Assessment

A comprehensive psychosocial and vocational assessment can be an important aspect of the overall assessment. Evaluation of the patient’s ongoing support system is important: What is the patient’s support network, including friends and family? What patterns of interpersonal and family relationships exist within the nuclear family, the extended family, and the family of choice? What means of financial support does the patient have? What job skills does the patient have? Also, both ethnic and cultural backgrounds may alter a person’s experience of both AOD and psychiatric conditions.