The ASI, which is probably the most widely used assessment instrument, includes several domains besides alcohol and drugs that help determine what kinds of services the patient needs. All the other instruments discussed in the article really focus on making DSM-IV diagnoses of mental disorders. In a clinical setting, it makes more sense to start with a screener—say, the Hopkins Symptom Checklist 90 (Lipman, Covi, and Shapiro, 1979
) or Brief Symptom Inventory (Derogatis and Spencer, 1982
)—than with one of these highly complex instruments. Then, if you need to make a diagnosis after that, you can administer the appropriate section of one of these interviews.
Svikis: In today’s drug treatment settings, making a specific diagnosis of drug abuse or drug dependence doesn’t usually change what you’re going to do for a patient or how you’re going to do it. To date, we have little evidence that empirically based treatments produce different outcomes for patients with one of these diagnoses versus the other.
Forman: Most payers are interested only in knowing, does this person need to be hospitalized, and if not, does this person meet the criteria for dependence in very gross terms? For that, it’s sufficient to use a checklist of the seven DSM-IV criteria, such as the one developed by Dr. Robert Brooner (for more information, contact Dr. Brooner at
Blaine: Nevertheless, the information on severity that these instruments tap into is potentially useful. It is possible that people on the high end of the severity spectrum will benefit more from intense and different services than those on the low end. One reason we lack evidence for this is that research tends to focus, rightly, on the people in greater distress, those at the higher end.
Svikis: That’s true. When I ran a program for pregnant drug-dependent women, the women with lower severity indicators were the ones most likely to leave treatment against medical advice in the first couple of days. Our clinical impression was that they self-selected out because their addictions were less severe than those of their peers, and the program intensity level was too high for them. They took a look around and said, “I don’t need to be here, yet.”
Forman: I am sure the majority of treatment providers would agree and would like to match each patient’s level of care to the severity of his or her problem. However, in most cases, programs’ resources are too constrained to offer multiple levels of care. Usually, the only level of care decision that gets made is whether the patient should be treated in rehab, an outpatient clinic, or a hospital.
Blaine: The article raises an important treatment planning issue: that of distinguishing the mood symptoms of withdrawal from those of major depression. Programs often deal with that by waiting 2 weeks to a month, until the patient has finished the withdrawal process, and then administering an instrument like the Beck Depression Inventory to see if the symptoms are still there.
Svikis: The issue of withdrawal versus depression is very complex. Many programs ask counselors to make this distinction based solely on the ASI, which covers only symptoms in the past 30 days. I believe additional screening tools may improve the validity and reliability of such decisions. Even in research settings, we can’t always tease these two entities apart. Among the difficulties is the fact that the length of substance-related mood symptoms can vary by substance. Also, some outpatients continue to use drugs, which can lead to a recurrence or exacerbation of such symptoms.