Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

278 IV. SPECIAL POPULATIONSDIAGNOSING SUBSTANCE USE DISORDERSAMONG PATIENTS SEEKING TREATMENTFOR PSYCHIATRIC DISORDERSCo-occurring SUDs are often overlooked in patients seeking treatment for psychiatricdisorders. The first step in the accurate diagnosis of SUDs is to systematicallyask the patient about the presence of substance use. Structured clinicalassessments have been demonstrated to improve detection of SUDs comparedto routine assessment in outpatient SPMI (Breakey, Calabrese, Rosenblatt,& Crum, 1998) and inpatient (Albanese, Bartel, Bruno, Morgenbesser, &Schatzberg, 1994) populations; they have also outperformed urine toxicologytesting (Albanese et al., 1994). Unfortunately, the increasing acuity of patientson inpatient units and the demanding time constraints of outpatient psychiatricpractice (Woodward, Fortgang, Sullivan-Trainor, Stojanov, & Mirin, 1991)may pose challenges to the systematic assessment of SUDs. In one outpatientstudy, adding the 4-item CAGE (Cut Down, Annoyed, Guilty, Eye-Opener;Ewing, 1984) questionnaire improved the sensitivity of detecting SUDs from62% to 97% in an SPMI population (Breakey et al., 1998). However, selfreportalone, without urine toxicology, can also lead to underdetection of substanceuse (Claassen et al., 1997; Shaner et al., 1993).Finally, contingencies play an important role in patients’ willingness to selfreportsubstance use. If patients are repeatedly encouraged to be honest in theirself-reports, and if they are told (and more importantly, if they believe) that therewill be no negative consequences of reporting use (e.g., being discharged from atreatment program or reported to a probation officer or employer), then they aremore likely to be forthcoming in reporting their use. If, however, they are concernedthat 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 isunlikely to know the clinician and will probably not believe (whether it is true ornot) that there will be no negative consequences for disclosing use, are likely to besuspect. However, in an outpatient treatment setting, where a patient has anopportunity to build a relationship with a clinician or treatment team, and perhapssees other patients self-disclosing and benefiting from that disclosure, selfreportsare likely to be more valid (Weiss, 1998).TREATMENT OF DUALLY DIAGNOSED PATIENTSA Heterogeneous PopulationSince “dually diagnosed” patients comprise a heterogeneous population, it followsthat their treatment should perhaps reflect that heterogeneity (Weiss,Mirin, & Frances, 1992); a “one size fits all” approach therefore will likely