Psychiatry Case Challenge: A 60-Year-Old Woman With Sleep Problems and Odd Behavior

Donald M. Hilty, MD, MBA; Jose Feliberti, MD


May 15, 2023

As with other lifelong diseases, a reconceptualization of SUDs is in order, using relapse as a measurement of treatment effectiveness rather than "just" a failure. For clinicians, brief interventions (eg, Screening, Brief Intervention, and Referral to Treatment [SBIRT]) are needed rather than guidelines, algorithms, and other publications, which are hard to understand and may not be operationally incorporated into treatment settings, much less outcome evaluation.[7,8]

Principles of the approach include screening, early triage/treatment, and ongoing monitoring. The setting of care may be primary care, mental health, or substance/residential. Good outcomes include reduced use or no use at all, decreased suffering, and improved level of function. Although remission is the ultimate goal, partial remission and relapse prevention are also goals. The primary symptom outcome targets are abstinence/less use and craving, with secondary measures including attendance, adherence, decreased recidivism, and success of concurrent treatments for other problems (eg, depression, sleep). Social measures include improved relationships; return to work or volunteering; and, for some, staying out of jail/fewer crimes over time compared with a certain period (eg, last year).

Options for discovering, triaging, monitoring, and assessing alcohol and substance issues include the CAGE questionnaire and Alcohol Use Disorders Identification Test (AUDIT), among others.[9,10] The advantages of these include good sensitivity for detection and brief time commitment for the physician and patient. However, follow-up is required to take action. Further screening may be done with the Michigan Alcohol Screening Test (MAST).[11]

The SBIRT is a newer, multistep instrument that screens, triages, and intervenes. It is a comprehensive, integrated, public health approach to the delivery of early intervention for individuals with risky alcohol and drug use and the timely referral to more intensive substance abuse treatment for those who have substance abuse disorders.

Finally, the Brief Addiction Monitor-Revised (BAM-R) is a 17-item, multidimensional instrument used to monitor progress for patients in treatment for an SUD.[12] The BAM includes items that assess risk factors for substance use, protective factors that support sobriety, and drug and alcohol use.

Clinician skill and attitude development are needed as much or more than knowledge. Best practices for prevention, assessment, and treatment of SUDs can be better integrated into training and lifelong learning for clinicians in medical settings. Healthcare systems face challenges, as well. They must help shift clinicians from an individual approach to a team-based, interprofessional model that adds support and a versatile skill set. Indeed, silos of mental health, substance, and primary care services are not functional, practical, and financially feasible at this point.


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