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Co-occurring
MENTAL ILLNESS and
SUBSTANCE USE
DISORDERS
A GUIDE TO DIAGNOSIS
AND TREATMENT
Edited by
Jonathan D. Avery, M.D.
John W. Barnhill, M.D.
CO-OCCURRING MENTAL ILLNESS
and
SUBSTANCE USE DISORDERS
A Guide to Diagnosis and Treatment
CO-OCCURRING MENTAL ILLNESS
and
SUBSTANCE USE DISORDERS
A Guide to Diagnosis and Treatment
Edited by

Note: The authors have worked to ensure that all information in this book is ac
curate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis
tent with standards set by the U.S. Food and Drug Administration and the gen
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea
sons and because human and mechanical errors sometimes occur, we recom
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessar
ily represent the policies and opinions of American Psychiatric Association
Publishing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.ap
pi.org/specialdiscounts for more information.
Copyright © 2018 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
First Edition
Manufactured in the United States of America on acid-free paper
21 20 19 18 17 5 4 3 2 1
American Psychiatric Association Publishing
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Names: Avery, Jonathan D., editor. | Barnhill, John W. (John Warren), editor. |
American Psychiatric Publishing, publisher.
Title: Co-occurring mental illness and substance use disorders : a guide to
diagnosis and treatment / edited by Jonathan D. Avery, John W. Barnhill.
Description: First edition. | Arlington, Virginia : American Psychiatric
Association Publishing, [2018] | Includes bibliographical references and
index.
Identifiers: LCCN 2017030620 (print) | LCCN 2017031909 (ebook) |
ISBN 9781615371594 (ebook) | ISBN 9781615370559 (pbk. : alk. paper)
Subjects: | MESH: Diagnosis, Dual (Psychiatry) | Mental Disorders—
diagnosis | Substance-Related Disorders—diagnosis | Mental Disorders—
therapy | Substance-Related Disorders—therapy | Problems and Exercises
Classification: LCC RC473.D54 (ebook) | LCC RC473.D54 (print) | NLM WM
18.2 | DDC 616.89/075—dc23
LC record available at https://lccn.loc.gov/2017030620
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
PART 1
THE INITIAL INTERVIEW AND
COMPREHENSIVE ASSESSMENT
1 The Initial Interview . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 The Comprehensive Assessment . . . . . . . . . . . . . . . 13

Christine Yuodelis-Flores, M.D., and Richard K. Ries, M.D.
PART 2
CO-OCCURRING DISORDERS
3 Depressive and Bipolar Disorders . . . . . . . . . . . . . . 25

Rocco A. Iannucci, M.D., and Roger D. Weiss, M.D.
4 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Rebecca A. Nejat, M.D., and Maria Andrea Baez, M.D.
5 Posttraumatic Stress Disorder . . . . . . . . . . . . . . . . . 49

J. David Stiffler, M.D., and Grace Hennessy, M.D.
6 Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 69
Bernadine H. Han, M.D., M.S., and Jonathan D. Avery, M.D.
7 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . 83
John W. Barnhill, M.D., and Jonathan D. Avery, M.D.
8 Attention-Deficit/Hyperactivity Disorder . . . . . . . . . 93
Sean X. Luo, M.D., Ph.D., and Frances R. Levin, M.D.
9 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Sean P. Kerrigan, M.D., and Evelyn Attia, M.D.
10 Gambling Disorder. . . . . . . . . . . . . . . . . . . . . . . . . 123
Mayumi Okuda, M.D., Silvia Franco, M.D., and
Ariel Kor, Ph.D.
PART 3
SPECIFIC TREATMENTS
11 Twelve-Step Programs . . . . . . . . . . . . . . . . . . . . . . 141

Luke J. Archibald, M.D.
12 Motivational Interviewing . . . . . . . . . . . . . . . . . . . 151

Howard R. Steinberg, Ph.D., David T. Pilkey, Ph.D., and
Steve Martino, Ph.D.
13 Inpatient Treatment of Co-occurring Disorders . . . 167

Zain Khalid, M.D., Sonal Batra, M.D., and
Erin Zerbo, M.D.
14 Pharmacological Interventions . . . . . . . . . . . . . . . . 185

PART 4
SPECIAL POPULATIONS
15 Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Shannon G. Caspersen, M.D., M.Phil.
16 Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Caitlin Snow, M.D.
17 LGBTQ Population . . . . . . . . . . . . . . . . . . . . . . . . . 225

Eric Yarbrough, M.D.
18 Incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Lauren Stossel, M.D.
Appendix: Answer Guide. . . . . . . . . . . . . . . . . 255

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
CONTRIBUTORS
Luke J. Archibald, M.D.

Clinical Assistant Professor of Psychiatry, NYU School of Medicine,
New York
Evelyn Attia, M.D.
Professor of Clinical Psychiatry, Weill Cornell Medical College, White
Plains, New York; Clinical Professor of Psychiatry, Columbia University
College of Physicians and Surgeons, New York, New York
Assistant Clinical Professor of Psychiatry, Assistant Dean of Student Af
fairs, Weill Cornell Medical College; Assistant Attending Psychiatrist,
New York-Presbyterian Hospital, Payne Whitney Clinic, New York,
New York
Maria Andrea Baez, M.D.
Clinical Assistant Professor of Psychiatry, New York University School
of Medicine, New York, New York
Professor of Clinical Psychiatry, DeWitt Wallace Senior Scholar, and
Vice Chair for Psychosomatic Medicine, Department of Psychiatry,
Weill Cornell Medical College; Chief, Consultation-Liaison Service,
New York-Presbyterian Hospital, Weill Cornell Medical Center Hospi
tal for Special Surgery, New York, New York
Sonal Batra, M.D.
Fellow, Pharmaceutical Medicine, Rutgers Robert Wood Johnson Med
ical School, Piscataway, New Jersey
vii
viii Co-occurring Mental Illness and Substance Use Disorders
Shannon G. Caspersen, M.D., M.Phil.

Clinical Instructor, Weill Cornell Medical College, New York-Presbyterian
Hospital, New York, New York
Silvia Franco, M.D.
Psychiatry Resident, The Icahn School of Medicine at Mount Sinai/
St. Luke’s–Roosevelt Hospital Psychiatry Program, New York, New
York
Bernadine H. Han, M.D., M.S.
Resident, Payne-Whitney Psychiatry, Weill Cornell Medicine/New
York-Presbyterian Hospital, New York, New York
Grace Hennessy, M.D.
of Medicine; Director, Substance Abuse Recovery Program, Depart
ment of Veterans Affairs, New York Harbor Healthcare System, New
York Campus, New York, New York
Rocco A. Iannucci, M.D.
Instructor in Psychiatry, Harvard Medical School, Boston, Massachu
setts; Director, McLean Fernside, Princeton, Massachusetts
Sean P. Kerrigan, M.D.
Assistant Professor of Psychiatry, Weill Cornell Medical College, New
York-Presbyterian Hospital, White Plains, New York
Zain Khalid, M.D.
PGY-2 Resident, Department of Psychiatry, Rutgers New Jersey Medi
cal School, Newark, New Jersey
Ariel Kor, Ph.D.
Department of Counseling and Clinical Psychology, Teachers College,
Columbia University, New York, New York
Frances R. Levin, M.D.
Kennedy-Leavy Professor of Psychiatry; Director, Division on Sub
stance Abuse, Department of Psychiatry, Columbia University, New
York, New York
Sean X. Luo, M.D., Ph.D.
Leon Levy Fellow, Department of Psychiatry, Columbia University,
New York, New York
Contributors ix
Steve Martino, Ph.D.

Professor of Psychiatry, Yale University School of Medicine, New Haven,
Connecticut; Chief, Psychology Service, VA Connecticut Healthcare
System, West Haven, Connecticut
Rebecca A. Nejat, M.D.
Chief Resident, Weill Cornell Department of Psychiatry, New York, New
York
Mayumi Okuda, M.D.
Director, Gambling Disorders Clinic, Department of Psychiatry, New York
State Psychiatric Institute/Columbia University, New York, New York
David T. Pilkey, Ph.D.
Assistant Professor of Psychiatry, Yale University School of Medicine,
New Haven, Connecticut; Program Manager, Substance Abuse Day
Program, VA Connecticut Healthcare System, West Haven, Connecticut
Richard K. Ries, M.D.
Professor, Department of Psychiatry and Behavioral Sciences, Univer
sity of Washington, Seattle, Washington
Caitlin Snow, M.D.
Assistant Professor of Clinical Psychiatry, New York-Presbyterian/
Weill Cornell Medicine, New York, New York
Howard R. Steinberg, Ph.D.
Assistant Professor of Psychiatry, Yale University School of Medicine,
New Haven, Connecticut; Program Manager, Psychosocial Residential
Rehabilitation Treatment Program, VA Connecticut Healthcare System,
West Haven, Connecticut
J. David Stiffler, M.D.
of Medicine; Medical Director, The Steven A. Cohen Military Family
Clinic, New York, New York
Lauren Stossel, M.D.
Forensic Psychiatry Fellow, New York University, New York, New York
Roger D. Weiss, M.D.
Professor of Psychiatry, Harvard Medical School, Boston, Massachu
setts; Chief, Division of Alcohol and Drug Abuse, McLean Hospital,
Belmont, Massachusetts
x Co-occurring Mental Illness and Substance Use Disorders
Eric Yarbrough, M.D.

Director of Psychiatry, Callen-Lorde Community Health Center, New
York, New York; President, The Association of LGBTQ Psychiatrists,
Philadelphia, Pennsylvania
Christine Yuodelis-Flores, M.D.
Associate Professor, Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, Washington
Erin Zerbo, M.D.
Assistant Professor, Department of Psychiatry, Rutgers New Jersey
Medical School, Newark, New Jersey
Disclosure of Competing Interests
The following contributors to this book have indicated a financial interest in or

other affiliation with a commercial supporter, a manufacturer of a commercial
product, a provider of a commercial service, a nongovernmental organization,
and /or a government agency, as listed below:
Frances R. Levin, M.D.—Dr. Levin received medication from U.S. World-
Med for this trial and served as a consultant to GW Pharmaceuticals and
Eli Lily, and served on an advisory board to Shire in 2006–2007. Dr. Levin
also serves as a consultant to Major League Baseball regarding the diag
nosis and treatment of ADHD.
The following contributors to this book have reported no competing interests

during the year preceding manuscript submission:
Luke J. Archibald, M.D. Sean X. Luo, M.D., Ph.D.
Jonathan D. Avery, M.D. Steve Martino, Ph.D.
Maria Andrea Baez, M.D. Rebecca A. Nejat, M.D.
John W. Barnhill, M.D. Mayumi Okuda, M.D.
Shannon G. Caspersen, M.D., David T. Pilkey, Ph.D.
M.Phil. Richard K. Ries, M.D.
Silvia Franco, M.D. Howard R. Steinberg, Ph.D.
Bernadine H. Han, M.D., M.S. J. David Stiffler, M.D.
Rocco A. Iannucci, M.D. Lauren Stossel, M.D.
Sean P. Kerrigan, M.D. Eric Yarbrough, M.D.
Zain Khalid, M.D. Christine Yuodelis-Flores, M.D.
Ariel Kor, Ph.D. Erin Zerbo, M.D.
INTRODUCTION
C o-occurring Mental Illness and Substance Use Disorders: A Guide to Diag

nosis and Treatment is an evidence-based approach to people with at least
two psychiatric disorders, one of which relates to substance use. This pop
ulation of patients was formerly known as having a “dual diagnosis.”
Our primary goal is to provide the clinician with a straightforward ap
proach to people with complicated presentations. Each chapter is based
on a specific case that is written in such a way as to highlight generaliz
able suggestions. Our strongest central recommendation is simple: peo
ple should be tactfully but persistently evaluated for a broad range of
co-occurring disorders, and then each of these disorders should be given
clinical attention. At times, treatment for a particular disorder can be de
ferred, but for most co-occurring disorders, therapeutic success is much
more likely if treatment is integrated, based on evidence, and focused on
all relevant diagnoses.
Within psychiatry, co-occurring disorders are more the rule than the ex
ception. People with substance use disorders typically have at least one
co-occurring psychiatric disorder, while people with a primary psychiat
ric disorder often have at least one co-occurring substance use disorder.
When there are two co-occurring disorders, there are often several others.
Substances of abuse have a complex relationship with mood, behav
ior, memory, and all the variables that go into making us human. It can
be challenging to determine whether the presentation (e.g., depression,
mania, confusion) is a manifestation of a primary psychiatric disorder
or of substance intoxication, withdrawal, or chronic use. Further, people
with co-occurring disorders often have complex psychosocial situations,
complicated histories, and a seemingly entrenched pattern of failed treat
xi
xii Co-occurring Mental Illness and Substance Use Disorders
ments. Given the number of psychiatric disorders and the number of sub
stances of abuse, the potential clinical complexity can feel overwhelming
to clinicians, families, and patients. Fortunately, there are straightfor
ward approaches to this complexity.
Let’s consider a difficult but fairly routine case of co-occurring disor
ders. David is a 19-year-old man who presents for an evaluation after
being arrested for selling MDMA (ecstasy) at a rave party. His affluent par
ents were able to get the criminal charges dropped, but they desperately
want help for their son. David has been smoking marijuana almost daily
since age 12 and has, in recent years, developed a daily habit of alternat
ing cocaine and heroin in order to “fine tune” his mood. He sells ecstasy at
rave parties in order to gain access to money, parties, drugs, and women.
David has successfully taken amphetamine for his attention-deficit/
hyperactivity disorder (ADHD) (combined presentation), which he, his
parents, and his teachers agreed was helpful. A recent psychiatrist dis
continued the amphetamine out of concern for abuse, though David
insisted that he tended to be “short” on the amphetamine by the end of the
month, not because he sells or over-uses, but because Sally, his 17-year-old
sister, steals his supply. Sally had always been “perfect,” but ever since a
difficult breakup with a possibly abusive boyfriend, she has become
moody and “way too skinny.”
David, himself, attends classes at a local junior college. He made B’s
in high school but missed about half of the school days between ninth
and twelfth grades so that he earned a GED rather than a high school di
ploma. David has briefly seen several psychotherapists, has recurrently
tried 12-step programs, and has, in the past year, twice relapsed imme
diately after 30-day drug rehabs. David’s parents are in the midst of a
stormy divorce fueled by the father’s persistent risk taking, irritability,
and sexual indiscretions. The father averages a liter of vodka every
2 days, which he says is the only thing that can get him to sleep. David’s
mother is depressed and anxious and averages about 4 mg of clonaze
pam each day. David says he is a “clean needle fanatic” and insists that
he will never get HIV, but he describes himself as a “nocturnal nihilist”
with little hope that he’ll live to reach age 21.
How best to approach David’s complexity? One option is to identify a
single problem as the focus for treatment. For example, David might be
seen to have cocaine, heroin, and marijuana use disorders and be referred
to either a 12-step program or a drug rehab. This approach has already
failed multiple times, however, and so it might be useful to broaden the
diagnostic possibilities to include undiagnosed and untreated depres
sive, anxiety, and/or insomnia disorder. The only co-occurring disorder
that has received clinical attention appears to be ADHD, and a recent
Introduction xiii
psychiatrist discontinued pharmacological treatment of the ADHD out

of concern that the treatment (amphetamine) could be fueling his other
substance use disorders. At this point, we would suggest that David
needs attention paid to these co-occurring disorders if he is going to live
successfully into adulthood. To help provide a clear but integrated plan,
a clinician might read this book’s chapters on ADHD, depression, anx
iety, adolescence, and 12-step programs.
This book also features chapters on how to effectively work with disor
ders that might be affecting other members of David’s family. For exam
ple, David’s sister may be stealing his amphetamines, but she may have
also developed an eating disorder, PTSD, and/or an anxiety or depres
sive disorder. David’s mother appears to have depression, anxiety, and a
benzodiazepine use disorder. His father might have an alcohol use dis
order as well as a diagnosis on the bipolar spectrum. In each case, the
likelihood of a successful outcome is enhanced if an integrated treat
ment plan is developed for their co-occurring disorders.
Before a treatment plan can be organized, however, it is necessary to
identify the co-occurring disorders. Inaccurate or incomplete diagnoses
will likely lead the treatment to founder, as will an insecure alliance. For
that reason, the initial face-to-face sessions are especially important in
this population. This book includes many tips on how to interview this
group of patients, including entire chapters on motivational interview
ing, the diagnostic assessment, and the initial interview.
Effective medications are available for both substance use disorders
and co-occurring psychiatric disorders. Addiction specialists are gener
ally aware of the strong evidence for medications that reduce craving,
but they might be slow to pharmacologically treat the co-occurring dis
orders. General psychiatrists may be comfortable using medications to
treat such disorders as depression or anxiety, but they may undervalue
such medications as naltrexone and buprenorphine, which are gener
ally effective and have few adverse effects. Co-occurring Mental Illness
and Substance Use Disorders: A Guide to Diagnosis and Treatment will main
tain a consistent point of view that medications for substance use disor
ders should be at least considered as part of an integrated treatment, as
should more “standard” psychiatric medications.
This book is organized around 18 cases. The first two cases address
interviewing and assessment. Each of the next eight cases focuses on a
specific group of mental illness (e.g., depressive disorders, ADHD) and
how to treat the mental illness and the substance use disorders that are
highly comorbid with that illness. The subsequent four cases focus on
specific treatments for co-occurring disorders. The final four cases focus
on treating co-occurring disorders in special populations.
xiv Co-occurring Mental Illness and Substance Use Disorders
You have options in reading this casebook. You can read the 18 cases
and discussions straight through. The cases do not depend on one another,
however, and so you might start with a case that sounds interesting or
about which you have a specific interest. The accompanying questions
can be used to test your knowledge after you have read the chapter, though
the questions can also be read prior to reading the chapter in order to
help organize your reading. However it is used, we hope that this case
book can improve the experience of the clinicians who work with this
population and improve the lives of the many people who suffer with
these co-occurring disorders.

PART 1
THE INITIAL INTERVIEW AND

COMPREHENSIVE ASSESSMENT
1
THE INITIAL INTERVIEW
T he core goals of the initial psychiatric evaluation are to ensure safety,

understand the patient, and help develop a workable treatment plan.
These straightforward principles are true for all patients, including people
with co-occurring disorders. This chapter will address the structure of the
initial interview and is intended to be digested alongside the book’s other
chapters, particularly the chapters on assessment (Chapter 2, “The Com
prehensive Assessment”) and motivational interviewing (Chapter 12,
“Motivational Interviewing”).
Most clinicians begin the initial interview by asking an open-ended
question like “Tell me about what brought you here today.” The initial
question is followed by a period of active listening in which the inter
viewer demonstrates ongoing interest by asking questions such as “Tell
me more about what you mean.” This relatively unfocused phase of the
interview gives the patient a chance to present his or her own concerns,
which helps build an alliance and lays the groundwork for later treat
ment discussions. Open-ended questions also provide the interviewer
with the opportunity to observe the patient and silently begin to make a
set of tentative hypotheses.
3
4 Co-occurring Mental Illness and Substance Use Disorders
TABLE 1–1. Physical symptoms that might point to substance use

disorders
Face: puffy, blushing, or pale
Poor overall health; runny nose; hacking cough
Poor hygiene
Unusual smells on breath, body, or clothes
Sweating
Cold palms
Tremor
Red, watery eyes
Pupils larger or smaller than usual
Needle marks
Poor physical coordination, stumbling gait
Altered activity and talkativeness
This early period of hypothesis generation is central to the evaluation

of a patient who may have co-occurring disorders. Some patients pre
sent with a “loud” substance use disorder, but “quieter” diagnoses like
anxiety or depression may be the bigger concern to the patient and may
be obstacles to effective treatment. Other patients present without a sub
stance use complaint but with a relatively obvious mood or anxiety dis
order; this initial phase of the interview may provide clues to a “quiet”
or hidden substance use disorder. In other words, the interview is an op
portunity both to hear the “chief complaint” of the patient and to listen
for what may not be clearly articulated.
Listening for what is not said is an interesting skill set that is part of
becoming a clinician. In addition to the patient’s actual words, the inter
viewer can learn from the “music” of the interview, such as the degree to
which the interaction feels antagonistic, cooperative, or needy. This
early phase of the interview is also an excellent time to tactfully observe
physical signs that are often found in people with co-occurring disor
ders (Table 1–1).
This early phase of the evaluation can help interest the patient in his
or her own problems. For example, the interviewer can ask, “Do you have
thoughts as to why your wife might have called for your appointment?”
or “Leaving aside what your husband wants for a moment, is there any
thing that is bothering you?” Genuine curiosity can help clarify the full
range of problems and can also help develop the alliance that will be cru
cial to the treatment’s eventual success.
The Initial Interview 5
This early phase of the interview is, thus, a time for the clinician to de
velop an alliance and begin to silently develop a differential diagnosis,
a history of the present illness, and a mental status examination (MSE).
A broad assessment effort is especially important in patients with co
occurring disorders, because evidence indicates that it is best to treat—or
at least explicitly recognize—co-occurring disorders from the outset of the
intervention.
Pressured for time, the busy clinician may decide to forgo this initial,
open-ended phase in the pursuit of symptom clarification. Without a
broad understanding of the patient’s complaints, however, this clinician
may develop a focused understanding of one aspect of the patient but
miss other diagnoses as well as the patient’s own concerns.
Although open-ended curiosity is generally the most effective initial
strategy during this initial phase, some patients are unable to open up
until asked some “warm-up” questions (e.g., demographic informa
tion). Still other patients are unable or unwilling to reveal sensitive in
formation soon after meeting someone. Each interview is a bit different,
and so the interviewer will likely have to remain flexible to be effective.
The later phase of the interview is focused on the interviewer’s effort
to convert the patient’s story into the interviewer’s own history of the pres
ent illness (HPI). This is an active process that requires the clinician to
elicit and synthesize an assortment of patient behaviors and symptoms,
bits of semi-reliable collateral information, possible comorbidities, un
spoken hypotheses, prior (mis)diagnoses, and psychiatric, medical, so
cial, family, and developmental histories.
Central to this reinterpretation of a patient’s story into an HPI is the
interviewer’s ability to shift from a relatively open-ended “conversation”
into more active, directive questioning. Interviewers make this transition
in different ways, but it is often useful for the interviewer to directly in
dicate that he or she would like to pursue some specific details for a few
minutes. This phase of data acquisition may involve a manualized as
sessment tool as described in Chapter 2, or it may be a more sponta
neously intuitive process. Although the goal of the initial interview may
be to arrive at a wonderfully robust three-dimensional picture of the pa
tient, it can be helpful to recall that no initial interview is ever complete:
additional information is likely to emerge as the relationship develops,
as collateral information emerges, and as the patient’s behaviors and
symptoms evolve during the ensuing weeks and months. In other words,
the interviewer need not feel pressured to completely “get” the patient
during the initial interview.
For example, in Chapter 5 (“Posttraumatic Stress Disorder”), Joe pres
ents with the problematic use of alcohol and marijuana. A former soldier,
he is also suffering a variety of anxiety symptoms. When meeting a psy

chiatric interviewer for the first time, a patient like Joe might focus on sub
stance abuse, or he might focus on anxiety or PTSD and insist that the al
cohol and marijuana use is under control. Joe might also insist that he
neither uses illicit drugs nor has a significant psychiatric issue; instead
he might insist that his primary problem is an overly zealous wife who
tricked him into the evaluation. The way Joe tells his story has implica
tions in regard to understanding the patient and planning treatment
options, but it is unlikely he will tell a completely thorough, historically
accurate story.
Different listening styles bring their own strengths and potential weak
nesses. For example, some excellent interviewers specifically target
DSM-5 symptom clusters throughout much of the interview. If done in
an unempathic way, however, excess focus on symptom lists can lead to
a shortchanging of the alliance and diagnostic depth.
Others might interview based on what feels to them to be a small tool
box of therapeutic options, ready to bypass the diagnostic process in or
der to more efficiently recommend their preferred treatment. For example,
a busy clinician might quickly assess a patient to have severe alcohol use
disorder with a history of poor adherence to outpatient treatment pro
grams. This can lead the clinician to short-circuit the assessment process
once he or she recognizes that the treatment suggestion will ultimately
be a half-hearted recommendation to Alcoholics Anonymous. Such a
short-circuiting of the evaluation is likely to lead the clinician to miss co
occurring disorder(s) that could be contributing to the repeated treat
ment failures.
A more psychodynamically oriented therapist may listen primarily
for unspoken psychological factors that contribute to psychiatric symp
toms. For example, an initial psychodynamically oriented interview
might yield a conclusion that unreliable early caregivers led the child to
anger and frustration that could not be adequately expressed for fear of
losing the parent’s affection. This lifelong tendency may contribute to
an adult patient’s anxious and avoidant interactional style and medica
tion nonadherence. At the same time, a co-occurring substance use or
psychiatric disorder can, by itself, lead to significant anger, frustration,
and nonadherence, regardless of underlying psychological issues. In
other words, working within a psychodynamic model may lead to a
stronger understanding of the person who has presented for help, but it
can also lead to missing the substance abuse and psychiatric diagnoses.
Regardless of one’s own theoretical tendency, it is generally wise to
spend at least some time paying conscious attention to each aspect of
the biopsychosocial framework. This can be especially helpful in pa
tients whose most obvious psychiatric diagnosis is so loudly obvious

that co-occurring disorders are ignored; recurrent treatment failures are
often the result of inadequate attention being paid to relatively “quiet”
co-occurring disorders. People with co-occurring disorders can also dis
tract and frustrate their interviewers through a variety of typical dis
tancing techniques. As is often the case in psychiatry, roadblocks can
often be sidestepped if the interviewer remains patient, persistent, tact
ful, and curious (see Table 1–2 for examples).
A safety assessment is part of every initial psychiatric evaluation. In
particular, we look for suicidality, homicidality, medical complications,
and the likelihood of withdrawal from a substance. Safety information
may come out naturally during the course of the interview, but it is gen
erally wise to explicitly ask specifically about safety issues.
Most of the MSE can be assessed as part of the overall interview. The
social, psychiatric, and developmental histories can help inform the di
agnosis and treatment, while the history of prior substance abuse treat
ments can often be the single most useful piece of collateral information.
It is difficult to know in advance when such information is going to be
vital, and historical data can feel unimportant if not linked to the patient’s
presenting problem. Initial interviews conclude with a differential diag
nosis and treatment plan, even if it is likely that both the diagnosis and
the treatment are uncertain and likely to evolve with additional time.
The initial interview depends on a working knowledge of the fields
of psychiatry and substance abuse. As is true for the fictional detective
Sherlock Holmes, we are unlikely to notice pivotal details without a
readily available knowledge base. As we listen, we silently consider,
discard, and reconsider a large amount of information. These tentative
assessments guide our interactions by helping us determine which is
sues should be more actively discussed and acted upon. Information ac
quisition can be felt as intrusive by the patient, but it can also be felt as
supportive: clinicians who tactfully ask knowledgeable questions are
implicitly communicating that they are genuinely interested and that
they understand psychiatry, substance use, and people.
Given the ubiquity of online resources, it might not seem necessary to
have a working knowledge of likely comorbidities, common symptom
constellations, and treatment strategies. Although much can be gained
by Internet access, it is unlikely that even the most dexterous inter
viewer can maintain eye contact with a patient while also trying to look
things up online. Such preparation often begins with a regular practice
of reading texts like this one. By helping to provide a framework for
how to understand patients, such texts help inform the interview and
help put other information into perspective.
TABLE 1–2. Typical comments that can de-skill an interviewer

My drug use is no big deal.
I need ___ mg of my drug every 4 hours.
My situation is hopeless.
I can stop whenever I want.
Life is too boring without my drug.
All my friends use more than I do.
I don’t know why my tox screen was positive—I don’t take drugs.
As if you would understand.
For example, in Chapter 10 (“Gambling Disorder”), Peter is a long-time

gambler who initially denied substance abuse. Given that about 75% of
men with a gambling disorder also have an alcohol use disorder, the
alert clinician might actively look for indications that Peter is not being
entirely forthcoming when he denies a problem with alcohol. Such clues
might include a withdrawal tremor, abnormal lab values, or collateral
information.
While we observe the patient, the patient is sizing us up. Are we trust
worthy, effective, and knowledgeable about the field? In regard to Peter,
for example, the clinician who doggedly pursues an alcohol history may
win that small piece of knowledge but lose the alliance. This may be a
necessary price to pay to address safety concerns, but it may come with
a cost to the alliance and eventual chances for treatment success. Con
cerns about the alliance need not lead the clinician to passivity, however,
and it may be reasonable for the interviewer to simply say to Peter that
alcohol use and gambling tend to co-occur. Such an assertion demon
strates the clinician’s knowledge base and gives the patient a chance to
elaborate on his earlier denial of an alcohol problem.
Three interacting philosophical notions tend to guide clinicians during
the initial interview. Many clinicians were taught a “lean” approach to
making a diagnosis. Sometimes called Occam’s razor, or the law of diag
nostic parsimony, this principle leads clinicians to search for the sim
plest explanation that can explain the clinical presentation. This princi
ple has been balanced off by Hickam’s dictum, which asserts that if
patients have one disorder, they are likely to have more than one (this
dictum is sometimes summarized as, “Patients can have as many diseases
as they damn well please”). In other words, Hickam’s dictum addresses
our tendency to try to find a single diagnosis when multiple diagnoses
are actively having an impact on one another. DSM-5 addresses this ten
dency by recommending that we identify pertinent diagnoses and gen

erally not try to identify the single diagnosis that is the crucial, under
lying precipitant of the patient’s suffering.
A third philosophical notion is Crabtree’s bludgeon, which posits that
human imagination can create underlying theories about any unrelated
bits of evidence. This assertion helps us slow down our tendency to pre
maturely identify a diagnosis and then search for supportive evidence
while ignoring contradictory evidence. Taken together, these three prin
ciples can help the clinician make sense of information while avoiding
the sorts of pitfalls that can bedevil any clinician. (For a further discussion
of these principles, see Mani et al. 2011.)
Negotiation is an integral part of the evaluation process. Negotiation
may take place at the end of the first session, or later, but treatments are
likely to fail without the patient’s participation. Negotiation might in
clude the presentation of a diagnosis or differential diagnosis; psycho
education; and exploration of treatment options. It can also be a good
time to ask about patient satisfaction and the likelihood that the patient
will participate in the recommended treatment. Exploration of these ques
tions can determine treatment success.
The write-up plays an important role in the interview. For many in
terviewers, the cognitive process involved in writing helps clarify what
can be a confusing amalgam of information. The writing process can
also lead to a recognition that there are holes in the story that warrant fol
low-up questions. If so, the clinician should feel free to go back and get
clarification directly from the patient. Most patients will feel gratified
that their clinician gave thought to their situation. Further, by demon
strating reflection, the clinician models the importance of remaining cu
rious about one’s own thoughts and behaviors. Finally, follow-up ques
tions and a well-formulated HPI tend to lead neatly to likely diagnoses and
treatments.
Knowledge of what is expected in a write-up can help catalyze an ef
fective interaction. On the other hand, knowing that a large amount of
information will eventually be expected can lead interviewers to feel
driven to get concrete information at the expense of other aspects of the
interview. As described above, zealous pursuit of data is likely to lead to
an inadequate interview.
Electronic medical records (EMRs) are a mixed blessing to the inter
viewer. Given the amount of time spent at a computer, it behooves the
clinician to take advantage of the positive aspects of the EMR. What col
lateral history is available? What have previous clinicians seen in this
patient? What have loved ones (or police officers) said about the pa
tient? Does the patient seem different from before? What therapeutic
intervention worked or failed? What lab results are available? Used in

conjunction with the interview, the EMR can be invaluable.
The interview is incomplete without a written assessment, diagnosis,
and plan. Compare these two summaries, written by psychiatrists who
saw the same medically hospitalized patient:
Conclusion #1
Assessment/Diagnosis: Alcohol use disorder, depressed.
Plan: AA.
Conclusion #2
Assessment: Asked to evaluate a 50-year-old man for depres
sion and alcohol abuse. He was seen to evaluate “depression”
on day 3 of an unexpected hospitalization for acute, perforated
appendicitis. He appears to have become depressed in the con
text of gradually escalating use of alcohol over the past 2 years.
Functioning poorly at work and in his marriage. No suicidality,
according to patient and wife. Aside from some tremor on hos
pital days 2–3, no withdrawal symptoms during this past week’s
hospitalization, though his currently heightened dysphoria might
reflect withdrawal. Patient denies depression prior to 2 years
ago, though he has strong family history of depression in multi
ple relatives. He claims that he shifted from drinking a few beers
per week to a six pack every night just after his mother died,
which was 2 years ago. Now drinks approximately 1–2 pints of
vodka per day. MCV 100; AST/ALT: 85/40. Patient educated
about several medication options (e.g., acamprosate, naltrex
one, antidepressant medication, disulfiram) and treatment op
tions (inpatient and outpatient rehabs, individual therapy) during
the hospitalization. Patient strongly prefers to first try AA and
then consider individual psychotherapy if his depression per
sists and/or he restarts drinking.
Diagnosis: Alcohol use disorder, moderate. Alcohol-induced
depressive disorder.
Plan: AA.
The second conclusion is obviously more informative, but is it worth

the time to summarize the situation when the diagnosis and treatment
recommendation are the same? I would suggest that the longer assess
ment is indeed more useful. It may seem odd to emphasize the written
report in a chapter on the interview, but, as with the development of the
HPI, the interview itself is shaped by what is ultimately going to be ex
pected. This is especially pertinent in regard to patients with co-occurring
disorders. For example, it can be tempting to interview someone like the
patient above and get stuck both with the diagnosis (e.g., Is the depres
sion secondary to alcohol?) and with the ongoing treatment (He’s refus
ing almost everything). In the face of uncertainty and likely nonadher
ence with an “optimal” treatment plan, the interviewer might decide to
cut short both the interview and the write-up. If the clinician intends to
write a well-thought-out HPI and concluding assessment, however, the
interviewer’s own thought is likely to become more reflective and so
phisticated, the write-up will be more helpful to the next interviewer, and
the interview itself stands a greater chance for success.
KEY POINTS
• Nonverbal observation and conversation are crucial to effec

tive evaluation.
• Without a working knowledge of psychiatry and substance
abuse, the interviewer will get lost.
• Development of the history of the present illness guides the
interview.
• The history of present illness is the creation of the interviewer.
• There is no single right way to interview.
• When in doubt, the interviewer should aim for warmth and
curiosity.
Questions
1. Which of the following is an example of the patient’s chief complaint?
A. “My parents are annoying.”

B. 36-year-old man with alcohol use disorder and a history of bi
polar disorder.
C. Recurrent trials of antidepressants and mood stabilizers have

failed.
D. Patient appears sullen, irritable, and with a mild intention
tremor.
2. Which of the following components of a psychiatric interview fo

cuses on a cross-sectional assessment of the patient?
A. History of present illness (HPI).

B. Mental status exam (MSE).
C. Assessment.
D. Treatment plan.
3. In the initial assesment of a patient for potentially co-occurring dis

orders, which one of the following is most crucial to clarify?
A. The single diagnosis that is causing the most difficulty.

B. All pertinent psychiatric diagnoses.
C. Sociopathy and illegal acts that might jeopardize treatment
success.
D. The family’s primary concerns.
Reference
Mani N, Slevin N, Hudson A: What Three Wise Men have to say about diagno
sis. BMJ 343:d7769, 2011 22187188
Suggested Readings
Barnhill J: The psychiatric interview and mental status exam, in The American
Psychiatric Publishing Textbook of Psychiatry, 6th Edition. Edited by Hales
RE, Yudofsky SC, Roberts LW. Washington, DC, American Psychiatric Pub
lishing, 2014, pp 3–30
MacKinnon RA, Michels R, Buckley PJ: The Psychiatric Interview in Clinical
Practice, 3rd Edition. Arlington, VA, American Psychiatric Association
Publishing, 2016
Miller WR, Rollnick S: Motivational Interviewing: Preparing People for Change,
3rd Edition. New York, Guilford, 2012
2
THE COMPREHENSIVE
ASSESSMENT
Christine Yuodelis-Flores, M.D.

Richard K. Ries, M.D.
A complete biopsychosocial assessment and integrated treatment plan

can be crucial when working with patients who have co-occurring dis
orders (CODs). In this chapter, we describe a comprehensive evaluation
that takes into account some of the unique aspects of this population.
For example, in addition to evaluating the patient for relevant diagno
ses and assessing their severity, the provider aims to determine the de
gree to which the mental illness is substance induced and understand how
the mental and addictive disorders interact with each other and how the
CODs affect psychosocial functioning.
This integrated evaluation will also assess the psychiatric symptoms,
diagnoses, and treatment during past episodes of substance abuse and
during periods of abstinence. This history will help clarify the role of the
substance in maintaining or worsening the psychiatric symptoms and/
or affecting the psychiatric treatment.
13
The COD assessment is multidimensional and evaluates not only the

degree of addiction and psychiatric illness but also withdrawal potential,
biomedical complications, additional mental health conditions, readiness
to change, relapse potential, and recovery environment. During the assess
ment process, the provider also investigates psychosocial issues such as
current strengths, supports, limitations, and cultural barriers.
Finally, while conducting a COD assessment, the provider will assign
the patient to one of the four categories in the Four Quadrant Model of
Care for COD (Figure 2–1). This model is used to determine the appropri
ateness of the treatment setting based on severity of symptoms. The as
sessment for COD is integrated by examining the information concern
ing one disorder in light of evidence concerning the other disorder. As
shown in Table 2–1, this 12-step process accords with Center for Substance
Abuse Treatment (CSAT) Treatment Improvement Protocol 42 (Center for
Substance Abuse Treatment 2005).
Use of this 12-step COD assessment process is illustrated in the fol
lowing clinical case.
Clinical Case
Douglas is a 45-year-old single male referred by his primary care
provider for psychiatric evaluation and care. Douglas agreed
to the evaluation because he has lost his job, is out of money,
has no social supports, and has psychiatric symptoms and sub
stance use that are increasingly problematic. His concerns can
be divided into four categories: a preoccupation with mind con
trol, mood and anxiety complaints, the use of psychoactive sub
stances, and serious psychosocial stressors.
Douglas’s most pressing and chronic concern relates to a
sense that his mind is being controlled by people who are in
serting thoughts, directing his behavior, and conducting exper
iments on him. He believes that 10 years ago a computer chip
was somehow implanted in his head while he was sleeping.
On awakening, he started to hear voices that comment on his
actions or discuss what he will do next. At times the voices are
overwhelming and prevent him from sleeping or concentrating
at work. He feels agitated by these taunting voices. He be
lieves that his friends and family were secretly involved with the
insertion of the computer chip, so he cut contact with everyone
he knew 5 years earlier.
He denies a family history of addictive disorders or mental
illness. He had been taking antipsychotic and antidepressant
medications for short periods in the past but stopped because
The Comprehensive Assessment 15
I II
Psychiatric Substance use Psychiatric Substance use
disorder: disorder: disorder: disorder:
LOW LOW HIGH LOW
severity severity severity severity
LOC: client served by primary care LOC: client served by mental health
clinic center
III IV
Psychiatric Substance use Psychiatric Substance use
disorder: disorder: disorder: disorder:
LOW HIGH HIGH HIGH
severity severity severity severity
LOC: client served by addiction LOC: client served by mental health

treatment program center with integrated COD
program
FIGURE 2–1. Four-quadrant Model of Care for Co-occurring

Disorders.
COD=co-occurring disorder; LOC=locus of care.
Source. National Advisory Council, Substance Abuse and Mental Health Services
Administration: Improving Services for Individuals at Risk of, or With Co-occurring
Substance-Related and Mental Health Disorders. Rockville, MD, SAMHSA, 1997.
he felt that the medical providers believed it was “all in his

head.” He has consulted with several doctors, but their physical
exams, X rays, and computed tomography scans found no chips
in his head or neck. He has been unable to find a neurosurgeon
willing to operate on him to remove the chip.
Douglas also reports anxiety and depressive symptoms. He
describes chronic dysphoria, anhedonia, and a sense of hope
lessness about whether his persecution will ever end. He has
had thoughts of “ending it all” but has never planned or at
tempted suicide. He says he is always tired, partly because he
sleeps so poorly. He says he often awakes after a few hours of
sleep with a pounding heart rate, shortness of breath, sweats,
a tremor, and voices screaming at him.
Douglas has a history of cannabis use since age 14 and cur
rently smokes “two or three bowls” daily. He also drinks about
six beers a night, most nights of the week. He denies any history
of alcohol withdrawal symptoms or seizures, but he does note
episodes of anxiety, sweating, tachycardia, and a tremor which
he associates with the voices. While Douglas has no history of
cocaine, gamma-hydroxybutyrate, hallucinogen, benzodiazepine,
TABLE 2–1. The 12-step assessment process for co-occurring

disorders (CODs)
1. Engage the client.
2. Upon receipt of appropriate client authorization(s), identify and
contact collaterals (family, friends, other treatment providers) to
gather additional information.
3. Screen and detect for COD.
4. Determine severity of mental and substance use disorders.
5. Determine appropriate care setting (e.g., inpatient, outpatient,
residential).
6. Determine diagnosis (or diagnoses).
7. Determine disability and functional impairment.
8. Identify strengths and supports.
9. Identify cultural and linguistic needs and supports.
10. Identify additional problem areas to address (e.g., physical health,
housing, vocational, educational, social, spiritual, cognitive).
11. Determine readiness for change.
12. Plan treatment.
Source. Center for Substance Abuse Treatment 2005.
or opiate use/abuse, he did smoke and inject methamphetamine

daily from age 24 to 35. After he developed psychotic symp
toms, he gradually decreased his methamphetamine use and
managed to completely stop on his own about 4 years ago. He
has gradually increased his level of cannabis and alcohol use
since stopping methamphetamine. He does not believe that the
methamphetamine caused his auditory hallucinations because
he stopped use so many years ago, and he believes that the
cannabis and alcohol use have only helped his anxiety, dysphoria,
and insomnia. He has never sought treatment for his substance
use disorder (SUD).
Despite the severity of his symptoms, Douglas worked as
a janitor and lived independently for the 5 years since rejecting
his friends and family. He was, however, recently fired for absen
teeism that he connects to increased substance use and wors
ening of his auditory hallucinations and feelings of persecution.
He has just lost his unemployment benefits, is unable to pay his
rent, and does not feel stable enough to seek employment.
Douglas was referred to the psychiatrist by a neurologist
who had diagnosed hepatitis C during an evaluation for the
mind-control chip. Douglas had generally refused medical and

psychiatric care for many years, though he has sporadically
agreed to take antidepressant and antipsychotic medication
in the past. He agreed to see a psychiatrist at this time be
cause he was feeling desperate.
At the end of the interview, Douglas is able to prioritize
goals in treatment as 1) decrease or resolve the anxiety, depres
sion, insomnia, and auditory hallucinations; 2) preserve his hous
ing; 3) find a new job; and 4) seek treatment for his medical
concerns.
Discussion
In the 12-step process for evaluation of CODs (Table 2–1), the first step is
to engage the patient. Eliciting the patient’s perspective of his problem
and desired treatment will help the provider to determine the degree of
insight and willingness to accept treatment. The provider should be em
pathetic and offer hope and desire to work with the patient and treat
ment team to figure out the best plan of action.
Step 2 is to identify collaterals and request signed releases of information in
order to gather more information. Although Douglas is isolated from friends
and family, he has been treated by a variety of physicians. It will be im
portant to identify those providers and review their assessments and treat
ment trials. A strong alliance may be able to overcome Douglas’s possi
ble reluctance to involve prior clinicians, especially if he recognizes that
such information may allow a more effective plan of treatment.
Step 3, screening and detecting for CODs, can be tricky when patients
have poor insight into illness. It is important to understand the chronol
ogy and course of his symptoms and the details of his substance use,
though the approach needs to be tactful and may not be completed during
the first visit. The assessment should include the severity of each substance
use problem and mental illness. In Douglas’s case, his methamphetamine
use disorder was severe, but he appears to have attained long-term re
mission without formal treatment. He uses cannabis and alcohol daily,
and they appear to be having a negative impact on his mental health.
His psychosis appears to have been precipitated by his past metham
phetamine use, but it may also be that the current psychosis was induced
by or is associated with his cannabis and alcohol use.
Douglas has significant psychotic, depressive, and anxiety symptoms.
It is possible that all of these symptoms are part of a primary psychosis
such as schizophrenia or a substance-induced psychosis. He might also

have some combination of a primary depressive disorder, a primary
anxiety disorder, and/or a substance-induced depressive or anxiety dis
order. The evaluation should also investigate possible mood swings or
manic episodes, because Douglas would also be at risk for a diagnosis
on the bipolar spectrum.
Step 4 is to assess the severity of the disorders and determine the quadrant
and locus of responsibility. Douglas has many features that indicate a se
vere mental illness: a chronic and intense psychosis, a lack of insight,
persistent dysphoria, insomnia, anxiety, and poor work and social func
tioning.
A suicide risk assessment is essential when evaluating a person with
CODs. Does the patient wish he were dead or does he want to die? Does
he have a plan for ending his life? How realistic is this plan and does he
have the capability to execute the act? Has he ever tried to kill himself?
What prevents him from killing himself?
The patient’s potential to harm others should also be assessed. Does
he feel a need to defend himself? Does he have a legal history, such as a
history of assault or stalking behaviors? Given his psychosis, uninten
tional harm to others may result from misinterpretations of reality.
The severity of Douglas’s SUDs is perhaps more moderate. He has
maintained abstinence from methamphetamine and appears to have
only mild withdrawal symptoms from alcohol and cannabis.
Using the Four Quadrants of Care for Co-occurring Disorders (Figure
2–1), the provider can assign Douglas to Quadrant II: more severe psy
chiatric illness and less severe SUD. When he was actively using daily
intravenous methamphetamine, the SUD would be considered more
severe.
Step 5 is to determine the appropriate care setting. Levels of care for
CODs include
1. Treatment at the primary care level with consultation, intervention,

and referral capabilities.
2. Outpatient addiction treatment program with psychiatric consulta
tion and treatment.
3. Psychiatric outpatient program treatment with co-occurring addic
tion treatment.
4. Inpatient or residential addiction treatment with psychiatric consul
tation and treatment.
5. Medically managed intensive inpatient addiction treatment with
psychiatric consultation and treatment.
6. Inpatient psychiatric hospitalization with medically managed addic

tion treatment.
When deciding on which level of care is needed for treatment of CODs,

the provider must determine the severity of both disorders. In regard to
addiction treatment, evaluation includes the patient’s potential for
overdose, withdrawal, and suicide. In addition to a severity assessment,
it is important to take into consideration patient preference. In this case,
Douglas has shown little desire for treatment of his substance use or
psychiatric disorders. He has agreed to psychiatric assessment and to
antipsychotic and antidepressant medications in the past. He would
likely refuse inpatient psychiatric care but may accept the offer of out
patient psychiatric care and case management to help him with issues
that bother him (e.g., insomnia, vocational and housing issues).
Regarding withdrawal potential, it will be important to ask the pa
tient if he has had an extended time without alcohol or cannabis, how he
tolerates days without substance use, and if he thinks he will have prob
lems if he should suddenly stop use of alcohol or cannabis. Given the
amount of substances consumed, his potential for serious withdrawal is
low and can be managed on an outpatient basis. Since he is in Quadrant
II, he will be most appropriately treated in a psychiatric outpatient COD
program. Such a program tends to use a team approach consisting of
psychiatrist, case manager, and addiction counselor. If his psychosis or
depression becomes more severe or if he is actively suicidal or threaten
ing to others, he would be more appropriate for psychiatric inpatient
stabilization.
Step 6 is to determine diagnoses. In this case, Douglas has several diag
noses that will be more clearly determined over time and with collateral
information. Enough information has been gathered to diagnose schizo
phrenia, but schizoaffective disorder and substance-induced psychosis
are also possibilities. He also has a depressive disorder and an anxiety
disorder, but it is unclear at this point whether they are primary or sub
stance-induced.
Step 7 is to determine disability and functional impairment. Douglas has
done remarkably well despite suffering from a severe mental illness. It
is possible that his boss provided a low-stress work environment for
him, but his functioning seems to have declined in the context of wors
ening cannabis and alcohol use. Douglas is more likely to enter into for
mal treatment if he is assured that vocational, housing, and medical
services will be included in his treatment plan. The co-occurring treat
ment program is also likely to be more successful if he is able to develop
relationships with mental health providers, addiction counselors, and
other clients in the program. Additional support in the future can be de
veloped through 12-step groups.
Step 8 is to identify strengths and supports. It is important to recognize
that Douglas has strengths. He has a strong work ethic and had, until re
cently, successfully maintained employment despite chronic psychosis.
He has never been psychiatrically hospitalized or attempted suicide. He
successfully stopped using methamphetamines without addiction treat
ment. These indicate that he has reasonably intact impulse control. Al
though in this case, Douglas denies any social supports, this should be
reevaluated as he gains trust and rapport with his treatment team. It is
important to identify family members, treatment providers, friends, and
organizations that the patient identifies as supportive in his or her life. If
patients are socially isolated, the treatment team will often become their
primary support.
Although the case does not focus on identifying cultural needs and sup
port (Step 9), areas to explore include ethnicity, religious background
and beliefs, gender identity and sexual orientation, learning disabilities,
and educational level.
Step 10 is to identify additional problem areas to address.
Medical issues are potentially significant. Douglas’s hepatitis C and
history of intravenous methamphetamine use indicate a need to screen
for additional diseases such as HIV disease, syphilis, and tuberculosis,
as well as to investigate medical causes of psychosis and medical com
plications of his substance use. Screening labs should include urine
toxicology as well as a comprehensive metabolic panel including liver
function, renal function, electrolytes, blood sugar or hemoglobin A1C,
and thyroid function tests, as well as a complete blood count. Many co
occurring disorder programs are integrated and have medical providers
associated with the program. After Douglas is engaged with his team, he
should establish care with and be evaluated by a primary care provider.
He should also be screened for dental problems, because severe tooth
decay and gum disease are common in persons with methamphetamine
dependence.
A vocational evaluation is a key element of a comprehensive COD pro
gram. Douglas is recently unemployed. Finding immediate employ
ment might interfere with or even derail his psychiatric and addiction
treatment, so the clinician should probably help him get short- or long
term disability. At the same time, Douglas wants to get a job, and so his
recovery plan must include vocational and educational placement and
support.
Housing is an important concern, since Douglas is unable to pay his
rent. He would likely resist residential addiction and psychiatric care be
cause he does not believe he requires addiction treatment. Community

psychiatric treatment programs usually have housing specialists who
may be able to help Douglas with housing options.
Social and spiritual supports can also be a crucial area of investigation.
Douglas is estranged from family and friends. Peer support specialists,
cognitive-behavioral therapy, recovery-oriented psychosocial group
therapies, relapse prevention therapy, and educational classes will pro
vide social supports for Douglas as he engages in treatment. Once he be
comes engaged in treatment, 12-step groups and religious affiliations can
also provide a more extensive sober support system.
Step 11 is to determine Douglas’s readiness for change. It is important to
determine the stage of readiness for change for each substance use disor
der. These stages include precontemplation, contemplation, preparation,
action, and maintenance. In this case, Douglas is in the maintenance stage
for his methamphetamine use disorder, but he is precontemplative regard
ing his alcohol and cannabis use.
Step 12 is to plan treatment. Treatment planning involves determining
the stages of change for each identified problem, while remaining aware
that different interventions will be necessary for different problems and
stages of change. Creating a biopsychosocial treatment plan for each psy
chiatric and addiction diagnosis will help increase insight and willing
ness to enter into treatment. Treatment goals—both short- and long-term—
should initially be derived primarily from the patient’s perspective and
then gradually altered and expanded as the assessment continues and
the patient’s insight and treatment progress.
KEY POINTS
• Assessment of patients with co-occurring disorders involves

a 12-step process. The process is multidimensional and in
cludes an assessment of the mental illness and substance use
disorder, their severities and complications, and how each
disorder affects the other. It is also used to
• determine the appropriate level of care and the patient’s
readiness for change, and to identify risks, strengths, and
supports.
• address medical, housing, vocational, cultural, social, spiri
tual, cognitive, and other concerns.
• Engaging the patient is essential for a comprehensive assess
ment and treatment plan and may take precedence over gath
ering information.
• Done correctly, this comprehensive biopsychosocial assess

ment will engage and motivate the patient, examine his or her
perspectives and desires, identify problems, establish diag
noses, and lead to a comprehensive treatment plan.
Questions
1. What is a core reason to use the Four Quadrant Model of Care for
Co-occurring Disorders?
A. It provides recommendations for psychiatric treatment alone.

B. It helps clinicians select the appropriate level of care.
C. It helps determine the stage of change of a patient.
D. It helps guide medication management.
2. What is the value of determining a patient’s readiness for change?
A. It can replace a comprehensive psychiatric evaluation.

B. It is essential in determining the types of interventions to
implement.
C. It can help the abstinent patient alone maintain abstinence.
D. It is rarely valuable, as patients with SUDs seldom want to
change.
3. The 12-step assessment process for co-occurring disorders
A. Does not include a determination of readiness for change.

B. Is multidimensional but does not take into account DSM-5.
C. Is necessary to develop a comprehensive treatment plan.
D. Includes establishing the diagnoses but not their severity.
Reference
Center for Substance Abuse Treatment: Substance Abuse Treatment for Persons
With Co-occurring Disorders. Treatment Improvement Protocol (TIP) Se
ries 42 (DHHS Publ No SMA-05-3992). Rockville, MD, Substance Abuse
and Mental Health Services Administration, 2005
PART 2
CO-OCCURRING DISORDERS
3
DEPRESSIVE AND
BIPOLAR DISORDERS
Rocco A. Iannucci, M.D.

Roger D. Weiss, M.D.
In order to effectively diagnose and treat the large number of people

who have co-occurring depressive or bipolar disorders and substance
use disorders (SUDs), the clinician must understand their interrelation
ships, pertinent demographic variables, and treatment strategies. In
this chapter, we explore the connections between mood and substance
use, with a focus on depression and cocaine.
A crucial statistical reality is that mood disorders are common, that
substance use is common, and that the two are often found in the same
person. There are many reasons for the common co-occurrence. Sub
stance abuse can lead to serious depressive and manic symptoms via in
toxication and withdrawal, for example, and chronic use of substances
of abuse can lead to serious mood problems through a direct physio
logical effect or as a consequence of maladaptive behaviors and psycho
social stress. People may try to “self-medicate” depression by using se
dating substances or stimulating substances, or both. Similarly, people
25
with mania may try to reduce insomnia or agitation with sedating med
ications or try to trigger the pleasurable symptoms of hypomania with a
stimulant. Other people with a mood disorder may just take whatever
substance is available in order to change their mood symptoms (Amer
ican Psychiatric Association 2013).
Not only do mood and substance use disorders commonly co-occur
in the same individual, either diagnosis worsens the prognosis of the
other. Each disorder is also associated with elevated risks of serious ad
verse outcomes such as accidental injury and suicide, with the greatest
risk in persons with both classes of disorder. Although the body of re
search guiding best practices in the treatment of these co-occurring con
ditions is growing, many questions remain.
The third iteration of the National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC-III) provides a measure of prevalence
and comorbidity rates for mood and substance use disorders. According
to this survey, the 2012–13 lifetime prevalence of an alcohol use disorder
in the United States was almost 30%; 13.9% of Americans had a lifetime
history of severe alcohol use disorder, and 13.9% had exhibited any alcohol
use disorder in the past year (Grant et al. 2015). The lifetime prevalence
of a drug use disorder was nearly 10%, with 6.6% having a moderate
to-severe drug use disorder and nearly 4% meeting past-year criteria
(Grant et al. 2004). Depressive and bipolar disorders are also common,
with 9.3% meeting past-year criteria for any mood disorder (over 7%
with past-year depression and 1.7% with mania in the past year) (Grant
et al. 2016). Mood disorders are strongly associated with having a severe
alcohol use disorder (odds ratio [OR]=1.8) or a moderate-to-severe drug
use disorder (OR=2.2) in the past 12 months (Grant et al. 2004, 2015).
We present the case of a man with cocaine use and mood symptoms to
illustrate common diagnostic challenges and to demonstrate a treatment
approach for those with co-occurring depressive or bipolar disorders and
SUDs.
Clinical Case
Robert is 36-year-old attorney presenting at the urging of his
husband, who unexpectedly came home during a weekday
and discovered Robert smoking cocaine in their living room.
Robert reports a 5-year history of cocaine use, beginning with
casual use at a party with colleagues from his law office. He
describes a pattern of use that was initially in his words “rec
reational,” using intranasally every 1–2 weeks on Friday or
Saturday nights. Shortly thereafter, he began to take an occa
Depressive and Bipolar Disorders 27
sional “bump” at work, with the goal of enhancing energy and

productivity. This pattern of use remained fairly stable for
about 2 years, when he began to experience increasing stress
and dissatisfaction at work, irritable and depressed mood, and
increased frequency of cocaine use. In the past year, he used
more days than not, generally in 2- to 3-day episodes of heavy
use followed by abstinence for a few days to recover from the
effects of cocaine. He has started to smoke “crack” cocaine
and is now missing work on a frequent basis. Because of his
husband’s concern, Robert had recently been free of use for a
period of 6 weeks, during which time he began attending
Cocaine Anonymous.
While abstaining from cocaine, Robert experienced per
sistent low energy, poor concentration, depressed mood, and
loss of interest and appetite over the course of 6 weeks, and
he then resumed use. He reports past episodes of reckless be
havior, irritable mood, and high energy interfering with sleep,
largely in the context of escalating cocaine use. He also re
ports a history of depression in college, preceding any regular
substance use. Known family history is significant for alcohol
use disorder in his father, as well as depression or bipolar dis
order in paternal aunts and uncles. Robert reports a desire to
stop using cocaine because of problems at work and in his re
lationship. However, he worries about how to cope with low
energy, depressed mood, and diminished sexual function that
he experiences when not using cocaine. Robert reports sur
reptitious use of cocaine to enhance sexual experiences but
denies sexual activity outside of the monogamous relation
ship with his husband.
Discussion
This case illustrates some of the diagnostic challenges inherent to the co
occurrence of mood symptoms and SUDs. Individuals like Robert who use
stimulants may induce symptoms that mimic bipolar disorder through a
pattern of manic-like intoxication followed by withdrawal resembling de
pression. At the same time, individuals with SUDs are known to be at in
creased risk for both major depression and bipolar disorder. Robert shows
further risk factors, including a family history of mood disorders, as well
as a personal history of at least one major depressive episode preceding
onset of cocaine use disorder. This information allows a diagnosis of major
depressive disorder at the initial assessment but raises concern that the
true diagnosis may be bipolar disorder. Robert also presents with symp
toms consistent with a moderate-to-severe cocaine use disorder.
Clarifying the diagnostic question of an independent versus a sub
stance-induced mood disorder in the presence of continuous drug or al
cohol use is challenging. In this situation, it can be helpful to retrospec
tively review for historical symptoms during periods of abstinence,
particularly periods lasting 30 days or longer. Substance-induced mood
symptoms typically resolve over that time course. Likewise, careful fam
ily history can contribute to a full picture of the risk of an independent
mood disorder. Nonetheless, it is important to note that many of those
individuals initially diagnosed with substance-induced depression or
mania will eventually be diagnosed as having an independent depressive
or bipolar disorder (Tolliver and Anton 2015).
Patients presenting with histories of depressive or manic symptoms
should undergo thoughtful, thorough examinations. Table 3–1 lists facets
of the history that require particular attention in this population. Major
depression, substance use disorders, and particularly bipolar disorders
are all associated with significant elevation in suicide risk (Tolliver and
Anton 2015). Continual assessment of suicide risk, starting at the initial
assessment, is therefore essential.
History, physical examination, and laboratory testing facilitate as
sessment of medical factors contributing to mood symptoms. These
may include thyroid illness, adrenal insufficiency, and other endocrine
illnesses; hepatic, pulmonary, or renal disease; metabolic abnormalities;
nutritional deficiencies; occult infections; and certain cancers. Sudden
onset of behavior changes could reflect a neurological condition, such as
dementia (especially the behavioral variant of frontotemporal demen
tia), multiple sclerosis, or stroke.
General screening tests are listed in Table 3–2, as are tests that may be
pursued based on information gathered during the history and physical
examination. Urine toxicology screening is generally advisable, because
many persons with SUDs may be using multiple substances. Those who
use stimulants will also commonly use sedatives such as alcohol, opi
oids, or benzodiazepines to moderate unpleasant sensations that occur
as the initial euphoria begins to subside. Hence, cocaine use disorders
co-occur with alcohol use disorder with a particularly high frequency. In
addition, tobacco use disorder is very common among individuals with
other SUDs and among those with mood disorders.
Collateral sources of information can be useful in the assessment of de
pressive and bipolar disorders and SUDs. Bipolar disorder manifests with
both subjective symptoms and outward signs; the patient may have lim
ited awareness of the latter, while familiar contacts can describe periods of
Depressive and Bipolar Disorders 29
TABLE 3–1. Important elements elicited in assessment of patients

with co-occurring substance-related and mood
symptoms
History of present illness Elicit both current mood symptoms and
substance-related symptoms.
Past psychiatric history Focus on time periods prior to initiation
of substance use and on any extended
periods of abstinence (greater than
30 days).
Review in detail suicidal ideation or
suicide attempts and violent thoughts or
behaviors. Include their relationship to
mood symptoms and to substance use.
Medications Gather a history of all medications,
including nutritional supplements or
complementary treatments.
Review the history of medication
adherence (overuse, taking by means
other than prescribed, unilateral
discontinuation).
Substance use history Gather details of history, with attempt to
clarify the presence or absence of mood
symptoms.
Clarify the relationship between mood
symptoms and substance use, if any.
Review what has been helpful or not
helpful in the past, including attitudes
to particular types of interventions,
such as medications, psychotherapy,
and self-help group involvement.
Family history Review family history of substance use
disorders, depressive and bipolar
disorders, other psychiatric disorders,
and suicide.
rapid speech, increased impulsiveness, or other hallmark signs. At times,

patients with SUDs may underrecognize or underreport problems related
to their substance use. An involved partner, friend, or family member can
add significantly to a thorough understanding of the scope of symptoms.
Substance use can cause medical illnesses and injuries, either as a direct
result of substance use or connected to associated behaviors. In this case,
TABLE 3–2. Typical laboratory and diagnostic assessment of

patients with mood and substance-related symptoms
Complete blood count
Electrolytes
Blood urea nitrogen and creatinine
Thyroid-stimulating hormone
Transaminases, bilirubin, alkaline phosphatase, albumin, and
total protein levels
Vitamin B12 and folate levels
Viral hepatitis immunoassay
HIV immunoassay
Urine toxicology screen
Other tests (e.g., head CT or MRI, ECG, chest X ray, blood cultures)
may be pursued based on particular symptoms
Note. CT=computed tomography; ECG=electrocardiogram; MRI=magnetic resonance
imaging.
Robert’s use of cocaine may cause a potentially dangerous combination of

vasoconstriction and acute hypertension that can predispose to cardiovas
cular complications such as angina pectoris, myocardial infarction, ven
tricular tachyarrhythmia, and hemorrhagic or nonhemorrhagic stroke. In
tranasal use of cocaine causes vasoconstriction of the nasal mucosa,
leading to symptoms of congestion, ulceration, or even perforation.
It is always important to take a thorough history of risky behaviors, in
cluding sexual practices. Manic patients can demonstrate hypersexual
behavior. Likewise, substance use is often marked by impaired judgment
and behavioral disinhibition. Stimulants in particular may be purpose
fully used to achieve disinhibition and to enhance sexual experiences and
perceived performance. Over time, their use can lead to sexual dysfunc
tion. Risk-taking may manifest as unsafe sexual or injection practices,
leading to infection with HIV, hepatitis, endocarditis, or other diseases.
Driving while intoxicated presents serious risk of accidental injury. Many
individuals become disinhibited or even aggressive when intoxicated,
increasing the likelihood of their becoming a victim or perpetrator of
violence.
In Robert’s case, although he denies risky sexual encounters outside
a monogamous relationship, he acknowledges stimulant use during
sexual behaviors. It will be important to address concerns he has about
sexual health and to evaluate and treat any psychological or physiolog
ical conditions interfering with normal sexual function.
Another random document with
no related content on Scribd:
Does argument, that the condition of free-labourers is, on the whole,
better than that of slaves, or that simply they are generally better fed,
and more comfortably provided, seem to any one to be
unnecessary? Many of our newspapers, of the largest circulation,
and certainly of great influence among people—probably not very
reflective, but certainly not fools—take the contrary for granted,
whenever it suits their purpose. The Southern newspapers, so far as
I know, do so, without exception. And very few Southern writers, on
any subject whatever, can get through a book, or even a business or
friendly letter, to be sent North, without, in some form or other,
asserting that Northern labourers might well envy the condition of the
slaves. A great many Southern gentlemen—gentlemen whom I
respect much for their moral character, if not for their faculties of
observation—have asserted it so strongly and confidently, as to shut
my mouth, and by assuring me that they had personally observed
the condition of Northern labourers themselves, and really knew that
I was wrong, have for a time half convinced me against my long
experience. I have, since my return, received letters to the same
effect: I have heard the assertion repeated by several travellers, and
even by Northerners, who had resided long in the South: I have
heard it publicly repeated in Tammany Hall, and elsewhere, by
Northern Democrats: I have seen it in European books and journals:
I have, in times past, taken its truth for granted, and repeated it
myself. Such is the effect of the continued iteration of falsehood.
Since my return I have made it a subject of careful and extended
inquiry. I have received reliable and unprejudiced information in the
matter, or have examined personally the food, the wages, and the
habits of the labourers in more than one hundred different farmers’
families, in every Free State (except California), and in Canada. I
have made personal observations and inquiries of the same sort in
Great Britain, Germany, France, and Belgium. In Europe, where
there are large landed estates, which are rented by lordly proprietors
to the peasant farmers, or where land is divided into such small
portions that its owners are unable to make use of the best modern
labour-saving implements, the condition of the labourer, as respects
food, often is as bad as that of the slave often is—never worse than
that sometimes is. But in general, even in France, I do not believe it
is generally or frequently worse; I believe it is, in the large majority of
cases, much better than that of the majority of slaves. And as
respects higher things than the necessities of life—in their
intellectual, moral, and social condition, with some exceptions on
large farms and large estates in England, bad as is that of the mass
of European labourers, the man is a brute or a devil who, with my
information, would prefer that of the American slave. As to our own
labourers, in the Free States, I have already said enough for my
present purpose.
But it is time to speak of the extreme cases, of which so much use
has been made, in the process of destroying the confidence of the
people of the United States in the freedom of trade, as applied to
labour.
In the year 1855, the severest winter ever known occurred at New
York, in conjunction with unprecedentedly high prices of food and
fuel, extraordinary business depression, unparalleled marine
disasters, and the failure of establishments employing large numbers
of men and women. At the same time, there continued to arrive,
daily, from five hundred to one thousand of the poorer class of
European peasantry. Many of these came, expecting to find the
usual demand and the usual reward for labour, and were quite
unprepared to support themselves for any length of time unless they
could obtain work and wages. There was consequently great
distress.
We all did what we thought we could, or ought, to relieve it; and with
such success, that not one single case of actual starvation is known
to have occurred in a close compacted population of over a million,
of which it was generally reported fifty thousand were out of
employment. Those who needed charitable assistance were, in
nearly every case, recent foreign immigrants, sickly people, cripples,
drunkards, or knaves taking advantage of the public benevolence, to
neglect to provide for themselves. Most of those who received
assistance would have thrown a slave’s ordinary allowance in the
face of the giver, as an insult; and this often occurred with more
palatable and suitable provisions. Hundreds and hundreds, to my
personal knowledge, during the worst of this dreadful season,
refused to work for money-wages that would have purchased them
ten times the slave’s ordinary allowance of the slave’s ordinary food.
In repeated instances, men who represented themselves to be
suffering for food refused to work for a dollar a day. A labourer,
employed by a neighbour of mine, on wages and board, refused to
work unless he was better fed. “What’s the matter,” said my
neighbour; “don’t you have enough?” “Enough; yes, such as it is.”
“You have good meat, good bread, and a variety of vegetables; what
do you want else?” “Why, I want pies and puddings, too, to be sure.”
Another labourer left another neighbour of mine, because, as he
alleged, he never had any meat offered him except beef and pork;
he “didn’t see why he shouldn’t have chickens.”
And these men went to New York, and joined themselves to that
army on which our Southern friends exercise their pity—of labourers
out of work—of men who are supposed to envy the condition of the
slave, because the “slave never dies for want of food.”[38]
In the depth of winter, a trustworthy man wrote us from Indiana:—
“Here, at Rensselaer, a good mechanic, a joiner or
shoemaker, for instance—and numbers are needed here
—may obtain for his labour in one week:
2 bushels of corn.
1 bushel of wheat.
5 pounds of sugar.
½ pound of tea.
10 pounds of beef.
25 pounds of pork.
1 good turkey.
3 pounds of butter.
1 pound of coffee.
1 bushel of potatoes.
and have a couple of dollars left in his pocket, to start with

the next Monday morning.”
The moment the ice thawed in the spring, the demand for mechanics
exceeded the supply, and the workmen had the master-hand of the
capitalists. In June, the following rates were willingly paid to the
different classes of workmen—some of the trades being on strike for
higher:—
Dollars per Week.
Boiler-maker 12 to 20
Blacksmith 12 to 20
Baker 9 to 14
Barber 7 to 10
Bricklayer 14 to 15
Boat-builder 15
Cooper 8 to 12
Carpenter (house) 15
Confectioner 8 to 12
Cigar-maker 9 to 25
Car-driver (city cars) 10
Car-conductor (city cars) 10½
Engineer, common 12 to 15
Engineer, locomotive 15
Harness-maker 10
Mason 10 to 15
Omnibus-driver 10
Printer 10 to 25
Plumber 15
Painter (house) 15
Pianoforte maker 10 to 14
Shipwright 18
Ship-caulker 18
Ship-fastener 18
Shoemaker 16
Sign painter 25 to 30
Sail-maker 15
Tailor 8 to 17
At this time I engaged a gardener, who had been boarding for a
month or two in New York, and paying for his board and lodging $3 a
week. I saw him at the dinner-table of his boarding house, and I
knew that the table was better supplied with a variety of wholesome
food, and was more attractive, than that of the majority of
slaveowners with whom I have dined.
Amasa Walker, formerly Secretary of State in Massachusetts, is the
authority for the following table, showing the average wages of a
common (field-hand) labourer in Boston (where immigrants are
constantly arriving, and where, consequently, there is often a
necessity, from their ignorance and accidents, of charity, to provide
for able bodied persons), and the prices of ten different articles of
sustenance, at three different periods:—
Wages of Labour and Food at Boston.
1836. 1840. 1843.
Wages. Wages. Wages.
$1.25 per $1 per $1 per
day. day. day.
Dollars. Dollars. Dollars.
1 barrel flour 9.50 5.50 4.75
25 lbs. sugar, at 9c. 2.25 2.00 1.62
10 gals. molasses, 4.25 2.70 1.80
42½c.
100 lbs. pork 4.50 8.50 5.00
14 lbs. coffee, 1.75 1.50 5.00
12½c.
28 lbs. rice 1.25 1.00 75
1 bushel corn meal 96 65 62
1 do rye meal 1.08 83 73
30 lbs. butter, 22c. 6.60 4.80 4.20
20 lbs. cheese, 10c. 2.00 1.60 1.40
44.00 28.98 22.00
This shows that in 1836 it required the labour of thirty-four and a half
days to pay for the commodities mentioned; while in 1840 it required
only the labour of twenty-nine days, and in 1843 that of only twenty-
three and a half days to pay for the same. If we compare the
ordinary allowance of food given to slaves per month—as, for
instance, sixteen pounds pork, one bushel corn meal, and, say one
quart of molasses on an average, and a half pint of salt—with that
which it is shown by this table the free labourer is usually able to
obtain by a month’s labour, we can estimate the comparative general
comfort of each.
I am not all disposed to neglect the allegation that there is
sometimes great suffering among our free labourers. Our system is
by no means perfect; no one thinks it so: no one objects to its
imperfections being pointed out. There was no subject so much
discussed in New York that winter as the causes, political and social,
which rendered us liable to have labourers, under the worst possible
combination of circumstances, liable to difficulty in procuring
satisfactory food.
But this difficulty, as a serious thing, is a very rare and exceptional
one (I speak of the whole of the Free States): that it is so, and that
our labourers are ordinarily better fed and clothed than the slaves, is
evident from their demands and expectations, when they are
deemed to be suffering. When any real suffering does occur, it is
mainly a consequence and a punishment of their own carelessness
and improvidence, and is in the nature of a remedy.
And in every respect, for the labourer, the competitive system, in its
present lawless and uncertain state, is far preferable to the slave
system; and any labourer, even if he were a mere sensualist and
materialist, would be a fool to wish himself a slave.
One New York newspaper, having a very large circulation at the
South, but a still larger at the North, in discussing this matter, last
winter, fearlessly and distinctly declared—as if its readers were
expected to accept the truth of the assertion at once, and without
argument—that the only sufficient prevention of destitution among a
labouring class was to be found in slavery; that there was always an
abundance of food in the Slave States, and hinted that it might yet
be necessary, as a security against famine, to extend slavery over
the present Free States. This article is still being copied by the
Southern papers, as testimony of an unwilling witness to the
benevolence and necessity of the eternal slavery of working people.
The extracts following, from Southern papers, will show what has
occurred in the slave country in the meanwhile:
“For several weeks past, we have noticed accounts of
distress among the poor in some sections of the South, for
the want of bread, particularly in Western Georgia, East
and Middle Alabama. Over in Coosa, corn-cribs are lifted
nightly; and one poor fellow (corn thief) lately got caught
between the logs, and killed! It is said there are many
grain-hoarders in the destitute regions, awaiting higher
prices! The L—d pity the poor, for his brother man will not
have any mercy upon his brother.”—Pickens Republican,
Carrolton, Ala., June 5, 1855.
“We regret that we are unable to publish the letter of
Governor Winston, accompanied by a memorial to him
from the citizens of a portion of Randolph county, showing
a great destitution of breadstuffs in that section, and
calling loudly for relief.
“The Claiborne Southerner says, also, that great
destitution in regard to provisions of all kinds, especially
corn, prevails in some portions of Perry county.”—Sunny
South, Jacksonville, Ala., May 26, 1855.
“As for wheat, the yield in Talladega, Tallapoosa,
Chambers, and Macon, is better even than was
anticipated. Flour is still high, but a fortnight will lower the
price very materially. We think that wheat is bound to go
down to $1.25 to $1.50 per bushel, though a fine article
commands now $2.25.
“Having escaped famine—as we hope we have—we trust
the planting community of Alabama will never again suffer
themselves to be brought so closely in view of it. Their
want of thrift and foresight has come remarkably near
placing the whole country in an awful condition. It is only
to a kind Providence that we owe a deliverance from a
great calamity, which would have been clearly the result of
man’s short-sightedness.”—Montgomery Mail, copied in
Savannah Georgian, June 25, 1855.
“Wheat crops, however, are coming in good, above an
average; but oats are entirely cut off. I am issuing
commissary, this week for the county, to distribute some
corn bought by the Commissioner’s Court, for the destitute
of our county; and could you have witnessed the
applicants, and heard their stories, for the last few days, I
am satisfied you could draw a picture that would excite the
sympathy of the most selfish heart. I am free to confess
that I had no idea of the destitution that prevails in this
county. Why, sir, what do you think of a widow and her
children living, for three days and nights, on boiled weeds,
called pepper grass?—yet such, I am credibly informed,
has been the case in Chambers County.”—From a letter to
the editor of the Montgomery (Ala.) Journal, from Hon.
Samuel Pearson, Judge of Probate, for Chambers County,
Alabama.
“Famine in Upper Georgia.—We have sad news from the
north part of Georgia. The Dalton Times says that many
people are without corn, or means to procure any. And,
besides, there is none for sale. In some neighbourhoods,
a bushel could not be obtained for love or money. Poor
men are offering to work for a peck of corn a day. If they
plead, Our children will starve,’ they are answered, ‘So will
mine, if I part with the little I have.’ Horses and mules are
turned out into the woods, to wait for grass, or starve. The
consequence is, that those who have land can only plant
what they can with the hoe—they cannot plough. It is
seriously argued that, unless assisted soon, many of the
poor class of that section will perish.”—California Paper.
[39]
No approach to anything like such a state of things as those extracts
portray (which extended over parts of three agricultural States) ever
occurred, I am sure, in any rural district of the Free States. Even in
our most thickly-peopled manufacturing districts, to which the staple
articles of food are brought from far-distant regions, assistance from
abroad, to sustain the poor, has never been asked; nor do I believe
the poor have ever been reduced, for weeks together, to a diet of
corn. But this famine at the South occurred in a region where most
productive land can be purchased for from three to seven dollars an
acre; where maize and wheat grow kindly; where cattle, sheep, and
hogs, may be pastured over thousands of acres, at no rent; where
fuel has no value, and at a season of the year when clothing or
shelter is hardly necessary to comfort.
It is a remarkable fact that this frightful famine, unprecedented in
North America, was scarcely noticed, in the smallest way, by any of
those Southern papers which, in the ordinary course of things, ever
reach the North. In the Charleston, Savannah, and Mobile papers,
received at our commercial reading-rooms, I have not been able to
find any mention of it at all—a single, short, second-hand paragraph
in a market report excepted. But these journals had columns of
reports from our papers, and from their private correspondents, as
well as pages of comment, on the distress of the labourers in New
York City the preceding winter.
In 1837, the year of repudiation in Mississippi, a New Orleans editor
describes the effect of the money-pressure upon the planters, as
follows:—
“They are now left without provisions, and the means of
living and using their industry for the present year. In this
dilemma, planters, whose crops have been from 100 to
700 bales, find themselves forced to sacrifice many of
their slaves, in order to get the common necessaries of
life, for the support of themselves and the rest of their
negroes. In many places, heavy planters compel their
slaves to fish for the means of subsistence, rather than
sell them at such ruinous rates. There are, at this moment,
thousands of slaves in Mississippi, that know not where
the next morsel is to come from. The master must be
ruined, to save the wretches from being starved.”
Absolute starvation is as rare, probably, in slavery, as in freedom; but
I do not believe it is more so. An instance is just recorded in the New
Orleans Delta. Other papers omit to notice it—as they usually do
facts which it may be feared will do discredit to slavery—and even
the Delta, as will be seen, is anxious that the responsibility of the
publication should be fixed upon the coroner:
“Inquest.—Death from neglect and starvation.—The
body of an old negro, named Bob, belonging to Mr. S. B.
Davis, was found lying dead in the woods, near Marigny
Canal, on the Gentilly Road, yesterday. The coroner held
an inquest; and, after hearing the evidence, the jury
returned a verdict of ‘Death from starvation and exposure,
through neglect of his master.’ It appeared from the
evidence that the negro was too old to work any more,
being nearly seventy; and so they drove him forth into the
woods to die. He had been without food for forty-eight
hours, when found by Mr. Wilbank, who lives near the
place, and who brought him into his premises on a
wheelbarrow, gave him something to eat, and
endeavoured to revive his failing energies, which had
been exhausted from exposure and want of food. Every
effort to save his life, however, was unavailing, and he
died shortly after being brought to Mr. Wilbank’s. The
above statement we publish, as it was furnished us by the
coroner.”—Sept. 18, 1855.
This is the truth, then—is it not?—The slaves are generally
sufficiently well-fed to be in tolerable working condition; but not as
well as our free labourers generally are: slavery, in practice, affords
no safety against occasional suffering for want of food among
labourers, or even against their starvation any more than the
competitive system; while it withholds all encouragement from the
labourer to improve his faculties and his skill; destroys his self-
respect; misdirects and debases his ambition, and withholds all the
natural motives which lead men to endeavour to increase their
capacity of usefulness to their country and the world. To all this, the
occasional suffering of the free labourer is favourable, on the whole.
The occasional suffering of the slave has no such advantage. To
deceit, indolence, malevolence, and thievery, it may lead, as may the
suffering—though it is much less likely to—of the free labourer; but
to industry, cultivation of skill, perseverance, economy, and virtuous
habits, neither the suffering, nor the dread of it as a possibility, ever
can lead the slave, as it generally does the free labourer, unless it is
by inducing him to run away.
CHAPTER VII.
COTTON SUPPLY AND WHITE LABOUR IN THE
COTTON CLIMATE.
Mr. Russell,[40] although he clearly sees the calamity of the South,

fully accepts the cotton planter’s opinion, that, after all, the system of
slavery is a necessary evil attending upon the great good of cheap
cotton. He says: “If the climate had admitted of the growing of cotton
on the banks of the Ohio, we should have seen that slavery
possessed as great advantages over free labour in the raising of this
crop as it does in that of tobacco.” If this is so, it is important that it
should be well understood why it is so as precisely as possible.
In his Notes on Maryland, Mr. Russell (p. 141) says: “Though a slave
may, under very favourable circumstances, cultivate twenty acres of
wheat and twenty acres of Indian corn, he cannot manage more than
two acres of tobacco. The cultivation of tobacco, therefore, admits of
the concentration of labour, and thus the superintendence and
management of a tobacco plantation will be more perfect and less
expensive than a corn one.” And this is the only explanation he
offers of the supposed advantage of slave labour in the cultivation of
tobacco (and of consequence in the cultivation of cotton). The chief
expense of raising Indian corn is chargeable to planting and tillage,
that of tobacco to the seedbed, the transplanting and nursing of the
young plants (which is precisely similar to the same operation with
cabbages), the hand-weeding, the hoeing after the plant has
“become too large to work without injuring the leaves by the swingle-
trees of a horse plough;”[41] “the topping,” “the suckering,” the
selection and removal of valueless leaves, and “the worming,” all of
them, except hoeing, being operations which can be performed by
children and child-bearing women, as they usually are in Virginia.[42]
The chief expense of raising cotton, as of Indian corn, is that of
planting and tillage. The principal difference between the method of
tillage of cotton and that of Indian corn is occasioned by the greater
luxuriance of weeds in the Southern climate and the slow growth of
the cotton plant in its early stages, which obliges the tillage process
to be more carefully and more frequently performed. For this reason,
the area of cotton cultivated by each labourer is less than of corn.
The area of corn land to a hand is much over-estimated by Mr.
Russell. On the other hand, the only mention he makes of the area
of cotton land to a hand (being the statement of a negro) would lead
to the conclusion that it is often not over three acres, and that five
acres is extraordinary. Mr. De Bow says,[43] in an argument to prove
that the average production per acre is over-estimated, “In the real
cotton region, perhaps the average number of acres per hand is ten.”
Mr. Russell observes of worming and leafing tobacco: “These
operations can be done as well, and consequently as cheaply, by
women and children as by full-grown men.” (Page 142.) After
reading Mr. Russell’s views, I placed myself, through the kindness of
Governor Chase, in communication with the Ohio Board of
Agriculture, from which I have obtained elaborate statistics, together
with reports on the subject from twelve Presidents or Secretaries of
County Agricultural Societies, as well as from others. These
gentlemen generally testify that a certain amount of labour given to
corn will be much better repaid than if given to tobacco. “Men are
worth too much for growing corn to be employed in strolling through
tobacco fields, looking for worms, and even women can, as our
farmers think, find something better to do about the house.” Children,
too, are thought to be, and doubtless are, better employed at school
in preparing themselves for more profitable duties, and this is
probably the chief reason why coarse tobacco[44] cannot be
cultivated with as much profit as corn in Ohio, while the want of
intelligent, self-interested labour, is the reason why the corn-field,
among the tall broad blades of which a man will work during much of
its growth in comparative obscurity, cannot be cultivated with as
much profit on soils of the same quality in Virginia as in Ohio. In
short, a class of labourers, who are good for nothing else, and who,
but for this, would be an intolerable burden upon those who are
obliged to support them, can be put to some use in raising tobacco,
and, therefore, coarse tobacco continues to be cultivated in some of
the principal slaveholding counties of Virginia. But this class of
labourers is of no more value in cotton culture than in corn culture.
Mr. De Bow says: “The South-west, the great cotton region, is newly
settled, and the number of children, out of all proportion, less than in
negroes [regions?] peopled, by a natural growth of population.[45]
Weak women and children are, in fact, not at all wanted for cotton
culture, the cotton planter’s inquiry being exclusively for ‘prime boys,’
or ‘A 1 field-hands.’”
Thus in every way cotton culture more resembles corn culture than it
does tobacco culture. The production of corn is larger in the
aggregate, is considerably larger per man engaged in its cultivation,
and is far larger per acre in Ohio than in Virginia.[46] I should,
therefore, be inclined to reverse Mr. Russell’s statement, and to say
that if the climate had admitted of the growing of cotton on both
banks of the Ohio, we should have seen that free-labour possessed
as great advantages over slavery in the cultivation of cotton as of
corn.
Mr. Russell echoes also the opinion, which every cotton planter is in
the habit of urging, that the production of cotton would have been
comparatively insignificant in the United States if it had not been for
slave labour. He likewise restricts the available cotton region within
much narrower limits than are usually given to it, and holds that the
slave population must soon in a great measure be concentrated
within it. As these conclusions of a scientific traveller unintentionally
support a view which has been lately systematically pressed upon
manufacturers and merchants both in Great Britain and the Free
States, namely, that the perpetuation of slavery in its present form is
necessary to the perpetuation of a liberal cotton supply, and also that
the limit of production in the United States must be rapidly
approaching, and consequently that the tendency of prices must be
rapidly upward, the grounds on which they rest should be carefully
scrutinized.
Mr. Russell says, in a paragraph succeeding the words just now
quoted with regard to the supposed advantages of slave labour in
raising tobacco:
“The rich upland soils of the cotton region afford a
profitable investment for capital, even when cultivated by
slaves left to the care of overseers. The natural increase
of the slaves, from two to six per cent., goes far to pay the
interest of the money invested in them. The richest soils of
the uplands are invariably occupied by the largest
plantations, and the alluvial lands on the banks of the
western rivers are so unhealthy for white labourers that
the slaveowners occupy them without competition. Thus
the banks of the western rivers are now becoming the
great cotton-producing districts. Taking these facts into
consideration, it appears that the quantity of cotton which
would have been raised without slave labour in the United
States would have been comparatively insignificant to the
present supply.”[47]
The advantages of slave-labour for cotton culture seem from this to
have been predicated mainly upon the unwholesomeness to free or
white labourers of the best cotton lands, especially of the alluvial
lands on the banks of rivers. Reference is made particularly to “the
county of Washington, Mississippi State [which] lies between the
Yazoo and Mississippi rivers. * * * The soil is chiefly alluvial, though
a considerable portion is swampy and liable to be flooded.”[48]
Mr. Russell evidently considers that it is to this swampy condition,
and to stagnant water left by floods, that the supposed insalubrity of
this region is to be chiefly attributed. How would he explain, then, the
undoubted salubrity of the bottom lands in Louisiana, which are
lower than those of the Mississippi, exposed to a more southern sun,
more swampy, and which were originally much more frequently
flooded, but having been dyked and “leveed,” are now inhabited by a
white population of several hundred thousand. I will refer to the
evidence of an expert:—
“Heat, moisture, animal and vegetable matter, are said to
be the elements which produce the diseases of the South,
and yet the testimony in proof of the health of the banks of
the lower portion of the Mississippi river is too strong to be
doubted. Here is a perfectly flat alluvial country, covering
several hundred miles, interspersed with interminable
lakes, lagunes, and jungles, and still we are informed by
Dr. Cartwright, one of the most acute observers of the day,
that this country is exempt from miasmatic disorders, and
is extremely healthy. His assertion has been confirmed to
me by hundreds of witnesses; and we know, from our own
observation, that the population presents a robust and
healthy appearance.” (Statistics are given to prove a
greater average length of life for the white race in the
South than in the North.)—Essay on the Value of Life in
the South, by Dr. J. C. Nott, of Alabama.
To the same effect is the testimony of a far more trustworthy
scientific observer, Darby, the surveyor and geographer of Louisiana:
—
“Between the 9th of July, 1805, to the 7th of May, 1815,
incredible as it may appear to many persons, I actually
travelled [in Southern Alabama, Mississippi, Louisiana,
and, what is now, Texas] twenty thousand miles, mostly on
foot. During the whole of this period, I was not confined
one month, put all my indispositions together, and not one
moment by any malady attributable to climate. I have slept
in the open air for weeks together, in the hottest summer
nights, and endured this mode of life in the most matted
woods, perhaps, in the world. During my survey of the
Sabine river, myself, and the men that attended me,
existed, for several weeks, on flesh and fish, without bread
or salt, and without sickness of any kind. That nine-tenths
of the distempers of warm climate may be guarded
against, I do not harbour a single doubt.
“If climate operates extensively upon the actions of human
beings, it is principally their amusements that are
regulated by proximity to the tropics. Dancing might be
called the principal amusement of both sexes, in
Louisiana. Beholding the airy sweep of a Creole dance,
the length of time that an assembly will preserve in the
sport, at any season of the year, cold or warm, indolence
would be the last charge that candour could lodge against
such a people.”[49]
“Copying from Montesquieu,” elsewhere says Mr. Darby, himself a
slaveholder, “climate has been called upon to account for stains on
the human character, imprinted by the hand of political mistake. No
country where Negro Slavery is established but must have parts in
the wounds committed on nature and justice.”
The unacclimated whites on the sea coast and on the river and
bayou banks of the low country, between which and the sea coast
there is much inter-communication, unquestionably suffer much from
certain epidemic, contagious, and infectious pestilences. This,
however, only renders the fact that dense settlements of whites have
been firmly established upon them, and that they are remarkably
exempt from miasmatic disease, one of more value in evidence of
the practicability of white occupation of the upper bottom lands.
There are grounds for doubting the common opinion that the
negroes at the South suffer less from local causes of disease than
whites. (See “Seaboard Slave States,” p. 647.) They may be less
subject to epidemic and infectious diseases, and yet be more liable
to other fatal disorders, due to such influences, than whites. The
worst climate for unacclimated whites of any town in the United
States is that of Charleston. (This, together with the whole of the rice
coast, is clearly exceptional in respect of salubrity for whites.) It
happens fortunately that the most trustworthy and complete vital
statistics of the South are those of Charleston. Dr. Nott, commenting
upon these, says that the average mortality, during six years, has
been, of blacks alone, one in forty-four; of whites alone, one in fifty-
eight. “This mortality” he adds, “is perhaps not an unfair test, as the
population during the last six years has been undisturbed by
emigration, and acclimated in greater proportion than at any previous
period.” If the comparison had been made between native negroes
and native or acclimated whites alone, it would doubtless show the
climate to be still more unfavourable to negroes.[50]
Upon the very district to which Mr. Russell refers, as offering an
extreme case, I quote the testimony of a Mississippi statistician:—
“The cotton-planters, deserting the rolling land, are fast
pouring in upon the ‘swamp.’ Indeed, the impression of the
sickliness of the South generally has been rapidly losing
ground [i. e. among the whites of the South] for some
years back, and that blessing [health] is now sought with
as much confidence on the swamp lands of the Yazoo and
the Mississippi as among the hills and plains of Carolina
and Virginia.”—(De Bow’s “Resources,” vol. ii., p. 43.)
Dr. Barton says:—
“In another place I have shown that the direct temperature
of the sun is not near so great in the South (during the
summer) as it is at the North. I shall recur to this hereafter.
In fact, the climate is much more endurable, all the year
round, with our refreshing breezes, and particularly in
some of the more elevated parts of it, or within one
hundred miles of the coast, both in and out of doors, at the
South than at the North, which shows most conspicuously
the folly of the annual summer migrations, to pursue an
imaginary mildness of temperature, which is left at home.”
Mr. Russell assumes that slave labour tends, as a matter of course,
to the formation of large plantations, and that free labour can only be
applied to agricultural operations of a limited scope. Of slaves, he
says: “Their numbers admit of that organization and division of
labour which renders slavery so serviceable in the culture of cotton.”
I find no reason given for this assertion, except that he did not
himself see any large agricultural enterprises conducted with free
labour, while he did see many plantations of fifty to one hundred
slave hands. The explanation, in my judgment, is that the cultivation
of the crops generally grown in the Free States has hitherto been
most profitable when conducted on the “small holding” system;[51]
the cultivation of cotton is, as a general rule, more profitable upon
the “large holding” system.[52] Undoubtedly there is a point below
which it becomes disadvantageous to reduce the farm in the Free
States, and this varies with local circumstances. There is equally a
limit beyond which it is acknowledged to be unprofitable to enlarge
the body of slaves engaged in cotton cultivation under one head. If
cotton were to be cultivated by free labour, it is probable that this
number would be somewhat reduced. I have no doubt that the
number of men on each plantation, in any case, would, on an
average, much nearer approach that which would be most
economical, in a free-labour cotton-growing country than in a country
on which the whole dependence of each proprietor was on slaves. Is
not this conclusion irresistible when we consider that the planter, if
he needs an additional slave hand to those he possesses, even if
temporarily, for harvesting his crop, must, in most cases, employ at
least a thousand dollars of capital to obtain it?
Mr. Russell has himself observed that—
“The quantity of cotton which can be produced on a
[slave-worked] plantation is limited by the number of
hands it can turn into the field during the picking or
harvesting of the crop. Like some other agricultural
operations, this is a simple one, though it does not admit
of being done by machinery, as a certain amount of
intelligence must direct the hand.”
The same is true of a wheat farm, except that much more can be
done by machinery, and consequently the extraordinary demand for
labour at the wheat harvest is much less than it is on a cotton
plantation. I have several times been on the Mississippi plantation
during picking time, and have seen how everything black, with
hands, was then pressed into severe service; but, after all, I have
often seen negroes breaking down, in preparation for re-ploughing
the ground for the next crop, acres of cotton plants, upon which what
appeared to me to be a tolerable crop of wool still hung, because it
had been impossible to pick it. I have seen what was confessed to
be many hundred dollars’ worth, of cotton thus wasted on a single
Red-River plantation. I much doubt if the harvest demand of the
principal cotton districts of Mississippi adds five per cent. to their
field-hand force. In Ohio, there is a far larger population ordinarily
engaged in other pursuits which responds to the harvest demand. A
temporary increase of the number of agricultural labourers thus
occurs of not less than forty per cent. during the most critical period.
An analogous case is that of the vintage in the wine districts of
France. In some of these the “small holding” or parcellement system
is carried to an unfortunate extreme under the influence of what are,
perhaps, injudicious laws. The parcels of land are much smaller, on
an average, than the smallest class of farms ordinarily cultivated by
free labour in the United States. But can any one suppose that if the
slave labour system, as it exists in the United States, prevailed in
those districts, that is to say, if the proprietors depended solely on
themselves, their families, and their regular servants, as those of
Mississippi must, at the picking time, there would not be a disastrous
falling off in the commerce of those districts? Substitute the French
system, unfortunate as in some respects it is, for the Mississippi
system in cotton growing, and who will doubt that the cotton supply
of the United States would be greatly increased?
Hop picking and cotton picking are very similar operations. The
former is the more laborious, and requires the greater skill. What
would the planters of Kent do if they had no one but their regular
labourers to call upon at their harvest season?
I observed this advantage of the free labour system exemplified in
Western Texas, the cotton fields in the vicinity of the German village
of New Braunfels having been picked, when I saw them, far closer
than any I had before seen, in fact, perfectly clean, having been
undoubtedly gleaned, by the poor emigrants. I was told that some
mechanics made more in a day, by going into the field of a
slaveowner and picking side by side with his slaves, being paid by
measure, than they could earn at their regular work in a week. The
degree of intelligence and of practice required to pick to advantage
was found to be very slight, less, very much, than in any single
operation of wheat harvesters. One woman was pointed out to me
who had, in the first year she had ever seen a cotton field, picked
more cotton in a day than any slave in the county.

Co Occurring Mental Illness and Substance Use Disorders A Guide To Diagnosis and Treatment 1st Edition Jonathan D Avery John W Barnhill

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Co Occurring Mental Illness and Substance Use Disorders A Guide To Diagnosis and Treatment 1st Edition Jonathan D Avery John W Barnhill

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Available Formats

Co Occurring Mental Illness and

Substance Use Disorders A Guide to

Youth Substance Abuse and Co Occurring Disorders 1st

Counseling Individuals With Co Occurring Addictive and

Opioid Use Disorders A Holistic Guide to Assessment

Diagnosis and Treatment of Mental Disorders Across the

Ending Discrimination Against People with Mental and

Dysphagia. Diagnosis and Treatment of Esophageal

Approach to the Psychiatric Patient Case Based Essays

Human Trafficking A Treatment Guide for Mental Health

Jonathan D. Avery, M.D.

1 The Initial Interview . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 The Comprehensive Assessment . . . . . . . . . . . . . . . 13

3 Depressive and Bipolar Disorders . . . . . . . . . . . . . . 25

5 Posttraumatic Stress Disorder . . . . . . . . . . . . . . . . . 49

9 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

11 Twelve-Step Programs . . . . . . . . . . . . . . . . . . . . . . 141

12 Motivational Interviewing . . . . . . . . . . . . . . . . . . . 151

13 Inpatient Treatment of Co-occurring Disorders . . . 167

14 Pharmacological Interventions . . . . . . . . . . . . . . . . 185

17 LGBTQ Population . . . . . . . . . . . . . . . . . . . . . . . . . 225

Appendix: Answer Guide. . . . . . . . . . . . . . . . . 255

Luke J. Archibald, M.D.

Shannon G. Caspersen, M.D., M.Phil.

Steve Martino, Ph.D.

Eric Yarbrough, M.D.

Disclosure of Competing Interests

The following contributors to this book have indicated a financial interest in or

The following contributors to this book have reported no competing interests

C o-occurring Mental Illness and Substance Use Disorders: A Guide to Diag­

psychiatrist discontinued pharmacological treatment of the ADHD out

Jonathan D. Avery, M.D.

THE INITIAL INTERVIEW AND

John W. Barnhill, M.D.

T he core goals of the initial psychiatric evaluation are to ensure safety,

TABLE 1–1. Physical symptoms that might point to substance use

This early period of hypothesis generation is central to the evaluation

he is also suffering a variety of anxiety symptoms. When meeting a psy­

tients whose most obvious psychiatric diagnosis is so loudly obvious

TABLE 1–2. Typical comments that can de-skill an interviewer

For example, in Chapter 10 (“Gambling Disorder”), Peter is a long-time

dency by recommending that we identify pertinent diagnoses and gen­

intervention worked or failed? What lab results are available? Used in

The second conclusion is obviously more informative, but is it worth

• Nonverbal observation and conversation are crucial to effec­

1. Which of the following is an example of the patient’s chief complaint?

A. “My parents are annoying.”

C. Recurrent trials of antidepressants and mood stabilizers have

2. Which of the following components of a psychiatric interview fo­

A. History of present illness (HPI).

3. In the initial assesment of a patient for potentially co-occurring dis­

A. The single diagnosis that is causing the most difficulty.

Christine Yuodelis-Flores, M.D.

A complete biopsychosocial assessment and integrated treatment plan

The COD assessment is multidimensional and evaluates not only the

LOC: client served by addiction LOC: client served by mental health

FIGURE 2–1. Four-quadrant Model of Care for Co-occurring

he felt that the medical providers believed it was “all in his

TABLE 2–1. The 12-step assessment process for co-occurring

or opiate use/abuse, he did smoke and inject methamphetamine

mind-control chip. Douglas had generally refused medical and

such as schizophrenia or a substance-induced psychosis. He might also

1. Treatment at the primary care level with consultation, intervention,

C o-occurring Mental Illness and Substance Use Disorders: A Guide to Diag

he is also suffering a variety of anxiety symptoms. When meeting a psy

dency by recommending that we identify pertinent diagnoses and gen

• Nonverbal observation and conversation are crucial to effec

2. Which of the following components of a psychiatric interview fo

3. In the initial assesment of a patient for potentially co-occurring dis

6. Inpatient psychiatric hospitalization with medically managed addic

• Done correctly, this comprehensive biopsychosocial assess