4/1/2011 9:00 AM 

Screening, Brief

Intervention and Referral to Treatment (SBIRT)

in Behavioral Healthcare

I. INTRODUCTION

This report discusses the evidence supporting the effectiveness of screening, brief intervention, 

and referral to treatment (SBIRT) as a comprehensive approach, as well as for the 

implementation and effectiveness of the individual components of SBIRT for different 

behavioral health conditions.1 The report describes briefly the underlying research that has been 

conducted in the prevention and early intervention of risky alcohol, substance abuse and tobacco 

consumption, as well as commonly reported mental health problems, and describes existing 

studies/models for specific populations and settings. Further, the report addresses the question of 

what a model SBIRT program is, compared to programs which include or adapt components of 

the comprehensive SBIRT approach. Literature reviews are included in Attachment I. This paper 

is intended for use by policy makers, research organizations and governmental agencies seeking 

to understand the complexities of the SBIRT model and/or considering the adoption and 

implementation of SBIRT systems change or behavioral health integration within primary care 

settings. 

Screening, brief intervention, and referral to treatment (SBIRT) was originally developed as a 

public health model designed to provide universal screening, secondary prevention2 (detecting 

risky or hazardous substance use before the onset of abuse or dependence), early intervention, 

and treatment for people who have problematic or hazardous alcohol problems within primary 

care and other health care settings (Babor et al., 2007; Babor & Higgins-Biddle, 2001). Based on 

the SAMHSA model, SBIRT is unique in its universal screening of all patients regardless of an 

identified disorder, allowing health care professionals to address the spectrum of such behavioral 

health problems even when the patient is not actively seeking an intervention or treatment for his 

or her problems. 

Following are the key points of this paper: 

− SBIRT has been defined by SAMHSA as a comprehensive, integrated, public health 

approach to the delivery of early intervention for individuals with risky alcohol and drug use, 

and the timely referral to more intensive substance abuse treatment for those who have 

substance abuse disorders. There is consensus that a comprehensive SBIRT model includes 

screening, brief intervention/brief treatment and referral to treatment. In addition to these 

 

1

 Excludes medical conditions. 

2

 There is some discussion about whether SBIRT is selective prevention (Kumpfer & Baxley, 

(1997) or early intervention given the overlap in SBIRT's approach and objectives. 
2

integral components, SAMHSA defines a comprehensive SBIRT model to include the 

following characteristics: 

• It is brief (e.g., typically about 5-10 minutes for brief interventions; about 5 to 12 

sessions for brief treatments). 

• The screening is universal. 

• One or more specific behaviors related to risky alcohol and drug use are targeted. 

• The services occur in a public health non-substance abuse treatment setting. 

• It is comprehensive (comprised of screening, brief intervention/treatment, and referral to 

treatment). 

• Strong research or experiential evidence supports the model’s effectiveness. 

− No standard SBIRT definition has been articulated by the U.S. Preventive Services Task 

Force or other authoritative/coordinating bodies. The SAMHSA definition of SBIRT is based 

on methodology that was developed during the implementation of a comprehensive SBIRT 

grant program comprised of all the integral components, and supported by research by the 

National Institute on Drug Abuse and the National Institute on Alcohol Abuse and 

Alcoholism.

− There is substantial research on the effectiveness of SBIRT in reducing risky alcohol 

consumption. However, the evidence for the effectiveness of SBIRT in reducing risky drug 

use, although promising, is still accumulating. The results for the SAMHSA model of 

SBIRT for drug misuse are inconsistent depending on the characteristics of the provider, the 

specific setting, and the patient population that is targeted for SBIRT implementation. While 

there is robust evidence for screening and referral for depression in primary care, to date, 

little empirical evidence for the use of comprehensive SBIRT-like models for mental health 

problems commonly reported by health care patients. There is also no research that has 

demonstrated the implementation or effectiveness of SBIRT-like models in addressing 

trauma or anxiety disorders in clinical health settings. 

II. THE SAMHSA SBIRT MODEL 

SBIRT is a comprehensive, integrated, public health approach to the delivery of early 

intervention for individuals with risky alcohol and drug use, as well as the timely referral to more 

intensive substance abuse treatment for those who have substance use disorders. Primary care 

centers, hospital emergency rooms, trauma centers, and community health settings provide 

opportunities for early intervention with at-risk substance users before more severe consequences 

occur. 

SAMHSA supports a research based comprehensive behavioral health SBIRT model which 

reflects the six following characteristics:

1. It is brief. The initial screening is accomplished quickly (modal time about 5-10 minutes) and 

the intervention and treatment components indicated by the screening results are completed 

in significantly less time than traditional substance abuse specialty care. 
3

2. The screening is universal. The patients, clients, students, or other target populations are all 

screened as part of the standard intake process.

3. One or more specific behaviors are targeted. The screening tool addresses a specific 

behavioral characteristic deemed to be problematic, or pre-conditional to substance 

dependence or other diagnoses. 

4. The services occur in a public health, or other non-substance abuse treatment setting. This 

may be an emergency department, primary care physician’s office, school, etc. 

5. It is comprehensive. The program includes a seamless transition between brief universal 

screening, a brief intervention and/or brief treatment, and referral to specialty substance 

abuse care. 

6. Strong research or substantial experiential evidence supports the model. At a minimum, 

programmatic outcomes demonstrate a successful approach. 

As a comprehensive or model approach, SBIRT has only been demonstrated to be effective for 

risky alcohol use. There is substantial evidence for the effectiveness of brief interventions for 

harmful drinking when delivered by a physician or other qualified health professional (Bien et al, 

1993; Kahan et al, 1995; Wilk et al, 1993). There is a growing body of literature showing the 

effectiveness of SBIRT for risky drug use (Madras et al, 2008; Saitz et al, 2010; Bernstein et al., 

2005) but the results vary by the characteristics of the provider, the specific setting, and the 

patient population that is targeted for SBIRT implementation. 

To determine the effectiveness of SBIRT beyond alcohol, a comprehensive literature review was 

conducted. SBIRT-like models including not only a simple screening tool, but also an 

appropriate and brief intervention that addressed the level of problem indicated by the screening 

results. Table 1 (p. 4) identifies the substance abuse and mental health conditions where SBIRT 

or components of SBIRT have been employed. The literature review did not include studies that 

employed SBIRT or approaches that are similar to SBIRT for general medical conditions such as 

blood pressure, HIV/AIDS, or other behavioral issues such as domestic violence. 

 

As shown in Table 1, the comprehensive SBIRT model has not been consistently demonstrated 

as effective in addressing harmful or risky drug misuse, depression, trauma, or anxiety problems. 

Findings showing the effectiveness of SBIRT for drug misuse are accumulating, and there is 

some programmatic data from the SAMHSA State SBIRT programs showing promising findings 

for depression among primary care patients. Public health approaches that are consistent with 

the SBIRT model have also been demonstrated for tobacco use. They are described in the latter 

sections of this paper. Table 1 presents a brief analysis of the evidence for the effectiveness of 

SBIRT for various behavioral health conditions. 
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Table 1. EFFECTIVENESS OF SBIRT AND ITS COMPONENTS 

FOR BEHAVIORAL HEALTH CONDITIONS

Screening

Brief 

Intervention1 Brief 

Treatment2

Referral to 

Treatment

Evidence for 

Effectiveness of

SBIRT

Alcohol 

Misuse/Abuse

   

Comprehensive SBIRT 

effective (Category B 

classification, 

USPSTF)

Illicit Drug 

Misuse/Abuse

 * *  Growing but 

inconsistent evidence

Tobacco Use    

Effective brief 

approach consistent 

with SBIRT (USPSTF; 

2008 U.S. Public 

Health Service (PHS) 

Clinical Practice 

Guideline 

Depression  —   No evidence to date for 

depression 

Trauma/Anxiety 

Disorders  * —  No evidence to date for 

trauma/anxiety 

disorders 

Key:  Evidence for effectiveness/utility of component 

* Component Demonstrated to show Promising Results 

— Not Demonstrated and/or Not Utilized

1

Brief intervention as defined by the SAMHSA SBIRT program involves 1-5 sessions lasting 5 

minutes to an hour. Among SBIRT grantees funded by SAMHSA, about 15% of patients receive 

scores that indicate a brief intervention. 

2

Brief treatment as part of SBIRT involves 5-12 sessions, lasting up to an hour. Among State 

SBIRT grantees funded by SAMHSA, about 3% of patients receive a score that dictates a brief 

treatment.
5

Chart 1. FLOW CHART FOR SBIRT PROCESS 

Screening

Universal screening helps identify the appropriate level of services needed based on the patient’s 

risk level. Patients who indicate little or no risky behavior and have a low screening score may 

not need an intervention. Those who have moderate risky behaviors and/or reach a moderate 

threshold on the screening instrument may be referred to brief intervention. Patients who score 

high may need either a brief treatment or further diagnostic assessment and more intensive, long 

term specialty treatment. Screening typically takes 5-10 minutes and can be repeated at various 

intervals as needed to determine changes in patients’ progress over time. Some commonly used 

screens for the implementation of SBIRT for alcohol and drug use are the Alcohol Use Disorders 

Identification Test (AUDIT), Drug Abuse Screening Test (DAST), Alcohol, Smoking, Substance 

Involvement, Screening Test (ASSIST), and the Cut Down, Annoyed, Guilty, Eye-Opener 

(CAGE). In addition, a recent study found a single question related to drug use to be effective in 

detecting drug use among primary care patients (Smith et al., 2010). 

Prescreening, which is not a core component of SBIRT but is frequently used, reduces the time 

needed by busy clinic staff to identify patients with risky behavior. Examples of validated prescreens are the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which 

consists of the first three alcohol consumption questions from the full 10-item AUDIT 

questionnaire, and the NIAAA prescreening question (“On any single occasion during the past 3 

months, have you had more than 5 drinks containing alcohol?”, Taj et al., 1998). If a patient 

scores high on any domain in the pre-screen, a full screen is conducted. 

Brief Intervention (BI) and/or Brief Treatment

Patients are provided with BI, brief treatment, or referral to intensive specialty treatment 

depending on their level of risk using a validated pre-screen and/or screening tool (Babor & 

Higgins-Biddle, 2001). With respect to substance abuse, in general only a small proportion of 

patients in primary care settings screened positive for some level of substance misuse, abuse or 

dependency. This is usually 5%-20%, but may be as high as 40% in some clinical settings. The 

majority of patients report minimal or no problems with alcohol or drugs and as such may be an 

ideal group for primary or universal prevention activities for maintenance of non-risky use or 

abstinence. The goal of a BI (which usually involves 1-5 sessions lasting about 5 minutes to one 

hour) is to educate patients and increase their motivation to reduce risky behavior. 
6

The goal of brief treatment (which usually involves 5-12 sessions) is to change not only the 

immediate behavior or thoughts about a risky behavior but also to address long-standing 

problems with harmful drinking and drug misuse and help patients with higher levels of disorder 

obtain more long term care. Based on performance data from state SBIRT grantees funded by 

SAMHSA, only about 3% receive a score that indicates a brief treatment. Patients referred to a 

brief treatment often have higher risk factors than those referred to a BI. Brief treatment may 

also require a manualized course of (advanced) motivational enhancement and cognitive 

behavioral approaches to help patients address unhealthy cognitions and behaviors associated 

with current use patterns and adopt change strategies. If patients report greater risk factors than 

what brief treatment can address, they are referred to specialty substance abuse care. In some 

cases, a patient may receive a BI first and then move on to a brief treatment or longer term care. 

Although the time required to execute BI/BT is generally considered brief, it is far too lengthy 

for physicians to do. Also, physicians cite concerns about angering or insulting patients by 

bringing up sensitive issues such as alcohol and/or drug use. While these concerns are 

understandable, when SBIRT is implemented properly, the time commitment is reasonable and 

acceptably low given the demonstrated success in identifying persons requiring referral to 

treatment (RT). Similarly, concerns about patient reactions can be neutralized by proper training 

for the providers and ensuring that access to referral services is available. In addition, SBIRT is 

frequently implemented by allied health professionals such as nurses, social workers, or health 

educators, with results and actions noted in the patient chart for physician notification and 

oversight. 

Referral to Treatment (RT)

Referral to treatment can be a complex process involving coordination across different types of 

services. As such, the absence of linkages to treatment referrals can be a significant barrier to the 

adoption of SBIRT. Referral is recommended when patients meet the diagnostic criteria for 

substance dependence or other mental illnesses as defined by the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition (DSM-IV).3

 In these cases, a referral to a 

specialized treatment provider is often made. Referral requires the primary care system to

establish new and complex linkages with the traditional specialty care system to connect clients 

who score in the problematic range to recognized, evidence based treatment in a timely manner. 

Although only 3% to 4% of screened patients in primary care settings typically need to be 

referred, the absence of a proper treatment referral will prevent the patient from accessing 

appropriate and timely care that can impact other psychosocial and medical issues. Research 

findings suggest that motivational-based BIs can increase patient participation and retention in 

substance abuse treatment (Hillman et al., 2001; Dunn and Ries, 1997). Strong referral linkages 

are critical, as well as tracking patient referrals. SAMHSA requires SBIRT grantees to have a 

comprehensive referral to treatment and follow-up system in place for the duration of the 

program. In the case where RT is incorporated into an integrated care model, this may require 

shifts in provider allocation and hiring. 

 

3 The diagnostic criteria are likely to change when DSM V is released in 2012 or 2013. 
7

The following characteristics of SBIRT identified in the research literature (see Reference 

section) have been shown to be important in effectively addressing behavioral health problems. 

They have therefore formed the foundation for the SAMHSA SBIRT programs. 

1) Use of brief, validated, universal pre-screening/screening tools. These tools allow health care 

professionals to address the problem behavior even when the patient is not actively seeking 

treatment for his or her problem. Prescreening/screening tools accurately and quickly identify 

individuals with problematic conditions in as little time as 2-4 minutes. Because of its 

briefness and its universal application (that is, can be used with all patients), SBIRT may be 

more generally accepted by health care professionals working in busy practices. 

2) Relatively easy to learn by diverse providers. The SBIRT approach is easy to learn relative to 

other behavioral treatment techniques that may require lengthy specialized training. As such, 

it can be implemented by diverse health professionals who work in busy medical settings 

such as physicians, nurses, social workers, health educators and paraprofessionals. 

3) Incorporation of strong referral linkages to specialty treatment. Approaches that are effective 

integrate comprehensive strategies that include referral to specialty treatments (Gentillelo, 

Donavan, Dunn & Rivara, 1999). While RT may be difficult in underserved areas, this 

should not deter programs from engaging in developing SBI activities as they have beneficial 

effects separate from the referral. However, the goal is to provide a quick handoff for 

dependent patients to specialty treatment if the primary care site cannot provide more 

intensive services for substance abuse. Establishing linkages with specialty care through 

identification of local treatment service contracts, an MOU agreement between sites, or 

dedicated central referral services has been a major barrier for many providers in their 

decision to adopt SBIRT. The availability of well established referral linkages to specialty 

care is essential to the uptake and maintenance of SBIRT, and closely tracking to confirm 

patient compliance with treatment is critical to good health care provision. Primary care 

locations engaged in referral to specialty care make efforts to determine the patient’s 

engagement and participation in treatment, as this may also affect the course of treatment in 

the general medical practice. 

III. ALCOHOL MISUSE, ABUSE, AND PREVENTION

There is substantial evidence from review studies (Babor, 2007; Bein et al, 1993; Kaner, et al., 

2009) and meta-analyses of randomized clinical trials (Beich et al., 2003; Bertholet et al, 2005) 

that show the effectiveness of SBIRT in reducing hazardous drinking in patients presenting in 

primary care and other health care settings. The U.S. Preventative Services Task Force 

(USPSTF) has recommended that “behavioral counseling interventions for risky/harmful alcohol 

use among adult primary care patients can provide an effective public health approach to 

reducing problematic drinking” (USPSTF, 2004). The USPSTF also concluded that counseling 

for risky drinkers should include advice to reduce current drinking; feedback about current 

drinking patterns; and explicit goal-setting, usually for moderation and assistance in achieving 

the goals. 
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Research also indicates that despite the robustness of the evidence for SBIRT’s effectiveness for 

unhealthy alcohol drinking, other factors can impact its effects. For example, studies have 

shown that multiple contacts or sessions (in contrast to a single contact) with a provider can 

increase the impact of SBIRT in reducing risky alcohol consumption (Brown et al., 2007; 

Longabaugh et al., 2001). Moreover, demographic factors and psychosocial conditions also 

have been shown to influence SBIRT’s effects on alcohol misuse (Saitz et al., 2006). For 

example, homelessness makes SBIRT less effective due to the challenges involved in working 

with this population, and brief interventions have improved linkages with those who can provide 

assistance to younger men and hospitalized women. 

The conduct of universal screening, brief intervention and treatment, and referral to treatment for 

alcohol disorders has been found to be effective in various healthcare settings for diverse patient 

populations including primary care (Babor et al., 2007), emergency departments (Gentilello et 

al., 1999), as well as schools and colleges (O'Brian et al., 2006). Data are currently being 

collected that suggest that SBIRT may also be effective in addressing alcohol problems in 

employee assistance programs (McPherson and Goplerud, 2008). Recent research also has 

demonstrated the efficacy of conducting screenings and BIs using innovative strategies such as 

the use of personalized feedback via the internet (Cunningham, 2010), as well as web-based 

outcomes monitoring to assist with treatment decisions and cognitive behavioral techniques 

(Roy-Bryne, 2010). 

Also promising is the utilization of computerized interventions which has been shown to be 

effective in augmenting and complementing the gains made through the initial face to face brief 

interventions. The Veterans Administration, for example, examined the use of electronic clinical 

reminders with patients following screening with the AUDIT-C and showed such approaches 

reinforced moderate drinking reductions at follow up (Williams, 2010). Other research reviews 

indicate that electronic methods can enhance brief interventions with substance users by offering 

assessment and feedback in brief motivational interviewing; monitoring individual treatment 

patient’s progress; tracking patients in aftercare; and providing educational opportunities for 

clinicians (Cucciare, 2009). Electronic intervention can also help bridge the treatment capacity 

gap by providing another source of assistance for women who do not complete traditional 

substance abuse treatment (Van DeMark, et al., 2010). In addition, the cost savings offered by 

the implementation of SBIRT in primary care are significant. One study (Gentilello, 2005) 

showed that for every one dollar spent on providing SBIRT approximately $3.81 is saved. The 

Washington State SBIRT program cost study also reflects similar savings. 

The concept of SBIRT can be applied across the continuum of care for alcohol problems. Based 

on the severity of the problem indicated by the screening results, interventions ranging from 

universal prevention to brief interventions to traditional specialty treatment can be provided to 

health care patients. For individuals who are abstinent, universal prevention practices can be 

implemented to sustain alcohol abstinence. For moderate risky drinking, the first two 

components of SBIRT – screening and brief interventions (SBI)– may be implemented which 

can address inappropriate expectancies (beliefs about substance use effects and social norms of 

acceptable behavior) and lack of motivation to change risk factors that contribute to substance 

abuse (Dimeff et al., 1999). 
9

Extensive research supports screening and brief intervention as effective universal and selective 

prevention strategies for alcohol problems. Universal screening with educational content has 

measurable prevention effects with accompanying feedback (Kunz et al., 2004). The prevention 

approach may also be successful for abstainers and non-risky drinkers by providing behavioral 

support and normative information to maintain healthy behaviors. For at-risk individuals, early 

identification and brief intervention around false expectancies, normative use misperceptions and 

skills acquisition can prevent progression to severe drinking problems. For example, the 

BASICS program, which is consistent with the SBIRT approach, has been shown to be effective 

in addressing problematic or risky drinking in college age groups (Dimeff et al., 1999). SBIs also 

incorporate motivational interviewing components (Miller and Rollnick, 2002) that are also 

integrated in brief treatment for higher risk patients. SBIs have proven effective in decreasing 

overall consumption and binge drinking (Casset et al., 2008; Hanewinkel & Wiborg 2005; Kunz 

Jr. et al., 2004; Martens et al., 2007; Heather et al., 2004; Toumbourou et al. 2007; Murphy et al., 

2001), as well as increasing productivity (Osilla et al., 2010). Evidence further demonstrates that 

strengthening resiliency, competencies, and social connectedness supports recovery for those 

individuals who show early symptoms of alcohol misuse. 

Extensive reviews of the effectiveness of SBI (Babor et al., 2007, 2008) have found that there are 

“irrefutable” improvements in short-term health benefits as well as indications of “substantial” 

long-term benefits. Follow up at three, six or nine month intervals can help document the 

effectiveness of SBI and reinforces normative ideation and skills enhancement for individuals 

with minimal risk behaviors. To achieve long term effects, SBI must be implemented with 

fidelity through targeted training for providers (Cameron et al., 2010; Seale et al., 2005; 

Christensen et al., 2004; Bray et al., 2009; Ronzani et al., 2008; Furtado et al., 2008; Heather et 

al., 2004; Tollison et al., 2008; Babor et al., 2004; Brown & Fleming, 1998). In many instances 

providers implementing SBI may not necessarily be physicians but allied health professionals 

such as nurses, counselors, health educators, and peers (Mastroleo, 2009; Blume & Marlatt, 

2004), who may experience fewer barriers in service provision than physicians (Babor et al., 

2004). Also, SBI can be conducted individually or with groups (Shellenberger et al., 2009; 

Henslee, 2009), with web-based instruments (i.e. college oriented E-Chug and E-Toke or 

Alcohol Skills Training Programs), or online feedback (Blume & Marlatt, 2004), and applied 

through strategic planning by communities or providers. 

IV. DRUG MISUSE, ABUSE, AND PREVENTION

In 1995, based on the scant availability of published research on SBIRT for drugs, the USPSTF 

(1995) determined that there was “insufficient evidence to recommend for or against” the 

effectiveness of using an SBIRT approach for drugs. Some researchers have cited the relative 

scarcity of validated brief drug screening tools (Smith PC, et. al., 2010) and the low prevalence 

rates of drug use (Saitz, 2010) in primary care settings, as two reasons for the comparatively 

small number of studies showing SBIRT’s effects with drugs (De Micheli D, et. al., 2004). 

Nevertheless, since 1995, there has been a growing body of investigator-initiated research as 

well as findings from SAMHSA-funded SBIRT projects that have shown promising results for 

the use of the comprehensive SBIRT approach, as well as selected use of individual components, 

in reducing risky drug use (Copeland et al., 2001). For instance, a randomized controlled trial 

indicated that BIs can reduce cocaine and heroin use (Bernstein et al., 2005). Motivational 
10

interviewing coupled with a self-help booklet given to regular amphetamine users also resulted 

in reduced levels of drug use (Baker, Lee, Claire, Lewin, Grant, & Pohlman, 2005). BIs for 

patients screening positive for cocaine, heroin, and amphetamine are also showing promising 

results in various settings beyond emergency departments (Cunningham et al., 2009). In small 

sample sizes, screening and BIs have been linked with reductions in the use of marijuana, 

amphetamine-type stimulants, cocaine, and heroin (Madras et al., 2008). The World Health 

Organization (2008) sponsored a multi-national study demonstrating that screening and brief 

interventions resulted in short-term reductions of a wide variety of illicit drugs, including 

marijuana, cocaine, amphetamine-type stimulants, and opioids. 

As with alcohol consumption, universal and selective prevention efforts may also be targeted to 

those with minimal or mild drug misuse. Like with alcohol, identified abstainers can benefit 

from supportive and normative information to maintain healthy lifestyles. For individuals at risk 

for drug problems, early identification and brief intervention around false expectancies and skill 

acquisition can prevent progression to more severe drug problems. In addition, tools that can be 

used for universal screening of drug use in health settings such as the DAST and the ASSIST as 

well as on-line tools such as E-TOKE (Electronic – THC Online Knowledge Experience) are 

prevention-ready applications designed to detect the presence of drug use. 

V. SBIRT AND TOBACCO USE

The utility of SBIRT approaches for all forms of tobacco use, especially smoking, has been 

endorsed by the USPSTF and has elicited interest in primary care and hospital personnel. 

Cigarette smoking continues to be the leading cause of preventable disease and death in the 

United States (USDHHS, 2004) and is attributed to approximately 443,000 deaths per year 

(CDCP, 2010) from lung cancer: ischemic heart disease, chronic obstructive pulmonary disease, 

strokes, and other diagnoses. Smoking also affects health outcomes of people other than the 

smokers, with smoking during pregnancy resulting in premature births, spontaneous abortions, 

stillbirths, and intrauterine growth retardation. In addition, research has shown that psychiatric 

disorders and cigarette smoking are frequently co-morbid conditions (Dome et al, 2010; Brown 

et al, 2008; Brown et al, 2002; Degenhardt & Hall, 2001; Grant et al, 2004). A recent study 

using data from the 2005-2006 National Survey on Drug Use and Health reported that adults 

with lifetime depression, anxiety, anxiety with depression, or major depressive episodes were 

more likely to be “current smokers, smoke with higher intensity and frequency, have more 

dependence, and have lower success at quitting” when compared to individuals without these 

psychiatric conditions (Trosclair & Dube, 2010). 

However, despite smoking's established risks and the health benefits of quitting, 23 percent of 

adults in the United States continue to smoke and more than 2,000 adolescents become regular 

tobacco users daily (NSDUH, SAMHSA). Nearly 90 percent of smokers start by age 18, and 25 

percent of teen smokers remain addicted as adults. Because 70 percent of smokers see a 

physician each year (Fiore, Bailey, Cohen, et al., 2000) clinicians have a unique opportunity to 

intervene and implement tobacco SBIRT in primary care settings and emergency departments. 

As such, the USPSTF strongly recommends that clinicians screen all adults for tobacco use and 

provide brief interventions, including screening, brief behavioral counseling (less than 3 

minutes), and pharmacotherapy delivered in primary care settings. The USPSTF also strongly 
11

recommends that clinicians screen all pregnant women for tobacco use and provide augmented 

pregnancy-tailored counseling to those who use tobacco products. These interventions have 

been shown to be effective in increasing the proportion of smokers who successfully quit 

smoking and remain abstinent after 1 year. 

The USPSTF advises that the clinical interventions for tobacco cessation that are cited in the 

2008 U.S. Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and 

Dependence (Fiore et al, 2008), become integrated in standard clinical practice. The PHS 

Guideline also recommends that clinicians use the screening instrument known as the 5A’s of 

tobacco use intervention, which provides a useful strategy for engaging all medical patients in 

smoking cessation discussions. The 5A’s are consistent with the SBIRT approach and parallel 

the screening and brief intervention or counseling components of the SBIRT model. 

 

1. Ask about tobacco use. 

2. Advise to quit through clear personalized messages. 

3. Assess willingness to quit.

4. Assist to quit. 

5. Arrange follow-up and support. 

The Guideline’s behavioral treatments include counseling, social support, problem solving, and 

cessation skills training offered in face-to-face individual or group formats or via telephone quit 

lines. Medication assisted treatments for tobacco use/dependence have also been suggested and 

include seven FDA-approved, first-line medications (i.e., bupropion SR, nicotine gum, inhaler, 

lozenge, nasal spray, and patch), and two second-line medications (clonidine and nortriptyline). 

The Agency for Healthcare Research and Quality (AHRQ) also reviewed tobacco guidelines 

developed in England in 2006 and supports recommendations for brief interventions for patients 

who use tobacco products, including: simple advice to stop, assessment of the patients’ 

commitment to quit, an offer of pharmacological or behavioral support, and provision of self 

help materials or referral to supportive resources such as Quit lines. 

VI. DEPRESSION

The USPSTF supports screening for adult depression where accurate diagnosis, effective 

treatment, and follow-up are available. The USPSTF also recommends screening adolescents 

(12-18 years of age) for major depressive disorder (MDD), again with accurate diagnosis, 

psychotherapy (cognitive behavioral or interpersonal), and follow-up. There are many commonly 

used screening tools for depressive symptoms, such as the Patient Health Questionnaire 2 (PHQ2) (Kroenke, et al., 2003) and the Patient Health Questionnaire 9 (PHQ-9) (Kroenke, et al., 2001) 

which both have established validity and reliability. 

Primary care physicians are the providers most likely to see patients when they first become 

depressed and are most capable of initiating and monitoring treatments with pharmacologic 

agents (McNaughton, 2009). Previous studies, however, have shown that at least half of patients 

with active depression seen by primary care physicians remain undiagnosed (Spitzer et al, 1994; 

Schulberg et al., 1988; Ormell et al, (1991). Depression is particularly prevalent among “high 
12

utilizers” of medical care resources, of whom as many as 40% have been found to have a current 

depressive illness (Katon et.al., 1990). Due to time constraints and training issues, physicians in 

primary care are often unable to provide effective behavioral interventions and treatments for the 

patients with mental disorders (McNaughton, 2009). 

Promising but preliminary data are available from SBIRT grantees funded by SAMHSA that 

indicate that the SBIRT approach may be adapted for depression treatment. For example, the 

State of Wisconsin incorporated depression screening into a Wisconsin Initiative to Promote 

Healthy Lifestyles (WIPHL) pilot program. Patients with mild or moderate depression were 

provided behavioral activation by health educators using specific protocols developed by the 

program. 

Behavioral activation also offers promise as a strategy for brief intervention and there is some 

evidence that it would fit an SBIRT-like approach. Behavioral activation assists individuals to 

identify and engage in daily activities and situations they find positively reinforcing and 

consistent with their long-term goals (Dimidjain et al., 2006). Behavioral activation as a brief 

intervention has been demonstrated in three meta-analyses, one randomized control trial, and one 

follow-up study of a previous randomized control trial, to be an effective intervention for the 

treatment of depression (Sturmey, 2009). 

 

VII. ANXIETY DISORDERS AND TRAUMA

Anxiety disorders are among the most common mental health problemsseen in primary care 

settings and as many as one-third of primary care patients have been found to have significant 

anxiety symptoms (Fifer, 1994). Approximately 15% of primary care patients have a current 

anxiety disorder, and 24% have had a lifetime anxiety disorder, as assessed by diagnostic

interviews (Nisenson et al., 1998). Primary care patients with anxiety disorderstypically have 

considerable disability and impairment in functioning (Roy-Byrne et al., 1999; Sherbourne et al., 

1996) and high utilization rates of general medical services which ultimately result in higher 

health care costs (Simon et al., 1995). Screening tools are also available for anxiety such as the 

Brief Symptom Checklist-18 (Derogatis, 2001) which provides a measure of both anxiety and 

depression. The My Mood Monitor (M-3) (Gaynes et al., 2010) screening is a valid and efficient 

one page tool for screening multiple common psychiatric illnesses in primary care and other 

settings. The M-3 can function both as a screen for specific anxiety and mood disorder 

diagnoses, as well as a general screen for the presence of any mood or anxiety disorder in 

addition to bipolar disorder and PTSD. 

Interventions such as passive psychoeducation, including bibliotherapy, have been shown to 

reduce symptoms of anxiety, psychological distress, and depression (Donker et al., 2009). These 

approaches may be offered as a brief intervention to patients who screen positive for mild or 

moderate levels of anxiety. Passive psychoeducational interventions are cost-effective and can 

be easily put into practice by non medical professionals and may have a less-stigmatizing impact 

on consumers, especially when delivered through a Web site, e-mail or a brochure (Donker et al., 

2009) . 
13

Evidence of emotional trauma is also common in primary care. Walker et al.(1993) report that 

rates as high as 37% for childhood sexual abuse and 29% for adult sexual assault are evident in 

primary care settings. Walker et al. found that 61% of women reported that they believed that it 

was appropriate for their primary care physician to ask about previous victimization, but only 4 

percent had been actually asked. In the Adverse Childhood Experiences (ACE) Study (Dube et 

al., 2004), patients received an assessment using the Family Health History and Health Appraisal 

questionnaires as measures. The authors found the reliability statistics of the ACE study support 

the use of these questionnaires for retrospective reports of adverse childhood experiences such as 

childhood maltreatment, household dysfunction, and other socio-behavioral factors. Other tools 

for screening trauma and anxiety include: the Trauma Symptom Inventory (Briere, 1995), the 

PTSD-8 (Hansen, et al., 2010), and the Primary Care PTSD Screen (PC-PTSD) (Prins, et al., 

2003). 

 

The National Child Traumatic Stress Network has developed an evidence-based practice which 

may be suitable for use in a BH SBIRT program. The Trauma Adaptive Recovery Group 

Education and Therapy for Adolescents and Pre-Adolescents (TARGET-A) has been evaluated 

in 248 clinical trials with control groups and can be completed in as little as 4 sessions. This 

intervention is designed for groups and/or individual children, adolescents and their parents that 

is easily adapted to settings where youth or families enter and leave services rapidly (NCTSN, 

2008). 

The prevalence of issues such as depression, anxiety, and trauma among primary care patients 

call for further exploration to determine if certain SBIRT components may be applied to 

symptoms of these disorders among medical patients. These findings also highlight the value of 

universal screening, a principal component of SBIRT, in addressing mental health issues in 

primary care and other health care settings.

VIII. IMPLICATIONS FOR FUTURE PROGRAMS

While there is substantial research for the effectiveness of SBIRT in reducing unhealthy alcohol 

use and tobacco use/misuse, the evidence for similar models in addressing drug abuse and mental 

health conditions such as depression, anxiety and trauma is still being developed. As such, 

SAMHSA would recommend investment in developing SBIRT-like models for most common 

behavioral health conditions, for use in public health settings. This would involve services 

research, demonstrations, and conducting rigorous comparative effectiveness evaluations of 

behavioral health SBIRT programs beyond those already proven effective for alcohol or tobacco, 

in possible collaboration with NIMH, NIAAA and/or NIDA. 

Numerous screening and intervention programs in a variety of settings and populations have 

recently defined themselves as “SBIRT programs.” Most often these programs do not meet the 

criteria established in this paper to be designated as a comprehensive SBIRT model. Both a 

strong research base and more consistent terminology and definitions for what constitutes a true 

SBIRT model are lacking. Although SBIRT and its components have been utilized across 

programs, the effectiveness of SBIRT programs can vary in their fidelity, application, and 

comprehensiveness. 
14

In considering the future of SBIRT program implementation, some or all of the following could 

be pursued: 

• Partnership with one or more external, authoritative bodies. This may involve approaching the 

US Preventative Services Task Force to develop an SBIRT definition and/or taxonomy which 

reflects the latest science-base approach and is vetted with the field. 

• Collaboration with NIH (NIDA, NIMH) and/or AHRQ to conduct more research on SBIRT 

approaches for drug abuse, depression, anxiety, trauma, etc., to help establish parameters that 

are critical to effective implementation. 

• Diversifying the SAMHSA SBIRT program portfolio and dedicating increased evaluation 

resources to examine the value of complementing SBIRT for alcohol and drugs with screening 

and intervention for other behavioral health conditions. 
15

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