Based on TIP 9

Assessment and 

Treatment of Patients With

Coexisting

Mental Illness

and Alcohol

and Other 

Drug Abuse 

KAP Keys

For Clinicians

CSAT’s

Knowledge Application Program

KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and

Other Drug Abuse

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting Mental

Illness and Alcohol and Other Drug Abuse

These KAP Keys were developed to accompany the Treatment

Improvement Protocol (TIP) Series published by the Center for

Substance Abuse Treatment (CSAT), Substance Abuse and

Mental Health Services Administration. These KAP Keys are

based entirely on TIP 9 and are designed to meet the needs of

the busy clinician for concise, easily accessed "how-to" information.

For more information on the topics in these KAP Keys, readers

are referred to TIP 9.

Introduction

TIP 8, Intensive Outpatient Treatment for Alcohol and Other

Drug Abuse (1994) BKD139

TIP 19, Detoxification From Alcohol and Other Drugs (1995)

BKD172

TIP 24, A Guide to Substance Abuse Services for Primary Care

Clinicians (1997) BKD234

TIP 27, Comprehensive Case Management for Substance

Abuse Treatment (1998) BKD251

TIP 29, Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities (1998) BKD288

Other Treatment Improvement Protocols (TIPs)

that are relevant to these KAP Keys:
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse

The ABC Model is a simple screening technique for the presence of psychiatric disorders. The substances used most often

by patients with dual disorders are the same as those used by

society in general: alcohol, marijuana, cocaine, and more

rarely, opioids. It is recommended that all front-line substance

abuse and mental health staff receive detailed training in the

use of a mental status exam and substance abuse screening

tests.

• Appearance, alertness, affect, and anxiety

Appearance: General appearance, hygiene, and dress

Alertness: What is the level of consciousness?

Affect: Elation or depression: gestures, facial expression, 

and speech

Anxiety: Is the individual nervous, phobic, or panicky?

• Behavior

Movements: Rate (hyperactive, hypoactive, abrupt, 

or constant?)

Organization: Coherent and goal-oriented?

Purpose: Bizarre, stereotypical, dangerous, or impulsive?

Speech: Rate, organization, coherence, and content

• Cognition

Orientation: Person, place, time, and condition

Calculation: Memory and simple tasks

Reasoning: Insight, judgment, problem solving

Coherence: Incoherent ideas, delusions

ABC Model for Psychiatric

Screening

1
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse

The CAGE questionnaire and the CAGE questionnaire modified

for illicit drugs (CAGE-AID) are rapid and accurate screening

tools for substance abuse disorders.

CAGE and CAGE-AID 2

The CAGE Questions Adapted to Include Drugs 

(CAGE-AID)

Have you felt you ought to cut down on your drinking or

drug use?

Have people annoyed you by criticizing your drinking or drug

use?

Have you felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs first thing in the

morning to steady your nerves or get rid of a hangover or

to get the day started?

Source: Brown 1992.

The CAGE Questionnaire

Have you ever felt you should cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you felt bad or guilty about your drinking?

Have you ever had a drink first thing in the morning to

steady your nerves or get rid of a hangover (eye-opener)?

Source: Mayfield et al. 1974.
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse

How to Increase Staff Knowledge

About Dual Disorders

3

• Create an individualized plan for each staff person, defining

strengths as well as deficits and areas of needed growth;

define a training plan with a timetable and components.

• Receive training at an established dual disorder treatment

program.

• Attend workshops on treating patients with dual disorders.

• Include on-the-job training:

- Substance abuse and mental health jointly 

facilitated groups

- Mental health workers on a substance abuse service

- Substance abuse workers on a mental health service

- Staff sharing

• Provide didactic inservice training:

- Train mental health workers in substance abuse 

treatment

- Train substance abuse treatment staff about mental 

health treatment

- Train staff in dual disorders

• Provide staff with important articles from the field by providing subscriptions to appropriate peer-reviewed journals.

Purchase textbooks on dual disorders.

• Work with local universities, colleges, and community college

programs to create a dual disorders training track.

• Train Social Security Income maintenance staff about

patients with dual disorders.

• Train substance abuse and mental health staff in a range of

social service areas, including income support, child welfare,

and special populations.

• Encourage an on-site application process for income support

programs at substance abuse and mental health treatment

facilities. Mental health and substance abuse treatment programs can request training and support from Federal, State,

or local administrators of various income support programs.

• Develop mobile outreach approaches to assist patients with

dual disorders in gaining access to income support programs

and other needed social service programs.

• Encourage an ongoing exchange among policy-level staff of

substance abuse, mental health, and Social Security agencies on Federal, State, and local levels.

• Allocate sufficient social service staff time to assist patients

who need a range of supports and services. 
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse

Mood and Personality

Disorders

4

Tips for Assessment of Mood Disorders

For depression:

• "During the last month, has there been a period of time during which you felt depressed most of the day nearly every

day?"

• "During this period of time, did you gain or lose any weight?"

• "Did you have trouble concentrating?"

• "Did you have problems sleeping or did you sleep too much?"

• "Did you try to hurt yourself?"

For mania:

• "During the past month, have you experienced times when

you felt so hyperactive that you got into trouble or were told

by others that your behavior was not normal for you?"

• "Have you recently experienced bouts of irritability during

which you would yell or fight with others?"

• "During this period, did you feel more self-confident than

usual?"

• "Did you feel pressured to talk a great deal or feel that your

thoughts were racing?"

• "Did you feel restless and irritable?"

• "How much sleep do you need?"

Key Issues and Concerns in the Treatment

of Personality Disorders

• Slow progress in therapy

• Suicidal behavior

• Patient contracting

• Transference and countertransference

• Clear boundaries

• Changing roles

• Resistence

• Subacute withdrawal

• Symptom substitution

• Somatic complaints

• Therapist well-being
KAP KEYS Based on TIP 9

Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse

Treating Anxiety and Dual

Disorders

5

Treating Anxiety During Substance Abuse

Treatment

• Anxiety treatment can be postponed unless anxiety interferes

with substance abuse treatment.

• Anxiety symptoms may resolve with abstinence and substance

abuse treatment.

• Affect-liberating therapies should be postponed until the

patient is stable.

• Psychotherapy, when required, should be recovery oriented.

• Nonpsychoactive medications should be used when medications are needed.

• Antianxiety treatments such as relaxation techniques can be

used with and without medications.

• A healthy diet, aerobic exercise, and avoiding caffeine can

reduce anxiety.

Dual-Focus Approach for Assessing and

Treating Patients with Dual Disorders

• Initial focus on severity of presenting symptoms, not on diagnosis of one disorder or another

• Acute crisis intervention and crisis management

• Acute, subacute, and long-term stabilization of patient

• Ongoing diagnostic efforts

• Multiple-contact longitudinal treatment
Easy Ways to Obtain Free Copies 

of All TIP Products

1. Call SAMHSA's National Clearinghouse for Alcohol and

Drug Information (NCADI) at 800-729-6686, 

TDD (hearing impaired) 800-487-4889.

2. Visit CSAT's Website at www.csat.samhsa.gov

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of

Communications, Substance Abuse and Mental Health

Services Administration, U.S. Department of Health and

Human Services.

DHHS Publication No. (SMA) 01-3558

Printed 2001

Ordering Information

TIP 9

Assessment and Treatment of Patients

With Coexisting Mental Illness and Alcohol

and Other Drug Abuse