Talking With Your 

Adult Patients 

About Alcohol, 

Drug, and/or 

Mental Health 

Problems

A Discussion Guide for Primary 

Health Care Providers

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov
The Role of the Primary Care Provider

Health care providers typically think of mental health 

problems and alcohol and substance use disorders as 

separate illnesses. Yet in many cases, a person has both 

(i.e., co-occurring disorders). Moreover, the association of medical problems with co-occurring mental 

and substance use disorders often results in these 

individuals being seen in primary care settings. 

Because people with co-occurring disorders are 

everywhere in our communities, every point of entry 

into the health care system is an opportunity for outreach, education, and connection to needed services. 

The primary care setting is ideal for identification of 

people with co-occurring disorders.

Depression and anxiety disorders may present as 

fatigue, headaches, and pain, whereas substance use 

disorders are associated with high rates of infections 

and complicate the management of many chronic illnesses such as hypertension and pain conditions.

 
REMOVE BLACK BOX

Most people with untreated co-occurring disorders 

are functionally impaired in school, at work, or within their families and communities. This impaired 

functioning leads to an overrepresentation in acute 

and high-cost health, criminal justice, and social welfare settings.

People with co-occurring disorders need help for 

both mental health and alcohol or drug problems. 

Failure to address both problems can undermine 

successful treatment of one or the other. Untreated 

mental and substance use disorders result in excess 

morbidity and frustration for patients and families.

Culturally competent identification of alcohol, drug, 

and/or mental health problems by primary care staff 

can help people receive targeted referrals and 

access needed services, which will enhance their 

physical health as well.

The enclosed card contains a guide for discussion.
One Way To Start the Discussion

You may want to ask your adult patients these 

questions at least once, ideally during or soon 

after the patient’s first contact, if the medical 

situation permits, as well as annually.

One way to introduce patients to these questions 

might be:

"To help us understand how we can help 

you, I would like to spend a few minutes 

asking you some questions that we use 

with our patients. The questions are about 

emotional or other stresses that can 

interfere with your physical health."
Questions About 

Mental Health Issues

1. Over the past 2 weeks, have you felt down, 

depressed, or hopeless?

2. Over the past 2 weeks, have you felt little interest 

or pleasure in doing things?

3. In the past year, have you had significant problems 

with insomnia, bad dreams, or falling asleep during 

the day?

4. In the past year, have you had problems with thinking 

about ending your life or thoughts about suicide?*

5. In the past year, have you had a hard time paying 

attention at school, work, or home?

6. Do you have any other worries or emotional concerns that you think would be good to talk about 

with a professional or someone in your community?

*Patients reporting suicidal thinking or thoughts of 

harming themselves should be evaluated immediately. For more information call 1-800-273-TALK 

(1-800-273-8255).
Questions About Drug and 

Alcohol Use 

How many times in the past year have you:

• (for men) had 5 or more drinks (beer, wine, or hard 

liquor) in a day?

• (for women or anyone over 65) had 4 or more 

drinks in a day?

• used recreational or prescription drugs to get high?

If the response to either of the above questions is 

one or more times, ask the CAGE questions below. 

(Also, please note that the more times per year to 

either question, the more serious the concerns.)

A. Have you ever felt you should Cut down on your 

drinking or drug use (use less alcohol or drugs)?

B. Have people Annoyed (irritated, angered, etc.) you 

by criticizing your drinking or drug use?

C. Have you ever felt bad or Guilty about drinking or 

drug use?

D. Have you ever taken a drink or a drug first thing in 

the morning (Eye-opener) to steady your nerves or 

get rid of a hangover?

See Resources for patients with "yes" responses.
For Adult Clients Who Need Evaluation

A positive answer to a mental health question 

(but negative answers to the drug/alcohol questions) should lead to an assessment by a mental 

health professional. 

A positive response to a drug/alcohol question 

(but negative answers to the mental health questions) should be addressed if necessary by 

consultation or referral to a specialist. 

Positive answers to both sets of questions should 

be addressed if necessary by consultation or 

referral to a specialist in both substance abuse 

and mental health.

In discussing a positive screen, one might emphasize that identifying a substance use and/or mental 

disorder is an important step in restoring a person’s physical health and helping that person realize his or her full potential.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov