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Primary Care and Co-Occurring


Many individuals with co-occurring mental and substance use disorders seek services in primary care settings long before they would ever seek services in specialty areas such as substance abuse or mental health agencies. As a result, primary care practitioners have a unique opportunity to identify individuals who may have a co-occurring disorder. Screening for co-occurring disorders in primary care settings may assist practitioners to recognize and address conditions early, which has the potential to significantly improve health outcomes.

Cross-screening improves quality of care and reduces costs for both systems of care.

Research also shows that individuals with serious mental illnesses die 25 years earlier on average than the general population; mostly because of medical illnesses such as cardiovascular disease or diabetes. Individuals also experience better outcomes when they receive treatment for physical conditions along with behavioral health services.

Screening Processes

Primary care practitioners have a selection of screening tools or processes from which to choose, to quickly assess the severity of the mental or substance use disorder and determine next steps. Screening can also serve as a baseline to measure clinical progress or practitioner effectiveness. Depending on the resources available, primary care practitioners may add a few threshold questions to existing intake forms or do a more in-depth screening. Common tools include:

For Alcohol and Other Drug Abuse:
CAGE Questionnaire. This questionnaire on alcohol, which requires only one minute to complete, can assist in diagnosing alcoholism.

Single Screener from the National Institute on Alcohol Abuse and Alcoholism. This tool consists of just one question regarding alcohol use.

DAST-10 (Drug Abuse Screening Test). This short assessment tool is used to detect drug abuse.

For Mental Health Issues:
PHQ-9 (Patient Health Questionnaire). This tool follows the Diagnostic and Statistical Manual (DSM-IVTR) and has nine criteria for depression, assessing symptoms, providing a metric for monitoring, medication management, and remission phases. The PHQ-2 is a two-item version of the PHQ-9 that can be used by practitioners to determine if there is a need for the next seven items. Both tools are shorter than most depression scales, and both can be self-administered or physician-administered by phone or in person. The PHQ-9 has been used successfully in multiple efforts to integrate primary care with access to behavioral care through proper patient screening and assessment.

Examples of questions from the PHQ-9


Practitioners providing co-occurring disorder treatment may monitor and screen for health indicators such as:

  • Personal History of Diabetes, Hypertension, Cardiovascular Disease
  • Family History of Diabetes, Hypertension, Cardiovascular Disease
  • Weight/Height/Body Mass Index (BMI)
  • Blood Pressure
  • Blood Glucose or HbA1C
  • Lipid Profile
  • Tobacco Use/History
  • Substance Use/History
  • Medication History/Current Medication List, with Dosages
  • Social Supports

They may also monitor access to and utilization of primary care services (medical and dental).

Integrated systems of care may use a universal screening tool to measure wellness in physical health, mental health, and substance abuse areas. One example of that is the Duke Health Profile, a 17 question self-assessment that measures physical health, mental health, social health, general health, and other areas. They also may have quality measures for the system of care that include screening for both physical health (e.g. statin use, blood pressure) and behavioral health issues (e.g. risk behavior) within a period of time.

Resources and Links