When Should Assessment Occur?

Assessment of comorbid mental disorders should occur a) for all at first contact, b) when triggered by positive responses to screening, c) when the client requests it, d) when the client has or is likely to drop out from treatment, e) when progress is not as expected, or f) when there is an unexpected or abrupt change in the client’s condition.  

A first step in assessment of comorbid mental disorders is consideration of their severity. Milder symptoms of anxiety and depression may not need separate attention, but more severe forms may change the focus and setting of treatment. The Kessler 10 Symptom Scale otherwise known as the K10 is a widely used measure of psychological distress that appears suitable to screen for wide a variety of mental disorders (see Appendix). A briefer 6 item version, the K6, appears to have similar screening properties and may be preferred for brevity. It also may be repeated to monitor progress and as an outcome measure in people with anxiety and depressive disorders. 

Differential diagnosis may take time and should not be a barrier to starting treatment focused on symptoms. As above a period of abstinence (conventionally 4-6 weeks), or significantly reduced drinking, is a key method. In addition, taking a careful history may reveal that comorbid mental disorders began before drinking. For example, antidepressant treatment for depressive disorder is more effective when that disorder began before the onset of drinking or when the depression persists beyond abstinence compared to depression that only occurs within “active alcohol use disorder”. It may also be useful to pay attention to the symptoms present – low mood, agitation, insomnia and arousal may be explained as the effect of drinking or as a separate anxiety or depressive disorder, while phobic avoidance, flashbacks, thought disorder are more likely to indicate separate mental disorders. Where there is confidence that a separate mental disorder is present, or there are disturbing impairing symptoms, optimal intervention should be made available without delay. 

Following a positive screen on the K10 or K6 a more detailed assessment for specific mental disorders may be required. We found little evidence to recommend for or against any of the typically available options such as referral for a psychiatric opinion, the use of structured or semi structured diagnostic interviews, further questionnaires to assess specific disorder, and/or a clinical interview. In the absence of definitive evidence, clinical consensus is that any of these methods for more comprehensive assessment is acceptable if they can be achieved in a timely, co-ordinated, compassionate and engaging way. 

Where there is more time available or the likelihood of comorbidity is higher, specific screening questionnaires for common comorbidities are likely to provide additional information as part of a comprehensive assessment. Standardised questionnaires with validation for screening against gold standard clinical interview in comorbid samples are the Adult Attention deficit hyperactivity disorder (ADHD)Self-Report Scale for ADHD (level C evidence), The Psychosis Screener (also with level C evidence). The Trauma Screening Questionnaire (TSQ) and Primary care PTSD screen (PC-PTSD) (D), Short Sleep Index for insomnia (D), The Eating Disorder Examination –Questionnaire EDEQ for eating disorder (D), and the Iowa Personality Disorder Screen (IPDS-SR, 11items) and the Standardized Assessment of Personality-Abbreviated Scale (SAPAS-SR, 8 items) for personality disorders (D) may be used.  

Formal routine monitoring of progress with feedback to clinicians and consumers may be a useful in identifying those who are not progressing as expected (Crits-Christoph et al., 2012; Lambert, 2010) and additional benefits may result from standardised assessment of the barriers to progress (such as motivation and therapeutic alliance see Chapter 9). 

Assessment of comorbid mental disorders should be conducted regularly as the clinical picture can change with improvements in alcohol use. People with comorbid mood and alcohol use disorder should be regularly assessed and monitored for risk of suicide according to established guidelines (see Appendix 5). 

Chapter Recommendation Grade of recommendation
21.4 The K10 or K6 are recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders. A
21.5 Differential diagnosis of comorbid disorders should take place after resolution of withdrawal, which may account for some anxiety and depressive symptoms. B
21.6 To identify specific mental disorders the Adult ADHD Self-Report Scale (ASRS) is recommended to screen for Attention Deficit Hyperactivity Disorder as is The Psychosis Screener as a screen for psychotic disorders as part of a comprehensive assessment. C
21.7 The Trauma Screening Questionnaire (TSQ) and/or the Primary Care PTSD Screen (PC-PTSD) are recommended to screen for PTSD, Short Sleep Index for insomnia, Eating Disorder Examination –Questionnaire (EDEQ) for eating disorders, and the Iowa Personality Disorder Screen (IPDS-SR) and/or the Standardized Assessment of Personality-Abbreviated (SAPAS-SR) for personality disorders, as part of a comprehensive assessment. D
21.8 Routine standardised assessment of alcohol use and symptoms of comorbid disorders may alert clinicians to clients who are not progressing as expected to identify and manage barriers to progress. GPP