SCREENING FOR AT-RISK DRINKING Barry KL, Milner K, Blow FC, et al. Screening psychiatric emergency department patients with major mental illnesses for at-risk drinking. Psychiatr Serv. 2006;57:1039-1042.

Summary

This study determined the prevalence of at-risk drinking in a psychiatric emergency service (PES) and compared the characteristics and functioning of at-risk drinkers with schizophrenia or bipolar disorder with those of at-risk drinkers with depression or anxiety disorders. Of the adult patients who entered the PES and met study criteria, 148 had schizophrenia or bipolar disorder and 242 had depression or anxiety.

Twenty-three percent of persons with schizophrenia or bipolar disorder and 22% of those with depression or anxiety drank more than the recommended limits. Persons who had schizophrenia or bipolar disorder reported experiencing significantly more consequences from drinking than persons with depression or anxiety. Both groups reported significant depression in the days preceding their PES visit. The importance of assessing alcohol use and depression among all patients in a PES was demonstrated.

Commentary

This article makes a simple but very important point: patients who present with primary psychiatric conditions (in this instance, schizophrenia, bipolar disorder, depression, and anxiety disorders) are also likely to have coexistent alcohol and other substance abuse problems. This is particularly relevant in the emergency department (ED), because the clinician may not often know exactly what he or she is dealing with. If a patient has a diagnosis of schizophrenia, bipolar disorder, depression, or an anxiety disorder, one may conclude that this primary diagnosis is all that is going on; doing so, however, would be a mistake. Alcohol is often either a precipitant of the ED admission or an ongoing component of the psychiatric problem.

This is particularly problematic because the brief screening instruments for substance abuse alone, such as the CAGE questionnaire, are not as applicable to this dual diagnosis population and certainly not in the hurried environment of the ED. Therefore, in the absence of such useful aids, the clinician needs to have a high index of suspicion that persons with histories of mental disorders who present to the ED in crisis are extremely likely to have use/misuse/abuse of alcohol and illicit drugs as a component (or even the precipitant) of that crisis. Put more simply, substance abuse comorbidity should be considered more the rule than the exception.

Peter F. Buckley, MD

Professor and Chairman

Department of Psychiatry

Medical College of Georgia

Augusta