Alcoholism, Substance Abuse and Dependency > Chapter 7, Part D - Screening and Assessment
Treatment of Substance Users with Depressive Symptoms cont'd...

Chapter 7, Part D - Screening, Assessment and Treatment Planning

Screening and assessment begin at the earliest point of contact with the client and continue throughout treatment. Information about a client’s substance abuse and depressive symptoms should be monitored for positive changes as well as evidence that symptoms are getting worse. As noted earlier, screening and assessment should be integrated so that substance abuse and depressive symptoms are each explored within the context of the other.

Although making a diagnosis of mood disorder is outside the scope of practice for counselors, they should nonetheless learn the symptom sets (described in Appendix D of this TIP) so as to make an appropriate referral for assessment to someone who can diagnose and treat these disorders. Because of the interaction between depression and substance use disorders, it is especially important that a capable mental or behavioral health professional qualified in the State to diagnose and treat depresssion who also has training in substance use disorders make the diagnosis and direct treatment. Screening and assessment for substance abuse clients with depressive symptoms always needs to include screening for suicidality.


Screening is a planned and purposeful process that typically is brief and occurs soon after the client presents for services. Screening determines the likelihood that a client has co-occurring substance use and mental disorders or that his or her presenting signs, symptoms, or behaviors may be influenced by co-occurring issues such as depressive symptoms (CSAT, 2006). The purpose is to establish the need for an in-depth assessment.

Your job as a counselor is to watch the client for symptoms of depression, discuss them with your clinical supervisor when they appear, and, in concert with your supervisor, make a plan for how these symptoms will be addressed in treatment. The symptom list in Figure 1.1 (p. 5) provides a solid reference guide. Screening and assessment are discussed in chapter 4 of TIP 42 (CSAT, 2005b). Although screening instruments tend to be sensitive to the symptoms they track, one must rely on an expert clinical evaluation for clinical assessment and diagnosis.

Several screening tools can help determine the likelihood of the presence of depressive symptoms. Their selection depends on many factors and is part of the development of the screening and assessment process. One example is the Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item form that can be completed by the client in a few minutes. It asks the client to rate how frequently he or she had each symptom during the past week. The possible range of scores is 0 to 60. A copy of this instrument is in Appendix B of this TIP.

Another commonly used screening tool for depressive symptoms is the Beck Depression Inventory (BDI-II), a 21-item self-report of depressive symptoms. This widely used instrument is copyrighted by The Psychological Corporation and requires payment for its use. Information on BDI-II can be obtained from the publisher’s Web site (

It is important to note that these instruments do not assess suicidality, even though suicidality is a depression symptom. Therefore, as stated above, suicidal thoughts, intentions, and behaviors must be screened for and assessed independently in the clinical interview.

[QN.No.47.The screening tools for depressive symptoms that do not assess suicidality are:]

In addition to client self-report, it is important to observe the behavior of the client: that is, to watch for changes in mood, affect, and behavior that the client may minimize or find hard to articulate. Keep track of the intensity and duration of symptoms. As noted earlier, depressive symptoms may be the prelude to a depressive disorder. Signs of deterioration should be reported immediately to your clinical supervisor, who will need this information to decide whether a formal assessment for depression is needed.


Assessment “gathers information and engages in a process with the client that enables the provider to establish (or rule out) the presence or absence of a cooccurring disorder.” It “determines the client’s readiness for change, identifies client strengths or problem areas that may affect the processes of treatment and recovery, and engages the client in the development of an appropriate treatment relationship” (CSAT, 2006, p. 1). One outcome of the assessment may be the attribution of a DSM-IV-TR diagnosis, such as alcohol dependence or a depressive disorder. Another outcome is the initial treatment plan for the client.

Assessment for depressive symptoms may take place at intake in your program or may be the result of screening by the counselor. Assessments for depressive illness must be conducted by a mental health professional who has the required specialized training, skills, and licensure and/or certification. DSMIV-TR diagnosis is accomplished by referral to a psychiatrist, licensed psychologist, licensed clinical social worker, or other qualified healthcare professional who is licensed by the State to diagnose mental disorders.

Certain assessment instruments can be obtained and administered only by a licensed psychologist. Your clinical supervisor or other staff associated with your program may be licensed mental health professionals who are qualified to assess and diagnose for depression. Therefore, “referral” does not necessarily mean to someone outside your agency. If a referral is to be made, appropriate program protocols should be observed. For example, you may need to refer through your clinical supervisor or your program administrator. It is also important to explain the purposes and processes of the referral to the client and to elicit cooperation in the referral and assessment process. Finally, it is important to gain written consent from clients to discuss their cases with other professionals, particularly in other programs.

The American Society of Addiction Medicine’s (ASAM’s) patient placement criteria (PPC-2R; ASAM, 2001) address the decisionmaking process for how a client with a substance use disorder diagnosis with co-occurring depression (or other disorders) can be treated in existing substance abuse treatment programs. The ASAM criteria offer a model for assessing across several life areas, suggesting the severity of symptoms (in this case, depressive symptoms) and the appropriateness of fit with a program’s services.

Note: The clients in the vignettes of chapter 2 have all been identified as experiencing depressive symptoms, not a DSM-IV-TR mood disorder, in their intake assessment or through a process of screening by their counselors and subsequent assessment by a qualified mental health professional.

Treatment Planning

As a substance abuse counselor, you may be legally entitled to work with clients who have depressive symptoms as defined earlier in this chapter. However, most States require additional training or credentials to provide treatment to clients with diagnosable depressive illness (see Figure 1.4, p. 15). Figure 1.6 provides guidance for determining who should work with a given client.

Client-Centered, Integrated Treatment Planning

A treatment plan for a person with substance use disorder and depressive symptoms should be client-centered and integrated. An excellent resource for integrated treatment planning is ASAM’s PPC-2R (ASAM, 2001).

Client-Centered—There is no one right approach to care for the client with a substance use disorder who also has depressive symptoms. A client-centered treatment plan is based on a careful assessment inclusive of immediate needs, motivation for change, and readiness for change (see “Stages of Readiness for Change,” p. 26). Cultural differences must be accommodated, respected, and incorporated into all aspects of treatment, but each individual must be viewed as a unique combination of culture, history, current situation, and stage of life.

Client-centered treatment planning is a process conducted in collaboration with the client. As the counselor, your job is to help the client explore various alternatives and educate the client about each option. Together you and the client can arrive at a mutually agreeable treatment plan. Helping a client explore potential risks and benefits, along with understanding the process for change and the effort that will be required, can help the client make informed choices.

Your success as a partner in the collaborative process of treatment planning will depend, in part, on your ability to enter the client’s world and to assist the client in articulating concrete treatment goals and objectives. Your creativity and flexibility are as important in this process as your clinical skills and experiences.

Integration—Integrated treatment planning is fundamental to providing services to persons with co-occurring substance use and mental health problems (see the definition below). For this TIP, integrated treatment planning means that:
  • You, the substance abuse counselor, take primary responsibility for helping the client work with both substance abuse issues and depressive symptoms (see Figure 1.6).
  • Your treatment plan addresses the client’s substance abuse, depressive symptoms, and issues that may arise through the interaction of the two (e.g., depressive symptoms as a cue for craving).
  • The treatment plan includes specific client goals and objectives for substance abuse and for depressive symptoms.
  • The treatment plan provides for monitoring progress in both areas.

Observe how the counselors in the vignettes in chapter 2 integrate their treatment of substance abuse and depressive symptoms, recognizing that the symptoms of one problem significantly alter the presentation of symptoms of the other problem. This is particularly true when the drug used by the client produces a depressive effect on the client’s thinking and behavior.

Treatment Planning as an Ongoing Process

As the client progresses in treatment, new challenges will emerge, new issues may arise, and some initial plans will need to be abandoned. Clinical work requires the counselor to use not only continuous feedback in the form of objective clinical indicators of progress, but also subjective information from the client to guide the client’s recovery at each stage.

As suggested earlier, a client with a substance use disorder who shows no signs of depressive symptoms at intake may begin to experience depressive symptoms as recovery proceeds. Similarly, a client whose depressive symptoms are currently mild may spiral downward into a clinically diagnosable depression during your work together. Finally, a client who initially shows depressive symptoms may rapidly feel better as he or she adjusts to the routine of the program.

The need to be on the lookout for such changes and the need for further assessment when symptoms appear or worsen were discussed earlier in this chapter. Such reassessment will sometimes require major alterations in the treatment plan. As with the initial treatment plan, revisions should be made in collaboration with the client.

The Role of Medications

A review of medical treatment for substance use and depressive disorders is beyond the scope of this manual. However, the treatment plan for a client with substance dependence and depression should always consider the use of appropriate psychoactive medication. Medication treatment will involve a psychiatrist, another physician, or another clinician licensed to prescribe in your State who should also make a careful diagnostic assessment. In the diagnostic assessment, it is important for such clinicians to establish whether depressive disorder is present, because the evidence suggests that a diagnosis of one of these depressive syndromes is important for antidepressant medications to be effective (Nunes and Levin, 2004; Nunes, Sullivan, & Levin, 2004). Without such a diagnosis, it is not clear whether depressive symptoms respond to antidepressant medication. Evidence from a meta-analysis of clinical trials of antidepressant medications for clients with alcohol or drug dependence (Nunes and Levin, 2004) showed that depression improved with a placebo for many clients, but all patients (including those on the placebo) received a manual-guided psychosocial intervention, such as relapse prevention or drug counseling.
Alcoholism, Substance Abuse and Dependency > Chapter 7, Part D - Screening and Assessment
Page Last Modified On: August 18, 2014, 10:27 AM