Dual Diagnosis: Mental Illness and Substance Abuse - Report Example

Table of contents Table of contents 1 Dual diagnosis 1 Substance abuse 3 Relationship between mental illness and substance abuse 4 Difficulties encountered when identifying dual diagnosis 5 Clinical assessment for dual diagnosis 5 Management of dual diagnosis 5 Integrated approach to dual diagnosis 6 Initial Treatment programs for dual diagnosis 7 Medical detoxification 7 Group discussions 9 Using Long-term residential programs 10 Adoption of partial hospitalization for outpatient patient 10 Adoption of intensive outpatient program 10 Recommendations of intensive case management 11 Counseling 11 Motivational interviewing 11 Cognitive behavioural therapy 12 Staff education on dual diagnosis 13 Substance withdrawal scales 13 Bibliography 14 Dual diagnosis Dual diagnosis (Johnson, 1997) is a medical term that is used to describe presence of clinical signs of mental illness and substance abuse in a patient. Other terms (Hasin, 1996) that have equivalent meaning to dual diagnosis condition are co-morbid disorders, co-morbidity, co-occurring disorders, concurrent disorders, dually diagnosed and multiple disorders. Some health professionals (Folstein, 1975) consider the medical term dual diagnosis as failing to fully define the multiple illnesses that is linked with mental illness and substance abuse. This is because diagnosis of related ill-health has many clinical signs (Folstein, 1975) than mental illness or substance abuse. On the same note, the term dual diagnosis (Folstein, 1975) is also used to describe persons that have development handicaps, social handicaps, emotional handicaps and emotional handicaps that may or may not have a link to mental ill-health or substance abuse. Specifically, dual diagnosis (Folstein, 1975) is used to denote persons who have serious mental illness that is coupled with substance abuse and the same persons must be undergoing therapy in hospitals or in a residential community set up for substance rehabilitation. There is no fixed term that is internationally accepted to describe dual diagnosis condition (Folstein, 1975). Dual diagnosis is not an abrupt medical condition (Drake, 1993) and gradually develops in an individual over time. Patients that have mental illness have a high chance of being victims of substance abuse and vice versa. Patients that have dual diagnosis have characteristic etiological mechanism (Drake, 1993: Hasin, 1996). For instance, they may have primary psychiatric disorder that is secondary to substance abuse (Brooner, 1998) or substance abuse that is secondary to psychiatric disorder (Folstein, 1975) or they may exhibit psychiatric clinical signs that are linked to substance intoxication or withdrawal (Brooner, 1998: Hasin, 1996). According to DSM-IV (American psychiatric association, 1994) a distinction can be made between independent or primary psychiatric dual diagnosis and substance induced or organic psychiatric dual diagnosis. There are two etiological factors that are characteristic of dual diagnosis (Brooner, 1998). Following guidelines of the super sensitivity mode (Mueser et al, 1998) there is presence of underlying anti-social personality disorder and the second is vulnerability of people with severe mental illness to non-depended substance abuse. Use of inclusive and pragmatic approach (Brooner, 1998) generates a triple diagnosis that is characterized by severe psychiatric disorder coupled with substance abuse (Johnson, 1997), with or without presence of underlying primary personality disorder (Brooner, 1998) or substance abuse induced by psychiatric disorder (Brooner, 1998) or substance abuse dependence with personality disorder but without dual diagnosis psychiatric disorder (Brooner, 1998: Folstein, 1975). Assessment criteria for dual diagnosis are carried out by analyzing first, substance abuse and its possible interaction with psychiatric disorder (Babor, 1992). Second, determining effects of substance abuse in relation with achievement of personal goals (Babor, 1992: Brooner, 1998) of the patient like how the patient relates with others in the workplace and conduct of the patient (Babor, 1992) when given an opportunity for a leisure time. Third, carrying out risk assessment (American Psychiatric Association, 1993) of the patient’s possibility of inflicting self harm; harm to others, self neglect or presence of sexually transmitted infections. Carrying out assessment with aim of devising motivation for change (American Psychiatric Association, 1993) and hence determining modalities for treatment. Substance abuse Substance abuse (Woody, 1995) is a condition that is characterized by continuous pathological use of medication, non-medically or non-prescribed drugs or toxins. This implies, if a patient is on a given medication and continuously (Woody, 1995: Babor, 1992) uses the prescribed drugs by a physician, it amounts into drug abuse. Similarly, continuous use of drugs like alcohol, cigarettes or cocaine, amounts into drug abuse (Drake, 1993). Substance abuse (Woody, 1995: Babor, 1992) therefore is a repeat pattern of substance use whose consequence is an observable social handicap that has relations to use or repeated use of the drug. Some of the effects that are characteristic of substance abuse are inter-personal conflicts (Weiss, 1998) that is subject to development of bad temper fast, failure of a person to meet work guidelines (Weiss, 1998; Folstein, 1975: American Psychiatric Association, 1993) or work specifications, failure of a person to meet family responsibilities because the individual has become a ‘slave’ (American Psychiatric Association, 1993) of substance abuse, lack of education of children if the individual is married because the individual spends his or her earnings servicing the condition (American Psychiatric Association, 1993: Weiss, 1998) or lack of paying rent. Substance abuse leads into substance dependence (American Psychiatric Association, 1993; Weiss, 1998; Hasin, 1996) that is also termed as substance addiction. Substance dependence has clinical symptoms that are characterized by physiological and behavioral misfits (Weiss, 1998). These observable features that are related to physiological and behavioral factors are linked to desire of the individual to take in more of the drug in order to maintain their desired effect of feeling “high” (Weiss, 1998: American Psychiatric Association, 1993). There are also characteristic withdrawal clinical signs if the individual stops using the drugs. Withdrawal symptom is the major contributing factor to substance abuse relapse (Skinner, 1982). Substance abuse (Woody, 1995) is more pronounced in individuals who have began the habit and this is an indicator of possible future substance dependence. Peer pressure is the main driving force towards substance dependence and substance abuse (Babor, 1992: Folstein, 1975). Drugs are known to establish social groups that have high substance dependence and this makes users not to fail to get their drugs because their peers can provide the drugs. This is common in boarding school setting. In many cases, substance dependence or substance addiction can appear even without a slight indication of substance abuse (American Psychiatric Association, 1993). Similarly, substance abuse can become chronic without developing into substance dependence. This is where most substance abuse users lie whether they are adults or students. Substance abuse is the common ill-health for dual diagnosis disorder mainly in adults suffering from illnesses such as schizophrenia or bipolar disorder. Substance abuse is also common among patients that have clinical signs characterized by depression, eating disorders, anxiety as well as post traumatic stress disorder (Folstein, 1975). Relationship between mental illness and substance abuse In many instances, the psychiatric disorder (Rounsaville, 1986; Weiss, 1998) is the first to develop in a patient. The patient is the one who propagates (American Psychiatric Association, 1993) the psychiatric disorder when they try to counter associated stress or depression with alcohol or drugs like cocaine as optional self medication methods. This tendency is responsible for development of substance dependence (Johnson, 1997) because the psychiatric disorder is not appropriately managed and a habit of substance dependence results. For some patients, substance dependence occurs first especially for the young between the ages of 13-18 years. In the young population, substance abuse is taken as primary condition leading into depression, anxiety, emotional drain and mental related misfits. This means that the first step would be to reverse the propagation process by detoxifying (Hien D, 1996: McCusker, 1995) the body of toxins that have accumulated in the blood stream as a result of substance dependence. Difficulties encountered when identifying dual diagnosis Dual diagnosis is not an easy illness to identify in a person (Kranzler, 1998). This is because the clinical signs of one disorder for instance, mental ill-health, overlaps with the clinical symptoms of the other disorder say substance abuse (Kranzler, 1998; Johnson, 1997: Skinner, 1982). Therefore there is likelihood of health professional that treats and manages the dual diagnosis to under-diagnose (Kranzler, 1998) mental illness sandwiched in substance abuse because even the family members may not be aware that their patient is substance dependent. Second, the clinical behavioural signs (Carroll, 1993) of a substance abuser are similar to clinical behavioral signs of a mentally ill patient and this makes efficient separation of the two disorders hard. Thirdly, adequate time is required to carry out analysis that provides information on substance abuse sandwiched in mental illness and vice versa (Carroll, 1993). In both disorders, there is characteristic lack of self care and this constitutes a clinical sign of psychiatric disorder. Clinical assessment for dual diagnosis The four main clinical assessments for dual diagnosis are dual diagnosis screening (Foy, 1991) using Chemical Use, Abuse and Dependence Scale (CUAD). Two, using dual diagnosis screening that employs Alcohol Use Disorder Identification Test (AUDIT) (Babor, 1992). Three dual diagnosis administration of the Psychiatric Research Interview for Substance and Mental Disorder (PRISM) (Hasin, 1996) and fourth is dual diagnosis screening that involves biochemical analysis of hair (McCusker, 1995) as opposed to urine for substance abuse. Management of dual diagnosis The recommended management for the dual diagnosis should seek to establish long term guidelines for lapsing and chronic disorder (Torrens, 1991); secondly adoption of close liaison with criminal justice system to assist in the medication process (American Psychiatric Association, 1993). Third, adoption of enhanced care programs for the dual diagnosed patients (Drake, 1993) and fourth, establishment of community residential care approach backed up by stable living conditions (American Psychiatric Association, 1993). Integrated approach to dual diagnosis Integrated approach is the best method for the management of dual diagnosis disorder (American Psychiatric Association, 1993: Brooner, 1998). Treatment and management of dual diagnosis disorder should be backed by comprehensive assessment of dual diagnosis predisposing factors (Brooner, 1998). Intervention methodologies for the dual diagnosis for a particular patient should rhyme the patient’s medical condition. This therefore means application of case management approach. In all cases, a detox (McCusker, 1995) should be carried out first under supervised setting. Patient active participation that is also termed as patient engagement should be reinforced. There should be periodic contact with the patient either via phone calls or one on one visit to the patient (Drake, 1993). This helps to develop a therapeutic alliance that eventually satisfies the basic needs of the dual diagnosis patient. During all one on one visits, or phone calls, the patient should be persuaded to develop behavioral change and take part in active work. The act of persuading the dual diagnosis patient should be aimed at making the patient less depended (Carroll, 1993) on the drug on day-to-day life. There is also need for adoption of active treatment approach (American Psychiatric Association, 1993) using recommended drugs that are able to manage the dual diagnosis ill-health based on case management strategies. Motivational talk (Hasin, 1996:Carroll, 1993) on minimization of substance dependence should encourage the dual diagnosis patient to have a better vision of life and successes that they ought to have achieved if they were not substance dependent. At this point, precautions should be taken so that the patient is not pushed to a state where they could start blaming themselves for their conditions. It is important to use encouraging words (Folstein, 1975) like ‘some things happen so that we could learn’ or ‘everybody has got its own time when his or her talent should shine’ and that their time to ‘add value has finally come’. The staffs who are assigned to the dual diagnosed patient should evaluate and manage the dual diagnosis case by employing risk factors (Busto, 1989) that are likely to lead into relapse. It is important for the patient to be able to self-manage (Busto, 1989) their possibility of developing relapse. This step calls for application of close monitoring approach (Carroll, 1993). Close monitoring is very efficient in management of dual diagnosis and the patient should have close medical supervision (American Psychiatric Association, 1993:Franken, 1999) to ensure they use any dose they are given according to prescription. Close monitoring should also factor in periodic urine assessment for drug load in the blood as well as biochemical analysis of the hair that produces better results compared to urine sample analysis. Close monitoring should also be coupled with cognitive behavioral therapy (American Psychiatric Association, 1994). This should either be applied in group, individual or family setting. The dual diagnosis patients should be rehabilitated in order to be economically viable. This should be accomplished in the community setting with establishment of residential programs (Carroll, 1993) that cater for the dual diagnosis patient. Dual diagnosed patients that suffer from mental illnesses like schizophrenia should be put on antipsychotic medication especially clozapine (Babor, 1992: American Psychiatric Association, 199 Initial Treatment programs for dual diagnosis Medical detoxification It is recommended that medical detoxification (Craig, 1996:Franken, 1999: McCusker, 1995) is done before any treatment is initialized on the patient. Detoxification is the process of weaning patients from their regular substance dependence. Detoxification process (Craig, 1996) should therefore be geared towards making the patient to stop using the drugs, or should be aimed at gradually making the patient to reduce their drug dose (McCusker, 1995). Gradual reduction helps to reduce related side effects of withdrawal. Tapering should be imposed on the patient because detoxification process is potentially life threatening (Franken, 1999). In acute cases, detoxification should be coupled with medication in order to manage psychological symptoms of withdrawal. Methadone is commonly used to assist patients to adjust to the tapering of especially heroin use. Medical detoxification should take 4-6 days in a medically supervised treatment centre. The program of medical detoxification should involve counseling to trigger behavioural change (Carroll, 1993) of the substance abuser and help the substance abuser to manage relapse. The counseling session should be coupled with medication using appropriate drug and backed up by group discussion among other patients that have similar medical condition. After detoxification is carried out, a treatment mode should be designed for the dual diagnosis patient and this is depended on three crucial steps that are first, assessment of the patient substance level in the blood following detox (Craig, 1996); secondly, formulation of a treatment plan based on the results of assessment and thirdly implementation of recommended psychiatric management. Assessment involves comprehensive medical and psychiatric evaluation of the patient. The patient evaluation is based on patient’s drug history that is carried out through interview with the patient. The interview should produce physical clinical signs and psychiatric factors that are related to substance abuse and substance dependence (Hasin, 1996). Family alcohol dependence should also be evaluated. Physical evaluation is used to show clinical signs of substance abuse. Every drug has its own observable physical characteristics. Physical features that are worth to be observed are availability of needle marks on the skin and nasal erosion especially resulting from heroine substance dependence (Pettinati, 1999). Eating habits and reactions of the patient when eating should reveal if there is possibility of esophageal erosion. The health professional should seek permission of the patients to carry out analysis of their blood, urine and hair. This helps to determine that the patient actually takes drugs because in many cases, patients are reluctant to admit that they are involved in substance abuse (Brooner, 1998) or suffer from substance dependence. After successful assessment has been carried out, a treatment plan should be designed. As the patient progresses with treatment, the treatment plan should be shifted in order to meet current medical needs of the patient. A treatment plan for the patient depends on four main factors. First, strategy for psychiatric management (Babor, 1992) for the patient that is adopted; second, a strategy for side effects of substance abuse (Drake, 1993) or strategy for abstinence from substance abuse (Brooner, 1998); third, efforts to ensure compliance with treatment program (American Psychiatric Association, 1994) and fourth, treatment for other related problems with substance abuse (Brooner, 1998). The patient can either be subjected to one of the four treatments setting namely, hospital based treatment, partial hospitalization, residential treatment or outpatient treatment plan. The plans are subject to change over time because dual diagnosis requires a long term management. Psychiatric management (Foy, 1991) of the patient is the third step in treatment of dual diagnosis and is characterized by implementation of the treatment plan that has been arrived at. Psychiatric management of the dual diagnosis illness involves establishing relationship (Folstein, 1975) with the patient that is built on mutual trust. Patient and health professional mutual trust is a very important because it is required in efficient monitoring the patient's progress; managing the patient's relapses and withdrawal; diagnosing and treating associated psychiatric disorders; and helping the patient adhere to the treatment plan through therapy and the development of skills and social interactions that reinforce a drug-free lifestyle (Busto, 1989). Depending on severity of the problem, the treatment process of dual diagnosis illness may require patients to undergo psychosocial therapy (Havassy, 2004). Some patients are also recommended to undergo pharmacological treatment. Psychosocial therapeutic modalities include adopting cognitive-behavioral therapy, behavioral therapy, and individual psychodynamic or interpersonal therapy. In some patients group therapy, family therapy, and self-help groups are handy. Pharmacologic treatment may include medications that ease withdrawal symptoms and reduce craving (Carroll, 1993). Group discussions Group discussions enable dual diagnosed victims to discuss problems that made them to be recommended for a therapy (Carroll, 1993). Victims of dual diagnosis are able to help other patients suffering from dual diagnosis by giving their suggestions, insights, and empathy regarding their problems (Carroll, 1993). There are no rules that govern group therapy discussions. The patients are supposed to participate according to their abilities. The only simples rules that are provided to patients is that hey are not supposed to share with other people what they discussed in their group therapy sessions. The same rule is also applied to group discussions in Voluntary and Counseling Treatment (VCT) centres for Human Immuno Virus (HIV). This simple rule is meant to protect confidentiality of other members of the group. Sometimes, if the patients happen to come from the same estate, they are advised not to meet after the group therapy (Brooner, 1998). The group discussion should be flexible. The role of the therapist is only to control the discussion when it goes away from the main agenda that the therapist lays down. The therapist is supposed to explain the value of constructive suggestion of the patients (Folstein, 1975). This helps to create an environment where the patient’s inputs are valued and patients are able to understand there are other people who have similar problems as they do. Group discussion equips patients with a characteristic social acceptance (Carroll, 1993) from other members. The aim of group discussion is to help the patient to understand that other persons have similar disorders and this instills a sense of self esteem (Carroll, 1993). Using Long-term residential programs Long term residential programs (Drake, 1993) are recommended for acute cases and the length of stay is approximately one year depending on patient’s severity of substance abuse and impact of other prevailing factors like level of social care and degree of isolation that the patient had been exposed to following mental illness (Babor, 1992). Long term residential programs should be meant for patients who have high degree of substance dependence and suffer bouts of substance relapse (Havassy, 2004). Residential long term program is backed up by group discussion and counseling session to fully motivate the patient to completely abandon substance abuse. Adoption of partial hospitalization for outpatient patient Partial hospitalization (Hasin, 1996) should be recommended for patients that have high substance dependence and those who suffer bouts of substance relapse. The partial hospitalization is required to ensure there is a frequency of a meeting ranging from three to five days in a week. The sessions should last for 4-6 hours in day and should be intensive. The success of the patient should be measured by questionnaires (Hasin, 1996) on the patient to determine if the approach that is being used is fruitful or not. Close medical monitoring should also be adopted for an outpatient with acute mental illness. Adoption of intensive outpatient program The program should be tailored such that the patient meets (Carroll, 1993) a psychiatrist for a minimum of three days in a week. Each session should last for 3-4 hours a day. The relapse prevention and management programs should take place at the patients place of work or in the school in case of a student in order to evaluate medication progress and response of the patient in their normal daily life setting (Foy, 1991). Recommendations of intensive case management A case management approach is recommended and this should involve assignment of a case manager (Carroll, 1993) to the patient in order to carry out follow up responsibilities. Follow up program ensures the patient adheres to doctors’ appointments and medication management (Foy, 1991). This is made possible through weekly personal contact with the patient or through phone calls to the patient. Counseling Counseling can be done on the patient as an individual, group of patients with related dual ill-health, a couple or family therapy (Carroll, 1993). Counseling is effected through a one on one conversation. Facial talk therapy provides a dual diagnosis patient with a chance for emotional healing (Foy, 1991) through education that helps the patient to understand the primary cause of their substance abuse and substance dependence habits. Counseling makes it possible for the patient to make constructive decisions concerning their lives. The counseling sessions should last for utmost 40 minutes. Motivational interviewing According to the American Psychiatric Association, there are three goals for the treatment of people with substance use disorders. First, the patient should be able to abstain from substance abuse (American Psychiatric Association, 1993) and substance dependence. Second, the patient should be in a position to manage frequency (American Psychiatric Association, 1994) and severity of relapse episodes. Third, the patient should be in a position to develop psychological and emotional skills (American Psychiatric Association, 1994) that are necessary to restore and maintain personal, occupational and social health. These goals (American Psychiatric Association, 1993;1994) are achievable through active participation of the dual diagnosis patient. It is the responsibility of the health professional assigned to the dual diagnosis patient to evaluate social trends that could fuel dual diagnosis disorder. The health professional should use questionnaires to determine the opinion of the patient with regard to social life. If there are people that the patient isolates from (Carroll, 1993), it is responsibility of the health personnel to encourage the patient by explaining what causes the isolation. The patient should be encouraged to have active social life, interact with friends and not to ‘feel unwanted’ (Foy, 1991). The health professional should also take part in advising the patient about foods that they need in order to boost their cognitive skills and motor development. Expectant mothers should use balanced diets that have enough iodine and iron because these two micro nutrients affect development of brain, cognitive skills, behavioral development and motor skills. Children between the ages of two years and six years of age should be given foods that have higher iodine and iron because it is at this age, especially two-three years that motor skills and cognitive abilities of a child develops. Cognitive behavioural therapy Cognitive behavioral therapy is type of action based psychosocial therapy. Cognitive behavioral therapy recognizes that negative thinking of a patient is responsible for triggering or stimulating negative emotions (Foy, 1991: Carroll, 1993) that characterize behavioral outputs of the patients. Negative thinking (Foy, 1991) leads into adoption of mal-behavioral traits that interfere with the patient’s day to day normal life. Cognitive behavioral therapy is therefore meant to change the patient’s thoughts or thinking that is termed as cognitive pattern with the aim of restoring patient’s behavioral and emotional state (Havassy, 2004). Cognitive behavioral therapy should be used if behavioral and personality disorders (McCusker, 1995) characterized by distress and depression are observed during assessment. Cognitive behavioral therapy is a treatment method that is very effective for several cases of mental disorders like affective (mood) disorders, personality disorders, social phobia, obsessive-compulsive disorder (OCD), eating disorders or anorexia, substance abuse, anxiety or panic disorder, agoraphobia, post-traumatic stress disorder (PTSD) and attention-deficit hyperactivity disorder (ADHD) (Weiss, 1998:Pettinati, 1999). Cognitive behavioral therapy is also used in management of chronic pain for patients that are suffering from rheumatoid arthritis, back problems and cancer. Cognitive behavioral therapy is not recommended for patients with severely psychotic patients and for cognitively impaired patients especially that have organic brain disease or a traumatic brain injury (American Psychiatric Association, 1993:1994). Staff education on dual diagnosis The staff that is responsible for dual diagnosis treatment should have access (Foy, 1991: Kranzler, 1998) to relevant related dual diagnosis services that are important in management of the disorders like crisis support services, housing services, after care skills and management of dual diagnosis, therapeutic skills for dual diagnosis and should also understand legal services and procedures that support dual diagnosis ailments. The staff should have adequate training on responsible and flexible approaches for management (Johnson, 1997) of dual diagnosis like assessment techniques for dual diagnosis, the role of patient engagement in management of dual diagnosis disorders, skills on period’s recommended for patient retention without affecting the level of disorder, and evaluation techniques (Drake, 1993: Kranzler, 1998) for the patient’s recovery path. The staff also needs to be equipped with skills for counseling and management (Folstein, 1975) of dual diagnosis disorder like monitoring technique for the dual diagnosis disorders, skills in risk management and dual diagnosis risk assessment of the patients. The staff education on dual diagnosis should be able to cover substance abuse (American Psychiatric Association, 1993:1994) and substance dependence with respect to alcohol abuse (American Psychiatric Association, 1993), behavioral trends of dual diagnosis, evaluation of codependence patterns of dual diagnosis, management of trauma associated with dual diagnosis and eating disorders that affect nutrient balance (Folstein, 1975). The staff should stress importance of family support for the patients of dual diagnosis and help patients suffering from dual diagnosis to seek compatible social relationships that are not likely to lead into relapse. There should be fitness programs that are meant to involve the patients into physical activities. Availability of exercise programs have been shown to reduce stress and depression by suppressing hormones that bring about stress and depression. Substance withdrawal scales The function of a substance withdrawal scale (Foy, 1991) is to help in diagnosis of the withdrawal syndrome; second, help to show when a drug therapy (Busto, 1989) is needed; third help to alert staff when there is a serious development (Skinner, 1982) of withdrawal symptoms that may need intensive medical intervention and fourth should help to reveal when medication can be discontinued or appropriate time when the patient should be safely discharged. Examples of substance withdrawal scales are Total Severity Assessment (TSA) that was developed by Gross et al. (1973) in order to improve differentiation of severity degrees and quantify withdrawal syndrome. Secondly, there is Selected Severity Assessment (SSA) scale that is used for clinical use. Thirdly, there is Clinical Institute Withdrawal Assessment (CIWA) scale that was developed from SSA scale. Conclusion The success rate of recovery from dual diagnosis is hard to determine with certainty. Many individual experience relapse within a period of three to four years although this can be reduced by using pharmacological treatments. Relapses are commonly experienced within the first year and are associated with work related problems, marriage linked problems, problems with relationships and death of a spouse. Relapse is effectively managed by having supportive family or being associated with drug free friends. Integrated approach should be adopted for effective long term management of dual diagnosis. Bibliography American Psychiatric Association. (1993). Diagnostic and Statistical Manual of Mental Disorders (4th, ed. ed., Vols. DSM-IV). Washington, DC: APA. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. Washington: APA. Babor, T. L. (1992). AUDIT: The Alcohol use Disorders Identification Test. World Health Organisation . Brooner, R. a. (1998). Preliminary Evidence of Good Treatment Response in Antisocial drug Abusers. 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