Evidence Supporting the Effectiveness of an SBIRT

4/1/2011 9:00 AM

Screening, Brief

Intervention and Referral to Treatment (SBIRT)

in Behavioral Healthcare

I. INTRODUCTION

This report discusses the evidence supporting the effectiveness of screening, brief intervention,

and referral to treatment (SBIRT) as a comprehensive approach, as well as for the

implementation and effectiveness of the individual components of SBIRT for different

behavioral health conditions.

The report describes briefly the underlying research that has been

conducted in the prevention and early intervention of risky alcohol, substance abuse and tobacco

consumption, as well as commonly reported mental health problems, and describes existing

studies/models for specific populations and settings. Further, the report addresses the question of

what a model SBIRT program is, compared to programs which include or adapt components of

the comprehensive SBIRT approach. Literature reviews are included in Attachment I. This paper

is intended for use by policy makers, research organizations and governmental agencies seeking

to understand the complexities of the SBIRT model and/or considering the adoption and

implementation of SBIRT systems change or behavioral health integration within primary care

settings.

Screening, brief intervention, and referral to treatment (SBIRT) was originally developed as a

public health model designed to provide universal screening, secondary prevention

(detecting

risky or hazardous substance use before the onset of abuse or dependence), early intervention,

and treatment for people who have problematic or hazardous alcohol problems within primary

care and other health care settings (Babor et al., 2007; Babor & Higgins-Biddle, 2001). Based on

the SAMHSA model, SBIRT is unique in its universal screening of all patients regardless of an

identified disorder, allowing health care professionals to address the spectrum of such behavioral

health problems even when the patient is not actively seeking an intervention or treatment for his

or her problems.

Following are the key points of this paper:

− SBIRT has been defined by SAMHSA as a comprehensive, integrated, public health

approach to the delivery of early intervention for individuals with risky alcohol and drug use,

and the timely referral to more intensive substance abuse treatment for those who have

substance abuse disorders. There is consensus that a comprehensive SBIRT model includes

screening, brief intervention/brief treatment and referral to treatment. In addition to these

Excludes medical conditions.

There is some discussion about whether SBIRT is selective prevention (Kumpfer & Baxley,

(1997) or early intervention given the overlap in SBIRT's approach and objectives.

integral components, SAMHSA defines a comprehensive SBIRT model to include the

following characteristics:

• It is brief (e.g., typically about 5-10 minutes for brief interventions; about 5 to 12

sessions for brief treatments).

• The screening is universal.

• One or more specific behaviors related to risky alcohol and drug use are targeted.

• The services occur in a public health non-substance abuse treatment setting.

• It is comprehensive (comprised of screening, brief intervention/treatment, and referral to

treatment).

• Strong research or experiential evidence supports the model’s effectiveness.

− No standard SBIRT definition has been articulated by the U.S. Preventive Services Task

Force or other authoritative/coordinating bodies. The SAMHSA definition of SBIRT is based

on methodology that was developed during the implementation of a comprehensive SBIRT

grant program comprised of all the integral components, and supported by research by the

National Institute on Drug Abuse and the National Institute on Alcohol Abuse and

Alcoholism.

− There is substantial research on the effectiveness of SBIRT in reducing risky alcohol

consumption. However, the evidence for the effectiveness of SBIRT in reducing risky drug

use, although promising, is still accumulating. The results for the SAMHSA model of

SBIRT for drug misuse are inconsistent depending on the characteristics of the provider, the

specific setting, and the patient population that is targeted for SBIRT implementation. While

there is robust evidence for screening and referral for depression in primary care, to date,

little empirical evidence for the use of comprehensive SBIRT-like models for mental health

problems commonly reported by health care patients. There is also no research that has

demonstrated the implementation or effectiveness of SBIRT-like models in addressing

trauma or anxiety disorders in clinical health settings.

II. THE SAMHSA SBIRT MODEL

SBIRT is a comprehensive, integrated, public health approach to the delivery of early

intervention for individuals with risky alcohol and drug use, as well as the timely referral to more

intensive substance abuse treatment for those who have substance use disorders. Primary care

centers, hospital emergency rooms, trauma centers, and community health settings provide

opportunities for early intervention with at-risk substance users before more severe consequences

occur.

SAMHSA supports a research based comprehensive behavioral health SBIRT model which

reflects the six following characteristics:

1. It is brief. The initial screening is accomplished quickly (modal time about 5-10 minutes) and

the intervention and treatment components indicated by the screening results are completed

in significantly less time than traditional substance abuse specialty care.

2. The screening is universal. The patients, clients, students, or other target populations are all

screened as part of the standard intake process.

3. One or more specific behaviors are targeted. The screening tool addresses a specific

behavioral characteristic deemed to be problematic, or pre-conditional to substance

dependence or other diagnoses.

4. The services occur in a public health, or other non-substance abuse treatment setting. This

may be an emergency department, primary care physician’s office, school, etc.

5. It is comprehensive. The program includes a seamless transition between brief universal

screening, a brief intervention and/or brief treatment, and referral to specialty substance

abuse care.

6. Strong research or substantial experiential evidence supports the model. At a minimum,

programmatic outcomes demonstrate a successful approach.

As a comprehensive or model approach, SBIRT has only been demonstrated to be effective for

risky alcohol use. There is substantial evidence for the effectiveness of brief interventions for

harmful drinking when delivered by a physician or other qualified health professional (Bien et al,

1993; Kahan et al, 1995; Wilk et al, 1993). There is a growing body of literature showing the

effectiveness of SBIRT for risky drug use (Madras et al, 2008; Saitz et al, 2010; Bernstein et al.,

2005) but the results vary by the characteristics of the provider, the specific setting, and the

patient population that is targeted for SBIRT implementation.

To determine the effectiveness of SBIRT beyond alcohol, a comprehensive literature review was

conducted. SBIRT-like models including not only a simple screening tool, but also an

appropriate and brief intervention that addressed the level of problem indicated by the screening

results. Table 1 (p. 4) identifies the substance abuse and mental health conditions where SBIRT

or components of SBIRT have been employed. The literature review did not include studies that

employed SBIRT or approaches that are similar to SBIRT for general medical conditions such as

blood pressure, HIV/AIDS, or other behavioral issues such as domestic violence.

As shown in Table 1, the comprehensive SBIRT model has not been consistently demonstrated

as effective in addressing harmful or risky drug misuse, depression, trauma, or anxiety problems.

Findings showing the effectiveness of SBIRT for drug misuse are accumulating, and there is

some programmatic data from the SAMHSA State SBIRT programs showing promising findings

for depression among primary care patients. Public health approaches that are consistent with

the SBIRT model have also been demonstrated for tobacco use. They are described in the latter

sections of this paper. Table 1 presents a brief analysis of the evidence for the effectiveness of

SBIRT for various behavioral health conditions.

Table 1. EFFECTIVENESS OF SBIRT AND ITS COMPONENTS

FOR BEHAVIORAL HEALTH CONDITIONS

Screening

Brief

Intervention

Brief

Treatment

Referral to

Treatment

Evidence for

Effectiveness of

SBIRT

Alcohol

Misuse/Abuse

   

Comprehensive SBIRT

effective (Category B

classification,

USPSTF)

Illicit Drug

Misuse/Abuse



* *



Growing but

inconsistent evidence

Tobacco Use

 

Effective brief

approach consistent

with SBIRT (USPSTF;

2008 U.S. Public

Health Service (PHS)

Clinical Practice

Guideline

Depression



—

 

No evidence to date for

depression

Trauma/Anxiety

Disorders



—



No evidence to date for

trauma/anxiety

disorders

Key:  Evidence for effectiveness/utility of component

* Component Demonstrated to show Promising Results

— Not Demonstrated and/or Not Utilized

Brief intervention as defined by the SAMHSA SBIRT program involves 1-5 sessions lasting 5

minutes to an hour. Among SBIRT grantees funded by SAMHSA, about 15% of patients receive

scores that indicate a brief intervention.

Brief treatment as part of SBIRT involves 5-12 sessions, lasting up to an hour. Among State

SBIRT grantees funded by SAMHSA, about 3% of patients receive a score that dictates a brief

treatment.

Chart 1. FLOW CHART FOR SBIRT PROCESS

Screening

Universal screening helps identify the appropriate level of services needed based on the patient’s

risk level. Patients who indicate little or no risky behavior and have a low screening score may

not need an intervention. Those who have moderate risky behaviors and/or reach a moderate

threshold on the screening instrument may be referred to brief intervention. Patients who score

high may need either a brief treatment or further diagnostic assessment and more intensive, long

term specialty treatment. Screening typically takes 5-10 minutes and can be repeated at various

intervals as needed to determine changes in patients’ progress over time. Some commonly used

screens for the implementation of SBIRT for alcohol and drug use are the Alcohol Use Disorders

Identification Test (AUDIT), Drug Abuse Screening Test (DAST), Alcohol, Smoking, Substance

Involvement, Screening Test (ASSIST), and the Cut Down, Annoyed, Guilty, Eye-Opener

(CAGE). In addition, a recent study found a single question related to drug use to be effective in

detecting drug use among primary care patients (Smith et al., 2010).

Prescreening, which is not a core component of SBIRT but is frequently used, reduces the time

needed by busy clinic staff to identify patients with risky behavior. Examples of validated pre-

screens are the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which

consists of the first three alcohol consumption questions from the full 10-item AUDIT

questionnaire, and the NIAAA prescreening question (“On any single occasion during the past 3

months, have you had more than 5 drinks containing alcohol?”, Taj et al., 1998). If a patient

scores high on any domain in the pre-screen, a full screen is conducted.

Brief Intervention (BI) and/or Brief Treatment

Patients are provided with BI, brief treatment, or referral to intensive specialty treatment

depending on their level of risk using a validated pre-screen and/or screening tool (Babor &

Higgins-Biddle, 2001). With respect to substance abuse, in general only a small proportion of

patients in primary care settings screened positive for some level of substance misuse, abuse or

dependency. This is usually 5%-20%, but may be as high as 40% in some clinical settings. The

majority of patients report minimal or no problems with alcohol or drugs and as such may be an

ideal group for primary or universal prevention activities for maintenance of non-risky use or

abstinence. The goal of a BI (which usually involves 1-5 sessions lasting about 5 minutes to one

hour) is to educate patients and increase their motivation to reduce risky behavior.

The goal of brief treatment (which usually involves 5-12 sessions) is to change not only the

immediate behavior or thoughts about a risky behavior but also to address long-standing

problems with harmful drinking and drug misuse and help patients with higher levels of disorder

obtain more long term care. Based on performance data from state SBIRT grantees funded by

SAMHSA, only about 3% receive a score that indicates a brief treatment. Patients referred to a

brief treatment often have higher risk factors than those referred to a BI. Brief treatment may

also require a manualized course of (advanced) motivational enhancement and cognitive

behavioral approaches to help patients address unhealthy cognitions and behaviors associated

with current use patterns and adopt change strategies. If patients report greater risk factors than

what brief treatment can address, they are referred to specialty substance abuse care. In some

cases, a patient may receive a BI first and then move on to a brief treatment or longer term care.

Although the time required to execute BI/BT is generally considered brief, it is far too lengthy

for physicians to do. Also, physicians cite concerns about angering or insulting patients by

bringing up sensitive issues such as alcohol and/or drug use. While these concerns are

understandable, when SBIRT is implemented properly, the time commitment is reasonable and

acceptably low given the demonstrated success in identifying persons requiring referral to

treatment (RT). Similarly, concerns about patient reactions can be neutralized by proper training

for the providers and ensuring that access to referral services is available. In addition, SBIRT is

frequently implemented by allied health professionals such as nurses, social workers, or health

educators, with results and actions noted in the patient chart for physician notification and

oversight.

Referral to Treatment (RT)

Referral to treatment can be a complex process involving coordination across different types of

services. As such, the absence of linkages to treatment referrals can be a significant barrier to the

adoption of SBIRT. Referral is recommended when patients meet the diagnostic criteria for

substance dependence or other mental illnesses as defined by the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (DSM-IV).

In these cases, a referral to a

specialized treatment provider is often made. Referral requires the primary care system to

establish new and complex linkages with the traditional specialty care system to connect clients

who score in the problematic range to recognized, evidence based treatment in a timely manner.

Although only 3% to 4% of screened patients in primary care settings typically need to be

referred, the absence of a proper treatment referral will prevent the patient from accessing

appropriate and timely care that can impact other psychosocial and medical issues. Research

findings suggest that motivational-based BIs can increase patient participation and retention in

substance abuse treatment (Hillman et al., 2001; Dunn and Ries, 1997). Strong referral linkages

are critical, as well as tracking patient referrals. SAMHSA requires SBIRT grantees to have a

comprehensive referral to treatment and follow-up system in place for the duration of the

program. In the case where RT is incorporated into an integrated care model, this may require

shifts in provider allocation and hiring.

The diagnostic criteria are likely to change when DSM V is released in 2012 or 2013.

The following characteristics of SBIRT identified in the research literature (see Reference

section) have been shown to be important in effectively addressing behavioral health problems.

They have therefore formed the foundation for the SAMHSA SBIRT programs.

1) Use of brief, validated, universal pre-screening/screening tools. These tools allow health care

professionals to address the problem behavior even when the patient is not actively seeking

treatment for his or her problem. Prescreening/screening tools accurately and quickly identify

individuals with problematic conditions in as little time as 2-4 minutes. Because of its

briefness and its universal application (that is, can be used with all patients), SBIRT may be

more generally accepted by health care professionals working in busy practices.

2) Relatively easy to learn by diverse providers. The SBIRT approach is easy to learn relative to

other behavioral treatment techniques that may require lengthy specialized training. As such,

it can be implemented by diverse health professionals who work in busy medical settings

such as physicians, nurses, social workers, health educators and paraprofessionals.

3) Incorporation of strong referral linkages to specialty treatment. Approaches that are effective

integrate comprehensive strategies that include referral to specialty treatments (Gentillelo,

Donavan, Dunn & Rivara, 1999). While RT may be difficult in underserved areas, this

should not deter programs from engaging in developing SBI activities as they have beneficial

effects separate from the referral. However, the goal is to provide a quick handoff for

dependent patients to specialty treatment if the primary care site cannot provide more

intensive services for substance abuse. Establishing linkages with specialty care through

identification of local treatment service contracts, an MOU agreement between sites, or

dedicated central referral services has been a major barrier for many providers in their

decision to adopt SBIRT. The availability of well established referral linkages to specialty

care is essential to the uptake and maintenance of SBIRT, and closely tracking to confirm

patient compliance with treatment is critical to good health care provision. Primary care

locations engaged in referral to specialty care make efforts to determine the patient’s

engagement and participation in treatment, as this may also affect the course of treatment in

the general medical practice.

III. ALCOHOL MISUSE, ABUSE, AND PREVENTION

There is substantial evidence from review studies (Babor, 2007; Bein et al, 1993; Kaner, et al.,

2009) and meta-analyses of randomized clinical trials (Beich et al., 2003; Bertholet et al, 2005)

that show the effectiveness of SBIRT in reducing hazardous drinking in patients presenting in

primary care and other health care settings. The U.S. Preventative Services Task Force

(USPSTF) has recommended that “behavioral counseling interventions for risky/harmful alcohol

use among adult primary care patients can provide an effective public health approach to

reducing problematic drinking” (USPSTF, 2004). The USPSTF also concluded that counseling

for risky drinkers should include advice to reduce current drinking; feedback about current

drinking patterns; and explicit goal-setting, usually for moderation and assistance in achieving

the goals.

Research also indicates that despite the robustness of the evidence for SBIRT’s effectiveness for

unhealthy alcohol drinking, other factors can impact its effects. For example, studies have

shown that multiple contacts or sessions (in contrast to a single contact) with a provider can

increase the impact of SBIRT in reducing risky alcohol consumption (Brown et al., 2007;

Longabaugh et al., 2001). Moreover, demographic factors and psychosocial conditions also

have been shown to influence SBIRT’s effects on alcohol misuse (Saitz et al., 2006). For

example, homelessness makes SBIRT less effective due to the challenges involved in working

with this population, and brief interventions have improved linkages with those who can provide

assistance to younger men and hospitalized women.

The conduct of universal screening, brief intervention and treatment, and referral to treatment for

alcohol disorders has been found to be effective in various healthcare settings for diverse patient

populations including primary care (Babor et al., 2007), emergency departments (Gentilello et

al., 1999), as well as schools and colleges (O'Brian et al., 2006). Data are currently being

collected that suggest that SBIRT may also be effective in addressing alcohol problems in

employee assistance programs (McPherson and Goplerud, 2008). Recent research also has

demonstrated the efficacy of conducting screenings and BIs using innovative strategies such as

the use of personalized feedback via the internet (Cunningham, 2010), as well as web-based

outcomes monitoring to assist with treatment decisions and cognitive behavioral techniques

(Roy-Bryne, 2010).

Also promising is the utilization of computerized interventions which has been shown to be

effective in augmenting and complementing the gains made through the initial face to face brief

interventions. The Veterans Administration, for example, examined the use of electronic clinical

reminders with patients following screening with the AUDIT-C and showed such approaches

reinforced moderate drinking reductions at follow up (Williams, 2010). Other research reviews

indicate that electronic methods can enhance brief interventions with substance users by offering

assessment and feedback in brief motivational interviewing; monitoring individual treatment

patient’s progress; tracking patients in aftercare; and providing educational opportunities for

clinicians (Cucciare, 2009). Electronic intervention can also help bridge the treatment capacity

gap by providing another source of assistance for women who do not complete traditional

substance abuse treatment (Van DeMark, et al., 2010). In addition, the cost savings offered by

the implementation of SBIRT in primary care are significant. One study (Gentilello, 2005)

showed that for every one dollar spent on providing SBIRT approximately $3.81 is saved. The

Washington State SBIRT program cost study also reflects similar savings.

The concept of SBIRT can be applied across the continuum of care for alcohol problems. Based

on the severity of the problem indicated by the screening results, interventions ranging from

universal prevention to brief interventions to traditional specialty treatment can be provided to

health care patients. For individuals who are abstinent, universal prevention practices can be

implemented to sustain alcohol abstinence. For moderate risky drinking, the first two

components of SBIRT – screening and brief interventions (SBI)– may be implemented which

can address inappropriate expectancies (beliefs about substance use effects and social norms of

acceptable behavior) and lack of motivation to change risk factors that contribute to substance

abuse (Dimeff et al., 1999).

Extensive research supports screening and brief intervention as effective universal and selective

prevention strategies for alcohol problems. Universal screening with educational content has

measurable prevention effects with accompanying feedback (Kunz et al., 2004). The prevention

approach may also be successful for abstainers and non-risky drinkers by providing behavioral

support and normative information to maintain healthy behaviors. For at-risk individuals, early

identification and brief intervention around false expectancies, normative use misperceptions and

skills acquisition can prevent progression to severe drinking problems. For example, the

BASICS program, which is consistent with the SBIRT approach, has been shown to be effective

in addressing problematic or risky drinking in college age groups (Dimeff et al., 1999). SBIs also

incorporate motivational interviewing components (Miller and Rollnick, 2002) that are also

integrated in brief treatment for higher risk patients. SBIs have proven effective in decreasing

overall consumption and binge drinking (Casset et al., 2008; Hanewinkel & Wiborg 2005; Kunz

Jr. et al., 2004; Martens et al., 2007; Heather et al., 2004; Toumbourou et al. 2007; Murphy et al.,

2001), as well as increasing productivity (Osilla et al., 2010). Evidence further demonstrates that

strengthening resiliency, competencies, and social connectedness supports recovery for those

individuals who show early symptoms of alcohol misuse.

Extensive reviews of the effectiveness of SBI (Babor et al., 2007, 2008) have found that there are

“irrefutable” improvements in short-term health benefits as well as indications of “substantial”

long-term benefits. Follow up at three, six or nine month intervals can help document the

effectiveness of SBI and reinforces normative ideation and skills enhancement for individuals

with minimal risk behaviors. To achieve long term effects, SBI must be implemented with

fidelity through targeted training for providers (Cameron et al., 2010; Seale et al., 2005;

Christensen et al., 2004; Bray et al., 2009; Ronzani et al., 2008; Furtado et al., 2008; Heather et

al., 2004; Tollison et al., 2008; Babor et al., 2004; Brown & Fleming, 1998). In many instances

providers implementing SBI may not necessarily be physicians but allied health professionals

such as nurses, counselors, health educators, and peers (Mastroleo, 2009; Blume & Marlatt,

2004), who may experience fewer barriers in service provision than physicians (Babor et al.,

2004). Also, SBI can be conducted individually or with groups (Shellenberger et al., 2009;

Henslee, 2009), with web-based instruments (i.e. college oriented E-Chug and E-Toke or

Alcohol Skills Training Programs), or online feedback (Blume & Marlatt, 2004), and applied

through strategic planning by communities or providers.

IV. DRUG MISUSE, ABUSE, AND PREVENTION

In 1995, based on the scant availability of published research on SBIRT for drugs, the USPSTF

(1995) determined that there was “insufficient evidence to recommend for or against” the

effectiveness of using an SBIRT approach for drugs. Some researchers have cited the relative

scarcity of validated brief drug screening tools (Smith PC, et. al., 2010) and the low prevalence

rates of drug use (Saitz, 2010) in primary care settings, as two reasons for the comparatively

small number of studies showing SBIRT’s effects with drugs (De Micheli D, et. al., 2004).

Nevertheless, since 1995, there has been a growing body of investigator-initiated research as

well as findings from SAMHSA-funded SBIRT projects that have shown promising results for

the use of the comprehensive SBIRT approach, as well as selected use of individual components,

in reducing risky drug use (Copeland et al., 2001). For instance, a randomized controlled trial

indicated that BIs can reduce cocaine and heroin use (Bernstein et al., 2005). Motivational

interviewing coupled with a self-help booklet given to regular amphetamine users also resulted

in reduced levels of drug use (Baker, Lee, Claire, Lewin, Grant, & Pohlman, 2005). BIs for

patients screening positive for cocaine, heroin, and amphetamine are also showing promising

results in various settings beyond emergency departments (Cunningham et al., 2009). In small

sample sizes, screening and BIs have been linked with reductions in the use of marijuana,

amphetamine-type stimulants, cocaine, and heroin (Madras et al., 2008). The World Health

Organization (2008) sponsored a multi-national study demonstrating that screening and brief

interventions resulted in short-term reductions of a wide variety of illicit drugs, including

marijuana, cocaine, amphetamine-type stimulants, and opioids.

As with alcohol consumption, universal and selective prevention efforts may also be targeted to

those with minimal or mild drug misuse. Like with alcohol, identified abstainers can benefit

from supportive and normative information to maintain healthy lifestyles. For individuals at risk

for drug problems, early identification and brief intervention around false expectancies and skill

acquisition can prevent progression to more severe drug problems. In addition, tools that can be

used for universal screening of drug use in health settings such as the DAST and the ASSIST as

well as on-line tools such as E-TOKE (Electronic – THC Online Knowledge Experience) are

prevention-ready applications designed to detect the presence of drug use.

V. SBIRT AND TOBACCO USE

The utility of SBIRT approaches for all forms of tobacco use, especially smoking, has been

endorsed by the USPSTF and has elicited interest in primary care and hospital personnel.

Cigarette smoking continues to be the leading cause of preventable disease and death in the

United States (USDHHS, 2004) and is attributed to approximately 443,000 deaths per year

(CDCP, 2010) from lung cancer: ischemic heart disease, chronic obstructive pulmonary disease,

strokes, and other diagnoses. Smoking also affects health outcomes of people other than the

smokers, with smoking during pregnancy resulting in premature births, spontaneous abortions,

stillbirths, and intrauterine growth retardation. In addition, research has shown that psychiatric

disorders and cigarette smoking are frequently co-morbid conditions (Dome et al, 2010; Brown

et al, 2008; Brown et al, 2002; Degenhardt & Hall, 2001; Grant et al, 2004). A recent study

using data from the 2005-2006 National Survey on Drug Use and Health reported that adults

with lifetime depression, anxiety, anxiety with depression, or major depressive episodes were

more likely to be “current smokers, smoke with higher intensity and frequency, have more

dependence, and have lower success at quitting” when compared to individuals without these

psychiatric conditions (Trosclair & Dube, 2010).

However, despite smoking's established risks and the health benefits of quitting, 23 percent of

adults in the United States continue to smoke and more than 2,000 adolescents become regular

tobacco users daily (NSDUH, SAMHSA). Nearly 90 percent of smokers start by age 18, and 25

percent of teen smokers remain addicted as adults. Because 70 percent of smokers see a

physician each year (Fiore, Bailey, Cohen, et al., 2000) clinicians have a unique opportunity to

intervene and implement tobacco SBIRT in primary care settings and emergency departments.

As such, the USPSTF strongly recommends that clinicians screen all adults for tobacco use and

provide brief interventions, including screening, brief behavioral counseling (less than 3

minutes), and pharmacotherapy delivered in primary care settings. The USPSTF also strongly

recommends that clinicians screen all pregnant women for tobacco use and provide augmented

pregnancy-tailored counseling to those who use tobacco products. These interventions have

been shown to be effective in increasing the proportion of smokers who successfully quit

smoking and remain abstinent after 1 year.

The USPSTF advises that the clinical interventions for tobacco cessation that are cited in the

2008 U.S. Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and

Dependence (Fiore et al, 2008), become integrated in standard clinical practice. The PHS

Guideline also recommends that clinicians use the screening instrument known as the 5A’s of

tobacco use intervention, which provides a useful strategy for engaging all medical patients in

smoking cessation discussions. The 5A’s are consistent with the SBIRT approach and parallel

the screening and brief intervention or counseling components of the SBIRT model.

1. Ask about tobacco use.

2. Advise to quit through clear personalized messages.

3. Assess willingness to quit.

4. Assist to quit.

5. Arrange follow-up and support.

The Guideline’s behavioral treatments include counseling, social support, problem solving, and

cessation skills training offered in face-to-face individual or group formats or via telephone quit

lines. Medication assisted treatments for tobacco use/dependence have also been suggested and

include seven FDA-approved, first-line medications (i.e., bupropion SR, nicotine gum, inhaler,

lozenge, nasal spray, and patch), and two second-line medications (clonidine and nortriptyline).

The Agency for Healthcare Research and Quality (AHRQ) also reviewed tobacco guidelines

developed in England in 2006 and supports recommendations for brief interventions for patients

who use tobacco products, including: simple advice to stop, assessment of the patients’

commitment to quit, an offer of pharmacological or behavioral support, and provision of self

help materials or referral to supportive resources such as Quit lines.

VI. DEPRESSION

The USPSTF supports screening for adult depression where accurate diagnosis, effective

treatment, and follow-up are available. The USPSTF also recommends screening adolescents

(12-18 years of age) for major depressive disorder (MDD), again with accurate diagnosis,

psychotherapy (cognitive behavioral or interpersonal), and follow-up. There are many commonly

used screening tools for depressive symptoms, such as the Patient Health Questionnaire 2 (PHQ-

2) (Kroenke, et al., 2003) and the Patient Health Questionnaire 9 (PHQ-9) (Kroenke, et al., 2001)

which both have established validity and reliability.

Primary care physicians are the providers most likely to see patients when they first become

depressed and are most capable of initiating and monitoring treatments with pharmacologic

agents (McNaughton, 2009). Previous studies, however, have shown that at least half of patients

with active depression seen by primary care physicians remain undiagnosed (Spitzer et al, 1994;

Schulberg et al., 1988; Ormell et al, (1991). Depression is particularly prevalent among “high

utilizers” of medical care resources, of whom as many as 40% have been found to have a current

depressive illness (Katon et.al., 1990). Due to time constraints and training issues, physicians in

primary care are often unable to provide effective behavioral interventions and treatments for the

patients with mental disorders (McNaughton, 2009).

Promising but preliminary data are available from SBIRT grantees funded by SAMHSA that

indicate that the SBIRT approach may be adapted for depression treatment. For example, the

State of Wisconsin incorporated depression screening into a Wisconsin Initiative to Promote

Healthy Lifestyles (WIPHL) pilot program. Patients with mild or moderate depression were

provided behavioral activation by health educators using specific protocols developed by the

program.

Behavioral activation also offers promise as a strategy for brief intervention and there is some

evidence that it would fit an SBIRT-like approach. Behavioral activation assists individuals to

identify and engage in daily activities and situations they find positively reinforcing and

consistent with their long-term goals (Dimidjain et al., 2006). Behavioral activation as a brief

intervention has been demonstrated in three meta-analyses, one randomized control trial, and one

follow-up study of a previous randomized control trial, to be an effective intervention for the

treatment of depression (Sturmey, 2009).

VII. ANXIETY DISORDERS AND TRAUMA

Anxiety disorders are among the most common mental health problems

seen in primary care

settings and as many as one-third of primary

care patients have been found to have significant

anxiety symptoms (Fifer, 1994). Approximately 15% of primary care patients have a current

anxiety disorder, and

24% have had a lifetime anxiety disorder, as assessed by diagnostic

interviews (Nisenson et al., 1998). Primary care patients with anxiety disorders

typically have

considerable disability and impairment in functioning

(Roy-Byrne et al., 1999; Sherbourne et al.,

1996) and high utilization rates of general medical services which ultimately result in higher

health care costs (Simon et al., 1995). Screening tools are also available for anxiety such as the

Brief Symptom Checklist-18 (Derogatis, 2001) which provides a measure of both anxiety and

depression. The My Mood Monitor (M-3) (Gaynes et al., 2010) screening is a valid and efficient

one page tool for screening multiple common psychiatric illnesses in primary care and other

settings. The M-3 can function both as a screen for specific anxiety and mood disorder

diagnoses, as well as a general screen for the presence of any mood or anxiety disorder in

addition to bipolar disorder and PTSD.

Interventions such as passive psychoeducation, including bibliotherapy, have been shown to

reduce symptoms of anxiety, psychological distress, and depression (Donker et al., 2009). These

approaches may be offered as a brief intervention to patients who screen positive for mild or

moderate levels of anxiety. Passive psychoeducational interventions are cost-effective and can

be easily put into practice by non medical professionals and may have a less-stigmatizing impact

on consumers, especially when delivered through a Web site, e-mail or a brochure (Donker et al.,

2009) .

Evidence of emotional trauma is also common in primary care. Walker et al.(1993) report that

rates as high as 37% for childhood sexual abuse and 29% for adult sexual assault are evident in

primary care settings. Walker et al. found that 61% of women reported that they believed that it

was appropriate for their primary care physician to ask about previous victimization, but only 4

percent had been actually asked. In the Adverse Childhood Experiences (ACE) Study (Dube et

al., 2004), patients received an assessment using the Family Health History and Health Appraisal

questionnaires as measures. The authors found the reliability statistics of the ACE study support

the use of these questionnaires for retrospective reports of adverse childhood experiences such as

childhood maltreatment, household dysfunction, and other socio-behavioral factors. Other tools

for screening trauma and anxiety include: the Trauma Symptom Inventory (Briere, 1995), the

PTSD-8 (Hansen, et al., 2010), and the Primary Care PTSD Screen (PC-PTSD) (Prins, et al.,

2003).

The National Child Traumatic Stress Network has developed an evidence-based practice which

may be suitable for use in a BH SBIRT program. The Trauma Adaptive Recovery Group

Education and Therapy for Adolescents and Pre-Adolescents (TARGET-A) has been evaluated

in 248 clinical trials with control groups and can be completed in as little as 4 sessions. This

intervention is designed for groups and/or individual children, adolescents and their parents that

is easily adapted to settings where youth or families enter and leave services rapidly (NCTSN,

2008).

The prevalence of issues such as depression, anxiety, and trauma among primary care patients

call for further exploration to determine if certain SBIRT components may be applied to

symptoms of these disorders among medical patients. These findings also highlight the value of

universal screening, a principal component of SBIRT, in addressing mental health issues in

primary care and other health care settings.

VIII. IMPLICATIONS FOR FUTURE PROGRAMS

While there is substantial research for the effectiveness of SBIRT in reducing unhealthy alcohol

use and tobacco use/misuse, the evidence for similar models in addressing drug abuse and mental

health conditions such as depression, anxiety and trauma is still being developed. As such,

SAMHSA would recommend investment in developing SBIRT-like models for most common

behavioral health conditions, for use in public health settings. This would involve services

research, demonstrations, and conducting rigorous comparative effectiveness evaluations of

behavioral health SBIRT programs beyond those already proven effective for alcohol or tobacco,

in possible collaboration with NIMH, NIAAA and/or NIDA.

Numerous screening and intervention programs in a variety of settings and populations have

recently defined themselves as “SBIRT programs.” Most often these programs do not meet the

criteria established in this paper to be designated as a comprehensive SBIRT model. Both a

strong research base and more consistent terminology and definitions for what constitutes a true

SBIRT model are lacking. Although SBIRT and its components have been utilized across

programs, the effectiveness of SBIRT programs can vary in their fidelity, application, and

comprehensiveness.

In considering the future of SBIRT program implementation, some or all of the following could

be pursued:

• Partnership with one or more external, authoritative bodies. This may involve approaching the

US Preventative Services Task Force to develop an SBIRT definition and/or taxonomy which

reflects the latest science-base approach and is vetted with the field.

• Collaboration with NIH (NIDA, NIMH) and/or AHRQ to conduct more research on SBIRT

approaches for drug abuse, depression, anxiety, trauma, etc., to help establish parameters that

are critical to effective implementation.

• Diversifying the SAMHSA SBIRT program portfolio and dedicating increased evaluation

resources to examine the value of complementing SBIRT for alcohol and drugs with screening

and intervention for other behavioral health conditions.

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