Assessment Step 4—Application to Case Examples Cases 1 and 2. Both Maria M. and George T. are examples of clients with serious addiction who also have serious mental disorders, but do not appear to be seriously disabled. They would therefore meet criteria for quadrant III and should be placed in programs for people who have less serious mental disorders and more serious substance use disorders. Note that though the diagnosis of bipolar disorder is typically considered a serious mental illness, the quadrant system emphasizes the acute level of disability/severity of the mental and substance use disorders of the individual, rather than relying solely on diagnostic classification. Case 3. Jane B., the homeless woman with paranoid schizophrenia, generally would meet criteria for serious and persistent mental illness in almost every State, based on the severity of the diagnosis and disability, combined with the persistence of the disorder. Jane B. also has serious addiction. In the quadrant model, if she already has been identified as a mental health priority client (e.g., has a mental health case manager), she would be considered quadrant IV, and referral for mental health case management services would be important.
Determination of serious mental illness (SMI) status Every State mental health system has developed a set of specific criteria for determining who can be considered seriously mentally ill (and therefore eligible to be considered a mental health priority client). These criteria are based on combinations of specific diagnoses, severity of disability, and duration of disability (usually 6 months to 1 year). Some require that the condition be independent of a substance use disorder. These criteria are different for every State. It would be helpful for substance abuse treatment providers to obtain copies of the criteria for their own States, as well as copies of the specific procedures by which eligibility is established by their States’ mental health systems. By determining that a client might be eligible for consideration as a mental health priority client, the substance abuse treatment counselor can assist the client in accessing a range of services and/or benefits that the client may not know is open to her or him. Determining SMI status begins with finding out if the client already is receiving mental health priority services (e.g., Do you have a mental health case manager? Are you a Department of Mental Health client?). • If the client already is a mental health client, then he or she will be assigned to
Assessment
quadrant II or IV. Contact needs to be made with the mental health case manager and a means of collaboration established to promote case management. • If the client is not already a mental health client, but appears to be eligible and the client and family are willing, referral for eligibility determination should be arranged. • Clients who present in addiction treatment settings who look as if they might be SMI, but have not been so determined, should be considered to belong to quadrant IV. For assistance in determination of the severity of symptoms and disability, the substance abuse treatment clinician can use the Dimension 3 (Emotional/Behavioral) subscales in the ASAM PPC-2R or LOCUS, especially the levels of severity of comorbidity and impairment/functionality.
Determination of severity of substance use disorders Presence of active or unstable substance dependence or serious substance abuse (e.g., recurrent substance-induced psychosis without meeting other criteria for dependence) would identify the individual as being in quadrant III or IV. Less serious substance use disorder (mild to moderate substance abuse; substance depen-
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