Treating Concurrent Disorders in RAAM Clinics, Outpatient Settings and Bed-Based Programs
Rationale and Approach
Mental health disorders are very common in people with substance use disorders yet patients in emergency departments with these co-occurring disorders are less likely to receive psychiatric care than patients without a substance use disorder. This gap in care is compounded by long wait lists for community-based services that include psychiatric consultations and Assertive Community Treatment for people with serious mental illness.
Assessment and Treatment of Psychiatric Disorders Common in Substance Use
| Diagnosis | Assessment Tools | Treatment Guidelines | First-line Medications |
|---|---|---|---|
|
Posttraumatic stress disorder |
PTSD Checklist for DSM-5 (PCL-5) |
Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress and Obsessive-Compulsive Disordersa |
Fluoxetine, sertraline, venlafaxine XR, paroxetine |
|
Major depressive disorder* |
Patient Health Questionnaire (PHQ-9) |
CANMAT 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adultsc |
Escitalopramd, sertraline, duloxetine, mirtazapine, bupropion or othersc |
|
Generalized & social anxiety disorder* |
General Anxiety Disorder-7 (GAD-7) |
Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress and Obsessive-Compulsive Disordersa |
Escitalopramd, sertraline, venlafaxine XR, paroxetine, pregabalin, gabapentine
|
|
Substance-induced psychosis/ schizophrenia |
Clinical assessment |
Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disordersf
|
Antipsychotics such as risperidone, olanzapine. paliperidone, aripiprazole,g and long-acting injectable formulations (aripiprazole, paliperidone) |
- a Katzman et al., BMC Psychiatry, 2014; 14.
- b Prazosin has some off-label evidence for alcohol use disorder; see Simpson et al., Am J Psychiatry, 2018; 175, 1216–1224.
- c Lam et al., Can J Psychiatry, 2024; 69, 641–687.
- d Escitalopram and citalopram have advisories about QT prolongation, particularly if combined with methadone.
- e Pregabalin and gabapentin have misuse potential and should be monitored and not prescribed in large amounts.
- f Addington et al., Can J Psychiatry, 2017; 62, 594–603.
- g Aripiprazole labels now warn about risk of pathological gambling, hypersexuality and other impulsive behaviours.
- * Recent guidelines for treating alcohol use disorder warn against regular use of SSRIs for depression or anxiety without careful consideration. Wood et al., CMAJ, 2023; 95, E1364–E1379.
Tanya S. Hauck MD PhD FRCPC; Stephanie Rochon RPHT; Kelly Kokus DNP, NP-PHC, MScN; Ilan Nachim MD CCFP; Leslie Buckley MD MPH FRCPC; Raquel Williams MSc OT, OT Reg. (Ont.) © CAMH
Treatment of Concurrent Disorders and Stimulant Use Disorder in RAAM Clinics, Outpatient Settings and Bed-Based Programs © 2025 Centre for Addiction and Mental Health.