Conceptualization And Assessment The Primary versus Secondary Disorder Problem

When a clinician uses the Structured Clinical Interview for DSM-IV (e.g., SCID-IV: First, Spitzer, Gibbon, & Williams, 1995) to interview a patient, the interviewer is encouraged to indicate the primary, secondary, and tertiary disorders, as well as their temporal primacy (chronological appearance) in the patient's life. Accordingly, it seems fitting and proper to try to ascertain the following: Which came first (and which is more clinically relevant), the alcohol and/or substance problem, or the depression? However, in the case of mutually interacting disorders such as depression and alcohol and other drug abuse or dependence, attempts to disentangle the causes and effects without a longitudinal assessment are often difficult (e.g., Ramsey, Kahler, Read, Stuart, & Brown, 2004) and may erroneously minimize the clinical significance of the disorder deemed to be secondary. For example, even when there is clear evidence that the depressive disorder predated the substance use problem, and the substance use problem is not officially diagnosed as being severe, some research has suggested that this "secondary" substance use problem is still a top clinical priority. Relatively lesser amounts of alcohol and other drugs can have particularly deleterious effects on individuals who are clinically depressed (e.g., Mueser, Drake, & Wallach, 1998), including an increase in the risk of suicide (e.g., Cornelius et al., 1995). Therefore, one school of thought (from a treatment standpoint) is to consider both disorders to be primary (Mueser et al., 2003). Thus, therapists can tell these patients that the goal of therapy entails "dual recovery" (Evans & Sullivan, 2001), in which both the mood disorder and the substance use disorder are of central importance.

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