How to Screen Psychiatric Inpatients With SMI for SUD Intervention
How should clinicians use objective admission data to identify psychiatric inpatients with serious mental illness who need substance use disorder intervention?
Psychiatric inpatients with serious mental illness often have co-occurring substance use disorders that are missed when assessment depends on self-report during acute decompensation. This guide applies to adults aged 18 to 65 years hospitalized with serious mental illness in inpatient psychiatric settings where clinicians need a standardized way to decide who should be referred for addiction evaluation and intervention.
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Confirm the patient fits the algorithm's intended population
Use this workflow for psychiatric inpatients with serious mental illness, including schizophrenia spectrum disorders, bipolar disorder, and severe major depression, in the 18 to 65 year age range. The study excluded patients older than 65 years because the NHHSRA was originally developed and validated only for ages 18 to 65 years.
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Collect the objective admission data used by the NHHSRA
Assemble the objective information available at admission that the algorithm is built on rather than relying mainly on patient self-report. The article specifies recent positive urine toxicology results, history of substance use disorder diagnoses, legal mandates for treatment, and current pharmacologic substance use treatment regimens as NHHSRA data elements.
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Run the sequential yes or no decision tree
Apply the NHHSRA in its stepwise format, assessing each criterion as yes or no in sequence. In this structure, a yes at one step may trigger a later assessment or directly prompt referral, while a no sends the patient to the next branch until the patient reaches a final classification.
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Classify the patient as needing or not needing intervention
Complete the algorithm until it reaches one of its 2 terminal outputs: needs SUD intervention or does not need intervention. In the study, the NHHSRA was coded as positive when it would classify the patient as needing SUD intervention and negative when it would not identify the patient for intervention.
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Refer positive screens for formal addiction evaluation
Use a positive NHHSRA result to prompt referral to addiction psychiatry services during the inpatient stay. The article describes the target intervention group as patients for whom pharmacologic relapse-prevention treatment or motivational or relapse-prevention psychotherapy with a substance use counselor would be clinically meaningful.
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Complete the addiction consultation using multiple data sources
The study's reference standard evaluation included direct clinical interview, electronic health record review, toxicology review, Prescription Drug Monitoring Program data, and collateral information such as family input. Use this more complete assessment to determine whether an intervention is appropriate after screening identifies a patient as potentially needing services.
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Use a negative screen to complement, not replace, clinical judgment
Do not treat a negative NHHSRA result as definitive when concern for substance-related problems remains high. In this sample the tool had 96.6% sensitivity, 93.6% specificity, 98.5% positive predictive value, and an 86% negative predictive value, with 26 false negatives, so some patients needing intervention were not flagged by the algorithm.
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Be especially alert in higher-likelihood substance profiles
The article found that opioid use disorder was strongly associated with both clinician-recommended intervention and a positive NHHSRA screen compared with alcohol use disorder, while cannabis and other substance categories had lower adjusted odds. These associations should heighten awareness for referral needs but should not override the algorithm or individualized assessment.
Clinical Considerations
- The NHHSRA was developed and validated for adults aged 18 to 65 years, so this article does not support applying it to patients older than 65 years without adaptation.
- The study evaluated NHHSRA performance in a referred inpatient sample at a single state psychiatric hospital, so local staffing, expertise, and resource availability may affect performance elsewhere.
- The algorithm and analysis did not formally include structured measures of SUD severity, socioeconomic status, or prior outpatient SUD treatment.
- Mutually exclusive primary substance and psychiatric diagnosis categories do not fully capture the comorbidity and polysubstance use common in this population.
Bottom Line
Use the NHHSRA at admission to standardize addiction referrals for psychiatric inpatients with serious mental illness by applying objective clinical data, while preserving clinician judgment for patients whose substance-related needs may still be missed.
