Mental health screening and outcome
measurement in alcohol & drug users
Jaime Delgadillo, PhD
Leeds Primary Care Mental Health Service
Presentation outline:
1. Overview of methodological challenges
2. CCAS study: validity and reliability of brief
outcome measures
3. Implications for clinical practice
Detecting and monitoring
mental health problems:
Methodological challenges
Dual Diagnosis: epidemiology
Depression & anxiety disorders commonly co-exist with addictions
(Kessler et al, 1997; Merikangas et al, 1998; Farrell et al, 2001; Schifano et al, 2002)
CMD in primary care = 5 - 20%
(Katon & Schulberg, 1992;
Kroenke et al, 2007)
CMD in addictions treatment = 70 - 90%
(Strathdee et al, 2002; Weaver et al, 2003)
Adverse health & social consequences:
Greater risk of suicide, more frequent and riskier substance use, cycle of
relapse, homelessness, recurrent hospital admissions, treatment dropout,
etc.
(Harris & Barraclough, 1997; Havard et al, 2006; Bergman & Harris, 1985; Jeremy et al, 1992;
Drake, 2007; Ford et al, 1991)
Screening as usual?
Observational studies in routine addiction treatment tend to use brief
measures (BDI, HAM-D, BSI) and conventional cut-off scores, mostly
reporting symptom improvement at 6 – 12 months
(De Leon et al., 1973; Dorus and Senay, 1980; Kosten et al., 1990; Gossop et al., 2006)
Two reviews describe over 20 mental health measures (SCL-90, GHQ,
BDI, BAI, STAI, BPRS, K10, IES-R, etc) and recommend using these in
addictions research
(Dawe et al, 2002; Deady, 2009)
Little or no consideration for validity / reliability of these
questionnaires in addictions treatment
Methodological challenges
Several validation studies since the 70’s consistently report adequate
sensitivity but poor specificity
(Rounsaville et al, 1979; Hesselbrock et al, 1983; Willenbring, 1986; Weiss et al, 1989; Kush &
Sowers, 1996; Coffey et al, 1998; Boothby & Durham, 1999; Hodgins et al, 2000; Buckley et al,
2001; Franken & Hendriks, 2001; Zimmerman et al, 2004; Luty & O’Gara, 2006; Rissmiller et al,
2006; Swartz & Lurigio, 2006; Dum et al, 2008; Lykke et al, 2008; Seignourel et al, 2008;
Hepner et al, 2009; Holtzheimer et al, 2010; Lee & Jenner, 2010)
Consequently, using brief measures and conventional cut-offs in alcohol &
drug users may overestimate the prevalence of disorders
(Keeler et al, 1979; Hesselbrock et al, 1983)
Summary of key challenges
1. Using structured diagnostic interviews is seldom feasible due to
cost, training, time, constraints.
2. Common symptoms associated with substance use interfere with
the specificity of brief screening tools. This results in false positives.
3. Extreme measures of CMD symptoms (outliers) are likely to
fluctuate. This means that observed symptom changes may be
influenced by regression to the mean.
4. Observed changes in symptom scores may be due to measurement
error.
CCAS study:
validity and reliability of brief
outcome measures
CCAS study: design
Design
Diagnostic validation study. Recruitment period: 1 year. Prospective
cohort design, follow-up: 4-6 weeks.
Participants
103 clients in routine methadone maintenance treatment in Leeds,
excluding people with severe mental disorders.
Measures
CIS-R (Gold-standard diagnostic interview)
PHQ-9 (Depression)
GAD-7 (Anxiety disorders)
TOP (Patterns of alcohol & drug use and self-rated mental health)
Procedure
Complete brief measures  diagnostic interview  re-test after 4 weeks
CCAS study: sample
CCAS study: results
Table 1.
Psychometric properties of brief screening tools for common mental disorders
+PV
– PV
ICC
75
0.84
0.71
0.78
80
83
0.90
0.69
0.85
83
71
0.87
0.65
0.78
Cronbach’s
Cut
Sensitivity
Specificity
alpha
off
%
%
PHQ-9
0.84
≥12
80
GAD-7
0.91
≥8
≤12
TOP
(Delgadillo et al, 2011, 2012)
CCAS study: results
How stable are depression & anxiety symptoms
after 4-6 weeks watchful wait?
GAD-7
PHQ-9
Cut-off
Cut-off ≥≥12
9
RCI ≥ 5
7
Implications for clinical practice
Conclusions
1. Using cut-offs calibrated in clinical samples enhances specificity of
brief screening tools.
2. Using RCI results in more conservative and reliable assessment of
symptom change.
3. Approximately 25% of patients with a CMD reliably improve during a
watchful wait period in routine MMT (ES = .30). Watchful wait can help
to ‘screen out’ false positives and identify those who naturally
improve.
4. Given the reliability of TOP, a step-wise screening / monitoring
method may be feasible to implement in routine practice
COBID trial: recruitment strategy
Routine case-finding
If: TOP <= 12
Then:
PHQ-9 + GAD-7
If: PHQ-9 >= 12
Suitability screening interview &
informed consent
Random allocation
BA in primary care
Usual drugs treatment
+ guided self-help
Thank you for listening
Contact details:
jaime.delgadillo@nhs.net