Reliability of DSM-IV diagnostic criteria using the semi-structured assessment for drug dependence and alcoholism (SSADDA)

The semi-structured assessment for drug dependence and alcoholism (SSADDA) yields reliable DSM-IV diagnoses for a variety of psychiatric disorders, including alcohol and drug dependence. This study examines the reliability of individual DSM-IV criteria for lifetime substance dependence diagnoses and the impact of those criteria on diagnostic reliability. METHODS: Two hundred ninety-three subjects (52.2% women; 38.2% African American, 46.8% European American, 7.5% Hispanic) were interviewed twice over a 2-week period to examine the inter-rater reliability (n=173) or test-retest reliability (n=120) of the SSADDA. Cohen's kappa-statistic and its confidence interval were used to assess the reliability of individual diagnostic criteria. RESULTS: Overall, the inter-rater reliability estimates were excellent for individual DSM-IV criteria for nicotine and opioid dependence; good for alcohol and cocaine dependence, and fair for dependence on cannabis, sedatives and stimulants. The impact of any individual criterion on diagnostic reliability was minimal, consistent with the notion that the DSM-IV diagnosis of substance dependence measures an underlying construct that is relatively consistent across specific groups of substances. CONCLUSIONS: These results, combined with results from a study of the SSADDA's diagnostic reliability [Pierucci-Lagha, A., Gelernter, J., Feinn, R., Cubells, J.F., Pearson, D., Pollastri, A., Farrer, L., Kranzler, H.R., 2005. Diagnostic reliability of the semi-structured assessment for drug dependence and alcoholism (SSADDA). Drug Alcohol Depend. 80, 303-312], show that the instrument can be used reliably to assess substance dependence.     

Cannabis dimensionality: Dependence,abuse and consumption

Aims

Genetic research on substance use disorders usually defines phenotypes as a binary diagnosis, resulting in a loss of information if the disorder is inherently dimensional. The DSM-IV criteria for drug dependence were based on a theoretically dimensional (linear) model. Considerable investigation has been conducted on DSM-IV alcohol criteria, but less is known about the dimensionality of DSM-IV cannabis criteria for abuse and dependence. The aim of this study is to assess whether DSM-IV cannabis dependence (including withdrawal) and abuse criteria fit a linear measure of severity and whether a consumption criterion adds linearly to severity.

Design/setting/participants/measurements

Participants were 8172 in the National Epidemiologic Survey on Alcohol and Related Conditions who had ever used cannabis. Wald statistics were used to test whether categorical, dimensional or hybrid forms best fit the data. We examined the following as criterion sets: (1) dependence; (2) dependence and abuse; and (3) dependence, abuse and frequency of use. Validating variables included family history of drug problems, early onset of cannabis use, and antisocial personality disorder.

Findings

For cannabis dependence, no evidence was found for categorical or hybrid models; Wald tests indicated that models representing the seven DSM-IV dependence criteria as a linear severity measure best described the association between the criteria and validating variables. However, significant differences from linearity occurred after adding the four cannabis abuse criteria (p = 0.03) and the use indicator (p = 0.01) for family history and antisocial personality disorder.

Conclusion

With ample power to detect non-linearity, cannabis dependence was shown to form an underlying continuum of severity. However, adding abuse criteria, with and without a measure of consumption, resulted in a model that differed significantly from linearity for two of the three validating variables.     

Inter-rater reliability and concurrent validity of DSM-IV opioid dependence in a Hmong isolate using the Thai version of the Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA)

Because isolated populations offer relative genetic and environmental homogeneity, they are important resources for mapping genes for complex traits. Reliable and valid phenotypic characterization of the disease in the population studied is essential. We examined diagnostic reliability and concurrent validity of DSM-IV opioid dependence (OD) in a Hmong population in Thailand with historically high rates of opium (and heroin) use. 578 Thai-speaking Hmong individuals were assessed for lifetime OD, using Thai versions of both the Semi-Structured Assessment for Drug Dependence and Alcoholism (Thai SSADDA) and the Mini-Neuropsychiatric Interview (Thai MINI; adapted for lifetime diagnoses). In a subsample of 123 individuals, two raters interviewed each subject independently within a 2-week period. Chance-corrected agreement on the OD diagnosis was assessed between raters and instruments. Results showed excellent agreement for the DSM-IV diagnosis of OD both for the SSADDA (κ=0.97) and MINI (κ=1.00) and between the SSADDA and MINI (κ=0.97). Consistent with reliability assessments of English versions, our data demonstrate high reliability for Thai versions of the SSADDA and MINI in the diagnosis of OD. The high concordance between instruments supports the concurrent validity of the diagnosis. Either interview provides reliable, valid OD diagnoses in Thai-speaking Hmong individuals.     

Diagnostic orphans: comparing self-report lifetime course to groups with DSM-IV alcohol abuse and dependence

Research has highlighted the significant alcohol symptoms and mental health problems experienced by diagnostic orphans - individuals who experience 1-2 criteria of DSM-IV alcohol dependence but do not meet the criteria for a DSM-IV alcohol use disorder. This study used a sub-sample (n=34827) from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and formed mutually exclusive groups to compare the self-report retrospective course of diagnostic orphans to individuals with DSM-IV abuse and dependence. Multinomial logistic regressions were conducted to examine the associations between the groups and a range of demographic and clinical variables. Collectively, the findings demonstrate that diagnostic orphans shared similar characteristics to the abuse and dependence groups, but appeared to experience specific comorbid mental health problems. Orphan status has the potential to be a persistent condition and may result in significant dysfunction. In conclusion, diagnostic orphans represent a distinct group that may benefit from cost-effective treatment or intervention, designed to prevent the escalation of alcohol symptoms.     

Drug List as a Cognitive Support to Provide Detailed Information on a Patient's Drug Use: A Comparison of Two Methods Within the Assessment of Drug Misuse and Dependence

Background: It is important to identify the type of drugs a patient has used, especially when polydrug misuse has increased and new drugs and patterns of misuse are quickly spread. Objectives: In order to acquire sufficient information about drug use, an effective and simple form of mapping is needed. Methods: Persons actualized for Opioid Substitution Treatment (n = 135) were interviewed about their drug-history in a two-stage model. First, they were asked to write down the drugs misused, and dot those injected with a felt pen. Second, they were asked to do the same on a drug list provided as a cognitive support. For a subsample of 50 persons, the drug list included four fictive drugs to evaluate possible over-reporting. Results: The use of a drug list did not take longer than the traditional way of using open questions, i.e. about 5–8 minutes. Using a drug list gave a cognitive support resulting in a much higher proportion/number of reported drugs. The majority, 97%, used more than one drug. None of the patients who were given the drug list that included fictive drug names reported having used any of them. The respondents reported 43 additional substances to the 125 given on the list which improve our knowledge of the drug scene. Conclusions/importance: Using a drug-list was superior to open questions; it does not take more time and provides additional, clinically relevant information than open questions. Using a drug-list also gives improved knowledge of new drugs entering the local drug scene.     

Alcohol and Other Drug Use Disorders Among Homeless People in Australia

This paper describes alcohol and drug-use disorders among 210 homeless people in Australia, and compares the Australian findings with the international literature. While the prevalence of alcohol-use disorders among people who are homeless in Australia is comparable with other international studies, drug-use disorders appear to be more prevalent among Australian homeless than comparable international studies. Reasons for this difference are explored.     

Concurrent validity of cocaine and sedative dependence diagnoses in opioid-dependent outpatients

The present study evaluated the relationship between diagnoses of cocaine and sedative dependence and drug use early in treatment among opioid-dependent patients in methadone substitution therapy. New admissions (n = 138) were assessed via the Structured Clinical Interview for the DSM III-R (SCID) for presence of Axis I and Axis II disorders and followed for five weeks on standard methadone maintenance. Patients submitted urines three times per week tested for opioids, cocaine, and benzodiazepines. Patients diagnosed with current cocaine dependence (n = 90) submitted a higher proportion of cocaine-positive urines (M = 0.84) than patients diagnosed with past cocaine dependence (n = 32; M =0.28) and those diagnosed with no cocaine use disorder (n = 14; M = 0.12), P < 0.001. Current cocaine dependence diagnosis accounted for 52% of the cocaine use variance. Patients exhibiting current sedative dependence (n = 25) submitted a higher proportion of benzodiazepine-positive urines (M = 0.60) than patients with past sedative dependence (n = 44; M = 0.20) and those with no sedative use disorder (n = 60; M = 0.05), P < 0.001. Current sedative dependence diagnosis accounted for 37% of the benzodiazepine use variance. Lifetime major depression (12%) and antisocial personality disorder (39%) were the most common nonsubstance use comorbid diagnoses. Axis I nonsubstance use disorder was associated with benzodiazepine use, while Axis II disorder was associated with both benzodiazepine and cocaine use early in treatment (P < 0.05). These data demonstrate the concurrent validity of DSM-III-R cocaine and benzodiazepine use diagnoses, and support the potentially important relationship between drug use and other psychiatric disorders.     

Secondary Prevention of Drug Dependence through the Transcendental Meditation Program in Metropolitan Philadelphias

Using mailed questionnaires, the Transcendental Meditation program was investigated as an approach to the secondary prevention of substance dependence. Significant differences were found between a random sample of meditators and matched control subjects in usage levels and percentage of users for almost all legal and illegal drugs. Meditators had used more prescribed psychoactive medications before learning meditation, but usage levels returned to normal soon after starting. Former     

Factor structure and diagnostic efficiency of the BDI-II in treatment-seeking substance users

Screening instruments are needed to rapidly and efficiently identify depression in drug and alcohol users. The Beck Depression Inventory-Second Edition (BDI-II) has excellent validity in psychiatric, normative and primary care samples, but its diagnostic efficiency has not been examined in substance users. Using a large sample of treatment-seeking substance users and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) to establish diagnosis, we examined the factor structure of the BDI-II and its ability to detect clinical depression, defined as the presence of a Major Depressive Disorder (MDD) or substance-induced depression. A three-factor structure provided the best fit, and the diagnostic efficiency of the BDI-II was moderate, and independent of gender and substance of abuse. Subscores had lower diagnostic efficiency than the BDI-II total score. A range of possible cutoff scores with corresponding sensitivity, specificity, positive predictive power and negative predictive power is provided to aid clinicians and researchers in choosing the optimal parameters for their screening needs.     

Web-based training for primary care providers on screening,brief intervention,and referral to treatment (SBIRT) for alcohol,tobacco, and other drugs

This project evaluated a Web-based multimedia training for primary care providers in screening, brief intervention, and referral to treatment (SBIRT) for unhealthy use of alcohol, tobacco, and other drugs. Physicians (n = 37), physician assistants (n = 35), and nurse practitioners (n = 20) were recruited nationally by email and randomly assigned to online access to either the multimedia training or comparable reading materials. At baseline, compared to non-physicians, physicians reported lower self-efficacy for counseling patients regarding substance use and doing so less frequently. All provider types in both conditions showed significant increases in SBIRT-related knowledge, self-efficacy, and clinical practices. Although the multimedia training was not superior to the reading materials with regard to these outcomes, the multimedia training was more likely to be completed and rated more favorably. Findings indicate that SBIRT training does not have to be elaborate to be effective. However, multimedia training may be more appealing to the target audiences.     

Validation of the Primary Care Posttraumatic Stress Disorder screening questionnaire (PC-PTSD) in civilian substance use disorder patients

This study aimed to cross-validate and extend earlier findings regarding the diagnostic efficiency of the four-item Primary Care Posttraumatic Stress Disorder Screen (PC-PTSD) as a screening questionnaire for posttraumatic stress disorder (PTSD) among civilian patients with substance use disorder (SUD). The PC-PTSD was originally developed in a Veteran Affairs primary care setting (Prins, Ouimette, Kimerling, Cameron, Hugelshofer, Shaw-Hegwer, et al., 2004) and has been widely used in the U.S. army. The diagnostic efficiency of the screener was compared to those of an extended eight-item version of the PC-PTSD and the Posttraumatic Diagnostic Scale (PDS). The sample consisted of 142 participants with SUD and most of the participants (89%) were still using substances in the month preceding the assessment. Results showed a high sensitivity (.86) and moderate specificity (.57) for the PC-PTSD when using a cutoff score of 2. The diagnostic efficiency of the PC-PTSD was equivalent to the extended eight-item version and the 17-item PDS. Results suggest that the original PC-PTSD is a useful screening instrument for PTSD within a civilian SUD population. These findings have important clinical implications because screening for PTSD among patients with SUD is crucial to ascertain appropriate treatment allocation.     

The reliability of self-reported cannabis abuse,dependence and withdrawal symptoms: Multisite study of differences between general population and treatment groups

In NIDA-funded studies, 739 cannabis users were interviewed twice, one week apart, in St. Louis, Miami, and Sydney. To examine differences in reliability of DSM-IV cannabis abuse and dependence criteria, including 19 withdrawal symptoms, the sample was dichotomized by treatment status, GEN POP (n = 416) and TX (n = 278). GEN POP had good to excellent reliability for abuse criteria (κ = .56 to .86); TX was similarly reliable (κ = .58 to .82). The most reliable abuse criterion among both groups was “legal problems”; the least reliable was “failure to fulfill major role obligations”. The reliability of dependence criteria revealed similar patterns, with GEN POP (κ = .49 to .74) and TX (κ = .44 to .73) being equally reliable. The most reliable dependence criterion for both groups was “tolerance”; the least reliable was “continued use despite knowledge of physical or psychological harm”. Although not mentioned in the DSM-IV for cannabis, withdrawal symptoms (especially plausible ones) were commonly and reliably reported. These analyses are important to verify the harms of cannabis, including withdrawal, as well as confirming the reliability of the criteria.     

Psychometric Properties of the Turkish Versions of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in the Prison Setting

The aim of this study was to evaluate psychometric properties of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in prisoners with (n = 124) or without (n = 78) drug use disorder. Participants were evaluated with the DUDIT, the DAST-10, and the Addiction Profile Index-Short (API-S). The DUDIT and the DAST-10 were found to be psychometrically sound drug abuse screening measures with high convergent validity when compared with each other (r = 0.86), and API-S (r = 0.88 and r = 0.84, respectively), and to have a Cronbach’s α of 0.93 and 0.87, respectively. In addition, a single component accounted for 58.28% of total variance for DUDIT, whereas this was 47.10% for DAST-10. The DUDIT had sensitivity and specificity scores of 0.95 and 0.79, respectively, when using the optimal cut-off score of 10, whereas these scores were 0.88 and 0.74 for the DAST-10 when using the optimal cut-off score of 4. Additionally, both the DUDIT and the DAST-10 showed good discriminant validity as they differentiated prisoners with drug use disorder from those without. Findings support the Turkish versions of both the DUDIT and the DAST-10 as reliable and valid drug abuse screening instruments that measure unidimensional constructs.     

Substance use disorder trajectory classes: diachronic integration of onset age, severity, and course

Background

Substance use disorders (SUDs) may be characterized by onset age, severity, substance type, course, and outcomes. SUD phenotypes in the literature typically consider each of these features in isolation. Conceptual frameworks and data collection procedures for assessing SUD phenotypes are increasingly “diachronic” in approach, providing for characterizations “throughout time”. The recent availability of statistical procedures for the identification of latent classes offers the possibility of developing SUD phenotypes integrating these developmental features. This article illustrates the utilization of SAS-TRAJ mixture modeling to characterize variations in SUD symptom trajectories to define phenotypes.

Methods

The subjects were 332 adult males with SUDs. Their course of symptoms from early adolescence through middle adulthood was retrospectively determined. Symptom trajectories were defined by the number of DSM-IV SUD symptoms by year of age. SAS-TRAJ mixture models identified trajectory classes. Model development, evaluation, and selection using this approach are discussed.

Results

Among these men with SUDs, six trajectory classes were identified, including groups characterized by early-onset and severe SUD symptoms persisting into adulthood, an early-onset group similar in adolescence but improving in adulthood, and other groups with symptoms emerging later with varying degrees of severity and persistence. The SUD trajectory classes were significantly different on comorbid psychopathology, particularly childhood disruptive behavior disorders.

Conclusion

The results present a new method for the comprehensive depiction of heterogeneity in SUD symptoms. Future studies may determine the extent to which SUDs phenotypes based on the course of symptom development inform etiology, prevention and treatment research.     

Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on subsequent substance use disorder onset and vice versa

Objective

A large body of epidemiological research indicates that anxiety and mood disorders are highly comorbid with substance use disorders (SUDs). However, longitudinal research regarding their temporal relations is limited. The goal of this study was to assess whether emotional disorders (i.e., anxiety and mood disorders) predict the onset of SUDs, whether SUDs predict the onset of emotional disorders, or both.

Method

The current study used data from baseline assessment (N = 627) and four years of follow-up assessments from the NU/UCLA Youth Emotion Project to examine this question.

Results

In line with the self-medication hypothesis of emotional disorder/SUDs comorbidity, anxiety and unipolar mood disorders at baseline assessment were associated with later onsets of SUDs. In particular, social anxiety disorder (SAD) at baseline predicted onset of alcohol use disorders and PTSD predicted the onset of all SUDs. SUDs did not predict any anxiety or unipolar mood disorders with the exception that alcohol use disorders predicted the onset of obsessive compulsive disorder (OCD).

Conclusions

These findings, as well as the clinical implications and future directions for research, are discussed.     

Adopting early intervention for substance use disorders: a preliminary study of primary healthcare professionals in New York State

Abstract

Aims: Research has reported a lack of practice of early intervention for substance use disorders among primary healthcare professionals, and only a fraction of patients were asked about their substance use when visiting a primary healthcare office. This study examines conditions that may influence the adoption of early intervention [i.e., screening, brief intervention and referral to treatment (SBIRT)] among primary healthcare professionals. Methods: A pilot survey was emailed to primary care physicians, nurse practitioners, and physician assistants in New York State, and 248 recipients responded to the survey. Findings: Three areas appear to be associated with the adoption of SBIRT: percentage of respondents’ patients using marijuana (β?=?0.14; p?<?0.05); perceived ability to perform intervention (β?=?0.32; p?<?0.05); and perception of early intervention as a responsibility of primary care professionals (β?=?0.29; p?<?0.05). Conclusions: Training and education to promote SBIRT for primary care workers should focus on increasing their favourable attitudes towards the intervention as a strategy of preventive medicine and include the knowledge of the infrastructure of services for substance use disorders, especially for medical providers who see large numbers of patients at a high risk for alcohol and drug misuse.     

Sexual orientation and substance abuse treatment utilization in the United States: Results from a national survey

This study examined substance abuse treatment utilization across three dimensions of sexual orientation (identity, attraction, and behavior) in a large national sample of adults in the United States. Prevalence estimates were based on data collected from the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions. The sample consisted of 34,653 adults 20 years and older, and represented a population that was 52% women, 71% White, 12% Hispanic, 11% African American, 4% Asian, and 2% other race/ethnicities. An estimated 2% of the target population self-identified as lesbian, gay or bisexual; 4% reported same-sex sexual behavior, and 6% reported same-sex sexual attraction. Sexual minorities, especially women, had a greater likelihood of lifetime substance use disorders and earlier age of drinking onset. The majority of respondents with substance use disorders were untreated and lifetime substance abuse treatment utilization differed based on sexual orientation. Sexual minorities were found to have more extensive family histories of substance abuse problems. The findings indicate the underutilization of substance abuse treatment among all adults, and highlight some important factors to consider when working with sexual minorities.     

Comparisons of Alcohol and Drug Dependence in Terms of Attachments and Clinical Issues

Background: Alcohol and drug dependencies are associated with different social stigmas, and some studies suggest they might exhibit different clinical presentations. Further, the treatments for each vary considerably. Alcohol versus drug use problems were compared in terms of attachment patterns and related clinical treatment issues in two interlocking studies using converging logic and designs. Methods: In Study 1, alcohol versus drug dependence was defined in terms of a known groups design. Patients from an inpatient alcohol treatment center, patients receiving treatment for opiate dependence in a methadone maintenance clinic, and controls were compared on the 29 scales of the Attachment and Clinical Issues Questionnaire (ACIQ). Study 2 sampled a substantially different population (491 university students) and used different operational definitions of substance use problems, relying on screening instruments. Results: Study 1 found that, although the drug and alcohol dependent patients differed substantially from the controls, they did not differ from one another on any of the 29 ACIQ scales measuring attachments and clinical issues. Study 2 converged on the known groups design of Study 1, showing convergent and concurrent rather than discriminate evidence for the alcohol and drug dependence screening instruments. Conclusion: Alcohol and drug dependencies were not found to differ significantly in terms of attachments or clinical issues. These studies aimed to provide clearer and more empirically grounded guidance to the clinician and researcher.     

Effect of co-occurring disorders and intimate partner violence on substance abuse treatment outcomes

This retrospective cohort study examined risk factors for co-occurring substance use and mental disorders (COD) and the effect of COD and intimate partner violence (IPV) victimization among women and IPV-related arrest among men on 1-year substance abuse treatment outcomes. The study sample included clients admitted to Washington State publicly funded substance abuse treatment facilities in 2004–2007. COD was associated with a high substance use and IPV risk profile at admission. Having a COD decreased the odds of completing treatment by 30% among men and women and increased the risk of treatment reentry by 9% and 12% among men and women, respectively. IPV also decreased the odds of completing treatment among women and increased the risk of treatment reentry among men. Men with COD were less likely than those without COD to be arrested for substance-related crimes but more likely to be arrested for violence-related crimes in the follow-up period. Implications of these findings are discussed.