Performance of Screening Instruments for Alcohol Problems in the ER: A Comparison of Mexican- Americans and Mexicans in Mexico*

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender, injury, and acculturation subgroups suggests attention should be given to choosing the “best” instrument.     

The prevalence of dementia in a total population: a comparison of two screening instruments.

Two short screening tests for dementia, the Information/Orientation (IO) sub-test of the Clifton Assessment Scale (CAPE) and the Mini-Mental State Examination (MMSE) were included in a survey of 1579 elderly people of a large general practice. All those scoring 21 and under on the MMSE, a one in two sample of those scoring 22, 23 and a one in ten sample of the remainder were investigated further using the Cambridge Examination for Mental Disorders of the elderly (CAMDEX). The prevalences of moderate to severe dementia and mild to severe dementia determined from the CAMDEX interview were 4.8% and 14.2%, respectively. For detection of moderate to severe dementia, a cut-point of 21/22 on the MMSE gave a sensitivity of 100%, specificity of 85% and an overall prevalence of 19.7%; mild to severe dementia was best detected by a cut-point of 23/24 giving a sensitivity of 89%, specificity of 81% and prevalence of 28.5%. A cut-point of 7/8 on the IO sub-test gave a sensitivity and specificity for detecting moderate to severe dementia of 87% and 97%, respectively, with a prevalence of 7.3%; for mild to severe dementia a cut-point of 10/11 gave a sensitivity of 67%, specificity of 94% and prevalence of 14.7%.     

A comparison of substance use and injury among Mexican American emergency room patients in the United States and Mexicans in Mexico

BACKGROUND: Emergency room (ER) studies have found differences in the association of alcohol with injury (intentional and unintentional) across cultures. These differences may be due to differences in drinking patterns across cultures. Few comparative data have been reported on associations of alcohol and injury between Mexican American ER patients and ER patients living in Mexico, and general population studies suggest that Mexican Americans may adopt more frequent heavy drinking patterns after migrating to the United States. METHODS: A comparative analysis of drinking, drug use, and injury was performed in probability samples of 550 ER patients from Santa Clara County (San Jose, CA) and 1417 ER patients in Pachuca (Hidalgo), Mexico. RESULTS: Both injured and uninjured (i.e., medical conditions) patients in Pachuca were less likely to report heavy drinking, drug use, drunkenness, or alcohol-related problems compared with those in Santa Clara. Those scoring high on level of acculturation in Santa Clara were more likely to report both drinking and drug use before the event, and heavy drinking, drug use, and consequences related to drinking in the last year compared with those scoring lower. Those scoring low on acculturation were similar on substance use variables to those in the Pachuca sample. CONCLUSIONS: Findings suggest that alcohol's association with injury may not just reflect typical drinking patterns in a culture. Among Mexican Americans, this association my vary by acculturation, and those migrating to the United States may be at increased risk for alcohol-related injury as their drinking patterns undergo change to those of the dominant culture. The ER, in this context, may take on increasing importance as a site for health services providers to implement intervention and prevention services for alcohol-related consequences in this ethnic group.     

Brief interventions for alcohol problems: a review

Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.     

Expectancies, alcohol drinking and associated problems in university students in Mexico City

OBJECTIVE: To assess the relationship between alcohol use expectancies, drinking patterns, and alcohol-related problems, among college students in Mexico City. MATERIAL AND METHODS: This cross-sectional study was conducted in October 1998. Study subjects were 678 male and female college students aged between 17 and 25 years, from private and public schools. Alcohol expectancies were measured through the self-reported "Alcohol Expectancy Questionnaire" (AEQ), adapted for this population, with a high overall internal reliability coefficient (alpha = 0.93). RESULTS: Thirty-one per cent of study subjects, mainly males, reported heavy drinking (5 drinks or more per drinking occasion in the previous year), while 17% were non-consumers. Relationships for each of the AEQ scales, drinking patterns, and alcohol-related problems, were analyzed through a structural equations model. Analysis of variance showed a statistically significantly association between six AEQ subscales--alcohol as a facilitator of a group interaction, verbal expression, disinhibition, sexual enhancement, reduction of psychological tension and arousal aggression-(F = 5.23, df = 1, p < 0.05). CONCLUSIONS: Study findings from other countries show that effects attributed to alcohol, in anticipation of the drinking episode (expectancies), are closely related to alcohol intake. Our results showed that heavy drinkers had higher scores in six AEQ subscales, particularly those who reported having alcohol-related problems in the previous year. Alcohol expectancies related to higher alcohol intake were: facilitation of social interaction, decreasing psychological tension, and increasing arousal/aggression. The English version of this paper is available at: http://www.insp.mx/salud/index.html.     

Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder

A growing number of adults are seeking evaluation for Attention-Deficit/Hyperactivity Disorder (ADHD). Screening for substance use disorders should be included as part of any comprehensive ADHD evaluation. We describe the validity and reliability of the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT) in adults seeking evaluation for ADHD. Internal reliability estimates were excellent for both instruments. Scores on the DAST and AUDIT were higher among patients with a DSM-IV diagnosis of current drug abuse or dependence or current alcohol abuse or dependence, respectively. A cutoff score of 6 or above appears to be optimal for identifying individuals who are current drug abusers. A cutoff score of 6 or above on the AUDIT is suggested for detection of current alcohol abuse in this population. Comparable rates of substance use disorders were observed in ADHD and non-ADHD patients. Both measures are valid and reliable instruments for screening for alcohol and drug abuse among adults seeking evaluation for ADHD.     

Ways of coping and the health of relatives facing drug and alcohol problems in Mexico and England

Aims. To compare two contrasting socio-cultural groups in terms of parameters relating to the stress - coping - health model of alcohol, drugs and the family, and to test hypotheses derived from the model in each of the two groups separately. Design. Cross-sectional, comparative and correlational, using standard questionnaire data, supplemented by qualitative interview data to illuminate the findings. Participants. One hundred close relatives, mainly partners or parents, from separate families in Mexico City, and 100 from South West England. Data sources. Coping Questionnaire (CQ), Family Environment Scale (FES), Symptom Rating Test (SRT), Semi-structured interview. Findings. Mean symptom scores were high in both groups, and not significantly different. The hypothesis that relatives in Mexico City, a more collectivist culture, would show more tolerant - inactive coping was not supported, but there was support for the prediction that relatives in South West England would show more withdrawal coping. This result may be as much due to differences in poverty and social conditions as to differences in individualism - collectivism. As predicted by the stress - coping - health model, tolerant - inactive coping was correlated with symptoms, in both groups, after controlling for family conflict, but there was only limited support for a moderating role of coping. Wives of men with alcohol problems in Mexico City, and wives of men with other drug problems in South West England, reported particularly high levels of both engaged and tolerant - inactive coping. Conclusions. Tolerant - inactive coping may be bad for relatives' health: causality may be inferred but is not yet proved. Certain groups are more at risk of coping in this way. Qualitative data help understand the nature of tolerant - inactive coping and why it occurs despite the view of relatives themselves that it is counter-productive.     

The "WAM" score: sensitivity and specificity of a user friendly biological screening test for alcohol problems in trauma patients

Based on a weighted aggregation of three biological alcohol markers (gamma-glutamyltransferase, blood alcohol and mean corpuscular volume), this study presents a screening instrument for alcohol problems in trauma patients. The sex-specific performance of this instrument was explored on 1088 male and 352 female patients, 18years or older, admitted with blunt or penetrating trauma during a 30-month period to a regional level one trauma center in Seattle, Washington (USA). The sum of the differentially weighted alcohol markers (“WAM”), determined from one blood sample, formed a “score continuum” ranging from 0 to 24, The WAM scores distributed themselves across the trauma population with higher WAM scores being correlated to higher screening instrument scores for alcohol problems. By using two of the best established screening tests for alcohol problems (CAGE and SMAST) to define cut-off points for likely “alcohol abuse/dependence”, the WAM score of ≥ 7 in males showed 75% sensitivity and 83% specificity, whereas the WAM score of ≥ 6 for females displayed 85% sensitivity and 85% specificity. We conclude that a weighted combination of biological alcohol markers (WAM score) is a useful tool for identifying alcohol problems among trauma patients. Representing an alternative or addition to a more extensive interview, it could be used as a routine pan of the care of trauma patients.     

New drug treatments for alcohol problems: a critical appraisal

Abstract This review considers the novel drug treatments that have been suggested to help prevent relapse or attenuate drinking in people with alcohol problems. The evidence from randomized controlled trials for the efficacy of some of the main candidates: acamprosate, naltrexone, bromocriptine, selective serotonin re-uptake inhibitors and buspirone, was examined. Important methodological problems which may have introduced bias were detected in many of the trials. These included failure to test the integrity of the double blind, excluding or estimating outcome in early withdrawals and the comparison of groups on multiple outcome measures with selective reporting of results. In addition, the generalizability of some studies was limited by the procedures used for sample selection. In view of the potential adverse effects of drug treatment it is concluded that the evidence is not strong enough to support the introduction of any of these substances into routine clinical practice at present. The review also emphasizes the importance of methodological rigour to maximize objectivity in treatment evaluation research.     

Falls in older persons in Australia: screening instruments for general practitioners

Falls are a relatively common problem in older people in Australia causing significant morbidity including restricted activities of daily living and increased mortality. Falls may initiate institutionalisation and will increase in significance with the rapidly ageing population profile. Falls in older people are attributed to multiple factors and are potentially preventable with early detection and intervention. General practitioners, as the primary community medical care providers, are in an ideal position to screen all older patients for falls risk. A detailed history to identify falls risk factors should be complemented by screening with a simple and easy to use screening instrument. The requirements of a reliable and validated falls screening instrument are explored along with a review of available instruments. Although the literature is inconclusive, a suitable falls screening instrument is identified for use by general practitioners.     

Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT,POSIT, CAGE,and CRAFFT

BACKGROUND: Adolescents should be screened for alcohol misuse as part of routine care. The objective of this study was to compare the criterion validity of the Alcohol Use Disorders Identification Test (AUDIT), the Problem Oriented Screening Instrument for Teenagers substance use/abuse scale (POSIT), and the CAGE and CRAFFT questions among adolescents. METHODS: Fourteen- to 18-year-old patients arriving for routine healthcare at a large, hospital-based adolescent clinic completed the four screens and the criterion standard Adolescent Diagnostic Interview, which yields DSM-IV diagnoses of alcohol abuse and dependence. Receiver operating characteristic (ROC) curves were plotted to determine optimal cut-points. Areas under the ROC curves of the four screens were compared, and sensitivities and specificities were calculated. RESULTS: Participants' past 12-month alcohol diagnostic classifications were as follows: no use (58.6%), nonproblem use (13.0%), problem use (20.8%), abuse (5.4%), and dependence (2.2%). Optimal cut-points associated with problem use or higher were 2 for AUDIT, 1 for POSIT, 1 for CAGE, and 1 for CRAFFT. ROC curve area of the CAGE was significantly lower compared with areas of all other screens. Sensitivities (95% confidence intervals) were AUDIT 0.88 (0.83-0.93), POSIT 0.84 (0.79-0.90), CAGE 0.37 (0.29-0.44), and CRAFFT 0.92 (0.88-0.96); specificities were AUDIT 0.81 (0.77-0.85), POSIT 0.89 (0.86-0.92), CAGE 0.96 (0.94-0.98), and CRAFFT 0.64 (0.59-0.69). CONCLUSIONS: The AUDIT, POSIT, and CRAFFT have acceptable sensitivity for identifying alcohol problems or disorders in this age group. The CAGE is not recommended for use among adolescents.     

Tolerate, engage or withdraw: a study of the structure of families coping with alcohol and drug problems in South West England and Mexico City

Aims. To explore the structure underlying individual differences in the ways family members cope with drinking or drug problems. Design. Cross-sectional interview and questionnaire study of a series of family members in two contrasting socio-cultural groups. Setting. Mexico City and South West England. Participants. Two hundred and seven family members from separate families, three-quarters women, one-quarter men, mostly partners or parents. Data. Long semi-structured interviews; the Coping Questionnaire (CQ). Findings. Factor and subscale analyses of the CQ data and textual analysis of the interview reports were used to test the hypothesis that the underlying structure to coping could be described in terms of eight or nine coherent and distinct ways of coping. Neither form of analysis gave strong support to this hypothesis. Conclusions. It is concluded that the structure of coping can best be described in terms of three broad coping positions: tolerating, engaging and withdrawing. These conclusions challenge some previous assumptions about functional and dysfunctional ways of coping with excessive appetitive behaviour in the family.     

Readiness to exercise: a comparison of 3 instruments and an interview

Exercise stage of change (ESOC), or readiness to exercise, has been measured using at least 13 instruments and 4 interviews, yet no comparison studies are available to determine optimal measures for use by health care providers. This pilot study compares ESOC classification between 3 instruments (scale-ladder, scale-true/false, and scale-5 choice); explores the feasibility of using a face-to-face structured interview; compares classification between instruments and interview; and examines the influence of sex, age, and education level on stage classification. Thirty healthy adults completed ESOC instruments in random order and then the interview. Scale-ladder and scale-true/false instruments exhibited almost perfect agreement (weighted kappa, 0.897). All instruments exhibited substantial agreement with interview (weighted kappa, 0.620-0.790). Stage classification did not differ significantly by sex, age, or education level. The authors recommend word clarification revision of the scale-5 choice instrument and further testing of the interview.