Screening for alcohol problems: comparison of the audit,RAPS4 and RAPS4-QF among African American and Hispanic patients in an inner city emergency department

OBJECTIVE: to compare brief screening instruments for alcohol use disorders, the RAPS4, RAPS4-QF, and AUDIT, against DSM-IV criteria for alcohol dependence and alcohol abuse among African Americans and Hispanics in a sample of inner city emergency department (ED) patients. METHOD: a probability sample of 395 African American and Hispanic patients seeking care at King Drew Medical Center Emergency Department were interviewed regarding items related to the screening and diagnostic instruments, quantity and frequency of drinking and demographic characteristics. RESULTS: no difference was found between the RAPS4 and AUDIT for alcohol dependence. Sensitivity of the RAPS4-QF (the RAPS4 plus a quantity item and a frequency item) was significantly better than the AUDIT for African Americans and Hispanics, and for males, but not for females, although the RAPS4-QF identified all of those women positive for alcohol abuse criteria, compared to 93% identified by the AUDIT. CONCLUSION: the data suggest the RAPS4 and the RAPS4-QF perform well for identifying alcohol dependence and alcohol abuse, respectively, among minority ED patients. Additional research is needed to evaluate the RAPS4-QF as a stand-alone instrument and to evaluate both instruments across gender and ethnic subgroups in other populations and in other cultural settings.     

A brief screening instrument for problem drinking in the emergency room: the RAPS4. Rapid Alcohol Problems Screen

OBJECTIVE: While a number of brief screening instruments for identifying problem drinkers have been tested in clinical settings, instruments have not been found to perform as well for women as for men, or to perform uniformly across ethnic groups. The purpose of this study was to evaluate a shortened version of the RAPS (Rapid Alcohol Problems Screen) in an emergency room (ER) sample (N = 1,429; 51% female) and to determine the most efficient ordering of the items. METHOD: The sensitivity and specificity of each of the RAPS items were examined against current ICD-10 and DSM-IV criteria for alcohol dependence, and separately for harmful drinking or abuse. A four-item version of the RAPS (the RAPS4) was analyzed separately for men and for women, and for blacks, Hispanics and whites/others. RESULTS: Among the five original RAPS items, four items were found to be most efficient, with the single item of feeling guilt or remorse after drinking identifying 83% of those with alcohol dependence and 44% of those meeting criteria for harmful drinking or abuse. A positive response to any one of the four items (RAPS4) gave a sensitivity of 93% and specificity of 87% for alcohol dependence, and sensitivity and specificity were consistently high across gender and ethnic subgroups. Sensitivity and specificity for harmful drinking or abuse were lower (55% and 79%, respectively). CONCLUSIONS: Because of its brevity and high performance across demographic subgroups, the RAPS4 may hold promise in screening for alcohol use disorders in patient populations, and its utility warrants further evaluation in clinical settings.     

Gender, injury status and acculturation differences in performance of screening instruments for alcohol problems among US Hispanic emergency department patients

The sensitivity and specificity of several screening instruments including the CAGE, brief MAST, AUDIT, TWEAK, RAPS, and Trauma Scale, were evaluated against both ICD-10 and DSM-IV criteria for alcohol dependence and for harmful drinking and abuse in a probability sample of 586 Hispanic emergency department patients. Screening instruments were not as sensitive for females as for males, for those in the low acculturation group, or for non-dependent drinkers. Acculturation was positively associated with the likelihood of being a current drinker and among current drinkers, was positively associated with alcohol dependence and with harmful drinking or alcohol abuse.     

Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C,CRAFFT, RAPS4-QF,FAST, RUFT-Cut,and DSM-IV 2-Item Scale

Background

This study compared six of the briefest screening instruments for detecting DSM-IV-defined Alcohol Use Disorder (AUD) among older adolescents treated in Emergency Departments (ED).

Methods

The AUDIT-C, the RAPS4-QF, the FAST, the CRAFFT, the RUFT-Cut, and 2-Items from the Diagnostic and Statistical Manual IV of the American Psychiatric Association [American Psychiatric Association (1994). Diagnostic and Statistical Manual of Psychiatric Disorders, (1994) (DSM-IV). 4th ed. Washington D.C.: American Psychiatric Association] criteria for AUD (heretofore referred to as the DSM-IV 2-Item Scale) were evaluated against the criterion of a current DSM-IV diagnosis of either alcohol abuse or dependence. The instruments were administered to 181 alcohol-using older adolescents (57% males; age range 18–20 years) in an ED and compared using Receiver Operator Characteristic (ROC) analyses against the criterion of a current DSM-IV diagnosis of alcohol abuse or dependence.

Results

Of these instruments, the DSM-IV 2-Item Scale performed best for identifying AUD (88% sensitivity and 90% specificity), followed by the FAST and the AUDIT-C.

Conclusions

Two items from the DSM-IV criteria for AUD performed best for identifying ED-treated older adolescents with alcohol use disorders. The FAST and AUDIT-C performed well, but are longer and more difficult to score in the hectic environment of the Emergency Department.     

Performance of screening instruments for alcohol use disorders in emergency department patients in Argentina

The performance of the Alcohol Use Disorders Identification Test (AUDIT), CAGE, Brief Michigan Alcohol Screening Test (Brief MAST), Rapid Alcohol Problems Screen (RAPS), Rapid Alcohol Problems Screen-Quantity and Frequency (RAPS4-QF), and TWEAK was evaluated against a diagnosis of alcohol dependence and harmful drinking or alcohol abuse from ICD-10 and DSM-IV criteria. Data were collected from a probability sample of 779 patients admitted to the emergency department of a public general hospital in Mar del Plata, Argentina, during the year 2001. The majority of the patients sampled were male. The age range was 18 to 89 years, with a mean value of 36 years and a median of 31 years. Almost half of the sample had an elementary school education or less. All instruments were more sensitive for alcohol dependence than for harmful drinking or abuse and more sensitive for men than for women. Findings suggest the RAPS4 and RAPS4-QF may be preferred when screening for alcohol use disorders in the emergency department in Argentina. The study's limitations are noted.     

Screening for alcohol problems in two emergency service samples in Poland: comparison of the RAPS4, CAGE and AUDIT

Prior research on alcohol-related problems among emergency service patients in Poland found substantial alcohol involvement on the part of injured males, suggesting emergency services may be a productive venue for identifying patients who could benefit from a brief intervention or referral for treatment. Performance of the RAPS4, CAGE and AUDIT against ICD-10 and DSM-IV criteria for alcohol dependence and for alcohol abuse/harmful drinking was compared in probability samples of emergency service patients from two regions of Poland. Sensitivity of the RAPS4 and AUDIT was significantly better than the CAGE for alcohol dependence among males in Warsaw, but specificity was poorer. Among females, although numbers were small, sensitivity for alcohol abuse/harmful drinking and for alcohol dependence or abuse/harmful drinking was significantly better for the RAPS4-QF than for the CAGE or AUDIT at a cut point of 8 across both sites. Performance of the AUDIT at a cut point of 3 was similar to the RAPS4-QF for females. Among males, sensitivity was higher but specificity considerably lower for the RAPS4-QF compared to the CAGE at a cut point of 1 or for the AUDIT at a cut point of 8. Alternate cut points for the AUDIT optimized performance. Findings suggest some regional and gender differences in performance of screening instruments in these Polish samples, but no instrument or cut point is optimal in identifying those with alcohol use disorders. Additional cross-cultural research is needed to evaluate the performance of instruments, especially among females with alcohol use disorders.     

Performance of Screening Instruments for Alcohol Use Disorders in Emergency Department Patients in Argentina

The performance of the Alcohol Use Disorders Identification Test (AUDIT), CAGE, Brief Michigan Alcohol Screening Test (Brief MAST), Rapid Alcohol Problems Screen (RAPS), Rapid Alcohol Problems Screen-Quantity and Frequency (RAPS4-QF), and TWEAK was evaluated against a diagnosis of alcohol dependence and harmful drinking or alcohol abuse from ICD-10 and DSM-IV criteria. Data were collected from a probability sample of 779 patients admitted to the emergency department of a public general hospital in Mar del Plata, Argentina, during the year 2001. The majority of the patients sampled were male. The age range was 18 to 89 years, with a mean value of 36 years and a median of 31 years. Almost half of the sample had an elementary school education or less. All instruments were more sensitive for alcohol dependence than for harmful drinking or abuse and more sensitive for men than for women. Findings suggest the RAPS4 and RAPS4-QF may be preferred when screening for alcohol use disorders in the emergency department in Argentina. The study's limitations are noted.     

Screening for drug use disorders in the emergency department: performance of the rapid drug problems screen (RDPS)

Little research is available on brief screening instruments for identify those meeting diagnostic criteria for drug dependence or abuse. A brief, four-item screening instrument, called the rapid drug problems screen (RDPS), was developed from a similar instrument for alcohol use disorders, the rapid alcohol problems screen (RAPS). Performance of the RDPS was evaluated against DSM-IV and ICD-10 criteria for drug dependence and for dependence or abuse in a sample of 703 emergency department patients in Mexico City. Among males, sensitivity and specificity were 91 and 96%, respectively, for dependence and 93 and 96%, respectively, for dependence or abuse. Neither of the two females meeting diagnostic criteria for dependence or abuse were identified by the RDPS. Area under the receiver-operating characteristic curve indicates an optimum cut point of 1. The data suggest that the RDPS may hold promise as a brief screening instrument for substance use among males, but should be tested in larger populations of females meeting diagnostic criteria for drug use disorders, and across ethnic subgroups in other geographic locales.     

Screening instruments for alcohol problems: a comparison of cut points between Mexican American and Mexican patients in the emergency room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.     

Item functioning of the alcohol dependence scale in a high-risk sample

We conducted in-depth analyses of the functioning of items from the alcohol dependence scale (ADS) in a sample of high-risk alcohol drinkers, specifically 101 men and 93 women mandated to a domestic violence intervention program. We first conducted a maximum likelihood common factors analysis on the ADS, which indicated a primarily unidimensional factor structure. We then used a nonparametric kernel smoothing method to create item characteristic curves (ICC) and option characteristic curves (OCC) for each ADS item. Based on these curves, we identified nine of the 25 ADS items as reliably discriminating between those with no or minimal alcohol problems and those with symptoms of excessive or abusive drinking. Dichotomous scoring appeared most appropriate for these items. No differential item functioning (DIF) by gender was detected, indicating that these items assess alcohol problems similarly in both men and women. This nine-item empirically-derived abbreviation of the ADS appeared to be an efficient and effective measure in this sample; it was highly correlated with the original scale (r(s)=0.96) yet had superior distributional properties. Retained items reflected primarily excessive or hazardous drinking rather than alcohol dependence per se, suggesting that items targeting these types of symptoms may be most useful in high-risk samples. Combined with previous work with the ADS in treatment-seeking alcoholics, mapping of ADS item severities suggests a continuum of alcohol problem severity from heavy drinking to severe withdrawal that may be reliably tapped with dichotomous items.     

Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses

OBJECTIVE: The performance of three brief screens, the CAGE, TWEAK and Alcohol Use Disorders Identification Test (AUDIT), was evaluated against a DSM-IV diagnosis of alcohol abuse or dependence in an adolescent sample. METHOD: Adolescents (13-19 years old) who presented to an emergency department for treatment of an injury, and who tested negative for blood alcohol concentration at time of admission, were administered a structured diagnostic interview and modified versions of the CAGE, TWEAK and AUDIT. RESULTS: Of the 415 adolescents for whom complete data were available, 18% met criteria for a DSM-IV alcohol use disorder according to the Diagnostic Interview Schedule for Children (version 2.3). Teens who reported alcohol use in the last year (n = 261, 58% male, 71% white) were included in analyses that compared the performance of the three screening instruments. Receiver Operating Characteristic analysis indicated that the AUDIT demonstrated the best performance across the range of its cut-scores, with optimal performance at a cut-score of 4. The TWEAK performed optimally at a cut-score of 2 and the CAGE at a cut-score of 1. CONCLUSIONS: Routine alcohol screening among adolescents seen in a hospital setting is indicated. Two important directions for future research include the identification of adolescent-specific alcohol screening items, and the validation of an adolescent-specific definition of problem drinking that addresses limitations of DSM-IV alcohol diagnoses when applied to adolescents.     

Effects of item sequence on the performance of the AUDIT in general practices

BACKGROUND: One important task in identifying subjects with alcohol use disorders (AUDs) in the general medical practice setting is the development of effective screening instruments. Sensitivity of screening questionnaires might differ according to the introductory items. This study compares two versions of the alcohol use disorders identification test (AUDIT) with varied item sequence randomly applied to patients derived from a sample of general practitioners (GP) patients. METHODS: Participants were recruited from general practices in two northern German cities; they received two different versions of the AUDIT, one group receiving the original version starting with three items addressing frequency and quantity of alcohol use (AUDIT1), and a second group receiving a version in which these items were put at the end of the questionnaire (AUDIT2). In total, 10.803 screenings were conducted (refusal rate: 5%). Alcohol use disorders were diagnosed using the Munich-Composite International Diagnostic Interview (M-CIDI). RESULTS: Logistic regression analysis revealed that AUDIT1 subjects had higher scores in the consumption items of the AUDIT, whereas AUDIT2 subjects scored higher on items focussing on symptoms of alcohol dependence or abuse. CONCLUSION: The sequence upon which items of the AUDIT are presented influences the report of drinking patterns and symptoms of alcohol use disorders in GP patients.     

Cross-cultural invalidity of alcohol dependence measurement across Hispanics and Caucasians in 2001 and 2002

Aims

Do assessments of alcohol dependence demonstrate similarly validity across Hispanics and non-Hispanic Caucasians? This investigation examined this question.

Method

It employed confirmatory factor analyses for ordered-categorical measures to search for measurement bias on the AUDADIS, a standardized measure of alcohol dependence, across Hispanic (n = 4819) and non-Hispanic Caucasians (n = 16, 109) in a nationally representative survey of alcohol use in the United States conducted in 2001 and 2002.

Measurement

Analyses considered whether 27 items operationalizing the DSM-IV alcohol dependence construct provided equivalent measurement.

Findings and conclusions

Nine items revealed statistically significant bias, suggesting strong caution regarding the cross-ethnic validity of alcohol dependence. Sensitivity analyses established that item level differences erroneously impact alcohol dependence estimates among the 2001–2002 US Hispanic population. Biased measurement underestimates differences between Hispanics and non-Hispanic Caucasians, underestimates Hispanics' true use levels, and falsely minimizes current increases in drinking behavior evidenced among Hispanics. Findings urge improved public health efforts among the Hispanic community and underscore the necessity for cultural sensitivity when generalizing measures and constructs developed in the majority to Hispanic individuals.     

Screening Instruments for Alcohol Problems: A Comparison of Cut Points between Mexican American and Mexican Patients in the Emergency Room

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.     

Screening for cannabis use disorders in an adolescent emergency department sample

Cannabis, more often than alcohol, is the drug mentioned in substance-related reasons for treatment of an adolescent in an emergency department (ED). This study examined the prevalence of DSM-IV cannabis and alcohol diagnoses in an adolescent ED sample, evaluated the performance (i.e. sensitivity and specificity) of DSM-IV cannabis symptoms and other screening items as indicators of cannabis diagnosis status, and examined parent-adolescent agreement on the presence of cannabis and alcohol diagnoses. Adolescents (ages 13-19, n=442) admitted to an ED for a non-substance-related injury were administered the diagnostic interview schedule for children (DISC). Parents (n=272) of adolescents younger than age 18 completed the DISC-parent version to report on their child's drug use. A minority met criteria for a current DSM-IV cannabis or alcohol diagnosis: 7.9% for both alcohol and cannabis, 7.5% for cannabis-only, and 9.0% for alcohol-only. Frequency of cannabis use had the best overall performance in discriminating those with and without a cannabis diagnosis compared with items on perceived risk of cannabis use, peer cannabis use, and alcohol and cigarette use. Parent reports generally underestimated the adolescent's substance use. Questions on level of substance use generally provide an efficient method of screening adolescents for substance-related problems in an ED setting.     

Cross-national performance of the RAPS4/RAPS4-QF for tolerance and heavy drinking: data from 13 countries

OBJECTIVE: There are little data available on the performance of brief screening instruments for alcohol-use disorders cross-nationally; therefore, we analyzed the performance of one such instrument in a number of countries. METHOD: Performance of the RAPS4 for tolerance and the RAPS4-QF for heavy drinking are analyzed from emergency room data across 13 countries included in the combined Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the World Health Organization Collaborative Study on Alcohol and Injuries. RESULTS: The RAPS4 showed good sensitivity and specificity for tolerance across most of the countries, but was higher in countries that were higher on societal-level detrimental drinking patterns. Prevalence of tolerance was also higher in those countries with high detrimental drinking pattern scores. Sensitivity of the RAPS4-QF for heavy drinking was uniformly high across countries, while maintaining good specificity, and did not vary by detrimental drinking patterns. CONCLUSIONS: Findings suggest the RAPS4 and RAPS4-QF may hold promise cross-nationally. Future research should more fully address the performance of brief screening instruments for alcohol-use disorders (using standard diagnostic criteria) cross-nationally, with consideration of the impact of societal drinking patterns.     

Alcohol-Related Expectations among Mexican-American Women

The article explores alcohol expectations among Mexican-American women utilizing the Alcohol Expectancy Questionnaire and a series of quantity/frequency alcohol use measures. The results indicate that Mexican-American women generally have similar expectations about the benefits of alcohol use as women in the larger population. Within the sample of Mexican-American women however, there were differences in alcohol expectations based on occupational status and acculturation level: those Mexican-American women who are more acculturated and hold higher professional status occupations have higher expectations of the benefits of alcohol use than less acculturated Mexican-American women in blue-collar or service occupations. [Translations are provided in the International Abstracts Section of this issue.]     

The factor structure and severity of DSM-IV alcohol abuse and dependence symptoms in psychiatric outpatients

OBJECTIVE: The goal of the present study was to examine the factor structure and estimated severity of alcohol-use disorder (AUD) symptoms in a sample of treatment-seeking psychiatric outpatients. METHOD: Participants (n = 1,027; 51.2% women) met the screening criteria for the lifetime assessment of AUDs according to the Structured Clinical Interview for the DSM-IV (SCID-I/P; First et al., 1995) and as a result completed an assessment of alcohol abuse and dependence symptoms. The average (SD) age of the sample was 36.6 (11.4) years, and 71% of participants met lifetime DSM-IV criteria for an AUD. RESULTS: Exploratory factor analysis of the tetrachoric correlation matrix of alcohol abuse and dependence criteria revealed that a single factor best accounted for the data in this sample. Results of Rasch model analyses indicated that the severity ordering of the DSM-IV abuse and dependence symptoms was not consistent with the hierarchical structure suggested by the DSM-IV. Instead, abuse items were found to be spread across a full range of the AUD continuum and were not consistently in the lower ranges of severity. CONCLUSIONS: This study extends the literature by examining a treatment-seeking psychiatric outpatient sample and using a semistructured diagnostic interview administered by mental health professionals. Methodological considerations and implications for the conceptualization of AUD are discussed.     

Diagnostic validity of the MAST and the alcohol dependence scale in the assessment of DSM-III alcohol disorders

The comparative validity of the Michigan Alcoholism Screening Test (MAST) and the Alcohol Dependence Scale (ADS) in screening for current DSM-III alcohol abuse/dependence disorders is evaluated. These scales were administered to 501 patients presenting for treatment of alcohol or drug problems. DSM-III alcohol disorders are diagnosed using the Diagnostic Interview Schedule. Receiver Operating Characteristic (ROC) analysis is used to determine optimum threshold scores for the MAST and ADS and to compare the screening ability of the two instruments. Optimum cut points for the MAST and the ADS are 12/13 and 8/9, respectively. The overall accuracy of classification for both instruments using these threshold scores is 88%. The areas under the ROC curves are .91 and .90 (SD = .02) and there are no significant differences between the MAST and the ADS in their ability to screen for alcohol abuse or dependence in this population. The MAST and the ADS correlate highly with each other (.79). The results reported in our study should be applicable to the revised DSM-III since a field trial found a high level of agreement on alcohol disorders between the diagnostic systems. Categorical versus dimensional approaches to the assessment of alcoholism are discussed.     

Association between scores on the SAAST (a direct measure of alcohol misuse) and CAL scale (an indirect measure of alcohol misuse) among medical patients admitted for treatment of alcohol dependence

Patients with medical or social problems related to alcohol abuse or alcohol dependence frequently are seen in the health care delivery system. Direct and indirect screening methods are available, but contemporary data describing their combined effectiveness have not been reported. We determined the sensitivity of (a) an empirically derived, item-weighted, relatively "indirect" screening measure for alcohol misuse (the Common, Alcohol, Logistic [CAL] scale for the MMPI), (b) a "direct" approach to screening for alcohol misuse (the Self-Administered Alcohol Screening Test [SAAST]), and (c) their combined application. We obtained the responses to both measures from an archival sample of 361 medical patients (89 women, 272 men) who had been diagnosed with alcohol dependence by DSM-III-R criteria. The CAL scale and the SAAST both demonstrated high sensitivity. However, results favored the simultaneous use of a direct-in this study, the SAAST-and an indirect-in this study, the CAL scale-screening procedure.