Can Accurate Drinking Histories be Obtained from Psychiatric Patients by a Nurse Conducting Screening Interviews?

Three hundred and eighty-five psychiatric patients were screened by a nurse for alcohol-related problems, and a representative 112 were re-interviewed in a ‘blind’ fashion by a psychiatrist using either (a) the same screening interview, or (b) a much more detailed history schedule. Reliability measures between the two screening interviews were high for alcohol consumption as well as the Brief MAST, CAGE, and Reich tests. Similarly the more detailed ‘validity’ interview produced closely correlated estimates of alcohol consumption. Agreement was less good for women than men and for drinking in the month, as opposed to the year, before admission. The Brief MAST, CAGE, or Reich screening tests could usefully be incorporated into the routine nursing interview at first contact with psychiatric patients.     

Alcohol use disorders: screening and diagnosis

The purpose of this article is to provide an overview of empirically supported, primarily self-report methods of screening and diagnosis related to alcohol use disorders (AUDs). The discussion of screening instruments focuses on the primary care setting, and the diagnosis instruments discussion centers on the alcohol (and other drug) treatment setting. The literature shows that the AUDIT and the CAGE are the most widely validated methods of screening for AUDs in primary care and may be applied readily in that context. Similarly, a number of instruments designed to derive DSM-IV (and ICD-10) AUD diagnoses, as well as constructs related to how AUDs are defined, are available and can meet a variety of clinical needs. Future research priorities include further development of brief methods to identify hazardous drinkers or individuals who have an AUD, as well as refinement of diagnosis instruments to increase their application across treatment settings and subpopulations.     

Comparison of Screening Instruments for Alcohol Problems Between Black and White Emergency Room Patients from Two Regions of the Country

A number of brief screening instruments to identify alcohol dependence exist, but the validity of these instruments across ethnic groups or regions of the country is not well established. The sensitivity and specificity of a number of standard screening instruments (CAGE, brief MAST, AUDIT, TWEAK, and RAPS), as well as other measures (History of Trauma Scale, breathalyzer reading, self-reported drinking before the event, and consuming five or more drinks at a sitting at least monthly) are compared against ICD-10 and DSM-IV criteria for alcohol dependence between probability samples of Black and White emergency room patients in Santa Clara County, CA (n= 716) and in Jackson, MS (n= 1330). Variability in the sensitivity of screening instruments among current drinkers was found to be greater between samples for both Blacks and Whites, than for Blacks compared with Whites within the same sample. The AUDIT, TWEAK, and RAPS seemed to perform well by gender and injury status for both Blacks and Whites in the two samples, and no significant differences were found in the performance of these instruments across sample sites. To evaluate the influence of regional differences in alcohol dependence on differences found in the performance of screening instruments, using logistic regression with the simultaneous entry of demographic variables (age, gender, ethnicity, injury status, and site) and drinking variables (breathalyzer reading, serf-reported drinking before the event, and drinking five or more drinks at a sitting at least monthly) to predict alcohol dependence in a merged sample of these patients (Jackson vs. Santa Clara) site was not found to be significant Data suggest that, whereas region of the country may not be important in predicting alcohol dependence in emergency room populations, regional differences in the performance of screening instruments for alcohol dependence may exist, even when ethnicity is taken into account Given distinct regional differences in drinking patterns and problems in the U.S., further research on commonly used screening instruments is needed to determine those screeners most efficient for identifying problem drinking.     

Screening for Alcohol Use Patterns Among Methadone Maintenance Patients

Alcohol use among Methadone Maintenance Treatment (MMT) patients poses a major health risk, exacerbates psychopathology, and increases the risk of death by accidental overdose. Despite these factors, screening for alcohol use remains underutilized in the methadone community. Utilizing a self-report screening measure—the Michigan Alcohol Screening Test (MAST)—and consistent with the literature, we found high rates of alcohol problems among MMT patients. Benefits and limitations of using the MAST to screen for alcohol use patterns are discussed.     

Can Accurate Drinking Histories be Obtained from Psychiatric Patients by a Nurse Conducting Screening Interviews?

Three hundred and eighty-five psychiatric patients were screened by a nurse for alcohol-related problems, and a representative 112 were re-interviewed in a ‘blind’ fashion by a psychiatrist using either (a) the same screening interview, or (b) a much more detailed history schedule. Reliability measures between the two screening interviews were high for alcohol consumption as well as the Brief MAST, CAGE, and Reich tests. Similarly the more detailed ‘validity’ interview produced closely correlated estimates of alcohol consumption. Agreement was less good for women than men and for drinking in the month, as opposed to the year, before admission. The Brief MAST, CA GE, or Reich screening tests could usefully be incorporated into the routine nursing interview at first contact with psychiatric patients.     

The alcohol use disorders identification test (AUDIT) in a college sample.

This study was conducted to estimate the psychometric properties of the questionnaire section of the Alcohol Use Disorders Identification Test (AUDIT) in a college sample using DSM-III criteria for alcohol abuse as the criterion standard. This alcohol screening test was developed for the 10 country AMETHYST project. In this young adult sample the instrument exhibited a sensitivity of .84 and specificity of .71 when utilizing the recommended cut-off score of 11. The 10-item questionnaire section of the AUDIT appears to have important advantages over other alcohol screening instruments such as the CAGE and the MAST.     

A Critical Evaluation of Several Alcohol Screening Instruments Using the CIDI-SAM as a Criterion Measure

Four alcohol screening instruments (the AUDIT, CAGE, MAST, and Svanum's scale) were administered to a sample of 306 undergraduate students at a Midwestern university and were compared with regard to several test characteristics, using the alcohol section of the CIDI-SAM (DSM-IV version) as the criterion measure. The performance of these instruments was evaluated using two subsets of subjects: (1) students who currently met diagnostic criteria for alcohol dependence ( n = 35); and (2) students who met diagnostic criteria for alcohol dependence in the past and/or at present (i.e., lifetime diagnosis; n = 50). The AUDIT performed significantly better than the other three instruments in identifying students who were currently alcohol dependent, providing a moderate degree of clinical utility with this group. The four instruments did not differ significantly in their ability to identify students with a lifetime diagnosis; each measure provided only a modest degree of clinical utility with this group.     

Problem Drinking in a Military Endoscopy Clinic

The prevalence of alcohol problems was studied in a consecutive series of 60 soldiers attending an endoscopy clinic, in a matched sample of non-endoscoped soldiers from medical wards, and in a reference sample from the military alcohol treatment unit. Data were obtained using CAGE, MAST and SADQ questionnaires and MCV and Liver Function Tests and were analysed by discriminant function analyses. The endoscopy sample did not have an increased prevalence of problem drinking when compared to the medical inpatient sample. Of the instruments that were used, the MAST proved to he the most useful in identifying those patients that fulfilled the criteria for admission to the alcohol treatment unit and identified 50% of patients in the medical and endoscopy sample as having an alcohol problem.     

Development of a Screening Questionnaire for the General Hospital and General Practices

The purpose of this study was to develop a sensitive as well as brief screening questionnaire by combining the well-known instruments CAGE and the Michigan Alcoholism Screening Test (MAST) in detecting patients with alcohol dependence or abuse in general hospitals and general practices. The number of items was reduced by means of logistic regression and item analysis based on data of 1, 167 consecutive admissions of a general hospital who completed both questionnaires. Further data were derived from a sample of 774 patients from 10 randomly selected general practices. A solution with nine items was validated in a second sample of 436 hospital inpatients. In all three samples, cases screening positive were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry to provide ICD-10 and DSM-Ill-R or DSM-IV diagnosis. In addition, 103 subjects with negative screening results were interviewed in the second general hospital sample. On grounds of the data of all three samples, a solution of seven items was chosen. This instrument comprises two CAGE and five MAST questions (Luebeck Alcohol Dependence and Abuse Screening Test; LAST) and was significantly higher in sensitivity than CAGE and SMAST. Data were robust in all three samples. It is concluded that the LAST is an optimized instrument for use in general hospital and general practice.     

Screening for Pregnancy Risk-Drinking

The efficacy of alcohol screening questionnaires, the TWEAK, TACE, NET, MAST, and CAGE, in detecting periconceptional riskdrinking, 1 oz absolute alcohol/day, was investigated in 4743 African-American women attending an inner-city prenatal clinic who had reported ever drinking. Sensitivity, specificity, positive predictive value, efficiency, follow-up rates, and receiver operating characteristics of the questionnaires were examined to compare the overall effectiveness of the questionnaires and their performance at cutpoints defining positive scores ranging from 1 to 3. Relatively little difference between TWEAK, T-ACE, and MAST was seen in the receiver operating characteristic accuracy indices; NET and CAGE lagged behind. Sensitivity/specificity scores for the two questionnaires most sensitive at cut-point 1 were TWEAK (87/72) and T-ACE (83/75). At cut-point 2, sensitivity was optimized with respect to specificity; TWEAK (79/83) was significantly more sensitive than T-ACE (70/85; p = 0.002). At cut-point 3, the two most sensitive tests were MAST (61/92) and TWEAK (59/94). In general, measures of merit were not greatly affected by the time between conception and the administration of the screens. Screening was most sensitive for women interviewed during the first 15 weeks of pregnancy; riskdrinkers tended to delay entry into prenatal care, increasing positive predictive values associated with screening later in pregnancy.
This study confirms the utility, when screening for risk-drinking during pregnancy, of brief questionnaires that assess alcohol intake indirectly by asking women about their tolerance to alcohol's effects, psychological consequences of drinking, and significant others' concern about their drinking. It validates T-ACE and provides preliminary data indicating that TWEAK may outperform T-ACE.     

Alcoholism screening questionnaires

Objective: To assess the validity of the CAGE (cut down, annoyed, guilty feelings, eye-opener) questionnaire and the Michigan Alcoholism Screening Test (MAST) in distinguishing between elderly patients with and without alcohol abuse or dependence disorders. Design: A cross-sectional study, in which patients were interviewed with a “gold standard,” the alcohol module of the Revised Diagnostic Interview Schedule (DIS-III-R), and two screening questionnaires: the CAGE and the MAST. Setting: The study was conducted in the outpatient medical practice of a university teaching hospital. Patients: All English-speaking continuity patients 65 years of age or older able to participate were eligible; complete data were available for 154 (91%) of the 170 people who agreed to participate. Results: Sixty-seven patients (44%) were active drinkers, whereas 87 (56%) reported abstinence. Twenty-five patients (16%) metDiagnostic and Statistical Manual ofMental Disorders-III-Revised (DSM-III-R) criteria for alcohol abuse or dependence. A CAGE score of 2, the conventional cutoff point, had a sensitivity and a specificity of 48% and 99%, respectively. A MAST score of 5, the originally recommended cutoff point, had a sensitivity and a specificity of 52% and 91%, respectively. The areas under the receiver operating characteristic (ROC) curves were 0.91 for the CAGE and 0.61 for the MAST. Conclusion: The CAGE and the MAST were both characterized by low sensitivities at conventional cufoff points, but the CAGE was significantly more effective than the MAST in discriminating between elderly medical outpatients with and without alcohol abuse or dependence.     

Screening for Alcoholism Among Medical Inpatients: How Important Is Corroboration of Patient Self-Report?

Little Is known about the utility of collateral reports in substantiating self-report for individuals assessed in nonalcoholism treatment contexts. This study examined the concordance of 581 pairs of medical patient and collateral responses to a commonly used alcohol screening instrument, the CAGE Questions, as well as to reports of the patient's drinking consequences and alcohol consumption. Results demonstrated that patient/collateral concordance was marginal, but acceptable, on CAGE cut-off scores and, that similar to reports from alcoholism treatment settings, patients generally reported more drinking consequences than collaterals. Patient and collateral reports of the patient's alcohol consumption did not differ significantly. This pattern of patient and collateral reporting of alcohol consequences and consumption was found for both men and women, as well as for patients with a DSM-III-R diagnosis of alcohol dependence. The findings support the validity of patient self-report on alcoholism screening measures in medical settings. Furthermore, results demonstrated that the addition of collateral reports to information directly obtained from patients only modestly improved the Identification of alcohol dependence. The overall findings indicate that alcohol screening can be done effectively and efficiently in medical settings.     

Alcohol use disorders among emergency department-treated older adolescents: a new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF

BACKGROUND: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents. METHODS: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis. RESULTS: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%). CONCLUSIONS: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.     

Ethnic Differences in Performance of Screening Instruments for Identifying Harmful Drinking and Alcohol Dependence in the Emergency Room

This study examines sensitivity and specificity figures associated with screens used to predict harmful drinking and alcohol dependence among current drinkers. The study population comes from a probability sample of emergency room patients in Jackson, MS. Data are presented by gender and injury status (injured versus noninjured) for Blacks and for Whites. The Composite International Diagnostic Interview was used to assess ICD-10 criteria for harmful drinking and alcohol dependence, which were taken as standards. Predictors include screening instruments (CAGE, AUDIT, brief MAST, TWEAK, and History of Trauma Scale), breathalyzer reading, self-reported consumption before the injury or noninjury event, quantity and frequency of drinking, and an abbreviated alcohol dependence experiences measure used in general population surveys. Single items from these screening instruments were also tested as predictors. Overall, the TWEAK and the AUDIT performed best in terms of sensitivity and specificity, but variation across subgroups suggests that the search for a good screening instrument for general use must be continued.     

Screening for alcohol use patterns among methadone maintenance patients

Alcohol use among Methadone Maintenance Treatment (MMT) patients poses a major health risk, exacerbates psychopathology, and increases the risk of death by accidental overdose. Despite these factors, screening for alcohol use remains underutilized in the methadone community. Utilizing a self-report screening measure - the Michigan Alcohol Screening Test (MAST) - and consistent with the literature, we found high rates of alcohol problems among MMT patients. Benefits and limitations of using the MAST to screen for alcohol use patterns are discussed.     

Michigan assessment-screening test for alcohol and drugs (MAST/AD): evaluation in a clinical sample

In this study, we sought to evaluate a modification of the Michigan Alcohol Screening Test designed to include problems associated with other drug abuse/dependence besides alcohol. Scores of the lifetime Michigan Assessment-Screening Test/Alcohol-Drug (MAST/AD) were compared to other lifetime measures of substance abuse and dependence and to psychiatric scales reflecting current or recent symptoms. Two university medical centers with alcohol-drug programs located within departments of psychiatry hosted 520 patients with alcohol-drug-related diagnoses. Patients completed their own MAST/AD using a paper-and-pencil format. Based on interviews with the patient, a research associate rated the patients' substance-related problems on the Minnesota Substance Abuse Problem Scale (M-SAPS) and obtained information on lifetime treatment for substance abuse. An addictions psychiatrist determined abuse or dependence and made a current diagnosis of alcohol abuse/dependence only, drug abuse/dependence only, and alcohol plus drug abuse/dependence. The MAST/AD was highly correlated with the M-SAPS and several other measures of substance abuse morbidity. Patients with alcohol-only and drug-only diagnoses did not differ from one another on the MAST/AD, although both groups had lower scores than those with alcohol plus drug diagnoses. Current psychosocial morbidity as assessed by the patient and the psychiatrist was associated with the MAST/AD, although less strongly than with lifetime substance abuse measures. The lifetime MAST/AD demonstrates reliability as a severity measure for alcohol and/or drug abuse. With minor modification, this standard measure can be expanded from alcohol diagnoses to all substance diagnoses. This study in a clinical population did not demonstrate its utility as a screening instrument; additional work is needed to reveal its utility for this purpose.     

Hazardous and harmful alcohol consumption in primary care.

Increasing emphasis has been placed on the detection and treatment of hazardous and harmful drinking disorders, particularly among patients who are seen in primary care settings. In this review, we summarize the epidemiology and health-related effects of hazardous and harmful drinking and discuss current methods for their detection and treatment. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g., physical or psychological harm). Prevalence estimates range from 4% to 29% for hazardous drinking and from less than 1% to 10% for harmful drinking. Data from several recent large prospective studies suggest that alcohol consumption in quantities consistent with hazardous or harmful drinking may increase risk for adverse health events, such as hemorrhagic stroke and breast cancer. Existing screening instruments, such as the Michigan Alcoholism Screening Test (MAST) or the CAGE questionnaire, while excellent for detecting alcohol abuse or dependence, should not be used alone to screen for hazardous and harmful drinking. The Alcohol Use Disorders Identification Test (AUDIT) is currently the only instrument specifically designed to identify hazardous and harmful drinking. Treatment of these disorders in the form of brief interventions can be successfully accomplished in primary care settings, as demonstrated by a number of well-conducted randomized trials. Given its proven efficacy in the primary care setting, we recommend routine application of this treatment approach.     

Are there differences between older persons who screen positive on the CAGE questionnaire and the Short Michigan Alcoholism Screening Test-Geriatric Version?

OBJECTIVES: To determine (1) the extent of agreement between the CAGE (acronym for cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) and the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) in identifying older persons who may have possible alcohol use disorders (AUDs) and (2) whether persons identified as having possible AUDs by each of these screening measures differ in their drinking, demographic, or health-related characteristics. DESIGN: Secondary analysis of a cross-sectional study using data from a self-administered mailed survey sample. SETTING: Three organizations were surveyed: (1) members of the American Association of Retired Persons and, in southern California, (2) managed care enrollees in a large medical group and (3) attendees of a community-based senior health center. PARTICIPANTS: One thousand eight hundred eighty-nine persons aged 55 and older completing a health risk appraisal for older persons (Health Risk Appraisal for the Elderly (HRA-E)). MEASUREMENTS: The HRA-E included items on drinking behaviors (including amount of alcohol use, the CAGE, and the SMAST-G) and health and demographic characteristics. RESULTS: Twenty-six percent of all persons screened positive on the CAGE or the SMAST-G. Fewer than half of all persons screening positive on either the CAGE or the SMAST-G, screened positive on both measures. Among current drinkers, persons screening positive on the SMAST-G alone drank less than persons screening positive on the CAGE alone, and these persons drank less than those screening positive on both the SMAST-G and the CAGE. More men screened positive on the CAGE alone than on the SMAST-G alone. CONCLUSION: Fewer than half of persons screening positive on either the CAGE or the SMAST-G screened positive on both measures, suggesting that these instruments may be capturing different aspects of unsafe drinking. A screening strategy employing both brief measures may identify more AUDs among older persons having differing demographic and health characteristics.     

Predictors of alcohol-treatment seeking in a sample of older veterans in the GET SMART program

OBJECTIVES: To examine the predictive value of demographic characteristics and substance abuse indicators to explain treatment seeking for substance abuse problems by older male medical patients. DESIGN: Longitudinal analysis of screening data and treatment-seeking behavior. SETTING: Inpatient medical and outpatient substance abuse treatment center. PARTICIPANTS: Participants in the study were 855 medically ill male veterans aged 55 and older, who were screened for alcohol problems during inpatient medical treatment after clinician referral. MEASUREMENTS: The CAGE alcohol screen (Cut down on your drinking, Annoyed by criticism of your drinking, Guilty about your drinking, Eye-opener), drug use, and demographic measures administered at time of screening. Predictors of treatment seeking in the sample were examined using structural equation modeling. RESULTS: Expressed interest in treatment and later attendance at a pretreatment evaluation were associated with younger age and a higher CAGE alcohol screening score. Being unmarried and using drugs in addition to alcohol were associated with treatment interest but not with evaluation attendance. In the path model tested, the effect of higher CAGE score partially explained the effect of younger age on treatment seeking. CONCLUSION: The model examined shows utility in predicting alcohol-treatment seeking in this sample. Age-related factors may deter treatment seeking by older male medical inpatients.     

Screening for Alcohol Dependence and Abuse in Women: Description, Validation, and Psychometric Properties of a New Screening Instrument, SWAG, in a Population Study

In this study, we have evaluated the use of a screening instrument in the first phase of a population study of female alcoholism and alcohol problems. The instrument, called SWAG (Screening, Women, and Alcohol in Göteborg), is a 13-item questionnaire. It includes a modified version of CAGE. The study sample consisted of 3,130 women. Of these, a stratified sample of 479 were invited for interview. Validation was done against interview-based clinical diagnosis according to DSM-III-R (alcohol dependence and abuse), with additional use of medical record information. SWAG had similar sensitivity and specificity used on a population sample, as previously has been found for alcohol problem screening instruments tested in clinical settings. Positive predictive value, rarely reported in studies of other alcohol screening instruments, was 40 to 50%. With logistic regression, we developed a promising set of criteria, called SWAG-L, that had similar sensitivity, specificity, and positive predictive value as the longer version SWAG-1, at the same time it consisted of only four items. CAGE had considerably lower sensitivity than SWAG. SWAG can, so far, be recommended for use in epidemiological studies. It may also prove valuable in clinical settings, although that requires a different scoring method. The question, "I have/have had alcohol problems" was the single item that best predicted alcohol dependence and abuse.