Mental health screening and outcome measurement in alcohol drug users
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Mental health screening and outcome measurement in alcohol & drug users. Jaime Delgadillo, PhD Leeds Primary Care Mental Health Service. Presentation outline:. Overview of methodological challenges CCAS study: validity and reliability of brief outcome measures

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Mental health screening and outcome measurement in alcohol drug users

Mental health screening and outcome measurement in alcohol & drug users

Jaime Delgadillo, PhDLeeds Primary Care Mental Health Service

Presentation outline
Presentation outline: drug users

Overview of methodological challenges

CCAS study: validity and reliability of brief outcome measures

Implications for clinical practice

Detecting and monitoring mental health problems: drug users

Methodological challenges

Dual diagnosis epidemiology
Dual Diagnosis: drug usersepidemiology

Depression & anxiety disorders commonly co-exist with addictions

(Kessler et al, 1997; Merikangas et al, 1998; Farrell et al, 2001; Schifano et al, 2002)

CMD in primary care = 5 - 20% CMD in addictions treatment = 70 - 90%

(Katon & Schulberg, 1992; (Strathdee et al, 2002; Weaver et al, 2003)

Kroenke et al, 2007)

Adverse health & social consequences:

Greater risk of suicide, more frequent and riskier substance use, cycle of relapse, homelessness, recurrent hospital admissions, treatment dropout, etc.

(Harris & Barraclough, 1997; Havard et al, 2006; Bergman & Harris, 1985; Jeremy et al, 1992; Drake, 2007; Ford et al, 1991)

Screening as usual
Screening as usual? drug users

Observational studies in routine addiction treatment tend to use brief measures (BDI, HAM-D, BSI) and conventional cut-off scores, mostly reporting symptom improvement at 6 – 12 months

(De Leon et al., 1973; Dorus and Senay, 1980; Kosten et al., 1990; Gossop et al., 2006)

Two reviews describe over 20 mental health measures (SCL-90, GHQ, BDI, BAI, STAI, BPRS, K10, IES-R, etc) and recommend using these in addictions research

(Dawe et al, 2002; Deady, 2009)

Little or no consideration for validity / reliability of these questionnaires in addictions treatment

Methodological challenges
Methodological challenges drug users

Several validation studies since the 70’s consistently report adequate sensitivity but poor specificity

(Rounsaville et al, 1979; Hesselbrock et al, 1983; Willenbring, 1986; Weiss et al, 1989; Kush & Sowers, 1996; Coffey et al, 1998; Boothby & Durham, 1999; Hodgins et al, 2000; Buckley et al, 2001; Franken & Hendriks, 2001; Zimmerman et al, 2004; Luty & O’Gara, 2006; Rissmiller et al, 2006; Swartz & Lurigio, 2006; Dum et al, 2008; Lykke et al, 2008; Seignourel et al, 2008; Hepner et al, 2009; Holtzheimer et al, 2010; Lee & Jenner, 2010)

Consequently, using brief measures and conventional cut-offs in alcohol & drug users may overestimate the prevalence of disorders

(Keeler et al, 1979; Hesselbrock et al, 1983)

Summary of key challenges
Summary of key challenges drug users

  • Using structured diagnostic interviews is seldom feasible due to cost, training, time, constraints.

  • 2. Common symptoms associated with substance use interfere with the specificity of brief screening tools. This results in false positives.

  • 3. Extreme measures of CMD symptoms (outliers) are likely to fluctuate. This means that observed symptom changes may be influenced by regression to the mean.

  • 4. Observed changes in symptom scores may be due to measurement error.

CCAS study: drug users

validity and reliability of brief outcome measures

CCAS study: drug usersdesign


Diagnostic validation study. Recruitment period: 1 year. Prospective cohort design, follow-up: 4-6 weeks.


103 clients in routine methadone maintenance treatment in Leeds,

excluding people with severe mental disorders.


CIS-R (Gold-standard diagnostic interview)

PHQ-9 (Depression)

GAD-7 (Anxiety disorders)

TOP (Patterns of alcohol & drug use and self-rated mental health)


Complete brief measures  diagnostic interview  re-test after 4 weeks

Ccas study sample
CCAS study: drug userssample

Ccas study results
CCAS study: drug usersresults

(Delgadillo et al, 2011, 2012)

Ccas study results1
CCAS study: drug usersresults


Cut-off ≥ 12

RCI ≥ 7


Cut-off ≥ 9

RCI ≥ 5

How stable are depression & anxiety symptoms

after 4-6 weeks watchful wait?

Conclusions drug users

  • 1. Using cut-offs calibrated in clinical samples enhances specificity of brief screening tools.

  • 2. Using RCI results in more conservative and reliable assessment of symptom change.

  • 3. Approximately 25% of patients with a CMD reliably improve during a watchful wait period in routine MMT (ES = .30). Watchful wait can help to ‘screen out’ false positives and identify those who naturally improve.

  • 4. Given the reliability of TOP, a step-wise screening / monitoring method may be feasible to implement in routine practice

Cobid trial recruitment strategy
COBID trial: drug usersrecruitment strategy

Routine case-finding

If: TOP <= 12


PHQ-9 + GAD-7

If: PHQ-9 >= 12

Suitability screening interview & informed consent

Random allocation

BA in primary care

Usual drugs treatment

+ guided self-help

Thank you for listening

Thank you for listening drug users

Contact details:[email protected]