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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
Jaime Delgadillo, PhDLeeds Primary Care Mental Health Service
Overview of methodological challenges
CCAS study: validity and reliability of brief outcome measures
Implications for clinical practice
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)
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
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)
validity and reliability of brief outcome measures
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)
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
(Delgadillo et al, 2011, 2012)
Cut-off ≥ 12
RCI ≥ 7
Cut-off ≥ 9
RCI ≥ 5
How stable are depression & anxiety symptoms
after 4-6 weeks watchful wait?
If: TOP <= 12
PHQ-9 + GAD-7
If: PHQ-9 >= 12
Suitability screening interview & informed consent
BA in primary care
Usual drugs treatment
+ guided self-help