Conclusions

1. The ability of Global Appraisal of Individual Needs (GAIN) Scales in Predicting Clinical Psychiatric Diagnoses among Adolescents in Substance Abuse Treatment Geetha Subramaniam1, Patricia Shane2, Michael L. Dennis3, Melissa Ives3, Lora Passetti3 1Johns Hopkins University School of Medicine, Baltimore, MD; 2 Alta Bates Summit Medical Center,Sutter Health, Oakland, CA; 3Chestnut Health Systems, Bloomington, IL Introduction Results Figure 1. Identification of Disorders by Source (s) Research consistently suggests over 70% of adolescents seeking treatment for a substance use disorder (SUD) present with a co-occurring psychiatric disorder. Yet only 28% of public treatment records identified a co-occurring mental health disorder. This poster explores the validity and contribution of a widely used comprehensive intake assessment in improving identification of co-occurring psychiatric disorders among adolescents entering SUD treatment. Table 2. Comparison of Clinical Records & GAIN 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sensitivity \a Odds Ratio\b Clinical 96% Any Internal or External Disorder 6% 9% 81% Records GAIN OR (95% CI) 90% 94% Any Internal or External Disorder 4.9 (4.4 - 5.5) Methods 18% 12% 54% 84% Any Internalizing Disorder 86% 78% Any Internalizing Disorder 3.9 (3.5 - 4.2) 21% 14% 42% 76% Major Depressive Disorder Clinical Diagnoses: All clinical psychiatric diagnoses were made based on DSM-IV by a qualified clinician (e.g. psychiatrist, psychologist) as per usual standard for care at each of the sites. These were made independently of the GAIN (described below). GAIN: The Global Appraisal of Individual Needs, a comprehensive biopsychosocial structured interview, was administered at treatment intake by interviewers certified in it use. The GAIN incorporates mental health diagnostic scales related to internalizing disorders (e.g. depression, anxiety, trauma) and externalizing disorders (ADHD, conduct problems) that can be used as symptom counts or to approximate a diagnosis. Sites and Participants: Participants were recruited between 1999 and 2006 as part of 5 research projects conducted at three sites: 106 from Mountain Manor Treatment Center (MMTC), Baltimore, MD: 198 from Chestnut Health Systems (CHS), Bloomington, IL; and 393 from Thunder Road/ Sutter Health, Oakland, CA. Table 1 shows the characteristics of study participants. The bottom three rows are mental health symptom counts based on self reports using the GAIN. 82% 72% Major Depressive Disorder 3.5 (3.1 - 3.8) Table 1. Sample Characteristics Overall and by Site 32% 93% PTSD/Acute Stress Disorder 6.4 (5.9 - 6.9) PTSD/Acute Stress Disorder 3% 29% 11% 43% Total 26% 86% Other Anxiety Disorder 1.9 (1.4 - 2.4) Characteristic (n=697) 5% 27% 4% 37% Other Anxiety Disorder 67% 95% Any Externalizing Disorder 2.7 (2.3 - 3.2) Age - Mean (S.D.) 15.9 (1.2) 40% 89% ADHD Related 1.6 (1.3 – 2.0) 69% Male - % 5% 31% 57% 93% Any Externalizing Disorder Race: African American - % 25% 56% 93% Conduct Disorder Related 2.8 (2.4 - 3.2) Caucasian - % 69% 77% 44% Both Internal and External Disorder 0.8 (0.4 – 1.3) ADHD Related 8% 43% 21% 73% Single Parent Family - % 47% \a Sensitivity is the percent of "diagnoses" identified by each method In Juvenile/Criminal Justice System 68% 6% 37% 42% 85% Conduct Disorder Related relative to those identified by either method. 12.2 (2.2) Age of first use - Mean (S.D.) \b Odds Ratio of the extent to which the GAIN predicts increased likelihood 83% Weekly or more frequent substance use - % 37% 14% 10% 61% Both Internal & External Dis. of a clinical diagnosis and 95% confidence interval (CI) 84% Lifetime Dependence -% Conclusions 53% Any Prior Substance Abuse Treatment - % 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 84% Consistent with earlier research, these data found a high rate of co-occurring Axis-I psychiatric disorders. While there was substantial overall agreement, there were also many differences - particularly at more detailed levels of diagnosis. This suggests the value of considering both clinical diagnosis and self reports from a standardized measure rather than just relying on one or the other. The results also demonstrate that that the GAIN was moderately useful as a tool to identify those who are most likely to benefit from a clinical psychiatric evaluation. The mental health section of the GAIN can play a vital role, supplemented by other informants, in the identification of co-occurring psychiatric disorders. Entering Residential Treatment - % . Clinical Records Only GAIN Only Both 75% Lifetime Victimization 60% Prior mental health treatment history - % Figure 1 shows that having any co-occurring psychiatric diagnoses was recorded in 96% of 697 cases, including 6% only in the clinical record, 9% only in the GAIN and 81% where they agreed. As illustrated above, “which” diagnosis each found was more likely to vary. About 2/3rds of the time both clinicians and the GAIN both identified patients with “any” internalizing (54/84) or “any” externalizing disorder (57/93). With respect to specific diagnoses, the clinicians diagnosed a depressive disorder more often while the GAIN identified a greater number of the other specific diagnoses. In Table 2, the first set of columns compares the sensitivity of each method for detecting cases identified by the clinical expert or self report on the GAIN. The clinicians were more likely to identify any internalizing disorder and a depressive disorder. Self reports from the GAIN were more likely to identify stress, anxiety and externalizing disorders. The second set of columns examines the utility for using the GAIN as a diagnostic screener to predict who is likely to get each diagnosis by a clinician. All are significant at p<.05 and have large positive odds ratio. 31% Internalizing: Internal Mental Distress Scale (IMDS)\a 46% Externalizing: Behavior Complexity Scale (BCS)\b 38% Both Internalizing and Externalizing (IMDS +BCS) \a Percent of 41 past year symptoms related to somatic, depression, anxiety, and trauma disorders \b Percent of 33 past year symptoms related to inattentiveness, hyperactivity, impulsivity, and conduct disorders Grant Support This work was supported by CSAT grant s: TI 11424 (M.Fishman), TI013356 (S.Godley), TI-11432 (P.Shane), TI013313 (T. Gerstel); NIAAA grant AA010368 (M.Godley), NIDA Grant DA 018183 (S.Godley) and CSAT Contract 270-2003-00006 (M.Dennis). Statistical Analyses: The sensitivity (i.e., percent of cases correctly identified) of each method was evaluated relative to the combined approach. The ability of the GAIN to use self reported data to identify who is likely to get a diagnosis if they saw a clinician was tested using a simple odds ratio.