Concurrent DisordersConcurrent DisordersSWRK 2083SWRK 2083

Wk 3Wk 3

Screening IssuesScreening Issues

Keith Cameron, M.A., M.B.A.Keith Cameron, M.A., M.B.A.

(FYI)(FYI)Reliability “is the extent to which the measurements of a test remain consistent over repeated tests of the same subject under identical conditions. An experiment is reliable if it yields consistent results of the same measure. It is unreliable if repeated measurements give different results. It can also be interpreted as the lack of random error in measurement.”

Validity is a measure (there are several) of whether the tests is measuring what it is supposed to measure.

An Example: The WAIS IQ Test

It is reliable because it will result in the same score each time you give it.

It is valid (predictive validity) because it predicts how well you will do in college/university.

Terms for Substance Abuse and Mental Health Screening (FYI)

The sensitivity of a screening tool refers to its ability to detect the condition or health concern that it is intended to detect. A highly sensitive tool for mental health or substance abuse will, therefore, not miss too many people who have either a mental health or substance use disorder as determined by a subsequent diagnostic assessment.

The specificity of a screening tool refers to its ability to avoid saying that someone may have the problem or health concern when in fact they do not. A highly specific tool for mental health or substance abuse will, therefore, not identify too many people as possibly having either a mental health or substance use disorder only to have this ruled out by subsequent diagnostic assessment.

While the goal is usually to develop screening tools that are high in both sensitivity and specificity, one may lean toward high sensitivity and use later assessment to rule out the false positives. If, however, subsequent assessment of many false positives is seen as inappropriate (e.g., too expensive) one would lean toward higher specificity. Normally, one tries to strike a balance.

Q & A: note down answersQ & A: note down answers

1. Have you had a feeling of guilt or remorse after 1. Have you had a feeling of guilt or remorse after drinking alcohol? drinking alcohol?

2. Has a friend of family member ever told you 2. Has a friend of family member ever told you about things you said or did while you were about things you said or did while you were drinking that you could not remember? drinking that you could not remember?

3. Have you failed to do what was normally 3. Have you failed to do what was normally expected of you because of drinking? expected of you because of drinking?

4. Do you sometimes take a drink when you first 4. Do you sometimes take a drink when you first get up in the morning? get up in the morning?

Screening IssuesScreening IssuesHealth Canada ArticleHealth Canada Article

GoalGoal: Might this person have a problem with : Might this person have a problem with substance abuse & mental health that warrants substance abuse & mental health that warrants further further assessment? assessment? – Not Not about diagnosisabout diagnosis– Not Not aimed at getting a complete psychosocial profileaimed at getting a complete psychosocial profile

Build a therapeutic alliance with clients who often Build a therapeutic alliance with clients who often quit treatmentquit treatment– So more thorough assessment can be done…over timeSo more thorough assessment can be done…over time– ‘‘Therapeutic Alliance’ with Case Manager, allows for a Therapeutic Alliance’ with Case Manager, allows for a

more accurate assessment over timemore accurate assessment over time

Screening…Screening…

“…“…patients admitted to acute patients admitted to acute psychiatric settings often psychiatric settings often underreport their recent drug use…” underreport their recent drug use…” Health CanadaHealth Canada

Now, why would that be?Now, why would that be?

Diagnosis is uncertain…Diagnosis is uncertain…

One US study of 160 CD patients: One US study of 160 CD patients:

““Initial assessment produced a Initial assessment produced a definitive diagnosis in only 18% of definitive diagnosis in only 18% of the cases.” the cases.”

What contributes to poor rate What contributes to poor rate of accurate diagnosis? of accurate diagnosis?

Poor memoryPoor memory

Inconsistent reportingInconsistent reporting

Reassessment at 18 months = Reassessment at 18 months =

75% of cases couldn’t be properly diagnosed75% of cases couldn’t be properly diagnosed

Level 1 Screening:Level 1 Screening: M Health Client for Substance AbuseM Health Client for Substance Abuse

(4 alternatives)(4 alternatives)

1.1. Ask a few questionsAsk a few questionsa.a. Alcohol: sometimes answers correlate well with Alcohol: sometimes answers correlate well with

more sophisticated assessmentsmore sophisticated assessments

b.b. In mental health settings, clients not always In mental health settings, clients not always ready/able to be completely truthfulready/able to be completely truthful

c.c. Best predictor:Best predictor: awareness that others are awareness that others are concerned about their substance useconcerned about their substance use

Good Questions to Ask: Good Questions to Ask:

1. Have you ever had any problems 1. Have you ever had any problems related to your use of alcohol or related to your use of alcohol or other drugs? other drugs?

Good Questions…Good Questions…

2. Has a relative, friend, coworker or 2. Has a relative, friend, coworker or health worker been concerned with health worker been concerned with your drug or alcohol use, and your drug or alcohol use, and suggested cutting down? suggested cutting down?

Good Questions…Good Questions…

3. Have you ever said to another 3. Have you ever said to another person:person:

‘ ‘No I don’t have a problem with No I don’t have a problem with alcohol or drugs…when at the same alcohol or drugs…when at the same time you wondered to yourself:’time you wondered to yourself:’

‘ ‘Maybe I do have a problem?’Maybe I do have a problem?’

2. CAGE, RAPS4 Questionnaires2. CAGE, RAPS4 Questionnaires

Assesses drug/alcohol useAssesses drug/alcohol use

Brief, reasonably reliableBrief, reasonably reliable

CAGE: validated for SMI (severely mentally CAGE: validated for SMI (severely mentally ill)ill)

RAPS 4: limited research with SMIRAPS 4: limited research with SMI

                                             CAGE

1.Have you ever felt you should cut down, on your drinking? 2.Have people annoyed you by criticizing your drinking? 3.Have you ever felt bad or guilty about your drinking? 4.Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Scoring: Item responses on the CAGE are scored 0 for "no" and 1 for "yes" answers, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

CAGE Questions Adapted to Include Drugs (CAGE-AID)

1.Have you ever felt you ought to cut down on your drinking or drug use? 2.Have people annoyed you by criticizing your drinking or drug use? 3.Have you felt bad or guilty about your drinking or drug use? 4.Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

3. Index of Suspicion3. Index of Suspicion

Checklist of behaviours, psychosocial Checklist of behaviours, psychosocial indicatorsindicators

Checklist shows typical consequences Checklist shows typical consequences of a concurrent disorderof a concurrent disorder

Can raise ‘suspicion’ that client has Can raise ‘suspicion’ that client has substance abuse disorder and thus a substance abuse disorder and thus a C.DisorderC.Disorder

4. Case Manager Judgment4. Case Manager Judgment

In settings where clients meet with In settings where clients meet with case manager for the long term…case manager for the long term…

Research shows managers usually Research shows managers usually know if client meets DSM 4 diagnosis know if client meets DSM 4 diagnosis for substance abuse disorderfor substance abuse disorder

Level 1 Screening:Level 1 Screening:Substance Abuse Client for Mental Substance Abuse Client for Mental

HealthHealth1.1. Brief Version of Mental Status Brief Version of Mental Status

ExamExam– Verbal and non-verbal behaviour systematically observed Verbal and non-verbal behaviour systematically observed

during the interviewduring the interview– Observations made elsewhere and by other people involved Observations made elsewhere and by other people involved

(recorded with stated source(recorded with stated source

A.A. How client Appears:How client Appears: Appearance: Appearance: Hygiene, dress Hygiene, dress Alertness: Alertness: Level of consciousnessLevel of consciousness Affect: Affect: Mood, gesturesMood, gestures Anxiety:Anxiety: Nervous, phobic, panic?Nervous, phobic, panic?

Brief Mental Status…Brief Mental Status…

B.B. BehaviourBehaviour: :

Movements:Movements: Abrupt, Abrupt, hyperactive…?hyperactive…?

Organization:Organization: Coherent, goal-Coherent, goal-orientedoriented

Purpose: Purpose: Bizarre, impulsive?Bizarre, impulsive? Speech:Speech: Rate, contentRate, content

Brief Mental Status Exam…Brief Mental Status Exam…

C.C. CognitionCognition: :

Orientation: Orientation: Person, place, timePerson, place, time Calculation:Calculation: Memory, simple Memory, simple

taskstasks Reasoning:Reasoning: Insight, judgmentInsight, judgment Coherence:Coherence: Delusions, Delusions,

hallucinationhallucination

2. Ask a few questions…2. Ask a few questions…

Have you ever been Have you ever been given a mental given a mental health diagnosis by health diagnosis by a doctor? a doctor?

Have you ever been Have you ever been hospitalized for a hospitalized for a mental health-mental health-related illness? related illness?

Have you ever Have you ever harmed yourself, or harmed yourself, or thought about it, thought about it, but not as a result but not as a result of drug/alcohol of drug/alcohol use?use?

Key Issues…Key Issues…

Screening, assessment take timeScreening, assessment take time

‘‘Chicken & egg’ solved over timeChicken & egg’ solved over time

‘‘Time’ only comes from strong Time’ only comes from strong therapeutic alliancetherapeutic alliance