Screening questionnaires for problem drinking in adolescents: performance of AUDIT, AUDIT-C, CRAFFT and POSIT.

BACKGROUND/AIMS: Only rather few data on the validity of screening questionnaires to detect problem drinking in adolescents exist. The aim of this study was to compare the performance of the Alcohol Use Disorders Identification Test (AUDIT), its short form AUDIT-C, the Substance Module of the Problem Oriented Screening Instrument for Teenagers (POSIT), and CRAFFT (acronym for car, relax, alone, forget, family, and friends). METHODS: The questionnaires were filled in by 9th and 10th graders from two comprehensive schools. All students received an interview using the alcohol section of the Composite International Diagnostic Interview. Alcohol abuse and alcohol dependence according to DSM-IV as well as episodic heavy drinking served as criteria to validate the screening instruments. RESULTS: All 9th and 10th graders (n=225) of both schools participated. No significant differences were found for areas under the receiver operating characteristic curves ranging from 0.810 to 0.872. Cronbach's alpha was satisfactory (0.77-0.80) but poor for CRAFFT (0.64). Different cut-offs are discussed. CONCLUSIONS: Considering validity as well as reliability, AUDIT, AUDIT-C and POSIT performed well; however, the POSIT is quite lengthy. AUDIT-C showed good psychometric properties and has clear advantages because of its brevity.

The impact of having a loved one with alcohol consumption-related problems on subjective health status and health-risk behaviors in a general hospital sample.

Consecutively admitted inpatients of a general hospital in Northern Germany (N = 2903) completed a standardized screening questionnaire in 2005-2006 containing questions about alcohol consumption-related problems in loved ones, their own alcohol consumption, and other health-related aspects. Almost 26.2% reported having a loved one with alcohol consumption-related problems. The proportions of smokers and those who screened positively for at-risk consumption or alcohol abuse were significantly higher in those patients; they were significantly younger and reported worse overall states of health and emotional health. Since those patients showed a high risk of numerous health problems, psychological interventions were implemented. The study's limitation noted.

Severity of unhealthy alcohol consumption in medical inpatients and the general population: is the general hospital a suitable place for brief interventions?

OBJECTIVES: Evidence for brief interventions in general hospital (GH) settings is scarce, probably due to higher rates of dependent drinkers. The present study aims to compare unhealthy drinking patterns in GH patients with the general population (GP). METHODS: Sample 1 consisted of 4,075 individuals randomly drawn from registration office files, representing the non-institutionalised GP of a northern mixed rural-urban German area. Sample 2 consisted of 2,949 consecutively admitted patients from a GH covering the same area. RESULTS: Compared to individuals from the GP, GH patients revealed higher prevalence rates of alcohol dependence (1.3 vs. 5.5%) and alcohol abuse (1.2 vs. 2.8%), but did not differ significantly concerning at-risk drinking (5.1 vs. 6.2%). Multinomial logistic regression analysis controlling for age, sex and smoking using unrisky alcohol consumption as reference category belonging to the GH group was predictive for alcohol use disorders but not for at-risk drinking. CONCLUSION: Data show that a substantial number of individuals with unhealthy drinking patterns without alcohol use disorders can easily be accessed in GH settings if appropriate screening measures are conducted.

Mental health and readiness to change smoking behavior in daily smoking primary care patients.

PURPOSE: We examined the association between daily smokers' mental health according to the five-item Mental Health Inventory and the core constructs of the transtheoretical model (TTM): stage of change, processes of change, smoking cessation self-efficacy, and decisional balance. METHOD: Questionnaire data from 1,334 daily smoking primary care patients were used for multinomial logistic, linear, and ordinal logistic regression analyses controlling for effects of sociodemographic characteristics. RESULTS: Smokers with lower levels of mental health had increased odds to contemplate quitting within the next 6 months compared to not intending to quit at all. In addition, they reported an elevated use of change processes as well as an enhanced endorsement of positive and negative aspects of nonsmoking. However, in a subsample analysis performed on smokers in contemplation stage, low mental health was related to lower self-efficacy expectancies in negative affect situations. CONCLUSION: Mental health does not appear to constitute a precondition for readiness to change smoking behavior in daily smokers. Nonetheless, smokers with low mental health might require support to deal with negative affect situations.

Differences in help seeking rates after brief intervention for alcohol use disorders in general practice patients with and without comorbid anxiety or depressive disorders.

AIMS: To examine, if the utilization of help for problematic drinking after brief intervention (BI) differs between general practice (GP) patients with and without comorbid depression or anxiety disorders. METHODS: Longitudinal data of 374 GP patients, who met the diagnostic criteria of alcohol dependence or abuse according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and criteria of at-risk drinking or binge drinking, were drawn from a randomized controlled BI study. Participants were randomly allocated to either a control or one of two intervention groups, receiving a series of alcohol related BI. Of the sample, 88 participants were diagnosed with comorbid anxiety and/or depressive disorders. At 12-months follow-up, differences in utilization of formal help for drinking problems were assessed between comorbid and non-comorbid individuals. RESULTS: BI were significantly related to an increase in utilization of formal help in non-comorbid patients (chi(2 )= 4.54; df = 1; p < 0.05) but not in comorbid individuals (chi(2 )= 0.40; df = 1; p = 0.60). In a logistic regression analysis, comorbidity [odds ratio (OR) = 1.81; 95% confidence interval (CI) = 1.14-2.88; p = 0.01) and previous help seeking (OR = 15.98; CI = 6.10-41.85; p < 0.001) were found to be positive predictors for utilization of formal help. CONCLUSION: BIs do not seem to significantly support help-seeking in the comorbid. As comorbid anxiety and depression constitute a positive predictor for help-seeking, individuals with problematic drinking and comorbid anxiety or depressive disorders might benefit from more specialized support exceeding the low level of BI.

Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders.

AIM: To analyse gender differences in the efficacy of stepped care brief interventions for general practice patients with alcohol problems. METHODS: Data are part of "Stepped Interventions for Problem Drinkers," in which 10,803 patients from 85 general practitioners were screened using alcohol related questionnaires; 408 patients were randomized (32% were female) to a control (booklet only) or two different intervention groups: stepped care (feedback, manual, and up to three counselling sessions depending on the success of the previous intervention) and fixed care (four sessions). Response rate for the 12 months follow-up was 91.7%. RESULTS: Regression analysis revealed a significant effect size only in women (P = 0.039). After excluding alcohol dependents and binge drinkers, an effect size (R(2)) of 0.031 (P = 0.050) in women and an effect size (R(2)) of 0.069 (P = 0.057) in men was obtained. Among the patients in stepped care who, by the first assessment point, had reduced drinking to within safe-drinking limits, there was a tendency for females to have achieved this more often than males (40% vs. 24%; P = 0.089). CONCLUSIONS: In a heterogeneous sample, the intervention was only effective for women. Women tended to profit more from the first, less intensive intervention than men. When analysis was limited to those reporting "at risk" average daily consumption and "alcohol abuse," the gender differences in efficacy appeared to be less, but the study was not sufficiently powered to affirm that.

Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders.

BACKGROUND: Brief interventions (BIs) are effective methods to reduce problematic drinking. It is not known, if the effectiveness of BI differs between patients with or without comorbid depression or anxiety disorders. METHODS: In a randomized controlled BI study with two intervention groups and one control condition, data were collected from 408 general practice (GP) patients with alcohol use disorders, at-risk drinking or binge drinking. 88 participants were diagnosed with comorbid anxiety and/or depressive disorders. The effectiveness of BI was assessed at a 12-month follow-up in relation to the presence and absence of comorbidity. Reduction of drinking in six ordered categories (g/alcohol) between baseline and follow-up served as the outcome variable. RESULTS: BI were significantly related to reduction of drinking in the non-comorbid (-2.64 g/alcohol vs. -8.61 g/alcohol; p=.03) but not in the comorbid subsample (-22.06 g/alcohol vs. -22.09 g/alcohol; p=.76). Compared to non-comorbid participants, a significantly higher reduction of drinking was found for comorbid individuals (-6.55 g/alcohol vs. -22.08 g/alcohol; p=.01). An ordinal regression analysis revealed comorbidity to be a positive predictor for reduction of drinking (estimator=.594; CI=.175-1.013; p<.01). When entering the variables amount of drinking at baseline, intervention and classification of problematic drinking, these became significant predictors, whereas comorbidity showed only a tendency. CONCLUSION: BI did not significantly effect a reduction of drinking in comorbid patients. As BI are known to be less effective for dependent drinkers, a larger proportion of dependents among the comorbid might have limited the effectiveness of BI. Future studies with larger sample sizes of comorbid problem drinkers are necessary to confirm the results.

Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial.

BACKGROUND: Brief interventions for problem drinking in medical settings are effective but rarely conducted, mainly due to insufficient time. A stepped care approach (starting with a very brief intervention and intensifying efforts in case of no success) could save resources and enlarge effectiveness; however, research is lacking. The present study compares a full care brief intervention for patients with at-risk drinking, alcohol abuse or dependence with a stepped care approach in a randomized controlled trial. METHODS: Participants were proactively recruited from general practices in two northern German cities. In total, 10,803 screenings were conducted (refusal rate: 5%). Alcohol use disorders according to DSM-IV were assessed with the Munich-Composite International Diagnostic Interview (M-CIDI). Eligible participants were randomly assigned to one of three conditions: (1) stepped care (SC): a computerized intervention plus up to three 40-min telephone-based interventions depending on the success of the previous intervention; (2) full-care (FC): a computerized intervention plus a fixed number of four 30-min telephone-based interventions that equals the maximum of the stepped care intervention; (3) an untreated control group (CG). Counseling effort in the intervention conditions and quantity/frequency of drinking were assessed at 12-month follow-up. RESULTS: SC participants received roughly half of the amount of intervention in minutes compared to FC participants. Both groups did not differ in drinking outcomes. Compared to CG, intervention showed small to medium effect size for at-risk drinkers. CONCLUSIONS: Study results reveal that a stepped care approach can be expected to increase cost-effectiveness of brief interventions for individuals with at-risk drinking.

Development and evaluation of a screening instrument for alcohol-use disorders and at-risk drinking: the brief alcohol screening instrument for medical care (BASIC).

OBJECTIVE: Screening for problem drinking has not yet become standard practice in primary health care settings, and lack of time is an important barrier for general practicioners to intervene. Very brief screening instruments might help to implement screening into the daily routine in primary health care. The present study describes the development and evaluation of the Brief Alcohol Screening Instrument for medical Care (BASIC), using two independently drawn samples. METHOD: Sample 1 was recruited from general practices in two northern German cities. In total, 10,803 screenings were conducted. Item selection and validation of the BASIC was carried out in two equally sized random subsamples drawn from Sample 1. Sample 2 consisted of 2,949 consecutively admitted patients from a general hospital. Two different screening tools, both containing the Lübeck Alcohol abuse and dependence Screening Test (LAST) and one containing the full Alcohol Use Disorders Identification Test (AUDIT) and the other one the BASIC, were randomly handed out to study participants and compared according to validity criteria. As a gold standard for the detection of alcohol-use disorders, the Munich-Composite International Diagnostic Interview (M-CIDI) was used for screening positive individuals. RESULTS: In the first general-practice subsample, six items that performed comparably well to the AUDIT were identified. In the second study, these findings were replicated. Both questionnaires performed better than the complementary deployed AUDIT-C and LAST. CONCLUSIONS: Data show that the BASIC is an efficient screening tool that performs as well as the AUDIT in medical settings while being shorter in administration and scoring.

[Improvement of medical care by supporting the intention to change health risk behavior]. / Verbesserung der medizinischen Versorgung durch die Förderung der Intention zur Anderung gesundheitsriskanten Verhaltens.

A large proportion of disease and death cases could be prevented, if efficacious programs, particularly concerning tobacco smoking, obesity, and alcohol risk drinking, could be applied. Feasible approaches are based, among others, on the Transtheoretical Model of intentional health behavior change. This model allows to develop practical approaches to reduce risk factors of common diseases at the general population level. Evidence about the promotion of the intention to change health risk behaviors revealed successes, e. g., according to smoking cessation. The effects are growing by time. Intervention that is focused at the promotion of change of health risk behaviors can add to the improvement of health care.

Performance of the pictorial representation of illness and self measure in individuals with alcohol dependence, alcohol abuse or at-risk drinking.

BACKGROUND: The impact of chronic illnesses is not only influenced by one's physical functioning but also by its subjective importance to the individual's life. However, it is often difficult to asses such an impact in an appropriate way. PRISM (pictorial representation of illness and self measure) measures the perception of illness and first data on its validity have been published. The aim of the present study was to prove the applicability of PRISM regarding alcohol-dependent patients. Therefore, a comparison was made between alcohol-dependent patients, alcohol abusers and at-risk drinkers. METHOD: The sample consisted of 763 general practice patients, who scored above the cutoff in alcohol-related screening questionnaires. Of this sample, 330 were diagnosed as alcohol dependent, alcohol abusers (both according to DSM-IV) or at-risk drinkers. To prove the applicability, PRISM was put in context with the severity of alcohol dependence and the core constructs of the transtheoretical model of behavior change. RESULTS: PRISM was related to the severity of the drinking problem: the severer the drinking problem, the shorter the distance between self and illness. High correlations with aspects of alcohol consumption - such as adverse consequences from drinking, temptation to drink, and self-efficacy to abstain - were found. Concerning stages of change according to the transtheoretical model of behavior change, data show a significant difference in the self-illness separation between patients in the stage of contemplation compared to those in the precontemplation or action stage. CONCLUSIONS: The PRISM task is applicable to patients with alcohol use disorders. Within this group and in contrast to other chronic diseases, PRISM reveals a significant relationship not only to the severity of drinking, but also to the readiness to change one's drinking behavior.

The reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a German general practice population sample.

OBJECTIVE: Our goal was to analyze the retest reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a primary-care setting and recommend a cut-off value for the different alcohol-related diagnoses. METHOD: Participants recruited from general practices (GPs) in two northern German cities received the AUDIT, which was embedded in a health-risk questionnaire. In total, 10,803 screenings were conducted. The retest reliability was tested on a subsample of 99 patients, with an intertest interval of 30 days. Sensitivity and specificity at a number of different cut-off values were estimated for the sample of alcohol consumers (n=8237). For this study, 1109 screen-positive patients received a diagnostic interview. Individuals who scored less than five points in the AUDIT and also tested negative in a second alcohol-related screen were defined as "negative" (n=6003). This definition was supported by diagnostic interviews of 99 screen-negative patients from which no false negatives could be detected. As the gold standard for detection of an alcohol-use disorder (AUD), we used the Munich-Composite International Diagnostic Interview (MCIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: On the item level, the reliability, measured by the intraclass correlation coefficient (ICC), ranged between .39 (Item 9) and .98 (Item 10). For the total score, the ICC was .95. For cut-off values of eight points and five points, 87.5% and 88.9%, respectively, of the AUDIT-positives, and 98.9% and 95.1%, respectively, of the AUDIT-negatives were identically identified at retest, with kappa = .86 and kappa = .81. At the cut-off value of five points, we determined good combinations of sensitivity and specificity for the following diagnoses: alcohol dependence (sensitivity and specificity of .97 and .88, respectively), AUD (.97 and .92), and AUD and/or at-risk consumption (.97 and .91). CONCLUSIONS: Embedded in a health-risk questionnaire in primary-care settings, the AUDIT is a reliable and valid screening instrument to identify at-risk drinkers and patients with an AUD. Our findings strongly suggest a lowering of the recommended cut-off value of eight points.

Intention to change drinking behaviour in general practice patients with problematic drinking and comorbid depression or anxiety.

AIMS: This paper examines the interaction of intention to change drinking behaviour with comorbid depression and anxiety in pro-actively recruited individuals with a range of drinking problems. METHODS: Cross-sectional data of 408 general practice (GP) patients aged 18-64 years, who meet the diagnostic criteria of alcohol dependence or abuse according to DSM-IV, criteria of at-risk drinking or binge drinking, were drawn from a brief intervention study. Of the sample, 89 participants were diagnosed with comorbid anxiety and/or depressive disorders. The Transtheoretical Model (TTM) of behaviour change constructs: stages and processes of change, self-efficacy, and decisional balance were assessed in relation to presence and absence of the respective psychiatric disorders. RESULTS: Analysis including all categories of problematic drinking revealed comorbid anxiety and/or depression to be significantly related to later stages of change. Within subgroups, this was only true for alcohol abuse, not for dependence, at-risk or binge drinking. In addition, comorbidity was related to higher use of processes of change and more pros and cons of drinking, when compared to non-comorbid participants. Comorbid individuals showed higher temptation to drink and lower self-efficacy to abstain from drinking. Separate analyses of readiness to change drinking between the categories anxiety/no comorbidity and depression/no comorbidity both obtained significance, while for anxiety disorders, this was more profound. A multinomial logistic regression analysis revealed that adverse consequences better predicted readiness to change when compared to comorbidity. DISCUSSION: Individuals with problematic drinking and comorbid anxiety or depression may be well accessible for pro-active intervention to reduce drinking. Strategies should focus on the enhancement of coping skills to control temptation and self-efficacy.