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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, 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

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  1. Mental health screening and outcome measurement in alcohol & drug users Jaime Delgadillo, PhDLeeds Primary Care Mental Health Service

  2. Presentation outline: Overview of methodological challenges CCAS study: validity and reliability of brief outcome measures Implications for clinical practice

  3. Detecting and monitoring mental health problems: Methodological challenges

  4. Dual Diagnosis: epidemiology 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)

  5. Screening as usual? 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

  6. Methodological challenges 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)

  7. Summary of key challenges • 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.

  8. CCAS study: validity and reliability of brief outcome measures

  9. CCAS study: design Design Diagnostic validation study. Recruitment period: 1 year. Prospective cohort design, follow-up: 4-6 weeks. Participants 103 clients in routine methadone maintenance treatment in Leeds, excluding people with severe mental disorders. Measures CIS-R (Gold-standard diagnostic interview) PHQ-9 (Depression) GAD-7 (Anxiety disorders) TOP (Patterns of alcohol & drug use and self-rated mental health) Procedure Complete brief measures  diagnostic interview  re-test after 4 weeks

  10. CCAS study: sample

  11. CCAS study: results (Delgadillo et al, 2011, 2012)

  12. CCAS study: results PHQ-9 Cut-off ≥ 12 RCI ≥ 7 GAD-7 Cut-off ≥ 9 RCI ≥ 5 How stable are depression & anxiety symptoms after 4-6 weeks watchful wait?

  13. Implications for clinical practice

  14. Conclusions • 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

  15. COBID trial: recruitment strategy Routine case-finding If: TOP <= 12 Then: 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

  16. Thank you for listening Contact details:jaime.delgadillo@nhs.net

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