For many essential clinical and research purposes, however, only structured scripted interviews afford sufficient information and reliability. Clinicians also obtain a comprehensive, objective picture of the auxiliary services the patient may need to benefit maximally from treatment. In research, these instruments yield the diagnostic consistency that is indispensable to avoid misclassifying patients and compromising the interpretation of research results.
This article aims to help clinicians and researchers choose the structured assessment instruments appropriate for their needs. For six widely used instruments, we describe the validity and reliability characteristics; administration procedures; training requirements; and advantages and disadvantages based on patient population, treatment orientation, and staff skills.
The instruments are the. Thomas McLellan, principal developer of the ASI, has often contrasted two patients to illustrate the clinical importance of thorough assessments, such as those yielded by the ASI.
One patient, a physician, is severely physiologically addicted to opiates. The other, a young woman, has a milder physiological addiction. An assessment that focuses narrowly on drug abuse history might stop here, leaving the impression that the physician faces the greater challenge to recovery. The young woman, on the other hand, has no social supports except other drug abusers, is unemployed, and has never kept a job for long. In fact, she is the one with greater service needs— in particular, training in social and occupational skills.
In research, an appropriate assessment instrument can make the difference between null and significant findings. A recent review of trials to determine whether tricyclic antidepressants can help substance abusers with comorbid depression provides an illustrative example Nunes and Levin, Early trials demonstrated little or no benefit from the medications.
These trials admitted patients based on their current depressive symptoms as itemized in instruments such as the Hamilton Depression Scale Hamilton, or the Beck Depression Inventory Beck et al. Participants would have included some individuals who had comorbid major depression and others who were experiencing transient low moods related to intoxication, withdrawal, or stress reactions.
More recent studies, in contrast, admitted only individuals who met formal diagnostic criteria for major depressive disorder, which include persistent symptoms over a period of time. Some recent studies also delayed assessment until candidates had been abstinent for a week to ensure that they were past withdrawal. The assessment instruments we will discuss, with the exception of the ASI, all elicit the information required to diagnose substance use disorders and other psychiatric disorders according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision DSM-IV; American Psychiatric Association, Where the instruments differ is in.
Convenience features, such as modularity and availability in computer-based formats; and. A fully structured assessment instrument is a script. It specifies the questions the interviewer is to ask, exactly as written, as well as a choice of responses for the interviewee.
When asking the questions, the interviewer skips some, based on patient characteristics or previous responses, and avoids adding probes of his or her own. Both formats have advantages and disadvantages. Fully structured interviews are economical.
They require no clinical judgment, so trained lay interviewers can administer them. They generally take less time to administer.
Many large research studies and large treatment facilities use fully structured instruments, because staff members with little experience can perform the initial and followup assessments. Many assessment instruments are modular, permitting flexibility in the choice of sections used and diagnoses assessed. Thus, for example, researchers or clinicians who do not encounter psychotic individuals because of program regulations or a research protocol may omit a psychosis module. Several structured and semi-structured diagnostic interviews are available in computer-assisted formats.
Interviewers read questions to interviewees and enter responses into a computer rather than a paper form. Further, computerized administration saves many hours of data entry and avoids the errors that can occur in transferring data from paper into a computer database for analysis.
Computerizing the logic of the interview also reduces the need for post-interview data cleaning. The data go directly into a database that can immediately generate reports and statistics. Prior to adopting these measures, a CTN workgroup evaluated many measures for reliability, validity, efficiency, and suitability for widespread use in nonresearch settings.
All the instruments discussed in this article are highly reliable and valid, but the extent of their reliability or validity may differ in particular situations. The question of reliability is: Will users of the instrument consistently reach the same diagnostic conclusions?
A straightforward and rigorous way to answer this question is the test-retest method. Two or more clinicians use the instrument to conduct independent assessments of the same patient, and the degree of correlation among their findings is calculated.
Generally, a test-retest kappa score of 0. The question of validity is: Does the instrument truly and unambiguously assess the condition it is designed to evaluate? This question has more dimensions than the estimation of reliability; accordingly, validity is estimated with a number of methods.
Brief descriptions of these instruments follow. For a summary comparison of their properties, see Table 1. The ASI provides information that clinicians can use to address these problems with appropriate interventions or referrals. Finally, the administrator calculates a composite score from a subset of the distress and treatment need responses.
This score becomes the basis for treatment planning. Altogether, the ASI takes approximately 45 to 60 minutes to administer, plus 10 to 20 minutes for post-interview scoring. The DSM-III provided clinicians and researchers with standardized definitions and diagnostic criteria for more than psychiatric disorders, including substance abuse and dependence disorders.
Prior to this publication, clinicians and researchers commonly used the same diagnostic terms to mean different things, and clinicians often disagreed on whether patients had specific disorders Spitzer, Endicott, and Robins, ; Spitzer and Fleiss, Substance abuse professionals engaged in semantic debates over the definition of addiction—even over the very existence of such a condition. Some patients seeking treatment report too few symptoms to meet the criteria for either diagnosis.
In these cases, the specific symptoms, symptom clusters, and the severity of associated problems can inform effective strategies for intervention and management. Drug or alcohol dependence is diagnosed by documenting that a patient has experienced at least three of seven criteria for a particular substance within a month period.
The criteria are:. Great deal of time spent in activities necessary to obtain, use, or recover from the substance. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by the substance.
Withdrawal, in particular, predicts medical problems and poor outcome Hasin et al. Alternatively, a symptom or criteria count can function as a measure of dependence severity Hasin et al. The DSM-IV lists substance-specific intoxication and withdrawal symptoms for most of the common classes of drugs.
Planners for the DSM-V are considering the addition of a withdrawal syndrome for cannabis. Test-retest studies have repeatedly shown good to excellent reliability for the diagnosis of substance dependence with the DSM-IV Bucholz et al.
The DSM-IV substance dependence diagnosis also shows good validity in two forms of multi-method comparisons. The other compares diagnoses from a single system such as DSM-IV produced by different diagnostic interviews Cottler et al.
Studies of families with alcohol problems have validated the criteria for the substance dependence diagnosis. In addition, animal models support the validity of many elements of dependence Robinson, ; Tapper et al. Patients who do not meet the criteria for substance dependence may be diagnosed with substance abuse if they report experiencing one or more of four abuse symptoms repeatedly over a month period. The symtoms are:. Many clinicians have questioned the separation of substance dependence and substance abuse.
Studies have shown that the DSM criteria for abuse are less valid than those for dependence. However, these studies diagnosed substance abuse hierarchically, meaning that an abuse diagnosis was considered to be redundant if dependence was present. Women and minorities appear especially likely to experience dependence without abuse Hasin et al.
Studies that assessed abuse regardless of whether dependence was present showed better reliability for the criteria for abuse Bucholz et al. In summary, the DSM-IV hierarchical status of abuse is problematic, but the criteria yield reliable diagnoses. Extensive comorbidity between substance use disorders and other psychiatric disorders has been reported consistently in patients Nunes, Hasin, and Blanco, as well as in the general population Grant et al.
Such comorbidity can be serious. For example, studies with acceptable response rates 70 percent or more and reliable diagnostic assessments have consistently found an adverse effect of major depression on the outcome of substance use disorders Hasin, Nunes, and Meydan, Further, among patients with histories of substance dependence and major depression, the occurrence of a major depressive episode during periods of sustained abstinence predicts a higher number of suicide attempts Aharonovich et al.
To be accurate, assessments must address the fact that substance intoxication and withdrawal can mimic symptoms of depression, psychosis, or other independent psychiatric disorders. Psychiatric disorders that co-occur with substance intoxication or withdrawal can be considered primary if 1 symptoms substantially exceed the expected effects of the substance in the amount that was used; 2 there is a personal history of psychiatric symptoms during periods of extended abstinence; 3 the onset of psychiatric symptoms clearly preceded the onset of substance use; and 4 symptoms persisted for at least a month after the cessation of intoxication or withdrawal.
Symptoms that are not considered primary fall into the category either of expected effects of a substance or of a substance-induced disorder that exceeds intoxication or withdrawal effects and deserves independent clinical attention. Several studies have demonstrated good to excellent reliability and validity for the instrument Butler et al. ASI Manuals. Severity Scale www.
Clinical Training Version. These tools are broader in scope and often take special training and considerable time The Addiction Severity Index ASI is 12 years old and has been revised to include a new section on family history of alcohol, drug, and psychiatric problems. Journal of Substance Abuse and Treatment. Studies of the reliability and validity of the Addiction Severity Index.
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