1. Concurrent Disorders SWRK 2083 Wk 3 Screening Issues Keith Cameron, M.A., M.B.A.

2. (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.

3. 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.

4. Q & A: note down answers 1. Have you had a feeling of guilt or remorse after drinking alcohol? 2. Has a friend of family member ever told you about things you said or did while you were drinking that you could not remember? 3. Have you failed to do what was normally expected of you because of drinking? 4. Do you sometimes take a drink when you first get up in the morning?

5. Screening Issues Health Canada Article Goal: Might this person have a problem with substance abuse & mental health that warrants further Goal: Might this person have a problem with substance abuse & mental health that warrants furtherassessment? –Not about diagnosis –Not aimed at getting a complete psychosocial profile Build a therapeutic alliance with clients who often quit treatment Build a therapeutic alliance with clients who often quit treatment –So more thorough assessment can be done…over time –‘Therapeutic Alliance’ with Case Manager, allows for a more accurate assessment over time

6. Screening… “…patients admitted to acute psychiatric settings often underreport their recent drug use…” Health Canada “…patients admitted to acute psychiatric settings often underreport their recent drug use…” Health Canada Now, why would that be? Now, why would that be?

7. Diagnosis is uncertain… One US study of 160 CD patients: One US study of 160 CD patients: “Initial assessment produced a definitive diagnosis in only 18% of the cases.” “Initial assessment produced a definitive diagnosis in only 18% of the cases.”

8. What contributes to poor rate of accurate diagnosis? Poor memory Poor memory Inconsistent reporting Inconsistent reporting Reassessment at 18 months = Reassessment at 18 months = 75% of cases couldn’t be properly diagnosed

9. Level 1 Screening: M Health Client for Substance Abuse (4 alternatives) 1. Ask a few questions a.Alcohol: sometimes answers correlate well with more sophisticated assessments b.In mental health settings, clients not always ready/able to be completely truthful c.Best predictor: awareness that others are concerned about their substance use

10. Good Questions to Ask: 1. Have you ever had any problems related to your use of alcohol or other drugs?

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

12. Good Questions… 3. Have you ever said to another person: ‘No I don’t have a problem with alcohol or drugs…when at the same time you wondered to yourself:’ ‘No I don’t have a problem with alcohol or drugs…when at the same time you wondered to yourself:’ ‘Maybe I do have a problem?’ ‘Maybe I do have a problem?’

13. 2. CAGE, RAPS4 Questionnaires Assesses drug/alcohol use Assesses drug/alcohol use Brief, reasonably reliable Brief, reasonably reliable CAGE: validated for SMI (severely mentally ill) CAGE: validated for SMI (severely mentally ill) RAPS 4: limited research with SMI RAPS 4: limited research with SMI

14. 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)?

15. 3. Index of Suspicion Checklist of behaviours, psychosocial indicators Checklist of behaviours, psychosocial indicators Checklist shows typical consequences of a concurrent disorder Checklist shows typical consequences of a concurrent disorder Can raise ‘suspicion’ that client has substance abuse disorder and thus a C.Disorder Can raise ‘suspicion’ that client has substance abuse disorder and thus a C.Disorder

16. 4. Case Manager Judgment In settings where clients meet with case manager for the long term… In settings where clients meet with case manager for the long term… Research shows managers usually know if client meets DSM 4 diagnosis for substance abuse disorder Research shows managers usually know if client meets DSM 4 diagnosis for substance abuse disorder

17. Level 1 Screening: Substance Abuse Client for Mental Health 1. Brief Version of Mental Status Exam –Verbal and non-verbal behaviour systematically observed during the interview –Observations made elsewhere and by other people involved (recorded with stated source A. How client Appears: Appearance: Hygiene, dress Appearance: Hygiene, dress Alertness: Level of consciousness Alertness: Level of consciousness Affect: Mood, gestures Affect: Mood, gestures Anxiety:Nervous, phobic, panic? Anxiety:Nervous, phobic, panic?

18. Brief Mental Status… B. Behaviour: Movements:Abrupt, hyperactive…? Movements:Abrupt, hyperactive…? Organization:Coherent, goal-oriented Organization:Coherent, goal-oriented Purpose: Bizarre, impulsive? Purpose: Bizarre, impulsive? Speech:Rate, content Speech:Rate, content

19. Brief Mental Status Exam… C. Cognition: Orientation: Person, place, time Orientation: Person, place, time Calculation:Memory, simple tasks Calculation:Memory, simple tasks Reasoning:Insight, judgment Reasoning:Insight, judgment Coherence:Delusions, hallucination Coherence:Delusions, hallucination

20. 2. Ask a few questions… Have you ever been given a mental health diagnosis by a doctor? Have you ever been given a mental health diagnosis by a doctor? Have you ever been hospitalized for a mental health-related illness? Have you ever been hospitalized for a mental health-related illness? Have you ever harmed yourself, or thought about it, but not as a result of drug/alcohol use? Have you ever harmed yourself, or thought about it, but not as a result of drug/alcohol use?

21. Key Issues… Screening, assessment take time Screening, assessment take time ‘Chicken & egg’ solved over time ‘Chicken & egg’ solved over time ‘Time’ only comes from strong therapeutic alliance ‘Time’ only comes from strong therapeutic alliance