Item Bias in the CAGE Screening Test for Alcohol Use Disorders

OBJECTIVE: To explore potential item bias in the CAGE questions (mnemonic for cut-down, annoyed, guilty, and eye-opener) when used to screen for alcohol use disorders in primary care patients. DESIGN AND SETTING: Cross-sectional study, conducted in a university-based, family practice clinic, with the presence of an alcohol use disorder determined by structured diagnostic interview using the Alcohol Use Disorder and Associated Disabilities Interview Schedule. PATIENTS: A probability sample of 1,333 adult primary care patients, with oversampling of female and minority (African–American and Mexican–American) patients. MAIN RESULTS: Unadjusted analyses showed marked differences in the sensitivity and specificity of each CAGE question against a lifetime alcohol use disorder, across patient subgroups. Women, Mexican–American patients, and patients with annual incomes above $40,000 were consistently less likely to endorse each CAGE question “yes,” after adjusting for the presence of an alcohol use disorder and pattern of alcohol consumption. In results from logistic regression analyses predicting an alcohol use disorder, cut-down was the only question retained in models for each of the subgroups. The guilty question did not contribute to the prediction of an alcohol use disorder; annoyed and eye-opener were inconsistent predictors. CONCLUSIONS: Despite its many advantages, the CAGE questionnaire is an inconsistent indicator of alcohol use disorders when used with male and female primary care patients of varying racial and ethnic backgrounds. Gender and cultural differences in the consequences of drinking and perceptions of problem alcohol use may explain these effects. These biases suggest the CAGE is a poor “rule-out” screening test. Brief and unbiased screens for alcohol use disorders in primary care patients are needed

Effectiveness of Collaborative Care Depression Treatment in Veterans' Affairs Primary Care

OBJECTIVE: To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic. DESIGN: Patients were randomly assigned to treatment model by clinic firm. SETTING: VA primary care clinic. PARTICIPANTS: One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia. MEASUREMENTS: Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale. MAIN RESULTS: Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. CONCLUSIONS: Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives