Intermediate length neuropsychological screening of impairment among psychoactive substance-abusing patients: A comparison of two batteries

Journal of Substance Abuse, 8(1), 1-17 (1996)

Intermediate Length Neuropsychological Screening of Impairment Among Psychoactive Substance-Abusing Patients: A Comparison of Two Batteries William Fals-Stewart Harvard Medical School and Veterans Affairs Medical Center, Brockton and West Roxbury, MA

Two intermediate-length neuropsychological test batteries--the Brain Age Quotient-T Scored (BAQ-T) and the Neuropsychological Screening Battery (NSB)--were used to evaluate the cognitive functioning of substance-abusing patients. Patients entering residential treatment for substance abuse (n = 30) performed significantly worse on both batteries compared to demographically similar participants from a nonclinical control group (n = 30). Both batteries categorized over one third of the substance-abusing patients as cognitively impaired; the chance-corrected agreement (kappa) of the BAQ-T and NSB in classifying participants as either cognitively impaired or intact was satisfactory. The comparative merits and limitations of each battery are discussed.

T h e r e is n o w a m p l e evidence that the c h r o n i c ingestion o f certain psychoactive substances m a y result in n e u r o a n a t o m i c a l c h a n g e s that can give rise to different cognitive impairments. For instance, m a n y n e u r o p s y c h o l o g i c a l studies evaluating the effects o f long-term alcohol use have shown that, aside f r o m the p e r m a n e n t d a m a g e in the small subset o f a l c o h o l - d e p e n d e n t patients w h o d e v e l o p Korsakoff's s y n d r o m e o r alcoholic d e m e n t i a , there are patterns o f cognitive i m p a i r m e n t associated with p r o l o n g e d alcohol c o n s u m p t i o n that m a y i m p r o v e with e x t e n d e d sobriety. A l t h o u g h individuals w h o chronically abuse alcohol display relatively preserved verbal r e a s o n i n g a n d verbal l e a r n i n g skills, specific d e c r e m e n t s are evident o n tests o f p r o b l e m solving, c o n c e p t u a l shifting, visuospatial abstracting ability, a n d m e m o r y (Errico, Parsons, & King, 1991; Grant, 1987; Ryan & Butters, 1986). Studies e x a m i n i n g the cognitive f u n c t i o n i n g o f patients w h o abuse psychoactive substances o t h e r t h a n a l c o h o l have b e e n far less definitive. A m a j o r m e t h o d o l o g i c a l obstacle has b e e n that few individuals w h o e n g a g e in n o n m e d i c a l drug-taking limit themselves to only o n e substance (Winick, 1992), m a k i n g it difficult to discern, in

William Fals-Stewart, Department of Psychiau7, Harvard Medical School and Veterans Affairs Medical Center, Brockton and West Roxbury, MA. Portions of this project were completed when the author was with Alpha Addictions Research, Ithaca, NY. Correspondence and requests for reprints should be sent to William Fals-Stewart, Veterans Affairs Medical Center (116B1), 940 Belmont Street, Brockton, MA 02401. E-mail: .

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most instances, the neuropsychological sequelae of using any single drug. However, some preliminary neuropsychological studies with chronic cocaine abusers have revealed impairments in several different areas of cognitive functioning. Results suggest that cocaine use is associated with deficits in short-term verbal memory, visuospatial abilities, abstraction, and attention (Berry, Van Gorp, Herzberg, & Hinkin, 1993; O'Malley, Adamse, Heaton, & Gawin, 1992), which appear to recover with prolonged abstinence (O'Malley, Gawin, Heaton, & Kleber, 1989). Habitual users of sedative-hypnotics have impairments that resemble those observed in alcohol-dependent patients (Bergman, Borg, Engelbreckston, & Vikander, 1989). Neuropsychological studies of solvent-abusing patients have uncovered profound deficits in memory (Allison & Jerrom, 1984), as well as verbal and performance measures of intelligence (Mahmood, 1983). Neuropsychological studies of individuals who abuse multiple substances have revealed deficits in cognitive flexibility (Adams, Rennick, Schoof, & Keegan, 1975), abstracting ability, and visuospatial scanning (Grant &Judd, 1976; Grant et al., 1978). Conversely, neuropsychological investigations that have studied individuals who primarily abuse cannabis, opiates, hallucinogens, phencyclidine (PCP), or amphetamines have thus far yielded inconsistent and, at times, contradictory results (for a review, see Fals-Stewart, Schafer, Lucente, Rustine, & Brown, 1994). However, depending on the setting from which participants are drawn and the methods used for evaluation, most studies have found that one third to one half of substance-abusing patients have measurable cognitive deficits (e.g., Fals-Stewart & Lucente, 1994a; Goldstein & Shelley, 1982; O'Malley, Gawin, Heaton, & Kleber, 1989). The exact etiology of these decrements remains a source of much debate, although substance neurotoxicity'(Freund, 1982; Riley & Walker, 1978), heredity (Hegadus, Tartar, Hill, Jacob, & Winsten, 1984), avitaminosis (Victor, Adams, & Collins, 1971), and consequences of physical trauma that often transpire during inebriation (Wetzig & Hardin, 1990) have all been implicated. During the last decade, some researchers have turned their attention to how these deficits might impinge on efforts to treat effectively patients diagnosed with psychoactive substance use disorders. To benefit from psychosocial interventions, such as psychotherapy, patients must be capable of receiving new data, integrating it with existing informational stores, and translating this input into concrete behavioral change. Because these rudimentary cognitive processes are impaired among a certain subset of drug- and alcohol-addicted individuals, it has been hypothesized that cognitively impaired substance-abusing patients would have poorer treatment outcomes than their unimpaired counterparts. Although the link between cognitive status and treatment outcome is mediated by many factors, such as personality functioning (Fals-Stewart & Lucente, 1992, 1994b) and therapists' clinical assessments of patients with cognitive impairment (Fals-Stewart, Lucente, Shanahan, & Brown, 1995), preliminary results from recent investigations suggest that there may be a connection. In comparison to cognitively intact substance-abusing patients, impaired patients have higher dropout rates from residential treatment programs (Fals-Stewart & Lucente, 1994b; Fals-Stewart & Schafer, 1992), faster relapse rates after leaving treatment, and poorer long-term outcomes (Berglund, Leijonquist, & Horlen, 1977; O'Leary, Donovan, Chaney, & Walker, 1979).

Neuropsychological Screening of Substance Abuse

3

In turn, some researchers have recommended that commonly employed interventions used to treat substance abuse might need to be modified or augmented to accommodate the presence of neuropsychological impairment and the temporal improvements in cognitive functioning often seen among these patients. For example, Goldman (1990) argued that available treatments for alcoholism may overtax the limited cognitive resources of many alcohol-dependent patients. He recommended that patients being treated for alcoholism may absorb information more effectively if more difficult, abstract concepts are presented later in the treatment course, when cognitive processing has had time to improve. He also suggested that new therapeutic material be presented repeatedly, in a variety of different formats, in order to increase the probability that the information will be encoded and retained. Others have successfully employed cognitive training procedures to improve neuropsychological functioning of impaired alcoholic patients (Yoham, Schaeffer, & Parsons, 1988). A recent preliminary study (Fals-Stewart & Lucente, 1994b) indicated that computer-assisted cognitive rehabilitation accelerated the rate of neuropsychological recovery among cognitively impaired substance-abusing patients in a long-term residential treatment program. In that investigation, patients in the cognitive rehabilitation condition also stayed in residence significantly longer than impaired patients who did not receive this intervention; length of stay in long-term residential treatment has a robust positive relationship with treatment outcome (Charuvastra, 1981; DeLeon, 1993). Given the implications for treatment response and outcome, several authors (e.g., Fals-Stewart & Schafer, 1993; Goldman, 1990; Miller, 1985) have argued for the more widespread use of neuropsychological testing in substance abuse treatment programs. Such assessment information would provide therapists with some insights into whether their patients have any cognitive decrements that may need to be accounted for when devising and implementing treatment plans. However, for both clinical and practical reasons, use of neuropsychological testing has not been adopted in most treatment programs. Some of the more comprehensive neuropsychological test batteries, such as the Halstead-Reitan Battery (HRB; Reitan & Wolfson, 1985), are costly in terms of administration and scoring time (approximately 6-10 hr), making their use impractical in most settings. Alternatively, widely used brief cognitive assessment measures, such as the Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975), have unacceptably high false-negative error rates and may not increase the level of diagnostic accuracy achieved through clinical examination alone (Nelson, Fogel, & Faust, 1986). One potential solution is the use of intermediate-length neuropsychological screening batteries, which can provide much greater breadth and sensitivity than brief measures, in terms of functions assessed, and yet are not prohibitively time consuming (i.e., many of the intermediate batteries that have been assembled can be administered by trained personnel in 1-2 hr). Two such batteries include (a) a subset of tests from the HRB and the Wechsler Adult Intelligence Scale (WAIS; Wechsler, 1955), which will be referred to as the Brain Age Quotient-T Scored (BAQ-7), and (b) the Neuropsychological Screening Battery (NSB; Heaton, Thompson, Nelson, Filley, & Franklin, 1990). Each battery has been used in separate

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studies to assess the neurocognitive functioning of drug-abusing patients (e.g., Fals-Stewart & Lucente, 1994a, 1994b; O'Malley, Gawin, Heaton, & Kleber, 1989; Walker, Donovan, Kivlahan, & O'Leary, 1983). In this investigation, we were interested in comparing the performances of drug-abusing patients on the BAQ-Tand the NSB. Because these assessment devices are comprised of mostly different subtests, we wanted to compare their concOrdance in terms of classifying patients as impaired as well as examine the merits and limitations of each battery for use with substance-abusing patients. METHOD

Participants Padents for the study were recruited from consecutive admissions to a long-term residential inpatient substance abuse treatment program (8-19 months).1 Potential participants wcrc excluded if they (a) had a history of significant head trauma, (b) had a medical disorder that would interfere with test performance (e.g., color deficiency), (c) met the Diagnostic and Statistical Manual of Mental Disorders DSM-IIIR; American Psychiatric Association, 1987) criteria for schizophrenia, delusional (paranoid) disorder, or other psychotic disorders, or (d) were taking a prescribed medication that might affect central nervous system functioning. Patients also had to remain enrolled in the program for at least 2 weeks to be included in the investigation. Psychoactive substance use was strictly prohibited during treatment. Consumption of alcohol or other drugs at any point by patients during treatment was sufficient reason for removal from the program. Additionally, several procedures were employed to detect any covert drug use by patients during their stays. For instance, all residents were required to provide urine samples for analysis upon request by a clinical staff member. New patients (i.e., those enrolled in the program less than 30 days) were not allowed to leave the facility unless accompanied by a staff member and were not allowed to have visitors. Thus, the m i n i m u m program stay requirement greatly increased the likelihood that participants had not used any psychoactive substances during the 2-week interval prior to testing. This minimum 2-week drug-free period prior to testing is r e c o m m e n d e d by many authors (e.g., Miller, 1985; Parsons & Farr, 1981) to reduce the likelihood that any residual effects of psychoactive substances ingested directly prior to admission would adversely affect test performance. Forty-eight patients were asked to participate; 43 initially a g r e e d to enter the study. Ten of these patients left the program after less than 2 weeks and were not tested. Two of these patients were subsequently excluded because of medical conditions that would have interfered with test performance (i.e., 1 patient had recently fractured a bone in his dominant hand; 1 patient had multiple sclerosis); 1 other patient was excluded because of vision problems, leaving 30 participants in this group. IThis particular program specialized in the treatment of substance-abusingpatients whose primary drug of abuse was not alcohol.Applicantswho reported that their primarydrug of abuse was alcoholwere referred to other treatment programs and were thus not availablefor inclusion in this study.

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Participants for a nonclinical control group (n = 30) were recruited via two local newspaper advertisements. These participants were m a t c h e d to the substance-abusing patients on age, education, gender, and race, all of which have b e e n shown to be related to neuropsychological test p e r f o r m a n c e (Lezak, 1983). In addition to the exclusion criteria described for the substance-abusing patients, these r e s p o n d e n t s were excluded if they m e t DSM-III-R criteria for a psychoactive substance use disorder during 12 m o n t h s prior to the interview, if they ever m e t DSM-III-R criteria for d e p e n d e n c e on o n e or m o r e psychoactive substances, or if they used any psychoactive substance during the 2 weeks prior to the assessment. Nine volunteers were subsequently not included in the study because they m e t one or m o r e o f the exclusion criteria (n = 3) or did not fit the m a t c h i n g criteria (n = 6). Table 1 presents the d e m o g r a p h i c a n d b a c k g r o u n d characteristics o f the two samples. T h e groups were c o m p a r e d on each of these variables using analysis of variance (ANOVA) and chi-square tests. T h e matching p r o c e d u r e was generally effective; the groups were not significantly different, p < .05, in terms of age, education, race, or gender. However, a significantly greater p r o p o r t i o n of the nonclinical sample was married, ×9(1, N = 60) = 4.44, p < .05. Materials

Brain Age Quotient-T S c o r e d T h e BAQ-T consists of the Category Test (Halstead, 1947), the Tactual Performance Test Total T i m e and Location scores (Arthur, 1947), Part B of the Trail Making Test (Armitage, 1946), and Block Design a n d Digit Symbol tests f r o m the WAIS. 2 Collectively, these subtests sample a b r o a d range o f abilities, including p s y c h o m o t o r speed and dexterity, spatial ability and memory, c o n c e p t formation, cognitive flexibility, abstract reasoning, a n d nonverbal problem-solving skills. This set o f neuropsychological tests has b e e n used in several different neuropsychological studies of substance-abusing patients and has b e e n shown to be able to detect the type of cognitive deficits seen in this population (Fals-Stewart, 1992; Schau & O'Leary, 1977; Walker, Donovan, Kivlahan, & O'Leary, 1983). However, neuropsychological tests are not only sensitive to brain dysfunction. P e r f o r m a n c e s on m o s t o f these measures are related to certain d e m o g r a p h i c variables, particularly age, education, and g e n d e r (Finlayson, J o h n s o n , & Reitan, 1977; Parsons & Prigatano, 1978). Thus, for this investigation, BAQ-T subtest raw scores were converted to Tscores that were corrected for age, education, and gender. T h e s e conversions were m a d e using the comprehensive test n o r m s developed by H e a t o n , Grant, a n d Matthews (1991), which were based on the test p e r f o r m a n c e s o f a large sample o f participants (n = 486) ranging in age f r o m 17 to 80. Participants in this study were classified as cognitively impaired if they obtained an average battery rI'his subset of tests is often referred to as the Brain Age Quotient (BAQ; ReRan, 1973). As described in Reitan's (1973) original paper, raw scores on each subtest are converted to age-corrected Tscores. The mean Tscore is then identified in a conversion table which yields a corresponding value on a distribution with a mean of 100 and a standard deviation of 15. However, the major limitation of this scoring system, as noted by Reitan, is that the data for the original conversion table are based on the testing results of only 155 examinees between the ages of 30 and 65 years.

T a b l e 1.

Pretreatment Demographic a n d B a c k g r o u n d C h a r a c t e r i s t i c s f o r S a m p l e

Characteristic N

Substance-Abusing Patients

Nonclinical Controls

30

30

26.4 6.1 24--47

26.1 6.3 22--45

Age M SD Range Education (years) M SD Range G e n d e r (%) Male Female Married (%) Racial/Ethnic Composition (%) White African A m e r i c a n Hispanic N u m b e r o f Years o f problematic: Alcohol Use M SD Opiate Use M SD Cocaine Use M SD Cannabis Use M SD N u m b e r Meeting DSM-III-R Substance D e p e n d e n c e Criteria for: Cocaine Alcohol Cannabis Opiates Primary D r u g o f Abuse (N) Cocaine Opiates Cannabis Amphetamines

11.3 2.3 8--16

11.5 2.4 9-18

76.7 23.3 26.6

76.7 23.3 53.3*

63.3 26.7 10.0

70.0 23.3 6.7

7.8 4.3

---

7.5 3.1

---

7.2 3.4

---

7.4 3.5

---

21 16 12 12

-----

17 10 2 1

-----

*p < .05. Nou. A decision-tree algorithm was used to d e t e r m i n e each patient's primary d r u g o f abuse. U s i n g diagnostic information from the Structured Clinical Interview for the DSM-///'-R, we d e t e r m i n e d which substance h a d the m o s t severe DSM-1T1-R substance use severity classification, with d e p e n d e n c e being considered m o r e severe than abuse. If o n e substance h a d the h i g h e s t severity classification, it was considered the primary d r u g o f abuse. If two or m o r e substances obtained the same severity classification (e.g., a patient m e e t i n g criteria for Cocaine a n d Cannabis D e p e n d e n c e ) , f o u r subcriteria were u s e d to d e t e r m i n e primary d r u g o f abuse. Patients were asked: (a) which substance is the major p r o b l e m currently; (b) which d r u g did they m o s t frequently ingest d u r i n g the last 90 days; (c) which d r u g was m o s t frequently ingested (i.e., operationalized as the n u m b e r o f days o f use) d u r i n g the lastyear; a n d (d) which d r u g precipitated the m o s t prior treatm en t episodes. A d r u g received a p o i n t each time it obtained the h i g h e s t score on o n e o f the subcriteria. T h e d r u g that received the highest cumulative score across the subcriteria was listed as the prim a r y d r u g o f abuse. In case o f equal scores a m o n g two or m o r e classes o f substances, the d r u g that was m o s t frequently u s e d over the 90 days prior to the evaluation was designated as the primary d r u g o f abuse.

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7

T score of less than 40. This cutoff score on BAQ-Thas been shown to discriminate reliably between cognitively impaired and intact substance-abusing patients (as idenrifled by the Average Impairment Index of the HRB, Fals-Stewart, 1992). Neuropsychological Screening Battery The NSB was designed to provide a brief, standardized assessment of a relatively broad range of cognitive abilities, including psychomotor speed, sequencing efficiency, visual attention, verbal and nonverbal learning, delayed recall, visuoconstructional skills, expressive and receptive language functions, and reading comprehension. The battery consists of (a) the Symbol Digit Modalities Test (Smith, 1973), (b) Parts A and B of the Trail Making Test (Armitage, 1946), (c) the Numerical Attention Test (Lezak, 1983), (d) a story from the Wechsler Memory Scale (Wechsler, 1945), (e) part of the Rey-Osterrieth Complex Figure (Lezak, 1983), (f) Visual Naming, Aural Comprehension of Words and Phrases, and Reading Comprehension of Words and Phrases (all from the Multilingual Aphasia Examination; Benton & Hamsher, 1976), (g) Commands with Auditory Sequencing, abbreviated from the Western Aphasia Battery (Kertesz & Poole, 1974), and (h) a l-rain assessment of written and oral fluency, requiring the examinee to name as many words as possible that start with the letters p and r, respectively. A standardization sample was used to establish two test score cutoffpoints for the 18 subtests and the summary score. The first cutoff point was at the 1 standard deviation point (defining mild impairment), and the second cutoff point was at the bottom fifth percentile (defining severe impairment). The total summary score for the NSB is computed by assigning 1 point for each mildly impaired subtest score and 2 points for each severely impaired score. Across the 18 subtests, the cumulative score of 6 or greater is considered in the impaired range. These cutoffs were established using the test scores of 130 neurologically normal adults. Assessment of Premorbid Cognitive Functioning To ascertain whether neuropsychological test performance differences between comparison groups are due to discrepancies in cognitive ability prior to any neurological insult, it is important to obtain an estimate of premorbid neurocognitive functioning. The North American Adult Reading Test (NAART; Blair & Spreen, 1989) consists of 61 irregularly spelled words (e.g., debris, psalm, caveat) printed in two columns on both sides of an 8.5 in. X 11 in. card which is given to the examinee to read aloud. Each pronunciation error is counted as 1 point; the cumulative point total is the total score. This test, which assesses the level of reading prior to the onset of brain impairment, provides a lower-limit estimate of premorbid cognitive functioning (Stebbins, Wilson, Gilley, Bernard, & Fox, 1990). The NAART has high correlations with the Wechsler Adult Intelligence Scale--Revised (WAIS--R; Wechsler, 1981) Verbal Intelligence Quotient (r = .83) and the Full Scale Intelligence Quotient (r = .75); interrater reliability and internal consistency coefficients are excellent. Affeetive Measures As suggested by several authors, affective functioning, particularly anxiety and depression, appears to influence test performance negatively and should be assessed

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in neuropsychological studies (e.g., Errico, Nixon, Parsons, & Tassey, 1990; Sinha, Parsons, & Glenn 1989). Therefore, all participants in this study completed the Beck Depression Inventory (BDI; Beck & Beamesderfer, 1974; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report measure of depressive symptomatology commonly used in research on affective disorders (Hammen, 1980). Scores range from 0 to 63, with higher scores indicating greater levels of depression. Participants also filled out the Clinical Anxiety Scale (CAS; Westhuis & Thyer, 1986), a 25-item inventory designed to measure the severity of anxiety reported by respondents. The scale has a range of 0 to 100, with higher scores indicating greater anxiety. The CAS has excellent internal consistency, with a coefficient alpha of .94. This instrument is also able to discriminate reliably between control participants and those patients known to be suffering from anxiety. Drug U s e Measures

All participants were interviewed using the substance use modules of the Structured Clinical Interview for DSM-III-R (SCID-P; Spitzer, Williams, Gibbon, & First, 1990). The SCID-P was administered by one of two bachelor's-level interviewers, both of whom were trained by a psychiatrist with extensive experience using the SCID-P. The interrater reliability of the SCID-P was assessed using a paired-rater design. Videotaped interviews of 20 patients entering a drug abuse treatment center were independently observed by both primary interviewers and by the training psychiatrist. Chance-corrected agreement (kappa) between the two primary interviewers for the substance use disorders ranged from 1.00 to .80. Kappas between the psychiatrist and the primary interviewers for the substance use disorders also ranged from 1.00 to .80. These kappas reflect good to excellent observer agreement (Landis & Koch, 1977). The time-line follow back (TLFB) procedure (O'Farrell & Langenbucher, 1988; Sobell, Maisto, Sobell, & Cooper, 1979) is a reliable and valid method used to estimate use of alcohol and other drugs. The TLFB is a semistructured interview which makes use of a calendar and is used to determine the frequency and amount of participants' alcohol and drug use, as well as potentially related events (e.g., alcohol- or drug-related hospitalizations, halfway house stays, incarceration) during each day of a specified time period prior to the interview.

Procedure

Within I week of admission to the residential substance abuse treatment program, patients participated in a full psychosocial history interview. They also were administered the substance use modules of the SCID-P. These data were collected as part of the standard assessment provided to all patients admitted to the program. The neuropsychological assessments with the substance-abusing patients were initiated 14 days after their admissions and were conducted over a 2-day period. The nonclinical control participants began testing upon arrival at the clinic. All neuropsychological testing was conducted by one of two master's-level psychometricians trained to administer both batteries.

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9

For all participants, the test battery delivered o n the 1st day o f testing w0s c h o s e n r a n d o m l y ; the battery n o t c h o s e n was a d m i n i s t e r e d the following day. This p r o c e d u r e was used to r e d u c e (a) the potential negative effects o f fatigue o n subtest scores (which may have i m p a c t e d results if all subtests were a d m i n i s t e r e d within the same day) a n d (b) any influence administration o r d e r may have h a d o n battery p e r f o r m ance. T h e s t a n d a r d f o r m o f Part B o f the Trail Making Test, which is the only test t h a t these batteries share, was a d m i n i s t e r e d with the battery c h o s e n for the first testing occasion. T o decrease the effect o f practice o n this subtest's score, an alternative f o r m o f the test (Lewis & Rennick, 1979) was substituted into the battery given o n the 2 n d day.3 O n the 2 n d day o f testing, after c o m p l e t i o n o f the n e u r o p s y c h o l o g i c a l assessm e n t , the TLFB interview (using 90 days p r i o r to the interview as the target interval), the BDI, the CAS, a n d the N A A R T were a d m i n i s t e r e d to all participants. Individuals f r o m the nonclinical sample also c o m p l e t e d the substance use m o d u l e s o f the SCID-P to delineate the p r e s e n c e o f a c u r r e n t (past 90 days) a n d lifetime substance use disorder. Finally, all participants submitted u r i n e samples, w h i c h were analyzed to d e t e r m i n e if psychoactive substances h a d recently b e e n ingested. RESULTS D r u g a n d A l c o h o l U s e o f Participants P r i o r to A s s e s s m e n t

N o n e o f the substance-abusing patients r e p o r t e d any d r u g o r a l c o h o l use d u r i n g the 15 days in the residential t r e a t m e n t p r o g r a m . M e a n n u m b e r o f days abstinent f r o m a l c o h o l a n d o t h e r drugs r e p o r t e d by these patients p r i o r to testing was 49.8 days, with a r a n g e o f 15 to 69 days. Participants in the nonclinical c o n t r o l g r o u p also r e p o r t e d n o d r u g or a l c o h o l use d u r i n g the 15 days p r i o r to administration o f the s e c o n d battery. Average n u m b e r o f days o f abstinence f r o m alcohol a n d o t h e r psychoactive drugs for the nonclinical c o n t r o l g r o u p p r i o r to testing was 63.4 days, with a r a n g e o f 21 to 90 days. U r i n e assays for b o t h g r o u p s were negative for all drugs tested. Affective and Premorbid Cognitive Functioning of Substance-Abusing Patients and N o n c l i n i c a l C o n t r o l s

T h e n u m b e r o f p r o n u n c i a t i o n errors o n the N A A R T for the substance-abusing patients ( M = 34.1, SD = 6.2) a n d the nonclinical controls ( M = 33.8, SD = 7.4) was n o t significandy different, F(1, 58) = 1.21, ns, indicating that the participants in the two 3Because the normative data for both batteries are based on the standard form of Part B of the Trail Making Test, it was possible that the use of an alternative form might have influenced test results (even though the correlation of the standard and alternative forms is high). To address this concern, two methods were used to calculate the summary scores for each battery: (a) The score from participants' performances on the form of Part B of the Trail Making Test that was administered with the given battery was used to calculate the summary score; and (b) the score from the standard form of Part B of the Trail Making Test, administered on the 1st day of testing, was used in the calculation of summary scores for both batteries. The correlation between the standard and alternate forms with these participants was high, r(59) = .84. No difference was found in the summary indices when the scores from either form were used in the calculations. Thus, participants' performances on the alternative form are reported, and these scores are used in all subsequent calculations.

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W. Fals-Stewart

g r o u p s h a d c o m p a r a b l e p r e m o r b i d cognitive functioning. Thus, any resulting differences between the g r o u p s o n n e u r o p s y c h o l o g i c a l test p e r f o r m a n c e were n o t likely attributable to discrepancies in levels o f p r e m o r b i d cognitive f u n c t i o n i n g . However, the substance-abusing patients o b t a i n e d h i g h e r scores o n the BDI ( M = 9.1, SD = 6.7) t h a n the nonclinical controls ( M = 5.9, SD = 4.2), F(1, 58) = 8.39, p < .01. Substancea b u s i n g patients also scored h i g h e r o n the CAS ( M = 11.4, SD = 7.5) t h a n the n o n clinical c o n t r o l sample ( M = 5.4, SO = 6.1 ), F(1, 58) = 7.13, p < .01. Because the substance-abusing patients were f o u n d to have h i g h e r levels o f depression a n d anxiety than participants in the nonclinical c o n t r o l c o n d i t i o n , the BDI a n d CAS scores were used as covariates in the g r o u p c o m p a r i s o n s o n subtest a n d s u m m a r y scores for b o t h batteries. However, the inclusion o f the covariates in the linear m o d e l s did n o t c h a n g e any o f the findings (i.e., all significant a n d nonsignificant findings were the same, regardless o f w h e t h e r the covariates were o r were n o t included). For ease o f interpretation, the results o f the analytic c o m p a r i sons w i t h o u t inclusion o f the covariates are r e p o r t e d . 4 Neuropsychological Testing Performances of Substance-Abusing Patients and Nonclinical Control Participants

Differences between the substance-abusing patients a n d the nonclinical c o n t r o l g r o u p o n all B A Q - T subtests a n d the s u m m a r y score were assessed using separate ANOVAs; a sequential B o n f e r r o n i correction (Darlington, 1990) was used to c o n t r o l the n o m i n a l alpha (i.e., the m a x i m u m probability o f m a k i n g a T y p e I error).5 T h e s e c o m p a r i s o n s revealed that substance-abusing patients p e r f o r m e d m o r e p o o r l y o n five o f the six subtests and, consequently, h a d lower s u m m a r y scores t h a n participants in the nonclinical c o n t r o l sample. T h e m e a n (standard deviation) B A Q - T subtest a n d s u m m a r y scores for each g r o u p , a n d the results o f the b e t w e e n - g r o u p comparisons, are p r e s e n t e d in Table 2. Significantly m o r e substance-abusing patients were f o u n d to be cognitively i m p a i r e d (i.e., scored T < 40 o n the B A Q - T s u m m a r y score; 11 o f 30, 36.7%) c o m p a r e d to the nonclinical c o n t r o l g r o u p (2 o f 30, 6.7%), ×2(1, N = 60) = 7.95, p < .01. For the NSB, univariate g r o u p c o m p a r i s o n s for each subtest a n d the s u m m a r y score were c o n d u c t e d using ANOVAs with a sequential B o n f e r r o n i correction. T h e m e a n (standard deviation) NSB subtest a n d s u m m a r y scores for each g r o u p , a n d the results o f the b e t w e e n - g r o u p comparisons, are p r e s e n t e d in Table 3. Substance-abusing patients h a d significantly worse p e r f o r m a n c e s on 3 o f the 18 NSB subtests a n d 4The results from the covariance analysis are available from the author upon request. 5In this procedure, all pairwise Fs are computed and ranked from highest to lowest. The alpha level of the highest F, cx~,is evaluated at the per comparison error rate ofal × B, where B equals the number of palrwise tests to be performed. If this rejects, the next largest a, ct2, is tested at a~ × (B - 1), the remaining number of pairwise comparisons. If this rejects, the next largest difference is tested at as × (B - 2) and so on until a nonsignificant difference, p > .05, is encountered and the procedure is halted. Although this correction is fairly conservative, the results are nearly identical to those found if no c~ adjustment is made. The only discrepancy is that difference between the groups on the NSB Numerical Attention Test--Time is significant, p < .05, with no correction, but is not significant with the correction method described here.

T a b l e 2. B r a i n Age Q u o t i e n t - T S c o r e d (BAQ-T) S u b t e s t a n d S u m m a r y S c o r e s o f S u b s t a n c e - A b u s i n g P a t i e n t s a n d P a r t i c i p a n t s in a N o n c l i n i c a l C o n t r o l C o n d i t i o n

Subtest Digit Symbol Block Design Category Test Tactual Performance Test Time location Trail Making Test Part B Summary Score

Suhstance-Auslng Patients (n = 30)

Nonclinical Con~ol Participants (n = 30)

F(1, 58)

42.9 (8.7) 47.0 (9.0) 40.3 (7.5)

51.4 (10.5) 48.2 (9.6) 49.9 (10.1)

11.5" 0.3 18.0"*

41.7 (8.4) 41.9 (8.4)

51.0 (9.4) 49.5 (10.1)

16.1"* 10.0"

42.9 (9.3) 42.7 (8.3)

51.2 (10.1) 50.2 (9.8)

10.9" 9.9*

Note. Lower scores on these subtests (and the Summary Score) indicate poorer performance. *p < .01. **p < .001. (using sequential Bonferroni correction)

T a b l e 3. N e u r o p s y c h o l o g i c a l S c r e e n i n g B a t t e r y (NSB) S u b t e s t a n d S u m m a r y S c o r e s o f S u b s t a n c e - A b u s i n g P a t i e n t s a n d P a r t i c i p a n t s in a N o n c l i n i c a l C o n t r o l C o n d i t i o n Substance-Abusing Patients (n ffi 30)

Nonclinical Control Participants (n = 30)

Subtest

M

SD

M

SD

E(I, 58)

Symbol-Digit Modalitiesb Trail Making Test Part A~ Part B" Numerical Attention Test Time" Errors" Wechsler Memory Scale Story Story Learning b Story Memory" Rey-Osterrieth Complex Figure Figure Copy b Figure Learning b Figure Memory ~ Speech Articulation Rating b Visual Naming b Aural Comprehension b Reading Comprehension b Written Fluencyb Oral Fluencyb Commands with Auditory Sequencing b Sentence Repetition b Total Summary Score"

50.9

10.2

66.5

11.0

39.0**

24.3 84.2

5.7 22.9

22.8 63.1

7.4 24.1

2.0 12.1"

161.3 4.0

32.4 2.9

143.1 3.9

26.0 3.1

5.3 0.0

13.3 10.1

2.7 6.0

13.1 4,1

2.9 7.9

0.9 21.3"*

16.1 14.1 4.6 8.0 17.6 11.7 II.4 11.9 12.9 22.4

2.5 4.3 8.0 0.0 1.7 0.5 0.6 3.6 4.0 2.1

16.5 15.4 5.4 8.0 17.3 11.8 11,7 13,0 14.0 22,0

2.3 2.9 8.9 0.0 1.6 0.5 1.0 3.5 3.3 1.8

0.8 1.1 1.0 0.0 0.4 0.9 2.6 1.2 3.0 2.3

4.7 4.9

0.7 4.0

4.7 2.1

0.4 2.6

0.9 9.0*

•Higher scores indicate poorer performance. blower scores indicate poorer performance. • p < .05. **p < .01. (using sequential Bonferroni correction)

12

W. Fals-Stewart

had significantly higher summary scores (indicating worse cognitive functioning) than participants in the nonclinical control sample. Once again, significantly more substance-abusing patients were found to be cognitively impaired (i.e., scored -----6 on the NSB summary score; 12 of 30, 40.0%) compared to the nonclinical control group (3 of 30, 6.7%), X2(1, N = 60) = 7.20, p < .01. The kappa of the BAQ-Tand the NSB, with respect to the classification of cognitively impaired versus intact participants, was .81, which is considered satisfactory (Landis & Koch, 1977).

DISCUSSION

Clinical interest in the neurocognitive functioning of individuals who chronically ingest psychoactive substances has grown dramatically over the last 2 decades. Findings from some recent neuropsychological studies appear to have important implications for the treatment of drug addiction and alcoholism, leading several authors to contend that neuropsychological testing should play a more prominent role in the assessment of individuals seeking treatment for substance abuse. However, in order for treatment providers to implement such a recommendation, clinical concerns must be balanced against practical considerations. Thus, the ability of a given neuropsychologicalscreening device to assess a reasonablywide range of cognitive abilities and to detect the types of cognitive impairments typically found among substance-abusing patients must be weighed against the battery's costs (e.g., administration time, price of testing apparatus, time to train personnel to administer and score the battery). The BAQ-T and NSB are both intermediate-length neuropsychological testing batteries that have been used in prior research to assess the cognitive functioning of substance-abusing patients. In this investigation, patients admitted to a long-term residential substance abuse treatment facility performed significantly worse on these batteries, as evidenced by significantly more impaired global summary scores, compared to a demographically matched nonclinical control group. Both batteries identified over one third of the substance-abusing patients as cognitively impaired, with the BAQ-T and the NSB agreeing on most classifications. These findings replicate prior research indicating that substance-abusing patients do perform worse than nonclinical control samples on these batteries. Perhaps the greatest difference between the batteries is revealed when the subtest performances are examined. Compared to the nonclinical control participants, substance-abusing patients had significantly worse scores on five of the six BAQ-T subtests. However, the substance-abusing patients had worse scores than participants in the nonclinical control group on only 3 of 18 NSB subtests. The pattern of subtest scores on both batteries by the substance-abusing patients revealed deficits in attention, memory, learning, and cognitive flexibility. Expressive and receptive language functions, which are assessed by the NSB but not the BAQ-T, are relatively intact among substance-abusing patients. However, the summary scores of both batteries revealed significantly lower neurocognitive functioning among the substance-abusing patients. For substance abuse treatment providers wishing to make more general use of neuropsychological assessment in their facilities or practices, the question becomes, "Which battery is best?" This is difficult to answer for several reasons, most notably

Neuropsychological Screening of SubstanceAbuse

13

because neuropsychological battery selection should be predicated on several specific considerations, including the reason for referral and evaluators' familiarity with the tests available. Additionally, deciding which one of these batteries is superior as a general screening device is difficult because both appear to be adept at identifying cognitive impairment among drug-abusing patients. However, if a neuropsychological testing battery is sought as a general cognitive screening device for substance-abusing patients, to make selection more straightforward, some practical differences between the BAQ-Tand the NSB should be noted. Although both batteries appear to be sensitive to the types of cognitive impairments observed among substance-abusing patients, the NSB samples a broader range of abilities. Both batteries assess some similar cognitive skills, such as nonverbal problem solving, learning, attention, concentration, and psychomotor speed. The NSB places more emphasis on receptive and expressive language ability, verbal memory, reading comprehension, and visuoconstructional accuracy. Even though these cognitive capacities are not often impaired among substance-abusing patients, finding decrements in these areas may have important treatment implications, and assessing these skills could prove valuable with particular cases. Furthermore, such a broadbased initial assessment would serve as a useful guide for further, more comprehensive testing in cases where it is desired. After completion of the study, the psychometricians reported no increased difiqculty, in terms of time or ease of testing, in administering the NSB or the BAQ-T to the substance-abusing patients compared to the individuals in the nonclinical control group. In general, however, the NSB was more convenient and less time consuming to administer than the BAQ-T. As noted by Franklin, Heaton, Nelson, Filley, and Seibert (1988), "Clinical personnel with minimal equipment and training (approximately 8 hours) can administer the NSB in 30 to 45 minutes" (p. 1827). The NSB requires a set of stimulus materials (all of which can be held in a three-ring binder), a testing booklet for administration and scoring, a stopwatch, pencils, blank paper, a protractor, and a ruler. In contrast, the BAQ-Ttypically takes m u c h longer to administer (60-90 rain). Furthermore, some of the testing materials for the BAQ-T are too bulky to be portable and expensive. For instance, the Category Test (which costs several h u n d r e d dollars) consists of a slide projector, slides, a switchbox, and a projection screen enclosed in a large box. The NSB materials are comparatively far less expensive. One advantage of the BAQ-Tis that it is comprised of well-known subtests, drawn from two of the most widely used cognitive assessment batteries (i.e., the WAIS and HRB). Examiners familiar with these batteries who also have access to the readily available Heaton et al. (1991) norms will have little difficulty administering and scoring the BAQ-T. However, two of the subtests, Block Design and Digit Symbol, are taken from the WAIS and not from the updated WAIS--R. It may be difficult for some examiners to find WAIS materials (because the updated WAIS---R has been available since 1981 and has since supplanted the WAIS in general practice). Merely replacing the WAIS subtests with WAIS---R versions is not appropriate because the Block Design and Digit Symbol tests from the two batteries are slightly different (Lezak, 1983), and the BAQ-Thas not, as of yet, been psychometrically evaluated with WAIS---R subtest replacements. However, such a revalidation would not be difficult.

14

W. Fals-Stewart

Some limitations of this investigation should be noted. This study employed a relatively small sample size. Although the n u m b e r o f participants in the study provided sufficient statistical power to detect some univariate differences between the groups on the two batteries, other potentially important analyses could not be adequately conducted. For example, the comparison groups had significantly different scores on several subtests on each battery. However, performances on all o f the subtests that were lower for the substance-abusing patients may have been partially contingent u p o n the same cognitive skill, such as attention. In turn, the lower scores on these different subtests may reflect a group difference in one cognitive ability; it should not be assumed that the different subtests are measuring nonoverlapping constructs. A factor analysis of the battery subtests would help to reveal c o m p o n e n t s that may underlie different subtests; factor scores based on these c o m p o n e n t s could then be used as the d e p e n d e n t variables. Unfortunately, the participant-to-subtest ratio in this study makes such an analysis untenable (Tabachnick & Fidell, 1989). T h e subtests could have been orthogonalized, equally dividing shared variance a m o n g them and thus making them i n d e p e n d e n t (Gorsuch, 1991). This would make group comparison more straightforward statistically, but conceptually more difficult to interpret (e.g., what would the orthogonalized Category Test actually be measuring?). With these issues in mind, the subtest differences between the groups should be interpreted with caution. Because the sample size was relatively small, it should not be assumed that these findings are a reliable indication of the prevalence of cognitive impairment a m o n g patients with substance use disorders (although the results of this study are consistent with prior research in this regard). A replication o f this study with a larger sample of substance-abusing patients, being treated in different types of settings, would be necessary before any generalizable conclusions about the base rate o f cognitive dysfunction in this patient population could be reached. T h e patients who participated in this study would perhaps be best described as polysubstance users; in turn, the findings of this study are not applicable to individuals who chronically use one particular drug. T h e NSB, which has some significant practical and clinical strengths in comparison to the BAQ-T, has not been employed as frequently as the BAQ-Twith substance-abusing patients; continued evaluation of the batterywith this population is warranted. This study evaluated only two intermediate-length cognitive assessment batteries. Thus, future studies may compare other such batteries and thus be able to draw more definitive conclusions about the relative merits of each. However, the findings and recommendations of this investigation may prove useful to addiction treatment providers who desire to add neuropsychological evaluations to patient assessment procedures.

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