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The trauma questionnaire for detecting alcohol abuse: Limiting factors
Alcohol, Vol. 3, pp. 28%289, 1986. ©Ankho InternationalInc. Printed in the U.S.A.
0741-8329/86 $3.00 + .00
The Trauma Questionnaire for Detecting Alcohol Abuse: Limiting Factors I MARISTELA
GOLDNADEL
MONTEIRO, 2 MARIA LAURA NOGUEIRA AND JANDIRA MASUR 3
PIRES
D e p a r t a m e n t o de Psicobiologia, Escola Paulista de Medicina, Rua Botucatu 862-C.P. 20.399-04034, S6o Paulo, SP. Brasil R e c e i v e d 9 J a n u a r y 1986 MONTEIRO, M. G., M. L. N. PIRES AND J. MASUR. The trauma questionnaire for detecting alcohol abuse: Limiting factors. ALCOHOL 3(5) 287-289, 1986.--The trauma questionnaire proposed as a brief and non-intimidating instrument to identify alcohol abuse was applied in a Brazilian group of 109 known alcoholics and 109 non-alcoholics. Although the sensitivity (66%) and specificity (81%) values found were similar to figures previously reported, it was found that sensitivity is influenced by the respondents socioeconomic background. The finding that the only direct item on drinking was the one that most contributed to the sensitivity of the test was discussed. Detection of alcohol abuse
Alcoholism screening
Trauma questionnaire
T H E R E has been an effort to develop brief, easy to administer and less intimidating instruments for screening and early detection of alcoholism. The CAGE test is often quoted as an example of such an attempt [3, 4, 6]. A new brief questionnaire to identify alcohol abuse has been recently proposed in Canada [7]. It contains five questions about trauma, based on the assumption that there is a higher prevalence of injury among persons who drink excessively. The utility of the trauma questionnaire as a diagnostic aid for alcoholism was further assessed in a Brazilian population. Sensitivity and specificity values were calculated and compared with the data from Canada. Since the Canadian population has a higher socioeconomic level than the majority of our population, we decided to verify if differences in the socioeconomic background of the sample may influence the validity of the test. Considering that one out of the 5 questions of the questionnaire directly asks about drinking, its importance to the instrument sensitivity and specificity was also examined.
Diagnosis of alcoholism
at their majority at most two minimum wages per m o n t h - roughly equivalent to 114 U.S. dollars and with a literacy level equivalent to at most elementary school. This sample comprised 47 males and 22 females with a median age of 39 years (ranging from 20 to 62 years) who were admitted to an outpatient alcoholism treatment program. The same number of non-alcoholics, selected in different working settings, matched for sex, age, socioeconomic and literacy level, was the second group. The third group had 40 middle-upper class alcoholics admitted to an inpatient alcoholism treatment program and earning at least twenty minimum wages per month--roughly equivalent to 1140 U.S. dollars. The sample comprised 27 males and 13 females with a median age of 42 years (ranging from 28 to 61 years), the majority of them with an university degree. The last group, also selected in different working settings, had the same number of non-alcoholics matched to the third group for age, sex, socioeconomic background and literacy level. All patients from the first and third group met Research Diagnostic Criteria (RDC) for alcoholism (Spitzer et al. [8]) and were considered to be reliable responders. The remaining groups had abstainers, infrequent and light drinkers according to the classification of Cahalan and Cisin [1]. The interview consisted of general questions (identification, level of education, marital and socioeconomic status) and the 5 trauma questions. The questions of the trauma
METHOD A total of 218 individuals, divided into four groups, were studied. The first group had 69 low socioeconomic class alcoholics. They were an employed working population earning
1Financial support from Banco do Brasil/Fundo de Incentivo h Pesquisa Trcnico-Cientifica (FIPEC). 2Fellowship from FundaqS.o de Amparo h Pesquisa do Estado de Silo Paulo (FAPESP). aCareer Investigator from CNPq (Conselho Nacional de Desenvolvimento Cientifico e Tecnol6gico).
287
288
MONTEIRO
TABLE
TABLE
1
Specificity
Sensitivity a
2
COMPARISON OF THE TRAUMA QUESTIONNAIRE WITH OTHER TESTS
SENSITIVITY AND SPECIFICITY OF THE TRAUMA QUESTIONNAIRE AND THE RESPONDENTS SOCIOECONOMIC BACKGROUND Socioeconomic class
ET AL
%
(n)
%
(n)
Low U p p e r Middle
62 72
(69) (40)
Overall
66
(109)
82 80 81
(69) (40) (109)
Sensitivity (%)
Specificity (~)
66 88 64
8I 83 86
51
63
T r a u m a Questionnaire C A G E ~' G a m m a Glutamyl Transferase h Mean Corpuscular Volume h
"Masur, J. and M, G. Monteiro, 1983. t'Monteiro, M. G. and J, Masur, 1985.
aTwo or more positive a n s w e r s for a positive test.
TABLE
3
NUMBER AND PERCENTAGE OF POSITIVE RESPONSES TO EACH QUESTION OF THE T R A U M A QUESTIONNAIRE Alcoholics ( n = 109)
Questions a
l - - F r a c t u r e s or dislocations 2 - - R o a d Traffic Accidents 3---Injured your head 4 - - I n j u r e d in an assault 5 - - I n j u r e d after drinking
Non-Alcoholics (n = 109)
N
%
N
%
X 'z
p
49 38 38 31 80
45 35 35 28 73
38 20 10 10 3
35 18 11 11 3
2.3 7.6 20.94 13.22 115.34
n.s. 0.01 0.001 0.001 0.001
aSee the Method section for complete questions.
TABLE
4
NUMBER AND PERCENTAGE OF POSITIVE RESPONSES TO EACH QUESTION OF THE TRAUMA QUESTIONNAIRE AND THE RESPONDENTS SOCIOECONOMIC BACKGROUND L o w Socioeconomic Class
Questions a
l - - F r a c t u r e s or dislocations 2 - - R o a d Traffic Accidents 3 - - I n j u r e d your head 4 - - I n j u r e d in an assault 5---Injured after drinking
Alcoholics (n=69)
U p p e r Middle Class
NonAlcoholics (n=69)
Alcoholics (n=40)
NonAlcoholics (n=40)
N
%
N
%
X~
P
N
%
N
%
X~
P
40
26
38
0.12
n.s.
21
52
12
30
4.16
0.05
28 21
30
15
22
1.35
n.s.
17
42
5
12
9.02
0.01
30
8
12
7.37
0.01
17
42
3
7
13.0
0.001
21
27
7
10
15.6
0.001
12
30
4
10
4.5
0,05
19
74
1
I
47.1
0.001
29
72
2
5
38.3
0.001
51
,tComplete questions are provided in the Method section.
DETECTING ALCOHOL ABUSE
289
questionnaire, administered to all groups are the following: (Since your 18th birthday) (1) Have you had any fractures or dislocations to your bones or joints?; (2) Have you been injured in a road traffic accident?; (3) Have you injured your head?; (4) Have you been injured in an assault or fight (excluding injuries during sports)?; (5) Have you been injured after drinking? Two or more positive answers were taken as the criterion for a positive test, according to Skinner et al. [7]. RESULTS Table 1 shows the percent of alcoholic patients with a positive test (sensitivity), and the percent of non-alcoholics subjects with a negative test (specificity), considering at least two positive answers as the criterion for a positive result. The influence of the socioeconomic background on the sensitivity and specificity values of the trauma questionnaire is shown in the same table. A larger number of "true c a s e s " was detected among upper middle class respondents when compared to the low socioeconomic group. The values of sensitivity and specificity obtained for the total sample are compared with those found in previous studies for the CAGE test, gamma glutamyl transferase (GGT) and mean corpuscular volume (MCV) [2,5]. This comparison is shown in Table 2. The discriminative power of each question of the trauma questionnaire was assessed by comparing the number of positive results for known alcoholics and non-alcoholics by the chi-square test. Results for both the total sample or taking into account socioeconomic background are shown in Tables 3 and 4, respectively. Table 3 shows that with the exception of the first question, the other ones discriminated between alcoholic and non-alcoholic patients at a level of at least 1%. However, from the same table it can be concluded that the fifth question--which is the only one directly asking
about drinking--gives a major contribution to the sensitivity value found. Thus, the number of "true cases" for the other 4 questions remains within the range of 28-45%, while the figure for the last question is 73%. Considering the socioeconomic background, it was observed that the first two questions lacked discriminative power for the low class respondents, while all questions discriminated upper middle class alcoholics from non-alcoholics at a level of at least 5%. Again, the figures for the last question were much above those found for the remaining ones (Table 4). DISCUSSION The sensitivity (66%) and specificity (81%) values of the trauma questionnaire applied to a Brazilian population are similar to the figures of 68 and 81% reported by Skinner et al. [7]. Nevertheless, the lower sensitive values found for the low socioeconomic class subjects suggest that the utility of the test depends upon the social characteristics of the population under study. This is further reinforced with the observation that 2 out of the 5 questions did not discriminate between low class alcoholics and non-alcoholics, However, all five questions showed a discriminative power for the upper-middle class in accordance with data from Skinner et al. [7]. The comparison of the trauma questionnaire with results of other tests previously applied to Brazilian populations shows that it is less sensitive than the C A G E test (Table 2). Nevertheless it could be argued that the lower sensitivity of this test, due to its less intimidating nature, might be compensated for if it was used in populations less prone to admit heavy alcohol consumption. However, it should be emphasized that the question that directly asks about injury related to drinking is the most sensitive one.
REFERENCES 1. Cahalan, D. and I. H. Cisin. American drinking practices: summary of finding from a national probability sample. I. Extent of drinking by population subgroups. Q J Stud Alcohol 29: 130, 1968. 2. Masur, J. and M. G. Monteiro. Validation of the "CAGE" alcoholism screening test in a brazilian psychiatric inpatient hospital setting. Braz J Med Biol Res 16: 215-218, 1983. 3. Mayfield, D. G. and R. G. M. Johnston. Screening techniques and prevalence estimations in alcoholism. In: Phenomenology and Treatment o f Alcoholism, edited by W. E. Fann, I. Karacan, A. D. Pokorny and R. L. Williams. New York: Spectrum Publications, Inc., 1980. 4. Mayfield, D. G., G. McLeod and P. Hall. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 131: 1121-1123, 1974.
5. Monteiro, M. G. and J. Masur. Diagnostic of alcoholism: How useful is the combination of gamma glutamyl transferase with different biochemical markers? Drug Alcohol Depend 16:31-37, 1985. 6. Skinner, H. A. and S. Holt. Early intervention for alcohol problems. J R Coil Gen Pract 33: 787-791, 1983. 7. Skinner, H. A., S. Holt, R. Schuller, J. Roy and Y. Israel. Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Int Med 101: 847-851, 1984. 8. Spitzer, R. L., J. Endicott and E. Robins. Research Diagnostic" Criteria, 3rd edition. New York: Biometrics Research, New York State Psychiatric Institute, 1978.
0741-8329/86 $3.00 + .00
The Trauma Questionnaire for Detecting Alcohol Abuse: Limiting Factors I MARISTELA
GOLDNADEL
MONTEIRO, 2 MARIA LAURA NOGUEIRA AND JANDIRA MASUR 3
PIRES
D e p a r t a m e n t o de Psicobiologia, Escola Paulista de Medicina, Rua Botucatu 862-C.P. 20.399-04034, S6o Paulo, SP. Brasil R e c e i v e d 9 J a n u a r y 1986 MONTEIRO, M. G., M. L. N. PIRES AND J. MASUR. The trauma questionnaire for detecting alcohol abuse: Limiting factors. ALCOHOL 3(5) 287-289, 1986.--The trauma questionnaire proposed as a brief and non-intimidating instrument to identify alcohol abuse was applied in a Brazilian group of 109 known alcoholics and 109 non-alcoholics. Although the sensitivity (66%) and specificity (81%) values found were similar to figures previously reported, it was found that sensitivity is influenced by the respondents socioeconomic background. The finding that the only direct item on drinking was the one that most contributed to the sensitivity of the test was discussed. Detection of alcohol abuse
Alcoholism screening
Trauma questionnaire
T H E R E has been an effort to develop brief, easy to administer and less intimidating instruments for screening and early detection of alcoholism. The CAGE test is often quoted as an example of such an attempt [3, 4, 6]. A new brief questionnaire to identify alcohol abuse has been recently proposed in Canada [7]. It contains five questions about trauma, based on the assumption that there is a higher prevalence of injury among persons who drink excessively. The utility of the trauma questionnaire as a diagnostic aid for alcoholism was further assessed in a Brazilian population. Sensitivity and specificity values were calculated and compared with the data from Canada. Since the Canadian population has a higher socioeconomic level than the majority of our population, we decided to verify if differences in the socioeconomic background of the sample may influence the validity of the test. Considering that one out of the 5 questions of the questionnaire directly asks about drinking, its importance to the instrument sensitivity and specificity was also examined.
Diagnosis of alcoholism
at their majority at most two minimum wages per m o n t h - roughly equivalent to 114 U.S. dollars and with a literacy level equivalent to at most elementary school. This sample comprised 47 males and 22 females with a median age of 39 years (ranging from 20 to 62 years) who were admitted to an outpatient alcoholism treatment program. The same number of non-alcoholics, selected in different working settings, matched for sex, age, socioeconomic and literacy level, was the second group. The third group had 40 middle-upper class alcoholics admitted to an inpatient alcoholism treatment program and earning at least twenty minimum wages per month--roughly equivalent to 1140 U.S. dollars. The sample comprised 27 males and 13 females with a median age of 42 years (ranging from 28 to 61 years), the majority of them with an university degree. The last group, also selected in different working settings, had the same number of non-alcoholics matched to the third group for age, sex, socioeconomic background and literacy level. All patients from the first and third group met Research Diagnostic Criteria (RDC) for alcoholism (Spitzer et al. [8]) and were considered to be reliable responders. The remaining groups had abstainers, infrequent and light drinkers according to the classification of Cahalan and Cisin [1]. The interview consisted of general questions (identification, level of education, marital and socioeconomic status) and the 5 trauma questions. The questions of the trauma
METHOD A total of 218 individuals, divided into four groups, were studied. The first group had 69 low socioeconomic class alcoholics. They were an employed working population earning
1Financial support from Banco do Brasil/Fundo de Incentivo h Pesquisa Trcnico-Cientifica (FIPEC). 2Fellowship from FundaqS.o de Amparo h Pesquisa do Estado de Silo Paulo (FAPESP). aCareer Investigator from CNPq (Conselho Nacional de Desenvolvimento Cientifico e Tecnol6gico).
287
288
MONTEIRO
TABLE
TABLE
1
Specificity
Sensitivity a
2
COMPARISON OF THE TRAUMA QUESTIONNAIRE WITH OTHER TESTS
SENSITIVITY AND SPECIFICITY OF THE TRAUMA QUESTIONNAIRE AND THE RESPONDENTS SOCIOECONOMIC BACKGROUND Socioeconomic class
ET AL
%
(n)
%
(n)
Low U p p e r Middle
62 72
(69) (40)
Overall
66
(109)
82 80 81
(69) (40) (109)
Sensitivity (%)
Specificity (~)
66 88 64
8I 83 86
51
63
T r a u m a Questionnaire C A G E ~' G a m m a Glutamyl Transferase h Mean Corpuscular Volume h
"Masur, J. and M, G. Monteiro, 1983. t'Monteiro, M. G. and J, Masur, 1985.
aTwo or more positive a n s w e r s for a positive test.
TABLE
3
NUMBER AND PERCENTAGE OF POSITIVE RESPONSES TO EACH QUESTION OF THE T R A U M A QUESTIONNAIRE Alcoholics ( n = 109)
Questions a
l - - F r a c t u r e s or dislocations 2 - - R o a d Traffic Accidents 3---Injured your head 4 - - I n j u r e d in an assault 5 - - I n j u r e d after drinking
Non-Alcoholics (n = 109)
N
%
N
%
X 'z
p
49 38 38 31 80
45 35 35 28 73
38 20 10 10 3
35 18 11 11 3
2.3 7.6 20.94 13.22 115.34
n.s. 0.01 0.001 0.001 0.001
aSee the Method section for complete questions.
TABLE
4
NUMBER AND PERCENTAGE OF POSITIVE RESPONSES TO EACH QUESTION OF THE TRAUMA QUESTIONNAIRE AND THE RESPONDENTS SOCIOECONOMIC BACKGROUND L o w Socioeconomic Class
Questions a
l - - F r a c t u r e s or dislocations 2 - - R o a d Traffic Accidents 3 - - I n j u r e d your head 4 - - I n j u r e d in an assault 5---Injured after drinking
Alcoholics (n=69)
U p p e r Middle Class
NonAlcoholics (n=69)
Alcoholics (n=40)
NonAlcoholics (n=40)
N
%
N
%
X~
P
N
%
N
%
X~
P
40
26
38
0.12
n.s.
21
52
12
30
4.16
0.05
28 21
30
15
22
1.35
n.s.
17
42
5
12
9.02
0.01
30
8
12
7.37
0.01
17
42
3
7
13.0
0.001
21
27
7
10
15.6
0.001
12
30
4
10
4.5
0,05
19
74
1
I
47.1
0.001
29
72
2
5
38.3
0.001
51
,tComplete questions are provided in the Method section.
DETECTING ALCOHOL ABUSE
289
questionnaire, administered to all groups are the following: (Since your 18th birthday) (1) Have you had any fractures or dislocations to your bones or joints?; (2) Have you been injured in a road traffic accident?; (3) Have you injured your head?; (4) Have you been injured in an assault or fight (excluding injuries during sports)?; (5) Have you been injured after drinking? Two or more positive answers were taken as the criterion for a positive test, according to Skinner et al. [7]. RESULTS Table 1 shows the percent of alcoholic patients with a positive test (sensitivity), and the percent of non-alcoholics subjects with a negative test (specificity), considering at least two positive answers as the criterion for a positive result. The influence of the socioeconomic background on the sensitivity and specificity values of the trauma questionnaire is shown in the same table. A larger number of "true c a s e s " was detected among upper middle class respondents when compared to the low socioeconomic group. The values of sensitivity and specificity obtained for the total sample are compared with those found in previous studies for the CAGE test, gamma glutamyl transferase (GGT) and mean corpuscular volume (MCV) [2,5]. This comparison is shown in Table 2. The discriminative power of each question of the trauma questionnaire was assessed by comparing the number of positive results for known alcoholics and non-alcoholics by the chi-square test. Results for both the total sample or taking into account socioeconomic background are shown in Tables 3 and 4, respectively. Table 3 shows that with the exception of the first question, the other ones discriminated between alcoholic and non-alcoholic patients at a level of at least 1%. However, from the same table it can be concluded that the fifth question--which is the only one directly asking
about drinking--gives a major contribution to the sensitivity value found. Thus, the number of "true cases" for the other 4 questions remains within the range of 28-45%, while the figure for the last question is 73%. Considering the socioeconomic background, it was observed that the first two questions lacked discriminative power for the low class respondents, while all questions discriminated upper middle class alcoholics from non-alcoholics at a level of at least 5%. Again, the figures for the last question were much above those found for the remaining ones (Table 4). DISCUSSION The sensitivity (66%) and specificity (81%) values of the trauma questionnaire applied to a Brazilian population are similar to the figures of 68 and 81% reported by Skinner et al. [7]. Nevertheless, the lower sensitive values found for the low socioeconomic class subjects suggest that the utility of the test depends upon the social characteristics of the population under study. This is further reinforced with the observation that 2 out of the 5 questions did not discriminate between low class alcoholics and non-alcoholics, However, all five questions showed a discriminative power for the upper-middle class in accordance with data from Skinner et al. [7]. The comparison of the trauma questionnaire with results of other tests previously applied to Brazilian populations shows that it is less sensitive than the C A G E test (Table 2). Nevertheless it could be argued that the lower sensitivity of this test, due to its less intimidating nature, might be compensated for if it was used in populations less prone to admit heavy alcohol consumption. However, it should be emphasized that the question that directly asks about injury related to drinking is the most sensitive one.
REFERENCES 1. Cahalan, D. and I. H. Cisin. American drinking practices: summary of finding from a national probability sample. I. Extent of drinking by population subgroups. Q J Stud Alcohol 29: 130, 1968. 2. Masur, J. and M. G. Monteiro. Validation of the "CAGE" alcoholism screening test in a brazilian psychiatric inpatient hospital setting. Braz J Med Biol Res 16: 215-218, 1983. 3. Mayfield, D. G. and R. G. M. Johnston. Screening techniques and prevalence estimations in alcoholism. In: Phenomenology and Treatment o f Alcoholism, edited by W. E. Fann, I. Karacan, A. D. Pokorny and R. L. Williams. New York: Spectrum Publications, Inc., 1980. 4. Mayfield, D. G., G. McLeod and P. Hall. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 131: 1121-1123, 1974.
5. Monteiro, M. G. and J. Masur. Diagnostic of alcoholism: How useful is the combination of gamma glutamyl transferase with different biochemical markers? Drug Alcohol Depend 16:31-37, 1985. 6. Skinner, H. A. and S. Holt. Early intervention for alcohol problems. J R Coil Gen Pract 33: 787-791, 1983. 7. Skinner, H. A., S. Holt, R. Schuller, J. Roy and Y. Israel. Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Int Med 101: 847-851, 1984. 8. Spitzer, R. L., J. Endicott and E. Robins. Research Diagnostic" Criteria, 3rd edition. New York: Biometrics Research, New York State Psychiatric Institute, 1978.