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Cited by 35Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesSubstance Abuse Treatment and OutcomesMental Health Treatment and Access

Optimizing screening for depression, anxiety disorders, and post-traumatic stress disorder in inpatient addiction treatment: A preliminary investigation

Open access
Levitt, E.E., Syan, S.K., Sousa, S., Costello, M.J., Rush, B., Samokhvalov, A.V., McCabe, R.E., Kelly, J. +1 more·2021·Addictive Behaviors
DOI 10.1016/j.addbeh.2020.106649PMC PMC11381827
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Abstract

Objective Substance use disorders (SUD) are frequently comorbid with other psychiatric conditions, but a comprehensive diagnostic assessment is often not feasible clinically. Efficient psychometrically-validated screening tools exist for commonly comorbid conditions, but cutoff accuracies have typically not been evaluated in addiction treatment settings. This study examined the performance of several widely-used screening measures in relation to diagnostic status from a clinical interview to identify and validate cutoff scores in an inpatient SUD treatment setting.Method Participants were 99 patients in a large residential SUD treatment program in Ontario, Canada. Participants completed a screening battery, including the Patient Health Questionnaire - 9 (PHQ-9), Generalized Anxiety Disorder - 7 (GAD-7), and Post-Traumatic Stress Disorder Checklist-5 (PCL-5), and underwent a semi-structured diagnostic clinical interview. Receiver operating characteristic curves were used to determine optimal cutoff scores on the screening tool against the interview-based diagnosis.Results Area under the curve (AUC) was statistically significant for all screens and were as follows: PHQ-9 = 0.70 (95% CI = 0.59-0.80), GAD-7 = 0.74 (95% CI = 0.63-0.84), and PCL-5 = 0.79 (95% CI = 0.66-0.91). The optimal accuracy cutoff scores based on sensitivity and specificity were: PHQ-9 ≥ 16, GAD-7 ≥ 9, the PCL-5 ≥ 42.Conclusions In general, the candidate screeners performed acceptably in this population. However, the optimal cutoff scores were notably higher than existing guidelines for depression and PTSD, potentially due to the general elevations in negative affectivity among individuals initiating SUD treatment. Further validation of these cutoff values is warranted.Public health significance This study provides modified screening cutoff scores for major depression, anxiety disorders, and post-traumatic stress disorder in addiction treatment settings.

Integrity signals

Registry

Crossref · 10.1016/j.addbeh.2020.106649

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 13 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    All screening measures performed significantly better than chance.

    “The AUCs suggest that all measures performed significantly better than chance, discerning between participants with and without the disorders.”
    Quote in the paperSubstantial claim
  • Findingown data

    Kappa values indicated substantial to almost perfect agreement between alcohol, cocaine, and opioid use symptom checklists and their corresponding diagnoses.

    “For the current study, the Kappa values indicate that there was fair agreement between the PHQ-9 and a diagnosis of MDD; moderate agreement between the GAD-7, PCL-5, and Cannabis Symptom Checklist, and a diagnosis of anxiety, PTSD, and cannabis use disorder, respectively; and substantial agreement to almost perfect agreement between alcohol use, cocaine use, and opioid use symptom checklists, and”
    Quote in the paperSubstantial claim
  • Findingown data

    Accuracy was fair for major depressive disorder, anxiety disorders, and PTSD.

    “For MDD, anxiety disorders, and PTSD the accuracy was fair.”
    Quote in the paperSubstantial claim
  • Findingown data

    The anxiety screen's positive predictive power captured three-quarters of individuals who actually had the diagnosis.

    “The positive predictive power for anxiety was slightly better, capturing three-quarters of individuals who actually had the diagnosis.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Kappa values indicated moderate agreement between the PCL-5 and PTSD diagnosis.

    “For the current study, the Kappa values indicate that there was fair agreement between the PHQ-9 and a diagnosis of MDD; moderate agreement between the GAD-7, PCL-5, and Cannabis Symptom Checklist, and a diagnosis of anxiety, PTSD, and cannabis use disorder, respectively; and substantial agreement to almost perfect agreement between alcohol use, cocaine use, and opioid use symptom checklists, and”
    Quote in the paperSubstantial claim
  • Borderline: one of the tests for a substantial claim is unclear. 1
  • May combine two claims. 22
  • Classified as probably not a substantial claim. 8

  • Borderline on S1 (asserted), S4 (based): unclear from the text. May combine two claims.

    Findingnone given

    The previously validated PCL-5 cut-off of 31 would over-identify individuals, with specificity of 51%.

    “Again, the previously validated cut-off of 31 would over-identify individuals, with specificity of 51%.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S4 (based).

    Findingnone given

    The previously validated PHQ-9 cut-off of 10 would over-identify individuals with MDD.

    “In contrast, the previously validated score of 10 would over-identify individuals with MDD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A PCL-5 cut-off of 42 correctly identified 81% of individuals with PTSD and 77% of those without PTSD.

    “For the PCL-5, a cut-off of 42 would correctly identify 81% of individuals with PTSD and correctly identify 77% of individuals without PTSD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The PCL-5 demonstrated good sensitivity and excellent specificity.

    “For example, based on the optimal cut-offs in this sample, the PHQ-9 demonstrated good sensitivity and adequate specificity, and the PCL-5 demonstrated good sensitivity and excellent specificity, suggesting the cut-off scores generated in this sample are substantively accurate.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Kappa values for validated cut-offs were lower than or equal to those for optimal cut-offs for PHQ-9 and PCL-5, slightly lower for GAD-7, and almost identical for substance use checklists.

    “The κ values calculated for the validated cut off values were lower than or equal to those calculated using the optimal cut off score for the PHQ-9, and PCL-5, slightly lower for the GAD-7, and almost identical for the substance use checklists.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Optimal cut-off scores were considerably higher than validated cut-off scores, with PHQ-9 five points higher and PCL-5 ten points higher.

    “However, the optimal cut-off scores were considerably higher than the validated cut off scores, with the PHQ-9 being five points higher and the PCL-5, ten points higher.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A PHQ-9 cut-off of 16 correctly identified 72% of individuals with MDD and 64% of those without MDD.

    “For the PHQ-9, a cut-off of 16 yielded the optimal accuracy, correctly identifying 72% of individuals with MDD and correctly identifying 64% of individuals without MDD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The PHQ-9 demonstrated good sensitivity and adequate specificity.

    “For example, based on the optimal cut-offs in this sample, the PHQ-9 demonstrated good sensitivity and adequate specificity, and the PCL-5 demonstrated good sensitivity and excellent specificity, suggesting the cut-off scores generated in this sample are substantively accurate.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    SUD screens had positive predictive powers between 89% and 100% and negative predictive powers between 71% and 88%.

    “As expected, the screens for SUD had stronger predictive power, with positive predictive powers between 89–100%, and negative predictive powers between 71–88%.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The presence of a substance use disorder was assumed for participants because of the clinical setting.

  • May combine two claims.

    Findingown data

    When the previously validated PHQ-9 cut-off was applied, sensitivity increased to 100% and specificity decreased to 29%.

    “Additionally, in the current study, when the previously validated cut-off score for the PHQ-9 was applied in this sample, sensitivity increased to 100%, but specificity decreased to 29%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For the PCL-5, sensitivity did not increase with a higher cut-off, but correct identification of individuals who truly did not have the disorder improved.

    “For the PCL-5, the situation was somewhat different, insofar as sensitivity did not increase with a higher cut-off, but correct identification of individuals who truly did not have the disorder improved.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The GAD-7 sensitivity was adequate but suboptimal (66%).

    “However, similar to the PHQ-9, sensitivity was adequate but suboptimal (66%), suggesting it only correctly identified two-thirds of those who were subsequently determined to have an anxiety disorder.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Both PHQ-9 and PCL-5 had substantially higher cut-off scores in this study.

    “Both the PHQ-9 and PCL-5 in this study had substantially higher cut off scores and, as depression and PTSD are commonly comorbid with substance use, it is critical to establish valid screening values to correctly identify the need for more in depth diagnostic assessment and also guide treatment planning.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    When using the Delgadillo et al. (2011) cut-off with SUD outpatients, sensitivity was 90% and specificity was 37%.

    “Similarly, when using the cut off scores obtained by Delgadillo et al. (2011) with SUD outpatients, sensitivity was 90%, and specificity was 37%.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Delgadillo et al., 2011 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Only one prior validation of the PHQ-9 and GAD-7 exists in a substance use disorder sample, and it was outpatient.

    “In fact, to our knowledge the PHQ-9 and the GAD-7 have only been validated once in a SUD population and that was in an outpatient setting (Delgadillo et al., 2011; Delgadillo et al., 2012).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Delgadillo et al., 2011 source

      Not checked in the free run.

    • cites Delgadillo et al., 2012 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    People entering addiction treatment may have had a recent negative life event that led to admission and may therefore have elevated general negative affectivity.

    “Specifically, individuals in addiction treatment may have recently experienced a negative life event that precipitated admission to treatment, which may increase general negative affectivity.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Many commonly used screening questionnaires have strong validation in general psychiatric populations.

    “Although certain widely used screening questionnaires, have been well validated in general psychiatric settings, they have not been well established among people with SUD.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Diagnostic interviews were audiotaped and checked for accuracy by a second reviewer, with discrepancies resolved by a licensed clinical psychologist.

    “All diagnostic interviews were audiotaped and checked for accuracy by a second reviewer. Where discrepancies were present between the interviewer and the reviewer, the final disposition was made by a licensed clinical psychologist (JM).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Other disorders outside the scope of this study are also comorbid with SUDs and could not be addressed.

    “Furthermore, it is certainly the case that other disorders outside the scope of this study are also comorbid with SUDs (e.g., borderline personality disorder, antisocial personality disorder) and could not be addressed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The study may be representative of inpatient addiction services but not necessarily public inpatient SUD treatment programs or lower acuity settings.

    “Second, although this study may be representative of inpatient addiction services, they are not necessarily representative of public inpatient SUD treatment programs or lower acuity settings, such as outpatient SUD treatment clinics or general psychiatry programs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The sample size was modest, reducing statistical power and representativeness.

    “With regard to limitations, it is important to consider that the sample size was modest, reducing statistical power and reducing the representativeness of the sample.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The GAD-7 demonstrated high internal consistency (α = .92).

    “The GAD-7 demonstrated high internal consistency (α = .92).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The PCL-5 demonstrated good internal consistency (α = .83), and each subscale good to excellent (α's = .81 −.91).

    “The PCL-5 as a whole demonstrated good internal consistency (α = .83), and each subscale exhibited good to excellent internal consistency (α’s = .81 −.91).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The results should not be considered definitive, particularly the specific cut-off scores.

    “Nonetheless, the results should not be considered definitive, particularly in terms of the specific cut-off scores.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The GAD-7 is a global screen for anxiety disorders and does not reflect individual categories within anxiety disorders.

    “Third, the GAD-7 is a global screen for anxiety disorders, and therefore does not reflect individual categories within anxiety disorders (e.g. social anxiety, generalized anxiety, and panic disorder).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    This study supports calls for a more integrated treatment system.

    “Consistent with these trends, this study clearly supports calls for a more integrated treatment system, where programs are focussed on SUD and co-occurring conditions, and clinicians are cross-trained on management of concurrent disorders (McGovern et al., 2014; Drake et al., 2010).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites McGovern et al., 2014 source

      Not checked in the free run.

    • cites Drake et al., 2010 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    SUD screening instruments provide confirmatory evidence that efficient, low-burden screening measures accurately classify individuals diagnostically.

    “However, they provide confirmatory evidence that efficient, low-burden screening measures do indeed accurately classify individuals diagnostically.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The presence of a substance use disorder was assumed for participants because of the clinical setting.
27 of 27

  • The authors state this as an assumption.

    The presence of a substance use disorder was assumed for participants because of the clinical setting.

    “Although the presence of an SUD was assumed given the clinical setting, a secondary objective of the study was to also examine SUD screening in terms of its accuracy.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The YA-SUP assessment (called the 'battery') evolved through literature reviews, discussion of clinically important outcomes with stakeholders, and previous batteries that have been successfully deployed in similar clinical settings.

    “The YA-SUP assessment (called the 'battery') evolved through literature reviews, discussion of clinically important outcomes with stakeholders, and previous batteries that have been successfully deployed in similar clinical settings (71-73).”

    From Initial insights from a quality improvement initiative to develop an evidence-informed young adult substance use program (2022) · cites this paper as [72]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • GAD-7 optimal cutoff conflicts between abstract and discussion

    Major

    The abstract states the optimal GAD-7 cutoff was 9, but the discussion later says the study's optimal cutoff was 10 or greater. These two statements describe different optimal thresholds for the same result.

  • Two different optimal GAD-7 cut-offs are reported

    Major

    The abstract gives an optimal GAD-7 cut-off of 9 or greater, while the discussion gives 10 or greater. This changes which patients would screen positive.

  • Previously validated GAD-7 cut-off changes between sections

    Minor

    The measures section states that the validated GAD-7 cut-off in nonclinical settings is 10 or above, but the discussion describes the previously validated general-psychiatry cut-off as nine and above.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. MacKillop, 2016, Concurrent substance use disorders and PTSD in an inpatient addiction treatment program in Canada, Canadian Journal of Addiction, 7, 33

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Authors
Levitt, E. E., Syan, S. K., Sousa, S., Costello, M. J., Rush, B., Samokhvalov, A. V., McCabe, R. E., Kelly, J., & MacKillop, J.
Affiliations
  • Homewood Research Institute (CA)
  • Centre for Addiction and Mental Health (CA)
  • Peter Boris Centre for Addictions Research (CA)
  • Massachusetts General Hospital (US)
Corresponding author
MacKillop, J.
ORCID
Venue
Addictive Behaviors
Publisher
Elsevier BV
Published
2021-01
Volume
112
Pages
106649
ISSN
0306-4603 (ISSN-L)
DOI
10.1016/j.addbeh.2020.106649
PMC
PMC11381827
OpenAlex
W3084264499
Cited by
35
References
40
Citations by year
2026: 5 · 2025: 10 · 2024: 8 · 2023: 4 · 2022: 5 · 2021: 3
FWCI
2.90
Type
journal article
Language
en
Open access
Licence
Locations
  • Addictive Behaviors (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute on Alcohol Abuse and Alcoholism
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
depression screening, substance use disorders, inpatient addiction treatment, screening cut-off values, PHQ-9, GAD-7, PCL-5, comorbidities, diagnostic accuracy, negative affectivity
MeSH terms
Anxiety Disorders, Depression, Humans, Inpatients, Mass Screening, Ontario, Psychometrics, Sensitivity and Specificity, Stress Disorders, Post-Traumatic

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