Assessment tools for screening and clinical evaluation of psychosocial aspects in addictive disorders.

This article provides an overview of the tools for psychosocial assessment of substance use disorders. Various psychosocial factors need to be assessed for effective management of individuals and to carry out research in the field. These factors include socio-demographic characteristics, neuropsychological functions, psychiatric co-morbidities, psychological vulnerabilities such as personality traits, motivation, and cognitions related to drug use, and the psychosocial functioning of the individual and his family. The various tools used to assess these aspects have been outlined below and the brief descriptions provided can help in choosing the right tool based on the characteristics that need to be measured and logistics.

INTRODUCTION

Using assessment tools is an important aspect of management and research in addiction psychiatry. Addiction is a bio-psycho-social-spiritual disorder and the evaluative and management process of those suffering from addiction is incomplete if the psychosocial aspects are not accounted for1. This article outlines assessment tools used for those with substance use disorder that have a psychosocial focus.

Psychosocial factors in substance use disorders

Both biological and psychosocial factors influence the initiation and progression of dependence and their effects are not exclusive of each other. The following psychosocial aspects of substance abuse can be assessed:

Social determinants of substance use: For e.g. age, gender, socio-economic status, cultural affiliation, etc.

Psychological vulnerabilities: temperament, personality, developmental influences such as parenting

Cognitions related to substance: craving, salience, expectancy from substance use, etc.

Motivational level

Psychosocial impact on substance use: quality of life, disability experienced, etc.

Tools to assess the social determinants of substance use disorders:

The illness trajectory of an individual with substance use disorder is affected by socio-demographic factors such as gender, age, and factors that impact the socio-economic status of the person and his family23. Socio-economic class of a person can be determined by taking note of the socio-demographic details of an individual by asking questions off a semi-structured socio-demographic pro forma. These pro forma are the foremost section of any clinical assessment or research questionnaire for substance use disorders and contain information on age, gender, educational qualifications, professional qualification, current employment status, marital status, family background (joint family or nuclear family), place of residence (urban, rural, etc.), religion, etc., In India, the revised Kuppuswamy scale and BG Prasad socio-economic scale are used to determine an individual's socio-economic status4. These scales are revised regularly due to changes in the Consumer Price Index of India, as they are dependent on income evaluation.

Modified Kuppuswamy's socio-economic status scale, revised for 2016: The Kuppuswamy scale classifies the family into lower class, upper lower class, lower middle class, upper middle class, and upper class based on the monthly family income, the family head's occupation and education level.

The modified BG Prasad scale uses only the monthly family income to classify the family into lower class, lower middle class, middle class, upper middle class and upper class. It has some added advantages over the Kuppuswamy scale: applicable to both urban and rural areas, applicable to both individuals and families.

Tools to assess psychological vulnerabilities to SUDs

Certain psychological deficits make a person more vulnerable to SUDs and relapse. Craving is a strong, uncontrollable desire to do a specific activity. Its neurobiological correlates and its impact on the course of SUDs is well documented5. Impulsivity is an important determinant of an individual's vulnerability to drug abuse6. The tools that can measure craving and impulsivity are described below:

Craving/Impulsiveness:

Obsessive Compulsive Drinking Scale (OCDS): This is a 14-item self-rated instrument used to quantify and monitor obsessive thoughts about alcohol use and compulsive behavior towards drinking7. The three aspects regarding thoughts related to alcohol use: “resistance/control impairment,” “obsession,” and “interference” can be measured. The scale also has an adolescent version given by Deas et al. (2001)8 called the OCDS-A that can differentiate between problem drinkers and experimental drinkers in this age group.

Obsessive Compulsive Drug Use Scale (OCDUS) is a well known 12-item measure used to measure drug use craving. It measures three factors: thoughts about drugs and interference, desire and control, and resistance against thoughts and intention to use drugs9.

Desire for Drug Questionnaire (DDQ): is a 13-item self-report instrument that can measure three domains of craving for drug use: intention to use drugs, and negative reinforcement and control over desire to use drugs10.

Penn Alcohol Craving Scale (PACS): this is a short 5-item self-reported questionnaire that can be used in all age groups11. It assesses frequency, intensity, and duration of thoughts about drinking and the ability to resist drinking.

Alcohol Craving Questionnaire (ACQ-NOW) is a 47-item self-administered tool that can measure 4 dimensions of acute alcohol craving: emotionality, purposefulness, compulsivity, and expectancy12. A shorter version, ACQ-SF-R is also available that is reliable and sensitive to change.

UPPS Impulsive Behavior Scale (UPPS): This is a 45-item scale measures impulsivity across dimensions of the Five Factor Model of personality. The scale consists of 4 sub-scales: Premeditation, Urgency, Sensation and Perseverance13. The revised version, UPPS-P is a 59-item scale that assesses additional personality features for impulsive behavior14.

Barratt Impulsiveness Scale (BIS): This scale is commonly used to measure impulsive personality traits15. There are 30 items in the latest version and they are classified into 3 sub-scales: attentional impulsiveness, motor impulsiveness and motor-impulsiveness.

Tools to assess the cognitions vulnerabilities to SUDs

A cognitive vulnerability is defined as ‘an erroneous belief, cognitive bias, or pattern of thought that predisposes an individual to psychological problems’16. Individual with SUDs deal with certain cognitive vulnerabilities that arise due to their expectations from substance use, how confident do they feel about managing their craving and control towards their primary substance of abuse and what benefits and harms do they perceive from continuing to use drugs. The tools mentioned below help screen for and record the nature of these cognitive vulnerabilities:

Alcohol Expectancy Questionnaire (AEQ) is a 120 item self-report assessment tool that can measure one's expected positive reinforcement from alcohol use17. The responses can help determines the specific personal expectations from alcohol use in 6 domains: more positive experience, assertiveness, relaxation, arousal, sexual enhancement, greater social and physical pleasure and more assertiveness. The tool has an adolescent version, AEQ-A which has 90 items and notes expectation in the following 7 domains: “Global positive changes, sexual enhancement, cognitive and motor impairment, increased arousal, relaxation and tension reduction, enhanced social facilitation, and enhanced cognitive and motor skills”18.

Negative Alcohol Expectancy Questionnaire (NAEQ) is a 60-item self-report instrument that can measure what would be negative consequences of immediate alcohol use. These expected outcomes can indicate the motivation to quit alcohol use and monitored during therapy to gauge process. The questions enquire about outcomes expected in 3 different time frames: same day, next day and long-term outcomes. A shorter 22-item version is also available.

Cannabis Expectancy Questionnaire (CEQ) is a 45 item self report tool that can record both positive and negative outcomes that a person associates with cannabis use19.

Marijuana Effect Expectancy Questionnaire (MEEQ) and Stimulant Effect Expectancy Questionnaire (SEEQ) by are self report tools that assess the expectations of an individual from cannabis and cocaine use20. MEEQ also has smaller 6-itm version called the MEEQ-B21.

Alcohol Abstinence and Self Efficacy Scale (AASE): this is a self-administered scale that measures self-efficacy i.e. ability to avoid alcohol use in 20 different drinking situations such ‘When I am on vacation and want to relax’ or ‘When I am feeling angry inside’22. The responses to each of the situation are used to score items in 4 5-item sub-scales: ‘Negative Affect, Social/Positive, Physical and Other Concerns, and Withdrawal and Urges’.

Drink Refusal Self Efficacy Questionnaire (DRSEQ): is a self-administered 31-item measure of drinking that measures a person's self- perceived ability to resist drinking23. The questionnaire has three factors: drinking in situ ations characterized by social pressure, opportunistic drinking, and emotional relief. It is useful to monitor progress in therapy and to screen for problematic drinking. A revised version with sound psychometric properties, DRSEQ-R is also available24.

Drug Avoidance Self Efficacy Scale (DASES): consists of 16 situations that a client is asked to imagine self in25. The responses on a 7-point scale can adjudge a client's ability to cope with high-risk situations related to drug use.

Alcohol (and Illegal Drugs) Decisional Balance Scale: This is a 20-item self-rated instrument used the pros and cons of alcohol and drug use that are perceived by an individual on a 5 point likert scale26.

Alcohol and Drug Consequences Questionnaire (ADCQ): This is a 28-item self-rated instrument that measures that indicates the consequences of alcohol and drug use as experienced by a substance user27. This is useful information in case of individuals undergoing cognitive therapy for relapse prevention.

Brief Situational Confidence Questionnaire (BSCQ) This instrument lists 8 situations to the person in which they are likely to experience a drug or alcohol related problem28. Then they are asked how confident are they (in percentage) that they will be able to resist the urge to use the psychoactive substance. The information provided for each of the situations becomes a useful talking point when discussing relapse prevention in high-risk situations.

Motivation

Motivation to seek treatment for SUDs and to abstain from drug use has an important role to play in determining the treatment plan for a client. Commonly, motivation is defined by the readiness to seek treatment and readiness to change of an individual29. The stages of change: pre-contemplation, contemplation, preparation, action and maintenance are used to slot the client based on how motivated he/she is to quit substance use. Based on the stage, certain pharmacological and non-pharmacological interventions can be planned to reduce the possibility of continued drug use. Commonly used instruments to assess motivation are described below:

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES): This is a 19-item self-report questionnaire that scores an individual's motivation by assessing 3 domains: recognition of having a problem related to alcohol use; ambivalence regarding alcohol use; and steps being taken by a person to bring down alcohol use30. The individual's scores in these 3 domains helps to decide further psychosocial management of the individual.

University of Rhode Island Change Assessment Scale (URICA): This is a 31-item self-report tool to assess how a person feels about rectifying a ‘problem’ in their life and/or approaching therapy31. The term ‘problem’ could mean substance use. Based on the average scores on pre-determined sets of questions from the scale, it can be determined whether a person is in pre-contemplation, contemplation, action or maintenance stage of change, to provide a composite change score (C + A+ M-PC).

Readiness to change questionnaire (RCQ): This is a 12-item self-report questionnaire that is based on URICA32. It is structured around deciding whether a person is in pre-contemplation, contemplation, or action stage of change. For use in treatment settings, there is a treatment version available – RCQ-TV.

Motivation for Addiction Treatment-Hindi scale33: This scale was specifically developed for the Indian population. It assesses motivation to quit substance use and seek treatment irrespective of the kind of substance being used.

Tools to assess psychosocial impact of substance use

It is important to measure the psychosocial impact of substance use and to assess the change in the psychosocial status in an objective manner so as to plan targeted psychosocial interventions. The tools that assess disability due to SUDs and impact of SUDs on quality of life can be helpful objective measures that bring out these issues. Some of them are described below:

WHO Quality of Life (WHO-QOL) Assessment: The WHO-QOL is a 100 item questionnaire that assesses an individual's quality of life in 6 domains: physical, psychological, social relationships, environment, level of independence and spirituality34. The other versions of the scale are the WHO-QOL BREF which is an abbreviated version of WHOQOL-100. The WHO-QOL instruments for people living with HIV-AIDS is called WHOQOL-HIV. It is a 120 item questionnaire that assesses quality of life in the 6 domains. The Hindi version of WHO-QOL is useful for Indian populations35.

WHODAS 2.0: Several versions (36 and 12 item version; interviewer, self-rated or proxy version) of WHODAS are available for assessment of an individual's health status and disability experienced due to mental, physical and substance use related disorders36. Six domains of functioning are covered: cognition, mobility, self-care, getting along, life activities, and participation.

Tools to assess functioning of individuals with SUDs

The primary aim of treatment of SUDs is to improve their functioning. The client should be able to perceive the impact of interventions on their functioning and the treating team too needs to measure the functioning to decide if their efforts have been of any consequence. The functionality of an individual with SUDs is also an important research outcome. The tools that are commonly used to measure functioning are outlined below:

Global Assessment of functioning (GAF): This scale can be used to quantify the psychosocial functioning of an individual on a scale on 0 (inadequate information) to 100 (optimum functioning). The scale does not include impairment in functioning experienced due to physical ailments and environmental factors37.

Personal and Social Performance scale (PSPS): This scale was developed from the Social and Occupational Functioning Assessment Scale (SOFAS)38. It tests functioning in 4 domains: self-care, social useful activities, personal and social relationships, and disturbing and aggressive behavior. A score between 0 (inadequate information) to 100 (optimum functioning) can be given based on the assessments.

The instruments described so far are necessary for assessment of psychosocial functioning. In addition, impaired neuropsychological functioning and co-occurrence of psychiatric co-morbidity need to be screened and managed in individuals with SUDs. The sections below provide an overview of some of the instruments that can be used for this purpose.

Tools to assess neuropsychological functioning in those with SUDs

Substance use disorders could lead to impaired cognitive functioning and it is important to assess the baseline and changes in the neuropsychological performance and behavior of a person undergoing treatment, or as part of research. The neuropsychological functioning of a person can determine what sort of treatment approach will be best of a person, what will be the best rehabilitative plan, what kind of management strategy should be employed and what is the prognosis. Table 1 outlines the list of instruments that can be used to assess neuropsychological performance.

Table 1

Tests to assess neuropsychological performance

Table 1: Tests to assess neuropsychological performance Tools to assess psychiatric co-morbidities in those with SUDs

Individuals with SUDs often suffer from psychiatric disorders. The prevalence of dual diagnosis among the Indian population has been shown to be as high as 60% alcohol and opioid dependent patients52. It is essential to screen patients for psychopathology such as psychotic symptoms, mood and anxiety symptoms, and other specific psychiatric disorders such as eating disorder, sexual dysfunction that impact the diagnosis and management. An analysis for stress related disorders such as Post-traumatic Disorder (PTSD) is necessary, as those with SUDs have often experienced a traumatic event which acts as perpetuating factor for drug abuse53. Thus, an important part of psychosocial assessment is to screen and diagnose for these co-morbid conditions. Table 2 outlines some of the tools that have been used to assess psychiatric disorders in those with SUDs.

Table 2

Tests to assess psychiatric comorbidity

CONCLUSION

Psychosocial assessment of those with substance use disorders is an important step in formulation of a management plan and it also holds an important place as an outcome measure in substance use research. The tools described above are useful in screening for psychosocial deficits that one commonly comes across in those with SUDs. While some of these instruments have been adapted to be used on the Indian population, it is important to develop more such measurements that are appropriate and effective.[54-73]

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Conflicts of interest

There are no conflicts of interest.