NR 548 Week 5 Screening Tool Appraisal Example

Screening Tool Appraisal: The AUDIT and Its Three-Item Short Form in a Community Mental Health Clinic, Judged Against Its Validation Population, Its Cut Points and What It Cannot Establish

Student Name

College of Nursing, Chamberlain University

NR 548: Psychiatric Assessment for Psychiatric-Mental Health Nurse Practitioner

Instructor Name

Month Day, Year

Screening Tool Appraisal: The AUDIT and Its Three-Item Short Form in a Community Mental Health Clinic, Judged Against Its Validation Population, Its Cut Points and What It Cannot Establish

Why This Instrument

The patient whose evaluation I have been writing up this term told me at first about drinking "a few beers" at bedtime, and it took two follow-up questions to learn the real figure of six to eight beers on most nights. That experience raised the question of whether our clinic should use a structured alcohol screen at every intake instead of relying on how well an individual interviewer asks. The Alcohol Use Disorders Identification Test (AUDIT) is the instrument most often recommended for that purpose. This appraisal considers whether it would do the job in a community mental health clinic.

Purpose as the Developers Stated It

The AUDIT was developed through a World Health Organization collaborative project to detect hazardous and harmful alcohol consumption in primary care, including people whose drinking puts them at risk but who do not yet have alcohol dependence (Saunders et al., 1993). It has ten questions: three on consumption, three on dependence symptoms and four on alcohol-related problems. Each is scored 0 to 4, for a total of 0 to 40.

The developers' stated purpose settles the most important point first. The AUDIT is a screening instrument. A positive score identifies someone whose drinking needs further assessment; it does not diagnose an alcohol use disorder, which requires a clinical interview against diagnostic criteria. A clinic that treats an AUDIT score of 16 as a diagnosis has misused the tool.

The Validation Population

The original AUDIT was developed and tested with primary care patients in six countries: Australia, Bulgaria, Kenya, Mexico, Norway and the United States. The design was deliberately international so the instrument would work across cultures. Later research has tested it in many other settings, including emergency departments, college students and psychiatric outpatients, and a review of that research concluded that the AUDIT performs well across a wide range of populations, though optimal cut points vary (Reinert & Allen, 2007).

The distance between the validation population and our clinic matters. Our patients are adults with psychiatric symptoms, many of whom are depressed or anxious, and several use alcohol to manage those symptoms. Depression may affect how people answer questions about guilt or remorse after drinking, one of the AUDIT's items, which could raise scores. And people referred to a mental health clinic may be more guarded about alcohol than primary care patients, particularly if they fear it will affect their treatment. These differences do not disqualify the AUDIT, but they mean a score from our clinic should not be read as though it came from the original sample.

Properties in Plain Terms

Sensitivity is the proportion of people with a drinking problem whom the test correctly flags. Specificity is the proportion of people without a problem whom it correctly passes. In the original development study, a cut point of 8 identified most people with hazardous or harmful drinking while correctly passing most of those without, with high sensitivity and specificity in that sample (Saunders et al., 1993). Later studies have generally reported lower but still useful figures, especially in populations unlike the original one (Reinert & Allen, 2007).

In plain terms, for our clinic: most patients whose drinking is a problem will score 8 or more, and most patients who score under 8 will not have a serious problem. But some patients with a problem will score low, particularly those who minimize, and some patients who score high will turn out, on interview, not to need treatment for alcohol.

Cut Points as a Trade

A cut point is a choice. Lowering it catches more people with problem drinking but also flags more people who do not have one; raising it does the reverse. The conventional cut point of 8 favors catching cases, which suits a screening tool whose positive results lead to a conversation rather than a treatment. Scores are often grouped into zones: 8 to 15 suggesting advice on reducing drinking, 16 to 19 brief counseling and continued monitoring, and 20 or above further diagnostic evaluation for alcohol dependence. Lower cut points have been suggested for women and older adults, who experience harm at lower levels of drinking (Reinert & Allen, 2007).

For a mental health clinic, where alcohol often worsens mood, sleep and suicide risk, a low threshold for a closer look is reasonable. The cost of a false positive is a few extra questions; the cost of a missed case can be much higher, as the patient in this term's case shows.

The Short Form

The AUDIT-C uses only the three consumption questions, scored 0 to 12. In a study of male veterans in primary care, the AUDIT-C performed about as well as the full AUDIT in identifying heavy drinking and alcohol abuse or dependence (Bush et al., 1998). Its practical advantages are clear: it takes under a minute and fits easily on an intake form. Its limitation is that it measures consumption only, so it says nothing about dependence symptoms or harm. For a busy clinic, a sensible approach is to use the AUDIT-C at every intake and complete the full AUDIT when the short form is positive.

What the Tool Cannot Establish

The AUDIT cannot diagnose alcohol use disorder, establish whether alcohol is causing a patient's depression, or assess withdrawal risk. It depends entirely on honest self-report, which is exactly what failed in my first interview with the patient. A self-report questionnaire may help with that problem, since some people disclose more on paper than face to face, but it cannot solve it. A patient who writes "2 to 4 drinks" on the AUDIT when the real figure is eight will score low. The tool supplements a skilled interview; it does not replace one.

Recommendation

I would recommend that the clinic add the AUDIT-C to every intake packet, complete the full AUDIT for positive screens, use a cut point that favors sensitivity, and treat any positive result as a prompt for a clinical interview about drinking rather than as a conclusion. Staff should also be reminded that a negative score does not end the inquiry when the history or the examination suggests otherwise.

Any change to intake procedures should be reviewed after three months.

References

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Reinert, D. F., & Allen, J. P. (2007). The Alcohol Use Disorders Identification Test: An update of research findings. Alcoholism: Clinical and Experimental Research, 31(2), 185-199. https://doi.org/10.1111/j.1530-0277.2006.00295.x

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x