Brief Reports. Brief Screening for Psychological and Substance Abuse Disorders in Veterans With Long-Term Spinal Cord Injury

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1 Brief Reports Brief Screening for Psychological and Substance Abuse Disorders in Veterans With Long-Term Spinal Cord Injury Kenneth R. Weingardt Veterans Affairs Palo Alto Health Care System and Stanford School of Medicine Jeanette Hsu and Michael E. Dunn Veterans Affairs Palo Alto Health Care System University ABSTRACT. Objective: To determine rates of positive screens for psychological and substance use disorders in persons with long-term spinal cord injury (SCI). Study Design: A naturalistic cohort design wherein consecutive admissions during an 8-month period completed the screening battery. Setting: Veterans Affairs SCI Center. Participants: One hundred fifteen men, 2 women, mean age 57.4 years, injured an average of 20 years, readmitted for various reasons. Main Outcome Measures: The Alcohol Use Disorders Identification Test (AUDIT) and screening items for depression and anxiety disorders. Results: Rates of positive screens ranged from 6.2% for alcohol problems to over 40% for anxiety disorders. Positive screens for depression and anxiety correlated positively with the number of recent hospital admissions. Conclusions: Systematic brief screening for psychological and substance abuse disorders in this population revealed rates of positive screens at least equal to those in other medical patient populations. Kenneth R. Weingardt, Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Jeanette Hsu and Michael E. Dunn, Psychology Service, Veterans Affairs Palo Alto Health Care System. We wish to gratefully acknowledge Shannon Cook and William MacAllister for their assistance in data collection. Correspondence concerning this article should be addressed to Jeanette Hsu, PhD, Psychology Service, Veterans Affairs Palo Alto Health Care System, Menlo Park Division, 795 Willow Road (137-ATS), Menlo Park, California Rehabilitation Psychology, 2001, Vol. 46, No. 3, In the public domain DOI: //

2 272 Weingardt, Hsu, and Dunn Screening for psychological and substance abuse disorders in primary care has gained considerable popularity in recent years in order to identify patients presenting with somatic complaints who are in need of mental health or substance abuse interventions (e.g., Oliansky, Wildenhaus, Manlove, Arnold, & Schoener, 1997; Prestidge & Lake, 1987; Stein et al, 1999; Wittechen & Boyer, 1998). Although there is controversy about the best type of screening measure to use, some consensus has emerged that early identification and intervention for these disorders in primary care have utility because of the cost offset in terms of reduced health care utilization as well as the improvements in the quality of life among patients. Base rates of psychological and substance abuse disorders in patients with spinal cord injury (SCI) have typically been found to be equal to or greater than those in the general medical population. Studies have shown primary or associated mental health problems in at least 20% of primary care outpatients, with prevalence of psychiatric disorders as detected by the Primary Care Evaluation of Mental Disorders (PRIME-MD) at 28%-39% for any psychiatric disorder, 21%-26% for mood disorders, 15%-18% for anxiety disorders, and 5%-7% for alcohol abuse or dependence (Spitzer et al., 1994; Spitzer, Kroenke, & Williams, 1999; O'Malley et al., 1998). In a veteran population with SCI, Radnitz et al. (1996) found that major depression and substance abuse or dependence were the most frequently diagnosed disorders, similar to control participants who had suffered trauma that did not result in SCI. Kemp, Krause, and Adkins (1999) found that 42% of respondents in their community sample of individuals with SCI reported clinically significant depressive symptomatology. Reports of longitudinal research (e.g., Craig, Hancock, & Dickson, 1994) suggest that approximately 30% of persons with SCI have heightened levels of anxiety and depressive mood for up to 2 years after injury. Furthermore, the literature suggests that persons with SCI who report the highest levels of psychiatric distress are typically younger, male, and recently injured (Laatsch & Shahani, 1996; Kishi, Robinson, & Forrester, 1994). See Overholser and Schubert (1993) and Elliott and Frank (1996) for comprehensive reviews of the large literature on depression and SCI. In terms of substance abuse, the literature suggests that individuals with SCI use alcohol as much as, or more than, the general population, despite additional risk factors for negative health consequences, such as medication interactions and disability-related health problems (Moore & Li, 1994). Heinemann, Doll, Armstrong, Schnoll, and Yarkony (1991) found that 70% of their sample of patients with SCI reported experiencing problems resulting from substance use, with 16% indicating that they believed they needed treatment at some time. Despite the prevalence of these disorders in the SCI population, there is virtually no literature using brief screening measures with these patients. The present study represents an initial attempt to conduct in this specific inpatient population systematic screening for psychological and substance abuse problems of the kind that is being advocated in primary care settings.

3 Brief Screening in Spinal Cord Injury Inpatients 273 METHOD Participants Participants were 115 male and 2 female veterans consecutively admitted to the inpatient SCI unit of a large Department of Veterans Affairs Medical Center. Thirty-eight percent of participants were admitted for yearly interim evaluations, 45% for medical-surgical reasons, and 16% for rehabilitation. Fifteen percent of participants were African American, 4% were Hispanic, 1% were Asian-Pacific Islanders, 1% were Native Americans, and 79% were Caucasian. Mean age of participants was 57.4 years (SD = 14.2). Forty-seven percent had paraplegia, and 53% had tetraplegia; mean length of time since injury was 19.8 years (SD = 14.7); and mean length of stay was 56.4 days (SD = 71.8). Measures The screening instrument used in the present study was modified from one that was routinely used in primary care clinics in the medical center. It included a four-item screen for current and lifetime depression developed by Rost, Burnham, and Smith (1993) that was based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for Major Depressive Disorder. The items from this depression screening measure inquire about frequency, duration, and intensity of depressive symptoms in a branching question format. Three other items screened for anxiety: "In the last six months, have you been very nervous or anxious?"; "Have you had trouble controlling your feelings of worry?"; "Have you been feeling restless, irritable or having trouble sleeping?" Two items screened for panic attacks: "Have you ever had attacks of extreme anxiety, fear, or panic that seem to come on suddenly in situations or places that pose no 'real' danger?" and "Have you ever had a panic attack when you suddenly had a lot of physical symptoms, like racing heart, sweating, dizziness, shakiness, shortness of breath, choking or smothering sensation, nausea or abdominal distress?" Four items screened for current posttraumatic stress disorder (PTSD) symptoms (nightmares, intrusive thoughts, hypervigilance, and numbness or detachment). Screening items for anxiety disorders closely parallel DSM-IV criteria for these psychiatric disorders. The 10-item Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, De La Fuente, & Grant, 1993) is a comprehensive and wellvalidated instrument that measures physiological and psychological dependence on alcohol as well as the degree to which respondents report having experienced negative consequences from drinking. Scores of 8 or above on the AUDIT are suggestive of alcohol problems. The Drug Scale from the Addiction Severity Index (McLellan et al., 1992) was used to screen for the presence or absence of illicit drug use during the past 6 months. Finally, two items asked patients to rate their perceived health relative to ambulatory and disabled populations, and an

4 274 Weingardt, Hsu, and Dunn open-ended question asked patients to describe the way that they handle stress in their lives (i.e., ways of coping). Additional hospital utilization and demographic data, including length of stay, total number of admissions in the year prior to admission, total number of SCI outpatient appointments, length of time since injury, level of injury, and veteran status, were obtained from the hospital database. Procedure From October 1998 through May of 1999, each newly admitted patient was approached within 1 week of admission to complete the brief (10-min) screening interview. All but two patients agreed to be screened. Patients were interviewed at bedside by one of the authors or by one of two psychology graduate students who were completing a practicum in the SCI Unit. Immediately after completing the screening questions, each patient was asked a number of questions about those items for which he or she screened positive. The essence of these follow-up questions was a review of DSM-IV criteria for the disorder or disorders for which a respondent screened positive to ascertain whether the respondent actually met DSM-IV criteria for that disorder. RESULTS Rates of Positive Screens Overall, 45% of respondents screened positive for any psychiatric disorder, 16% for depression, 40% for any anxiety disorder (9% for generalized anxiety, 24% for panic attacks, 21% for current PTSD symptoms), and 6% for alcohol problems. Six percent of the sample acknowledged having used cannabis in the past 6 months, but none reported having used any other illicit drugs during that time period. Relationships Between Screening Measures, Demographic Variables, and Hospital Utilization Variables A significant positive correlation was found between the total number of admissions in the previous year and whether a patient screened positive for depression (r =.23, p =.01) and generalized anxiety (r =.30, p <.01). Figure 1 provides a graphical illustration of this relationship. However, when these variables were entered into a regression equation that also controlled for length of stay, number of outpatient appointments, age, level of injury, length of time since injury, and ratings of perceived health, the total number of admissions in the prior year did not predict positive screens for depression or anxiety. In addition, a multivariate analysis of variance identified a significant relationship

5 Brief Screening in Spinal Cord Injury Inpatients 275 ou jq 0) <it) k. 20 t=; 1 K - s * in - c u- O D One admission D Two admissions D Three or more n Depression Anxiety Figure 1. Percentage of patients who screened positive for depression and anxiety by the total number of admissions in the previous year. between age and alcohol problems, F(l, 101) = 6.4, p =.01, with younger participants reporting more alcohol problems than older ones. DISCUSSION Brief screening for psychological and substance use disorders has demonstrated utility in primary care settings and has also been used with medical inpatients, rheumatology outpatients, and oncology patients undergoing radiation therapy, among others. The present results suggest that rates of positive screens for psychiatric disorders in an inpatient population with SCI are either closely equivalent to or higher than rates found using the PRIME-MD in primary care outpatients. In particular, rates of positive screens on anxiety measures were markedly higher in this sample (40% for SCI vs. 11%-15% for primary care). Although the actual incidence of DSM-IV diagnoses in this sample is unknown, these results are consistent with the literature that the population of medical patients with SCI may be experiencing levels of psychological distress at higher rates than primary care medical outpatients. This finding supports the importance of accurate recognition and treatment of psychological problems in older inpatients with SCI well beyond the time of injury. Furthermore, positive screens for depression and any anxiety disorder in this sample of inpatients with SCI were significantly and positively correlated with the total number of admissions in the year prior to the index admission, suggesting that high utilizers of hospital resources may also be exhibiting symptoms of depression and anxiety, which may complicate their medical compliance, selfcare, and ability to seek social support (cf. DiMatteo, Lepper, & Croghan, 2000). As in other studies of high utilizing medical patients (e.g., de Boer, Wijker, & de Haes, 1997), this group of patients appears to be at highest risk of exhibiting depression, substance abuse, and other psychological problems. For panic attacks and PTSD, the screening items used in the current study

6 276 Weingardt, Hsu, and Dunn were lists of the DSM-IV diagnostic criteria for those disorders, and a participant who endorsed any of the criteria was coded as screening positive. In contrast, the screening measures for depression and generalized anxiety were somewhat more sophisticated, with question branching. For example, in the screening measure for depression, respondents were first asked how much of the time during the past week they had felt depressed. If they answered less than 1 day, they were coded as a negative screen and the rest of the depression items were skipped. If they answered more than 1 day, they were asked the other three screening questions. This difference in item construction may partially account for the relatively higher rates of positive screens for panic attacks and PTSD found in the present study. Limitations The conclusions reached by the current study cannot be generalized to a nonveteran population with SCI. Veterans and nonveterans have been found to differ significantly on indices of physical and psychological health (Hisnanick, 1994; Norquist, Hough, Golding, & Escobar, 1990). Because the veteran population is treated within an integrated medical system with continuity of care in which recognition and treatment of psychosocial problems is a priority, it is likely that nonveteran populations with SCI may actually exhibit even higher rates of psychological problems than the veteran population with SCI. Recommendations and Future Directions In the present study, the total number of admissions in the year prior to the index admission was significantly correlated with screening positive for depression and anxiety. With a larger sample size, the total number of admissions may emerge as a significant predictor of positive screens in a regression equation controlling for other hospital utilization and demographic variables. The high rates of positive screens and their correlation with number of admissions found in this study suggest that (a) systematic screening of all patients with SCI is an effective way to identify patients with significant psychological problems and (b) for this population of older veterans, psychosocial staff also need to focus supportive and therapeutic interventions on patients who are admitted multiple times per year (i.e., high utilizers of hospital resources). Interventions addressing psychological well-being could both help these patients improve their quality of life and reduce health care utilization costs. In addition, use of more well-validated screening measures, such as the PRIME-MD (Spitzer et al., 1994, 1999), would allow statistical comparisons of positive screens between patients with SCI and patients with other chronic medical conditions as well as provide greater validation for the existence of psychiatric disorders in this population. Finally, future research also needs to

7 Brief Screening in Spinal Cord Injury Inpatients 277 extend such screening studies to nonveteran populations with SCI, who may have even greater treatment needs than veteran populations with SCI. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Craig, A. R., Hancock, K. M., & Dickson, H. G. (1994). A longitudinal investigation into anxiety and depression in the first two years following a spinal cord injury. Paraplegia, 32(10), De Boer, A. G., Wijker, W., & de Haes, H. C. (1997). Predictors of health care utilization in the chronically ill: A review of the literature. Health Policy, 42, DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment. Archives of Internal Medicine, 60(14), Elliott, T. R., & Frank, R. G. (1996). Depression following spinal cord injury. Archives of Physical Medicine and Rehabilitation, 77, H816-H823. Heinemann, A. W., Doll, M. D., Armstrong, K. J., Schnoll, S., & Yarkony, G. (1991). Substance use and receipt of treatment by persons with long-term spinal cord injuries. Archives of Physical Medical Rehabilitation, 72, Hisnanick, J. J. (1994). Changes over time in the ADL status of elderly U.S. veterans. Age and Aging, 23(6), Kemp, B., Krause, J. S., & Adkins, R. (1999). Depression among African Americans, Latinos, and Caucasians with spinal cord injury: An exploratory study. Rehabilitation Psychology, 44, Kishi, Y., Robinson, R. G., & Forrester, A. W. (1994). Prospective longitudinal study of depression following spinal cord injury. Journal of Neuropsychiatric and Clinical Neurosciences, 6, Laatsch, L., & Shahani, B. T. (1996). The relationship between age, gender and psychological distress in rehabilitation inpatients. Disability and Rehabilitation: An International Multidisciplinary Journal, 18, McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Grisson, G., Pettinati, H., & Argeriou, M. (1992). The Addiction Severity Index (5th ed.). Journal of Substance Abuse Treatment, 9, Moore, D., & Li, L. (1994). Alcohol use and drinking-related consequences among consumers of disability services. Rehabilitation Counseling Bulletin, 38(2), Norquist, G. S., Hough, R. L., Golding, J. M., & Escobar J. L. (1990). Psychiatric disorder in male veterans and non-veterans. The Journal of Nervous and Mental Disease, 178(5), Oliansky, D. M., Wildenhaus, K. J., Manlove, K., Arnold, T., & Schoener, E. P. (1997). Effectiveness of brief interventions in reducing substance use

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