Evaluation of the Alcohol Use Disorders Identification

Research Report European Addiction Research

Eur Addict Res 2013;19:252–260 DOI: 10.1159/000343485

Received: May 21, 2012 Accepted: September 13, 2012 Published online: March 23, 2013

Evaluation of the Alcohol Use Disorders Identification Test and the Drug Use Disorders Identification Test among Patients at a Norwegian Psychiatric Emergency Ward Øystein Hoel Gundersen a, b Jon Mordal a, d Anne H. Berman e Jørgen G. Bramness b, c a

Psychiatric Department, Lovisenberg Deaconal Hospital, b Norwegian Centre for Addiction Research, University of Oslo, and c Norwegian Institute of Public Health, Oslo, and d Psychiatric Department, Central Hospital of Vestfold-Tønsberg, Tønsberg, Norway; e Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Key Words AUDIT ⴢ DUDIT ⴢ Emergency psychiatric patients ⴢ Psychosis ⴢ Cutoff scores

Abstract High rates of substance use disorders (SUD) among psychiatric patients are well documented. This study explores the usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT) in identifying SUD in emergency psychiatric patients. Of 287 patients admitted consecutively, 256 participants (89%) were included, and 61–64% completed the questionnaires and the Mini-International Neuropsychiatric Interview (MINI), used as the reference standard. Both AUDIT and DUDIT were valid (area under the curve above 0.92) and reliable (Cronbach’s alpha above 0.89) in psychotic and nonpsychotic men and women. The suitable cutoff scores for AUDIT were higher among the psychotic than nonpsychotic patients, with 12 versus 10 in men and 8 versus 5 in women. The suitable cutoff scores for DUDIT were 1 in both psychotic and nonpsychotic women, and 5 versus 1 in psychotic and nonpsychotic men, respectively. This study shows that AUDIT and DUDIT may provide precise information about emergency psychiatric patients’ problematic alcohol and drug use.

Introduction

A high prevalence of substance use disorders (SUD) such as alcohol use disorders (AUD) and drug use disorders (DUD) is well documented among psychiatric patients (e.g. [1]). In groups of psychiatric inpatients, prevalence rates of SUD as high as 50% are commonly reported [2–4]. The presence of SUD among psychiatric patients is associated with more severe symptoms, higher admission rates, and increased risk of violence and suicide [5– 8]. Many studies indicate that treatment of SUD among psychiatric patients is associated with better drug-related, psychiatric and psychosocial outcomes (e.g. [9–16]). Considering this, identification of SUD among psychiatric patients is of importance. SUD can be diagnosed with comprehensive interviews such as the Structured Clinical Interview for DSM-IV (SCID) [17], the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) [18] or with other less time-consuming structured interviews such as the Mini-International Neuropsychiatric Interview (MINI) [19]. Screening instruments do not provide a formal diagnosis, but may be useful to indicate the presence of SUD. Routine screening may increase identification of SUD

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Øystein Hoel Gundersen, MD Department of Psychiatry, Diakonhjemmet Hospital Postboks 85 Vinderen NO–0319 Oslo (Norway) E-Mail OysteinHoel.Gundersen @ diakonsyk.no

Table 1. AUDIT and DUDIT cutoff scores, sensitivities and specificities in a set of studies that examine validity and suitable cutoff scores

Study

Subjects/diagnosis

Sample Cut- Sensi- Specisize off tivity ficity

AUDIT1 [36] patients with schizophrenia – any AUD 71 ≥8 0.87 0.90 [37] outpatients with severe mental illness – any AUD 162 ≥8 0.90 0.70 [38] outpatients with first-episode psychosis – any AUD 79 ≥10 0.85 0.91 [39] outpatients with first-episode psychosis – any AUD men 131 ≥10 0.80 0.72 women 74 ≥8 0.88 0.71 [33] suspected offenders with signs of mental health problems – dependence 181 ≥13 0.83 0.78 DUDIT 2 [32] criminal justice and detoxification settings – dependence 154 ≥25 0.90 0.88/0.78 (ICD-10/DSM-IV) [39] outpatients with first-episode psychosis – any DUD men 131 ≥3 0.93 0.75 women 74 ≥1 1.00 0.77 [33] suspected offenders with signs of mental health problems – dependence 181 ≥12 0.85 0.85 [35] substance abusers in outpatient and residential treatment – drug problem 153 ≥8 0.90 0.85 1 2

Only studies in psychiatric populations included. All clinical trials included.

among psychiatric patients [20]. However, screening instruments often have a noncategorical structure. Analyses of sensitivity and specificity are needed to decide on diagnostic cutoff scores. However, these scores may vary between settings due to differences in prevalence and severity of the drug-related problems. The psychometric properties of the screening instruments should therefore be evaluated in the settings where they are used. Some screening instruments are clinical interviews, such as the Addiction Severity Index (ASI) [21], but most are self-report questionnaires. These are often quicker to administer and less resource-intensive compared to structured interviews and thus possibly easier to implement as routine screens in clinical practice. A number of self-report questionnaires have been developed, and examples of questionnaires for assessing alcohol use are the Evaluation of AUDIT and DUDIT

Michigan Alcohol Screening Test (MAST) [22] and the CAGE questionnaire [23]. For assessing substances other than alcohol, the Drug Abuse Screening Test (DAST) [24] has been used. As a 10-item self-report instrument, the Alcohol Use Disorders Identification Test (AUDIT) was designed to identify problematic alcohol use, even before it becomes an AUD [25]. Yielding a score on a continuous interval scale, it has advantages compared to the dichotomous yes/no structure of many other questionnaires. It was originally developed to screen patients in primary care settings, but has been applied and evaluated in various settings (e.g. [26–31]). The Drug Use Disorders Identification Test (DUDIT) was developed as a screening instrument for detecting drug-related problems [32]. It has a similar structure to AUDIT and has been found to have good potential for use as a parallel instrument in selected clinical samples [32]. The developers have evaluated DUDIT in Swedish population samples and among drug users in criminal justice and detoxification settings [32– 34]. It has also been tested among substance users in outpatient and residential settings and has been found to be reliable and valid [35]. AUDIT and DUDIT have been validated among psychiatric patients, with and without psychotic disorders, who are generally in outpatient settings and are between active psychotic episodes (table 1). Although cutoff scores have been suggested (for problematic use: 68 for men and 66 for women on AUDIT; and 66 for men and 62 for women on DUDIT) [31, 32], different scores are considered optimal depending on the population studied. AUDIT has been evaluated in a group of patients with chronic schizophrenia [36] and a group of patients with severe mental illness [37], with an optimal cutoff score for AUD of 8 for both men and women in both samples. AUDIT has also been evaluated in relation to AUD in two studies of patients with first-episode psychosis [38, 39]. Cassidy et al. [38] found an optimal cutoff score of 10 and Nesvåg et al. [39] identified an optimal cutoff score of 10 in men and 8 in women. DUDIT was also evaluated in the latter study, where the optimal cutoff score for DUD was 3 in men and 1 in women. Both AUDIT and DUDIT were evaluated in a clinical psychosis unit in Sweden, but this study did not report psychometric data [40]. Lately, AUDIT and DUDIT have been validated in a group of suspected offenders with signs of mental health problems, where a cutoff score of 13 corresponded to a diagnosis of alcohol dependence and a cutoff score of 12 corresponded to drug dependence [33]. To our knowledge, neither AUDIT nor DUDIT has been evaluated in an emergency psyEur Addict Res 2013;19:252–260 DOI: 10.1159/000343485

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chiatric setting, including patients with current psychotic symptoms. The aim of the present study is to evaluate the usefulness of AUDIT and DUDIT in identifying SUD in a group of emergency psychiatric patients with and without current psychosis, using MINI as the reference standard. We wanted to investigate the sensitivity and specificity of AUDIT and DUDIT in detecting AUD and DUD, respectively, using different cutoffs, thus validating these screening instruments in a new population.

Materials and Methods Procedure The study was conducted in a 27-bed emergency psychiatric ward at Lovisenberg Deaconal Hospital, Oslo, Norway, between September 2006 and February 2007. Crisis intervention and diagnostic evaluation are the main goals of this unit. Consecutively admitted patients, both voluntary and involuntary, were asked if they were willing to participate in a larger project assessing mental health and substance use, which included laboratory tests, AUDIT, DUDIT and MINI [41, 42]. The interviews were performed and questionnaires filled out as soon as possible after admission, along with routine assessments, and the results were documented in case notes. Exclusion criteria were dementia or mental retardation. Inclusion in the study required written informed consent, and the method was approved by the Regional committee for ethics in medical research and the Norwegian Data Inspectorate. Assessments AUDIT and DUDIT consist of 10 and 11 items, respectively. The items cover use, signs of harmful use and dependence; the first 3 items of AUDIT and the first 4 items of DUDIT refer to current behavior without a specific time frame, while the rest of the items in both instruments specifically relate to behavior within the last year. The items are scored from 0 to 4 and the maximum score is 40 for AUDIT and 44 for DUDIT [31, 32]. AUDIT and DUDIT were administered as self-report questionnaires, and filled out in the ward. Unanswered items were scored 0. The questionnaires were classified as not completed if 3 or more of the items were unanswered. For AUDIT, 167 patients (65%) completed all items and 29 (11%) missed 1 or 2 items. Of the questionnaires that were classified as not completed, 13 (5%) missed 3–9 items and 47 (18%) missed all 10 items. For DUDIT, 185 patients (72%) completed all items and 15 (6%) missed 1 or 2 items. Of the questionnaires that were classified as not completed, 7 (3%) missed 3–10 items and 49 (19%) missed all 11 items. AUD and DUD according to the DSM-IV abuse and dependence diagnoses were determined based on the Norwegian version of the MINI 5.0.0 [41]. In the MINI interview symptoms occurring within the last year are identified. For the MINI diagnoses of drug and alcohol dependence, excellent interrater and test-retest reliability have been reported, as well as moderate-togood and very good convergent validity relative to SCID and CIDI, respectively [43, 44]. The interviews were performed by 7 physicians, 2 psychologists and 2 psychiatric nurses, all with at

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least 1 year of clinical psychiatric practice. Prior to the study, all raters participated in a half-day seminar on the use of MINI, led by two experienced psychiatric researchers. The second author, a physician, completed an additional 1-day course in MINI, and provided individual training for all interviewers. Patients were also assessed by the physician on call using the Positive and Negative Syndrome Scale (PANSS) positive subscale [45]. We investigated the criterion validity and internal consistency of AUDIT and DUDIT. Criterion validity refers to how well certain variables predict an outcome based on information from other variables, usually an established measure, which in this case was MINI. Internal consistency was measured based on the correlations between different items of AUDIT and DUDIT, indicating whether items proposed to measure the same general construct produced similar scores. Adequate reliability was defined as internal consistency above 0.70 [46]. Sample Of 287 patients admitted consecutively, 256 (89%; 119 men and 137 women) were included, of which 176 (69%) completed the current psychosis section of MINI and 58 (33%) met the criteria for diagnosis with psychotic episode (fig. 1). Of the 119 men, 72 (61%) completed both AUDIT and MINI, while 73 (61%) completed both DUDIT and MINI. Of the 137 women, 85 (62%) completed both AUDIT and MINI, while 88 (64%) completed both DUDIT and MINI. For both AUDIT and DUDIT, the median time between administration of the questionnaires and the MINI interview was 1 day (mean 3 days, range: –16–69 days). For 1 patient the time in between was not registered. Two patients were interviewed with MINI more than 3 days before the administration of the AUDIT and DUDIT, and these were not psychotic at the time of MINI interview. MINI interviews more than 3 days after administration of AUDIT and DUDIT occurred for 32 and 35 patients, respectively, and 3 of these patients qualified for a MINI diagnosis of earlier psychotic episode (lifetime), but not a current psychotic episode. The mean age among the subjects that completed MINI, AUDIT and DUDIT was 35.2 years (SD = 8.9) for psychotic men and 40.8 years (SD = 14.9) for nonpsychotic men, while it was 37.9 years (SD = 17.5) for psychotic women and 38.8 years (SD = 16.4) for nonpsychotic women. A comparison between the patients who completed MINI, AUDIT and DUDIT with the patients who did not complete these instruments showed no statistically significant difference in age. The mean PANSS positive subscale score was, however, lower for the subjects who completed the instruments (14.8, SD = 7.7 vs. 18.7, SD = 8.1; p ! 0.001) compared to those who did not. Statistical Analyses The individuals were studied separately in four groups consisting of psychotic and nonpsychotic men and women. Student’s t test was used to investigate differences with respect to age and PANSS positive subscale score, while the Mann-Whitney U test was used to investigate differences in AUDIT and DUDIT. Pearson’s ␹2 test with Yates’ correction for continuity was used to investigate differences in prevalence of SUD. To assess the criterion validity of AUDIT and DUDIT, ROC analyses based on total scores of the instruments compared to MINI-based DSM-IV diagnoses were performed for all groups. The area under the curve (AUC) reflects overall performance of AUDIT and DUDIT, with 1.0 indicating perfect fit, and 0.5 no relationship compared with

Gundersen /Mordal /Berman /Bramness

287 patients admitted consecutively 8 patients excluded due to dementia or mental retardation 279 patients fulfilled inclusion criteria 23 patients refused to participate 256 patients included (119 men; 137 women)

Men:

Women:

AUDIT (n = 72) DUDIT (n = 73) and MINI

AUDIT (n = 85) DUDIT (n = 88) and MINI

Psychotic

Nonpsychotic

Psychotic

Nonpsychotic

AUDIT: 26 DUDIT: 27

AUDIT: 46 DUDIT: 46

AUDIT: 23 DUDIT: 27

AUDIT: 62 DUDIT: 61

Fig. 1. Flow chart of patient inclusion.

AUD and DUD. AUC values below 0.60 indicate a low fit, between 0.60–0.70 marginal, 0.70–0.80 modest, 0.80–0.90 moderate, and above 0.90 high accuracy [47]. To examine the internal consistency of the instruments, Cronbach’s alpha coefficients were calculated. Except for calculations of sensitivity and specificity, which were performed manually, all statistical analyses were performed with SPSS 16.0.

Results

According to MINI, 12 of 26 (46%) of the psychotic men had AUD, and 10 of 27 (37%) had DUD. Among the nonpsychotic men, 16 of 46 (35%) had AUD, and 13 of 46 (28%) had DUD. Among the psychotic women, 3 of 23 (13%) had AUD, and 3 of 27 (11%) had DUD. Among the nonpsychotic women, 22 of 62 (36%) had AUD, and 13 of 61 (21%) had DUD. There were no statistically significant differences in either men or women between the psychotics and nonpsychotics with regard to frequency of SUD. Among the psychotic men, the mean AUDIT score was 12.9 (SD = 10.6) and the mean DUDIT score was 8.3 (SD = 11.7). Among the nonpsychotic men, the mean AUEvaluation of AUDIT and DUDIT

DIT score was 11.1 (SD = 10.4) and the mean DUDIT score was 7.2 (SD = 12.2). Among the psychotic women, the mean AUDIT score was 6.1 (SD = 7.5) and the mean DUDIT score was 3.6 (SD = 9.1). Among the nonpsychotic women, the mean AUDIT score was 7.8 (SD = 8.1) and the mean DUDIT score was 4.8 (SD = 9.0). When comparing psychotics and nonpsychotics, the AUDIT and DUDIT scores did not differ significantly in men or women. For AUDIT in relation to AUD, and DUDIT in relation to DUD, the AUC of the ROC analyses was at 0.92 or above for both AUDIT and DUDIT in psychotic and nonpsychotic men and women (table 2). Internal consistencies expressed in terms of Cronbach’s alpha were 0.89 or above for both instruments in psychotic and nonpsychotic men and women (table 2). Sensitivity and specificity for each cutoff score of AUDIT and DUDIT are listed in table 3. For psychotic men, at an AUDIT score of 12, the analysis yielded a sensitivity of 0.83 and specificity of 0.86, while a DUDIT score of 5 implied a sensitivity of 1.00 and specificity of 0.88. For nonpsychotic men, an AUDIT score of 10 implied a senEur Addict Res 2013;19:252–260 DOI: 10.1159/000343485

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Table 2. Internal consistency (Cronbach’s alpha) and criterion validity (AUC) of AUDIT and DUDIT

Men current psychosis

Women no current psychosis

current psychosis

no current psychosis

Internal consistency (Chronbach’s alpha) AUDIT 0.92 0.93 DUDIT 0.94 0.97

0.89 0.96

0.90 0.90

Criterion validity, AUC (95% CI) AUDIT 0.92 (0.82–1.00)*** DUDIT 1.00 (1.00–1.00)***

0.97 (0.89–1.00)* 1.00 (1.00–1.00)**

0.96 (0.92–1.00)*** 0.96 (0.91–1.00)***

0.93 (0.86–1.00)*** 0.93 (0.82–1.00)***

* p < 0.05; ** p < 0.01; *** p < 0.001.

sitivity of 0.88 and specificity of 0.73, and a DUDIT score of 1 implied a sensitivity of 0.92 and a specificity of 0.85. For psychotic women, at an AUDIT score of 8 the analysis yielded a sensitivity of 1.00 and specificity of 0.80, while a DUDIT score of 1 implied a sensitivity of 1.00 and specificity of 0.92. For nonpsychotic women, an AUDIT score of 5 implied a sensitivity of 0.95 and specificity of 0.83, and a DUDIT score of 1 implied a sensitivity of 1.00 and a specificity of 0.85.

Discussion

Both AUDIT and DUDIT showed high validity and reliability (internal consistency) among psychotic and nonpsychotic men and women in an emergency psychiatric ward. The suitable cutoff score for DUDIT in psychotic and nonpsychotic women was similar; however, all the other cutoff scores indicated higher suitable scores for psychotic than nonpsychotic patients. Except for the cutoff score of 10 for AUDIT in nonpsychotic men with sensitivity of 0.88 and specificity of 0.73, all the cutoff scores for AUDIT and DUDIT showed sensitivity and specificity above 0.80. It might be assumed that the psychometric properties of the self-report instruments AUDIT and DUDIT would be compromised in a busy emergency psychiatric ward with many patients having current psychotic symptoms. This was contradicted by the present study that gave an excellent validity among patients even with current psychosis. The cutoff scores for AUDIT were higher among the psychotic than nonpsychotic patients, with 12 versus 10 in men and 8 versus 5 in women. The discrepancy may be due to high regular consumption of alcohol among 256


psychotic patients, including high consumption among psychotic patients that do not fulfill the criteria of AUD, which inevitably elevates the cutoff scores [39]. Another explanation may be that patients with psychosis have different response sets compared to nonpsychotic patients, with a tendency to more openly report symptoms. With the exception of the cutoff score for nonpsychotic women, the cutoff scores for AUDIT are higher than the conventional scores. None of the prior studies that reported psychometric data [36–39] differentiated between patients with and without current psychotic symptoms, and only one differentiated between men and women [39]. Our study is in line with this latter study of first-episode psychotic patients that found AUDIT cutoff scores of 10 for men and 8 for women [39]. In the present study we found suitable cutoff scores for DUDIT to be 1 in both psychotic and nonpsychotic women, but 5 versus 1 in psychotic and nonpsychotic men, respectively. A cutoff score of 1 in women was also found in the Norwegian study of firstepisode psychosis patients [39]. This study found a cutoff score of 3 for men, which is also lower than the conventional scores. However, in the present study, the cutoff scores for DUDIT generally yielded very good sensitivity and specificity, and across all groups it was even possible to elevate the cutoff scores considerably above the conventional scores without violating the limit of a sensitivity and specificity at or above 0.80. Our study has some limitations. Between 36 and 39% of the patients did not complete one or more of the AUDIT, DUDIT or MINI assessments. A high degree of psychopathology and active psychosis may have been the reasons why the patients dropped out [41]. The higher PANSS positive subscale score of the patients that did not complete the instruments is an indication of this, and it Gundersen /Mordal /Berman /Bramness

Table 3. Data on sensitivity and specificity listed for each cutoff score of AUDIT and DUDIT in psychotic and nonpsychotic men and women a AUDIT

AUDIT cutoff

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Women with and without psychosis sensitivity

specificity

psy.

nonpsy.

psy.

nonpsy.

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.67 0.67 0.67 0.67 0.67

1.00 1.00 1.00 1.00 0.95 0.95 0.95 0.95 0.95 0.82 0.82 0.73 0.73 0.64 0.55

0.35 0.40 0.50 0.55 0.65 0.65 0.65 0.80 0.90 0.95 0.95 0.95 0.95 0.95 0.95

0.30 0.48 0.58 0.63 0.83 0.85 0.85 0.88 0.93 0.93 0.93 0.93 0.93 0.98 0.98

AUDIT cutoff

Men with and without psychosis sensitivity

specificity

psy.

nonpsy.

psy.

nonpsy.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.92 0.92 0.92 0.92 0.83 0.67 0.58 0.58

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.94 0.88 0.81 0.75 0.75 0.75 0.75

0.14 0.29 0.29 0.29 0.43 0.64 0.64 0.64 0.64 0.79 0.79 0.86 0.86 0.93 0.93

0.27 0.37 0.43 0.47 0.57 0.57 0.63 0.67 0.67 0.73 0.77 0.83 0.90 0.93 0.97

DUDIT cutoff

Men with and without psychosis

b DUDIT

DUDIT cutoff

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Women with and without psychosis sensitivity

specificity

psy.

nonpsy.

psy.

nonpsy.

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

1.00 1.00 0.92 0.92 0.92 0.92 0.85 0.85 0.69 0.69 0.69 0.69 0.62 0.62 0.62

0.92 0.92 0.92 0.92 0.92 0.96 0.96 0.96 0.96 0.96 1.00 1.00 1.00 1.00 1.00

0.85 0.88 0.90 0.90 0.90 0.92 0.94 0.94 0.94 0.96 0.96 0.96 0.96 0.96 0.96

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

sensitivity

specificity

psy.

nonpsy.

psy.

nonpsy.

1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

0.92 0.92 0.92 0.92 0.92 0.92 0.92 0.92 0.92 0.92 0.92 0.77 0.77 0.69 0.69

0.65 0.65 0.76 0.76 0.88 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

0.85 0.85 0.88 0.91 0.91 0.91 0.91 0.91 0.94 0.97 0.97 0.97 0.97 0.97 0.97

Conventional cutoff scores. Suitable cutoff scores nonpsychotic patients (sensitivity/specificity above 0.8). Suitable cutoff scores psychotic patients (sensitivity/specificity above 0.8).

Evaluation of AUDIT and DUDIT


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may have caused underrepresentation of most psychotic patients and thus possibly a too optimistic evaluation of the psychometric properties of AUDIT and DUDIT in this group. Further, the sample sizes of the psychotic men and women were relatively small (AUDIT and DUDIT were completed by 26 and 27 psychotic men, respectively, and by 23 and 27 psychotic women, respectively), and only 3 psychotic women met the criteria for AUD and DUD. Hence, the conclusions on suitable cutoff scores for psychotic men and women should be considered with caution. The group of nonpsychotic patients was larger, but these cutoff scores should also be regarded with caution. Missing scores on AUDIT and DUDIT items were scored as 0. This may have lowered the scores on these instruments. However, from a clinical point of view it seems likely that items were not scored because the patients did not have this symptom. Also, questionnaires missing more than 2 items were classified as not completed, and left out, minimizing the impact. Ideally, AUDIT, DUDIT and the MINI interview should have been administered approximately at the same time. However, the abuse and dependence diagnoses of MINI refer to symptoms within the last year. The problem relating to simultaneity is thus whether patients were psychotic at the time of filling out AUDIT, DUDIT or MINI and then became nonpsychotic before the administration of the other instruments. Thirty-seven patients had more than 3 days between instruments, but most of these were either stable psychotic (n = 18) or stable nonpsychotic (n = 16) patients. Only 3 patients were not psychotic but had a lifetime history of earlier psychosis at the time of the MINI interview, and these patients could possibly have been classified in the wrong group. In the present study, MINI was a reference standard for SUD. The instrument is quite brief to function as such a standard. MINI is, however, administered as a clinical

interview by a professional, and this allows for clinical judgement. This is regarded as sufficient for validating self-rating instruments like AUDIT and DUDIT. The Norwegian version of MINI has not yet been validated, but its test-retest reliability has been found satisfactory [41]. Also, the MINI has been validated in English with good results, and it is reasonable to assume that the Norwegian version, through translation processes and the development of several new editions, is close enough to the English version to be used as a reference standard. However, only the psychometric properties of the dependence sections of MINI have been evaluated, and this is a shortcoming for the present study. The abuse and dependence sections of the English version of MINI have previously been used as reference standards in a study validating RAFFT [48, 49]. Although all measures were based on the patients’ self-report, previous studies have indicated that severely mentally ill patients provide reliable information about their drug use [50, 51]. SUDs are often not detected in emergency psychiatric settings [51–53]. This situation may deprive patients of the opportunity to receive appropriate treatment, with possibly severe consequences for the patients’ psychiatric morbidity [5–8]. This study shows that AUDIT and DUDIT may provide precise information about the drug use of emergency psychiatric patients, and in view of the simplicity of the instruments, routine implementation may be possible.

Acknowledgments The authors want to thank all patients for their participation in the study. The study was funded by a grant from Eastern Norway Health Authorities.

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