CAGE questionnaire | |
---|---|
Purpose | assessment of problem drinking |
Part of a series on |
Psychology |
---|
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems. The questionnaire takes less than one minute to administer, [1] and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism. The CAGE questionnaire does not have a specific intended population, and is meant to find those who drink excessively and need treatment. The CAGE questionnaire is reliable and valid; however, it is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE questionnaire have been frequently implemented for such a purpose.
The CAGE questionnaire asks the following questions:
Two "yes" responses indicate that the possibility of alcoholism should be investigated further. [2]
The CAGE questionnaire, among other methods, has been extensively validated for use in identifying alcoholism. [2] CAGE is considered a validated screening technique with high levels of sensitivity and specificity. [3] It has been validated via receiver operating characteristic analysis, establishing its ability to screen for problem drinking behaviors. [4]
The CAGE questionnaire was developed in 1968 at North Carolina Memorial Hospital to combat the paucity of screening measures to detect problem drinking behaviors. The original study, conducted in a general hospital population where 130 patients were randomly selected to partake in an in-depth interview, successfully isolated four questions that make up the questionnaire today due to their ability to detect the sixteen alcoholics from the rest of the patients. [2]
Reliability refers to whether the scores are reproducible. Not all of the different types of reliability apply to the way that the CAGE is typically used. Internal consistency (whether all of the items measure the same construct) is not usually reported in studies of the CAGE; nor is inter-rater reliability (which would measure how similar peoples' responses were if the interviews were repeated again, or different raters listened to the same interview).
Criterion | Rating (adequate, good, excellent, too good*) | Explanation with references |
---|---|---|
Norms | Not applicable | Normative data are not gathered for screening measures of this sort |
Internal consistency | Not reported | A meta-analysis of 22 studies reported the median internal consistency was α= 0.74. [5] |
Inter-rater reliability | Not usually reported | Inter-rater reliability studies examine whether people's responses are scored the same by different raters, or whether people disclose the same information to different interviewers. These may not have been done yet with the CAGE; however, other research has shown that interviewer characteristics can change people's tendencies to disclose information about sensitive or stigmatized behaviors, such as alcohol or drug use. [6] [7] |
Test-retest reliability (stability) | Not usually reported | Retest reliability studies help measure whether things behave more as a state or trait; they are rarely done with screening measures |
Repeatability | Not reported | Repeatability studies would examine whether scores tend to shift over time; these are rarely done with screening tests |
Validity describes the evidence that an assessment tool measures what it was supposed to measure. There are many different ways of checking validity. For screening measures such as the CAGE, diagnostic accuracy and discriminative validity are probably the most useful ways of looking at validity.
Criterion | Rating (adequate, good, excellent, too good*) | Explanation with references |
---|---|---|
Content validity | Adequate | Items are face valid; not clear that they comprehensively cover all aspects of problem drinking |
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity) | Good | Multiple studies show screening and predictive value across a range of age groups and samples [8] |
Discriminative validity | Excellent | Studies not usually reporting AUCs, but combined sensitivity and specificity often excellent |
Validity generalization | Excellent | Multiple studies show screening and predictive value across a range of age groups and samples [8] |
Treatment sensitivity | Not applicable | CAGE not intended for use as an outcome measure |
Clinical utility | Good | Free (public domain), extensive research base, brief. |
*Table from Youngstrom et al.,[ full citation needed ] extending Hunsley & Mash, 2008; [9] [ pages needed ] *indicates new construct or category
The CAGE is designed as a self-report questionnaire. It is obvious to the person what the questions are about. Because talking about drinking behavior can be uncomfortable or stigmatized, people's responses may be subject to social desirability bias. The honesty and accuracy of responses may improve if the person trusts the person doing the interview or interpreting the score. Responses also may be more honest when the form is completed online, on a computer, or in other anonymous formats.
Some alternatives to the CAGE include:
Test [8] | Description [8] | |
---|---|---|
TWEAK | A 5-item questionnaire that was originally developed for pregnant women at risk for drinking problems | |
Michigan Alcoholism Screening Test (MAST) | A 25-item scale designed to assess lifetime symptoms of alcoholism with a focus on late-stage symptoms | |
Brief MAST | Shortened 10-item version of the MAST | |
Short Michigan Alcoholism Screening Test | A second shortened version of the MAST that does not include questions pertaining physical symptoms of drinking | |
Veterans Alcoholism Screening Test | A 25-item questionnaire similar to the MAST that distinguishes between current and past symptoms | |
Alcohol Use Disorders Identification Test (AUDIT) | A 10-item scale that focuses on symptoms experienced within the past year | |
Adolescent Drinking Index | A 24-item scale developed specifically to assess the degree of an adolescent (age 12–17) individual's drinking problem |
Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word alcoholism, it is not a recognized diagnostic entity, and the use of alcoholism terminology is discouraged due to its heavily stigmatized connotations. Predominant diagnostic classifications are alcohol use disorder (DSM-5) or alcohol dependence (ICD-11); these are defined in their respective sources.
Validity is the main extent to which a concept, conclusion or measurement is well-founded and likely corresponds accurately to the real world. The word "valid" is derived from the Latin validus, meaning strong. The validity of a measurement tool is the degree to which the tool measures what it claims to measure. Validity is based on the strength of a collection of different types of evidence described in greater detail below.
Survey methodology is "the study of survey methods". As a field of applied statistics concentrating on human-research surveys, survey methodology studies the sampling of individual units from a population and associated techniques of survey data collection, such as questionnaire construction and methods for improving the number and accuracy of responses to surveys. Survey methodology targets instruments or procedures that ask one or more questions that may or may not be answered.
Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol.
A questionnaire is a research instrument that consists of a set of questions for the purpose of gathering information from respondents through survey or statistical study. A research questionnaire is typically a mix of close-ended questions and open-ended questions. Open-ended, long-term questions offer the respondent the ability to elaborate on their thoughts. The Research questionnaire was developed by the Statistical Society of London in 1838.
The Alcohol Use Disorders Identification Test (AUDIT) is a ten-item questionnaire approved by the World Health Organization to screen patients for hazardous (risky) and harmful alcohol consumption. It was developed from a WHO multi-country collaborative study, the items being selected for the AUDIT being the best performing of approximately 150 items including in the original survey. It is widely used as a summary measure of alcohol use and related problems. It has application in primary health care, medical clinics, and hospital units and performs well in these settings. Using different cut-off points, it can also screen for Alcohol Use Disorder (DSM-5) and Alcohol Dependence. Guidelines for the use of the AUDIT have been published by WHO and are available in several languages. It has become a widely used instrument and has been translated into approximately fifty languages.
The Severity of Alcohol Dependence Questionnaire is a 20 item clinical screening tool designed to measure the presence and level of alcohol dependence.
Self-report sexual risk behaviors are a cornerstone of reproductive health–related research, particularly when related to assessing risk-related outcomes such as pregnancy or acquisition of sexually transmitted diseases (STDs) such as HIV. Despite their frequency of use, the utility of self-report measures to provide an accurate account of actual behavior are questioned, and methods of enhancing their accuracy should be a critical focus when administering such measures. Self-reported assessments of sexual behavior are prone to a number of measurement concerns which may affect the reliability and validity of a measure, ranging from a participant's literacy level and comprehension of behavioral terminology to recall biases and self-presentation.
The CRAFFT is a short clinical assessment tool designed to screen for substance-related risks and problems in adolescents. CRAFFT stands for the key words of the 6 items in the second section of the assessment - Car, Relax, Alone, Forget, Friends, Trouble. As of 2020, updated versions of the CRAFFT known as the “CRAFFT 2.1” and "CRAFFT 2.1+N" have been released.
The Eating Disorder Diagnostic Scale (EDDS) is a self-report questionnaire that assesses the presence of three eating disorders; anorexia nervosa, bulimia nervosa and binge eating disorder. It was adapted by Stice et al. in 2000 from the validated structured psychiatric interview: The Eating Disorder Examination (EDE) and the eating disorder module of the Structured Clinical Interview for DSM-IV (SCID)16.
The Patient Health Questionnaire (PHQ) is a multiple-choice self-report inventory that is used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform disorders. It is the self-report version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool developed in the mid-1990s by Pfizer Inc. The length of the original assessment limited its feasibility; consequently, a shorter version, consisting of 11 multi-part questions - the Patient Health Questionnaire was developed and validated.
The Michigan Alcoholism Screening Test (MAST) screening tool was developed in 1971, and is one of the oldest alcoholism-screening tests for identifying dependent drinkers. Its use is constructed for the general population. There are other versions of the MAST screening tool, all of which can be self-administered or via interview with someone who is trained in the tool being used. All MAST screening tools are scored on a point scale system.
The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire that assesses sleep quality over a 1-month time interval. The measure consists of 19 individual items, creating 7 components that produce one global score, and takes 5–10 minutes to complete. Developed by researchers at the University of Pittsburgh, the PSQI is intended to be a standardized sleep questionnaire for clinicians and researchers to use with ease and is used for multiple populations. The questionnaire has been used in many settings, including research and clinical activities, and has been used in the diagnosis of sleep disorders. Clinical studies have found the PSQI to be reliable and valid in the assessment of sleep problems to some degree, but more so with self-reported sleep problems and depression-related symptoms than actigraphic measures.
The Hypomania Checklist (HCL-32) is a questionnaire developed by Dr. Jules Angst to identify hypomanic features in patients with major depressive disorder in order to help recognize bipolar II disorder and other bipolar spectrum disorders when people seek help in primary care and other general medical settings. It asks about 32 behaviors and mental states that are either aspects of hypomania or features associated with mood disorders. It uses short phrases and simple language, making it easy to read. The University of Zurich holds the copyright, and the HCL-32 is available for use at no charge. More recent work has focused on validating translations and testing whether shorter versions still perform well enough to be helpful clinically. Recent meta-analyses find that it is one of the most accurate assessments available for detecting hypomania, doing better than other options at recognizing bipolar II disorder.
The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder. It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5–10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old. The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.
The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9–17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues. There is also a 10-item short form. The measure assesses the child's mood and behavior symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children's bipolar symptoms. The CMRS also can differentiate cases of pediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.
The Modified Checklist for Autism in Toddlers (M-CHAT) is a psychological questionnaire that evaluates risk for autism spectrum disorder in children ages 16–30 months. The 20-question test is filled out by the parent, and a follow-up portion is available for children who are classified as medium- to high-risk for autism spectrum disorder. Children who score in the medium to high-risk zone may not necessarily meet criteria for a diagnosis. The checklist is designed so that primary care physicians can interpret it immediately and easily. The M-CHAT has shown fairly good reliability and validity in assessing child autism symptoms in recent studies.
The 9-question Patient Health Questionnaire (PHQ-9) is a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression. It rates depression based on the self-administered Patient Health Questionnaire (PHQ). The PHQ is part of Pfizer's larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 takes less than 3 minutes to complete and simply scores each of the 9 DSM-IV criteria for depression based on the mood module from the original PRIME-MD. Primary care providers frequently use the PHQ-9 to screen for depression in patients.
The Attribution Questionnaire (AQ) is a 27-item self-report assessment tool designed to measure public stigma towards people with mental illnesses. It assesses emotional reaction and discriminatory responses based on answers to a hypothetical vignette about a man with schizophrenia named Harry. There are several different versions of the vignette that test multiple forms of attribution. Responses assessing stigma towards Harry are in the form of 27 items rated on a Likert scale ranging from 1 (not at all) to 9 (very much). There are 9 subscales within the AQ that breakdown the responses one could have towards a person with mental illness into different categories. The AQ was created in 2003 by Dr. Patrick Corrigan and colleagues and has since been revised into smaller tests because of the complexity and hypothetical that did not capture children and adolescent's stigmas well. The later scales are the Attribution Questionnaire-9 (AQ-9), the revised Attribution Questionnaire (r-AQ), and the children's Attribution Questionnaire (AQ-8-C).
Screening, Brief Intervention and Referral to Treatment (SBIRT) is a model that encourages mental health and substance use screenings as a routine preventive service in healthcare.