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The state of the art for treatment efficacy studies now requires manual guided treatments and tests of therapist adherence. This report provides findings regarding adherence assessment of therapists participating in an investigation of treatment matching in adolescent substance abusers. The Group Sessions Rating Scale (GSRS), a group-therapy process measure, was studied to determine its appropriateness for assessing group treatment of adolescents with a) substance use disorders (SUD), b) interrater reliability, c) internal consistency, and d) ability to discriminate the active ingredients of cognitive-behavioral therapy (CBT) from interactional therapy (IT). Interrater reliabilities were moderate to high, with those for CBT generally higher than those for IT. Internal consistency of CBT items was moderate, whereas those of IT were moderately high. Discriminability between the two treatment modalities was high. The frequency of active ingredients was generally therapy-specific: high for the relevant and low for the nonrelevant therapeutic modality items. The GSRS was found to be effective in the measurement of treatment process in adolescents with SUD.

The longitudinal, expert, all data (LEAD) procedure has been employed as a criterion for the assessment of the procedural validity of diagnostic instruments. This study evaluated the procedure's concurrent, discriminant and predictive validity. Interview and questionnaire data obtained from 100 individuals in a substance abuse treatment program were used to assess current and lifetime substance use disorders and common comorbid disorders. An experienced, doctoral-level clinician formulated LEAD diagnoses for each patient, based on an initial interview, ongoing clinical contact and the results of the research assessment and all available clinical records. LEAD-derived substance use diagnoses showed good concurrent, discriminant and predictive validity. The validity of comorbid diagnoses obtained using the LEAD procedure was generally fair to good. Comparison with diagnoses based only on the clinician's unstructured initial interview showed that the availability of additional data enhanced diagnostic validity. Diagnoses derived by a research technician using the Structured Clinical Interview for DSM-III-R showed validity comparable to that of LEAD diagnoses. To enhance its diagnostic validity, applications of the LEAD standard should include a structured interview. Other variations in the application of the LEAD standard, including a longer evaluation period, may also enhance its performance as a diagnostic criterion measure.

Structured or semi-structured interviews, including the Structured Clinical Interview for DSM-III-R (SCID), are used widely to maximize the reliability and validity of psychiatric diagnoses. Although the reliability of such interviews appears adequate, there has been little effort to evaluate their validity. In a sample of 100 substance abuse patients, we evaluated the concurrent, discriminant and predictive validity of SCID substance use diagnoses, as well as co-morbid disorders that occur commonly among these patients. The validity of current and life-time substance use diagnoses obtained by a research technician using the SCID was good; it was moderate for antisocial personality disorder and major depression and poor for anxiety disorders. Although accurate diagnosis of substance use disorders in substance abuse patients can be accomplished by a research technician, the diagnosis of co-morbid psychiatric disorders requires either additional expertise or the use of a diagnostic instrument specially designed for that purpose.

Although structured diagnostic interviews are increasingly being used in substance abuse treatment settings, there has been limited systematic evaluation of their ability to enhance reliability and validity of psychiatric diagnoses. The present report provides data on the concurrent, discriminant, and predictive validity of current substance use disorders and common comorbid diagnoses in a sample of 100 substance abuse patients. Diagnoses formulated primarily by master's-level clinicians in the usual course of their duties were compared with diagnoses formulated by research technicians using a semistructured interview. Results indicated that the validity of clinician diagnoses was good for substance use disorders, moderate for personality disorders, and poor for anxiety disorders and major depression. Greater validity was observed for substance abuse diagnoses formulated by research technicians using the semistructured interview. Based on these findings, we conclude that psychiatric diagnosis in substance abuse patients may be improved by adding elements of structured interviews to the clinician's usual assessment.

The Longitudinal, Expert, All Data (LEAD) procedure has been proposed as a criterion for the assessment of the procedural validity of diagnostic instruments. The authors evaluated the procedure's test-retest reliability and whether it enhanced diagnosis based on a single interview. Data were collected using interviews and questionnaires to assess current and lifetime substance use disorders and common comorbid disorders in 100 patients recruited from a substance abuse treatment program. An initial diagnostic interview was conducted by a primary expert who, at the end of treatment, formulated LEAD diagnoses for each patient, based on the results of the research assessment and all available clinical records. Secondary experts used a similar procedure in a subsample of 40 patients to provide a measure of test-retest reliability. Overall reliability of LEAD diagnoses was good, though it varied from excellent for substance use disorders to poor for some comorbid psychiatric disorders. As a consequence of the LEAD procedure, the total number of substance use diagnoses increased significantly, with no effect on diagnostic reliability. Based on these findings, we conclude that, while the overall reliability of the LEAD procedure is comparable to other diagnostic methods, there was considerable variability among groups of diagnoses. The additional cost of the procedure would appear to be justified only when diagnostic sensitivity is at a premium and principally for the diagnosis of psychoactive substance use disorders. Before it is widely used as a diagnostic criterion measure, the utility of the LEAD procedure should be evaluated in a variety of patient samples and under varying circumstances.

This report presents results of a field trial of Substance Use Disorders as defined by DSM-III-R, DSM-IV (proposed) and ICD-10. Diagnoses based on the three systems were derived from interviews using the Composite International Diagnostic Interview (CIDI) in a heterogeneous sample of 521 adults drawn from clinical and community settings. Two issues are addressed: (1) cross system agreement; and (2) syndrome coherence of proposed criterion sets for Substance Dependence in each of the three systems. Findings were as follows: (1) Cross system agreement for Dependence was generally high, especially between DSM-III-R and DSM-IV. (2) Cross system agreement was lower for DSM-III-R and DSM-IV Abuse and very low for DSM-IV Abuse and ICD-10 Harmful Use. (3) Agreement varied across drug categories with lowest DSM-III-R/DSM-IV agreement for alcohol abuse and DSM-IV/ICD-10 agreement for marijuana use disorders. (4) Overall prevalence differed for the three systems with DSM-IV yielding highest rates followed by DSM-III-R and ICD-10 in that order. (5) Factor analysis of Dependence criteria showed high loadings of all items on a single factor across the three diagnostic systems and for all categories of drugs. Implications for validity of the dependence syndrome construct and for revisions in DSM-IV are discussed.

This article describes a multidisciplinary team approach to the treatment of alcohol and drug dependence and comorbid disorders. The principal aim of this approach is the identification and treatment of patients' chemical dependence, as well as the medical and psychiatric disorders that contribute to and/or stem from the chronic use of alcohol and drugs. The focus of treatment is on the identification of high risk and other problem situations, training coping skills to handle these situations, developing insight, and enhancing patients' motivation for sobriety and ongoing treatment. In this article we describe the features of our program that address these various goals.

The ability of the Cognitive Status Examination (CSE), a brief neuropsychological screening instrument, to detect cognitive impairment in substance abusing patients was evaluated in 200 consecutive admissions to a drug/alcohol rehabilitation unit. While a significant proportion (25%) of patients screened were classified as impaired using the cutoff derived in the original study, agreement with an independent neurological impairment classification was much lower than that reported in the earlier work. Possible reasons for this discrepancy are discussed, including the relatively subtle nature of cognitive impairment in substance abusing patients. Implementation of regular screening did seem to heighten staff sensitivity to cognitive impairment in this sample. Alternate methods of determining the usefulness of cognitive screening tools (e.g., relationship to treatment relevant skills) are also discussed.

A contingency management system is described for enhancing participation in an inpatient chemical dependency rehabilitation program. The system employs reinforcers that are readily available in a residential milieu and makes receipt of them contingent upon appropriate patient behaviors. The behaviors include arranging aftercare treatment, involving family members in the treatment process, appropriate participation in ongoing treatment activities, and assisting with unit chores. A patient's status within the program is first regulated on a noncontingent basis, after which an accumulation of nine specified accomplishments results in the acquisition of a number of privileges. Accumulation of three demerits, given for inappropriate behaviors, results in a status reduction that can only be restored by completing ten additional behaviors. Improvement in patients' program involvement was documented in a number of areas, with a concomitant reduction in resistance to treatment. The system also resulted in an improvement in staff's charting of patients' behavior.