CORK Bibliography: TWEAK (Screening Test)

21 citations. January 1996 to present

Prepared: June 2008

Bradley KA; Boyd-Wickizer J; Powell SH; Burman ML. Alcohol screening questionnaires in women: A critical review. (review). Journal of the American Medical Association 280(2): 166-171, 1998. (54 refs.)

Objective.-To describe the performance of alcohol screening questionnaires in female patients. Data Sources.-We searched MEDLINE from 1966 to July 1997 for alcoholism or alcohol-drinking and for CAGE, AUDIT, BMAST, TWEAK, T- ACE, MAST, SMAST, or SAAST; Citations Indexes for newer screening questionnaires and those without acronyms; and MEDLINE from 1996 to July 1997 for alcoholism or alcohol-drinking and screening. Study Selection and Data Extraction.-Reviewed studies presented data for women comparing brief alcohol screening questionnaires with valid criterion standards for heavy drinking (greater than or equal to 2 drinks per day) or alcohol abuse or dependence in US general clinical populations. Sensitivities, specificities, and areas under receiver operating characteristic curves (AUROCs) were extracted. Data Synthesis.-Thirteen articles (9 studies) were reviewed. The CAGE questionnaire had AUROCs of 0.84 to 0.92 for alcohol abuse and dependence in predominantly black populations of women, but using the traditional cut point of 2 or more resulted in low sensitivities (38%- 50%) in predominantly white female populations. The TWEAK and Alcohol Use Disorders Identification Test (AUDIT) questionnaires had high AUROCs (0.87-0.93) for past-year alcohol abuse or dependence in black or white women, but had sensitivities less than 80% at traditional cut points. For detecting heavy drinking, the AUDIT questionnaire had AUROCs of at least 0.87 in female primary care patients. The TWEAK and T-ACE questionnaires had higher AUROCs (0.84-0.87) than the CAGE questionnaire (0.76-0.78) for detecting heavy drinking before pregnancy was recognized in black obstetric patients. Conclusions.-The CAGE questionnaire was relatively insensitive in predominantly white female populations. The TWEAK and AUDIT questionnaires have performed adequately in black or white women, using lower cut points than usual.

Bush KR; Kivlahan DR; Davis TM; Dobie DJ; Sporleder JL; Epler AJ et al. The TWEAK is weak for alcohol screening among female Veterans Affairs outpatients. Alcoholism: Clinical and Experimental Research 27(12): 1971-1978, 2003. (57 refs.)

Background: The optimal brief questionnaire for alcohol screening among female patients has not yet been identified. This study compared the performance of the TWEAK (tolerance, worried, eye-opener, amnesia, cutdown), the Alcohol Use Disorders Identification Test (AUDIT), and the AUDIT Consumption (AUDIT-C) as self-administered screening tests for hazardous drinking and/or active alcohol abuse or dependence among female Veterans Affairs (VA) outpatients. Methods: Women were included in the study if they received care at VA Puget Sound and completed both a self-administered survey containing the AUDIT and TWEAK screening questionnaires and subsequent in-person inter-views with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Sensitivities, specificities, positive and negative likelihood ratios, and areas under Receiver Operating Characteristic curves were computed for each screening questionnaire compared with two interview-based comparison standards: (1) active DSM-IV alcohol abuse or dependence and (2) hazardous drinking and/or active DSM-IV alcohol abuse or dependence, the more appropriate target for primary care screening. Results: Of 393 women who completed screening questionnaires and interviews, 39 (9.9%) met diagnostic criteria for alcohol abuse or dependence, and 89 (22.7%) met criteria for hazardous drinking or alcohol abuse or dependence. The TWEAK had relatively low sensitivities (0.62 and 0.44) but adequate specificities (0.86 and 0.89) for both interview-based comparison standards, even at its lowest cut-point ( 1). The AUDIT and AUDIT-C were superior, with the following areas under the receiver operating characteristic curve for active alcohol abuse or dependence and hazardous drinking and/or active alcohol abuse or dependence, respectively: AUDIT, 0.90 [95% confidence interval (CI), 0.85-0.95] and 0.87 (95% CI, 0.84-0.91); AUDIT-C, 0.91 (95% CI, 0.88-0.95) and 0.91 (95% CI, 0.88-0.94); and TWEAK, 0.76 (95% CI, 0.66-0.86) and 0.67 (95% CI, 0.60-0.74).Conclusions: The TWEAK has low sensitivity as an alcohol-screening questionnaire among female VA outpatients and should be evaluated further before being used in other female primary care populations. The three-item AUDIT-C was the optimal brief alcohol-screening questionnaire in this study.

Chang G; Wilkins-Haug L; Berman S; Goetz MA. The TWEAK: Application in a prenatal setting. Journal of Studies on Alcohol 60(3): 306-309, 1999. (18 refs.)

Objective: The TWEAK is a screening instrument used to identify women who are risk drinkers. potential limitations of previous studies of the TWEAK in the prenatal setting include indirect administration of the instrument to minority, indigent pregnant women. The purpose of this study is to assess the efficacy of the TWEAK when it is given directly to a sample of pregnant women of different socioeconomic backgrounds. Method: The original TWEAK, with two different tolerance questions, was administered to a sample of 135 pregnant women enrolled in a study of alcohol use during pregnancy at the obstetrics practices of the Brigham and Women's Hospital in Boston, Massachusetts. Results; The TWEAK, using the first tolerance question (number of drinks before feeling the first effects of alcohol) with the cut point set at more than two drinks, had the best predictive ability for lifetime alcohol diagnoses and risk drinking. The sensitivity of the TWEAK can be increased if the cut point for the first tolerance question if, set at two drinks, with some loss of specificity and predictive ability. Medical record assessment was the least sensitive but most specific method of identifying alcohol use by pregnant women. Conclusions: The TWEAK has promise as a screening instrument for identifying risk drugs during pregnancy. Future work should include testing in other clinical populations.

Cherpitel CJ. Brief screening instruments for alcoholism. Alcohol Health and Research World 21(4): 348-351, 1997. (17 refs.)

This article summarizes brief screening instruments for alcoholism, as well as a set of questions to ascertain quantity and frequency of drinking to ascertain possible harmful use. The tests discussed include the CAGE; the Brief MAST; the Alcohol Use Disorders Identification Test (AUDIT); and the TWEAK. There is also an overview of their use with women and members of minority groups. The group for which these tests are least sensitive is African-American women. The author provides a new test, the Rapid Alcohol Problems Screen (RAPS) drawing upon the most sensitive items from other tests.

Cherpitel CJ. Comparison of screening instruments for alcohol problems between black and white emergency room patients from two regions of the country. Alcoholism: Clinical and Experimental Research 21(8): 1391-1397, 1997. (40 refs.)

A number of brief screening instruments to identify alcohol dependence exist, but the validity of these instruments across ethnic groups or regions of the country is not well established. The sensitivity and specificity of a number of standard screening instruments (CAGE, brief MAST, AUDIT, TWEAK, and RAPS), as well as other measures (History of Trauma Scale, breathalyzer reading, self-reported drinking before the event, and consuming five or more drinks at a sitting at least monthly) are compared against ICD-10 and DSM-IV criteria for alcohol dependence between probability samples of Black and White emergency roam patients in Santa Clara County, CA (n = 716) and in Jackson, MS (n = 1330). Variability in the sensitivity of screening instruments among current drinkers was found to be greater between samples for both Blacks and Whites, than for Blacks compared with Whites within the same sample. The AUDIT, TWEAK, and RAPS seemed to perform well by gender and injury status for both Blacks and Whites in the two samples, and no significant differences were found in the performance of these instruments across sample sites. To evaluate the influence of regional differences in alcohol dependence an differences found in the performance of screening instruments, using logistic regression with the simultaneous entry of demographic variables (age, gender, ethnicity, injury status, and site) and drinking variables (breathalyzer reading, self-reported drinking before the event, and drinking five or more drinks at a sitting at least monthly) to predict alcohol dependence in a merged sample of these patients (Jackson vs. Santa Clara) site was not found to be significant. Data suggest that, whereas region of the country may not be important in predicting alcohol dependence in emergency room populations, regional differences in the performance of screening instruments for alcohol dependence may exist, even when ethnicity is taken into account. Given distinct regional differences in drinking patterns and problems in the U.S., further research on commonly used screening instruments is needed to determine those screeners most efficient for identifying problem drinking.

Cherpitel CJ. Differences in performance of screening instruments for problem drinking among blacks, whites and hispanics in an emergency room population. Journal of Studies on Alcohol 59(4): 420-426, 1998. (38 refs.)

Objective: The purpose of this study was to compare the performance of a number of standard screening instruments for alcohol dependence and harmful drinking/abuse by ethnicity (black, Hispanic and white) and by ethnicity and gender in an emergency room setting. Method: A probability sample of patients (N = 1,429) was breath analyzed and interviewed at the Santa Clara Valley Medical Center in San Jose, California. Sensitivity and specificity were analyzed among current drinkers (n = 857) for the CAGE, Brief MAST, AUDIT, TWEAK, RAPS and other items against combined ICD-10 or DSM-IV criteria for alcohol dependence and separately for alcohol dependence or harmful drinking or abuse. Results: Screening measures were not found to perform equally well by ethnicity or gender, with lower sensitivity found for women compared to men. Consistency in sensitivity of measures was found to vary considerably across ethnic and gender groups, with some measures (most notably the RAPS and the AUDIT) showing consistently high sensitivity across subgroups. None of the instruments performed nearly as well for identifying alcohol dependence or harmful drinking or abuse combined as for alcohol dependence alone. Conclusions: Analyses suggest that, while the RAPS may hold promise for identifying problem drinkers across ethnic and gender subgroups, it and other screening instruments currently in use require additional evaluation in a variety of settings to determine their usefulness for identifying those who could benefit from a brief intervention or referral for problem drinking.

Cherpitel CJ. Gender, injury status and acculturation differences in performance of screening instruments for alcohol problems among US Hispanic emergency department patients. Drug and Alcohol Dependence 53(2): 147-157, 1999. (44 refs.)

The sensitivity and specificity of several screening instruments including the CAGE, brief MAST, AUDIT, TWEAK, RAPS, and Trauma Scale, were evaluated against both ICD-IO and DSM-IV criteria for alcohol dependence and for harmful drinking and abuse in a probability sample of 586 Hispanic emergency department patients. Screening instruments were not as sensitive for females as for males, for those in the low acculturation group, or for non-dependent drinkers. Acculturation was positively associated with the likelihood of being a current drinker, and among current drinkers, was positively associated with alcohol dependence and with harmful drinking or alcohol abuse.

Cherpitel CJ. Performance of screening instruments for identifying alcohol dependence in the general population, compared with clinical populations. Alcoholism: Clinical and Experimental Research 22(7): 1399-1404, 1998. (24 refs.)

Screening instruments for problem drinking have been developed in clinical populations, and little is known of their performance in the general population. Sensitivity and specificity of the CAGE and the TWEAK for ICD-10 and/or DSM-IV criteria for alcohol dependence are compared among those sampled from the southern region in the 1995 National Alcohol Survey (n = 776), and from emergency room (ER) (n = 1327) and primary care clinic (n = 767) samples in Jackson, MS. Sensitivity of the CAGE was higher in both the ER (85%) and primary care (82%) samples than in the general population (75%), although differences were not significant, and this held for males and females alike. Sensitivity of the TWEAK was lower in the general population sample (83%) than in the ER sample (89%), but higher than in the primary care sample (75%). In the general population, sensitivity of both screeners was better (although not significantly so) among those making an ER or primary care visit during the last year than among those not doing so, with the largest difference found for the CAGE (85% vs. 65%, respectively). In a merged sample of the three sites, the interaction of site by screening instrument was not a significant predictor of alcohol dependence for either the CAGE or TWEAK. Data suggest that screening instruments may not perform as well in the general population as in some clinical populations, with more variation apparent across groups for some screeners than for others. Although further analysis is necessary to explore this issue further, attention should be given to selection of the best instrument for use in a given population.

Cherpitel CJ. Screening for alcohol problems in the US general population: A comparison of the CAGE and TWEAK by gender, ethnicity, and services utilization. Journal of Studies on Alcohol 60(5): 705-711, 1999. (42 refs.)

Objective: The purpose of this study was to compare the performance of two screening instruments for alcohol problems, the CAGE and the TWEAK, against ICD-10 and DSM-IV criteria for alcohol dependence by gender and ethnicity, and to evaluate whether characteristics associated with health services utilization may affect the performance of screening instruments, in a representative sample of the U.S. adult general population. Method: Data are from the Alcohol Research Group's 1995 National Alcohol Survey; these were weighted to account for the design effect inherent in multistage cluster sampling and oversampling of blacks and Hispanics. Effective sample size was 2,443: 797 blacks, 642 Hispanics and 1,004 whites and others (primarily Asian and Native American). Sensitivity and specificity were examined for both screening instruments. Logistic regression was used to evaluate the predictive value, separately, for the CAGE and TWEAK, controlling for gender, ethnicity, region of the country and service use (primary care and emergency room). Results: The TWEAK was more sensitive for men than for women, but no differences were found by service use, while the CAGE was more sensitive for men who had used the emergency room during the preceding year compared with those who had not. The TWEAK was more sensitive than the CAGE among white and Hispanic men, among men who had not used the emergency room and among whites who had no service use. Performance of neither the CAGE nor the TWEAK was found to vary by region of the country. Conclusions: Data suggest that while the performance of screening instruments may vary across demographic subgroups in the general population, instruments may perform equally well for identifying problem drinkers in general populations as in clinical populations.

Cherpitel CJ; Borges G. Performance of screening instruments for alcohol problems in the ER: A comparison of Mexican-Americans and Mexicans in Mexico. American Journal of Drug and Alcohol Abuse 26(4): 683-702, 2000. (40 refs.)

The performance of standard screening instruments and alternate measures against ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th revision) criteria for alcohol dependence and separately for harmful drinking/abuse were compared between probability samples of 1511 emergency room (ER) patients from three hospitals in Pachuca, Mexico, and 586 Mexican-American ER patients in Santa Clara County, California. Sensitivity was highest for the Alcohol Use Disorders Identification Test (AUDIT), TWEAK, and Rapid Alcohol Problems Screen (RAPS) for alcohol dependence; sensitivity was highest for holding five or more drinks for harmful drinking/abuse in both samples. All instruments performed better for alcohol dependence than for abuse/harmful drinking. Arrests for drinking and driving performed better in Santa Clara than in Pachuca, while a positive Breathalyzer reading and reporting drinking prior to the event performed better in Pachuca; both were significantly more sensitive among the injured compared to the noninjured in Pachuca. The data suggest that instrument performance may be similar between those in Pachuca and those in the low acculturation group in Santa Clara, relative to those scoring higher on acculturation. While standard screening instruments appear to work reasonably well in both samples for alcohol dependence, variation across gender. injury, and acculturation subgroups suggests attention should be given to choosing the ''best'' instrument.

Cherpitel CJ; Borges G. Screening instruments for alcohol problems: A comparison of cut points between Mexican-American and Mexican patients in the emergency room. Substance Use & Misuse 35(10): 1419-1430, 2000. (29 refs.)

The performance of alcohol use disorder screening instruments (CAGE, BMAST, AUDIT, TWEAK) at various cut points were compared between a Mexican American emergency room (ER) sample (n = 586) and a sample of ER-patients in Mexico (n = 1,417) using ICD-10 and DSM-IV criteria for alcohol dependence and harmful drinking/abuse by gender and injury status. Lowering cut points improved instrument performance substantially for females in both samples. Further research is needed to explore instrument performance by gender and level of acculturation.

Cherpitel CJ; Borges G; Medina-Mora ME. Screening for alcohol problems: A comparison of instrument performance between the ER and the general population among Mexican Americans in the US and Mexicans in Mexico. Addiction Research & Theory 9(1): 59-72, 2001. (32 refs.)

Relatively little is known about the performance of screening instruments for alcohol use disorders in the general population compared to clinical populations, or among Mexicans or Mexican Americans. The sensitivity and specificity of three screening measures: CAGE, TWEAK, and holding five or more drinks (HOLD), for alcohol dependence, are compared between ER and general population samples in the U.S. (Santa Clara, County, California) and in Mexico (Pachuca). In Pachuca sensitivity of the TWEAK and HOLD was significantly better in the general population compared to the ER, while in Santa Clara sensitivity of the CAGE was significantly better in the ER compared to the general population. HOLD appeared to perform better in the general population than in the ER in Santa Clara. The data suggest differential performance of screening instruments among Hispanics in the general population compared to the ER in both the U.S. and Mexico, and HOLD may be the measure of choice for identifying alcohol use disorders in the Hispanic general population.

Chung T; Colby SM; Barnett NP; Rohsenow DJ; Spirito A; Monti PM. Screening adolescents for problem drinking: Performance of brief screens against DSM-IV alcohol diagnoses. Journal of Studies on Alcohol 61(4): 579-587, 2000. (60 refs.)

Objective: The performance of three brief screens, the CAGE, TWEAK and Alcohol Use Disorders Identification Test (AUDIT), was evaluated against a DSM-IV diagnosis of alcohol abuse or dependence in an adolescent sample. Method: Adolescents (13-19 years old) who presented to an emergency department for treatment of an injury, and who tested negative for blood alcohol concentration at time of admission, were administered a structured diagnostic interview and modified versions of the CAGE. TWEAK and AUDIT. Results: Of the 415 adolescents for whom complete data were available, 18% met criteria for a DSM-IV alcohol use disorder according to the Diagnostic Interview Schedule for Children (version 2.3). Teens who reported alcohol use in the last year (n = 261, 58% male. 71% white) were included in analyses that compared the performance of the three screening instruments. Receiver Operating Characteristic analysis indicated that the AUDIT demonstrated the best performance across the range of its cut-scores, with optimal performance at a cut-score of 4. The TWEAK performed optimally at a cut-score of 2 and the CAGE at a cut-score of 1. Conclusions: Routine alcohol screening among adolescents seen in a hospital setting is indicated. Two important directions for future research include the identification of adolescent-specific alcohol screening items, and the validation of an adolescent-specific definition of problem drinking that addresses limitations of DSM-IV alcohol diagnoses when applied to adolescents.

Cremonte M; Cherpitel CJ. Performance of screening instruments for alcohol use disorders in emergency department patients in Argentina. Substance Use & Misuse 43(1): 125-138, 2008. (32 refs.)

The performance of the Alcohol Use Disorders Identification Test (AUDIT), CAGE, Brief Michigan Alcohol Screening Test (Brief MAST), Rapid Alcohol Problems Screen ( RAPS), Rapid Alcohol Problems Screen-Quantity and Frequency (RAPS4-QF), and TWEAK was evaluated against a diagnosis of alcohol dependence and harmful drinking or alcohol abuse from ICD-10 and DSM-IV criteria. Data were collected from a probability sample of 779 patients admitted to the emergency department of a public general hospital in Mar del Plata, Argentina, during the year 2001. The majority of the patients sampled were male. The age range was 18 to 89 years, with a mean value of 36 years and a median of 31 years. Almost half of the sample had an elementary school education or less. All instruments were more sensitive for alcohol dependence than for harmful drinking or abuse and more sensitive for men than for women. Findings suggest the RAPS4 and RAPS4-QF may be preferred when screening for alcohol use disorders in the emergency department in Argentina. The study's limitations are noted.

Dawson DA; Das A; Faden VB; Bhaskar B; Krulewitch CJ; Wesley B. Screening for high- and moderate-risk drinking during pregnancy: A comparison of several TWEAK-based screeners. Alcoholism: Clinical and Experimental Research 25(9): 1342-1349, 2001. (41 refs.)

Purpose: This study investigated the use of the TWEAK and nine alternative screeners for predicting high-risk and moderate-risk drinking during pregnancy. Method: The analysis was based on self-reports from 404 lifetime drinkers who presented for an initial visit at nine prenatal clinics in Washington, DC. Data were collected anonymously by having women directly enter their responses onto an audio, computer-assisted interview that was programmed onto a laptop computer. Pregnancy risk drinking status was based on both average daily volume of intake and frequency of drinking 3+ drinks in a day. Each of the alternative screeners was constructed by adding one additional risk indicator to the TWEAK, and three different scoring options were explored. Results: Using thresholds of 2 points for high-risk drinking and 1 point for moderate-risk drinking, the TWEAK demonstrated a sensitivity and specificity of 70.6% and 73.2% for high-risk drinking and a sensitivity and specificity of 65.6% and 63.7% for any (high- or moderate-) risk drinking during pregnancy. None of the alternative screeners resulted in significant improvement, but the addition of current smoking status showed enough promise to warrant further testing in larger samples. Conclusions: Despite some loss in sensitivity and specificity, the TWEAK, in its original or a modified form, can be extended to measures of high-risk drinking that incorporate infrequent heavy intake and can be used to test for moderate- as well as high-risk drinking. Because identification of moderate-risk drinkers substantially increases the pool of women targeted for intervention, cost implications must be considered in designing appropriate interventions.

Flynn HA; Waltont MA; Chermack ST; Cunningham RM; Marcus SM. Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings. Archives of Women's Mental Health 10(4): 155-161, 2007. (51 refs.)

The purpose of the study was to examine the rates and interrelationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care. While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (TWEAK and quantity and frequency of alcohol use in past year), and depression (Center for Epidemiological Studies Depression Scale - CESD and prior history of depression). Over 30% of women reported either violence receipt, alcohol use problems or depression risk. Significant interrelationships among all measured risk variables were found. Although violence receipt was significantly related to alcohol misuse, cigarette use, less education, and scoring above the cutoff on the CESD (>= 16) was most strongly associated with violence. Practitioners should be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.

Gareri J; Chan D; Klein J; Koren G. Screening for fetal alcohol spectrum disorder. Canadian Family Physician 51: 33-34, 2005. (6 refs.)

QUESTION I have several patients whom I suspect are drinking during pregnancy. How can I find out for sure if they are? ANSWER You can use one of the validated tools to screen for problem drinking. Motherisk uses the TWEAK test, but others are just as good. Following birth, you can test infants' meconium for metabolites of ethanol to detect whether they were exposed in utero to excessive drinking.

Kelly TM; Donovan JE; Kinnane JM; Taylor DMCD. A comparison of alcohol screening instruments among under-aged drinkers treated in emergency departments. Alcohol and Alcoholism 37(5): 444-450, 2002. (35 refs.)

Aims: Few studies have examined the adequacy of adult-validated alcohol screening measures when used with adolescents and young adults. A total of 103 subjects (55 males, 48 females) participated in a study of alcohol use among under-aged drinkers conducted in two emergency departments. Methods: Participants completed three brief screening instruments for problematic alcohol use: the Alcohol Use Disorders Identification Test (AUDIT); a modified version of the TWEAK; and the CAGE. Results and Conclusions: Missing data on the TWEAK, lower internal consistency for the TWEAK and CAGE, and the better ability of the AUDIT to differentiate problem drinkers from non-problem drinkers, suggest that the AUDIT performs best in screening for problematic alcohol use among under-aged drinkers treated in emergency departments.

Marcus SM; Flynn HA; Blow FC; Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. Journal of Women's Health & Gender-Based Medicine 12(4): 373-380, 2003. (49 refs.)

Objectives: This study aimed to describe the prevalence of depressive symptomatology during pregnancy when seen in obstetric settings, the extent of treatment in this population, and specific risk factors associated with mood symptoms in pregnancy. Methods: A total of 3472 pregnant women age 18 and older were screened while waiting for their prenatal care visits in 10 obstetrics clinics using a brief (10 minute) screening questionnaire. This screen measured demographics, tobacco and alcohol (TWEAK problem alcohol use screening measure), and depression measures, including the Center for Epidemiological Studies-Depression scale (CES-D), use of antidepressant medications, past history of depression, and current treatment (i.e., medications, psychotherapy, or counseling) for depression. Results: Of women screened, 20% (n = 689) scored above the cutoff score on the CES-D, and only 13.8% of those women reported receiving any formal treatment for depression. Past history of depression, poorer overall health, greater alcohol use consequences, smoking, being unmarried, unemployment, and lower educational attainment were significantly associated with symptoms of depression during pregnancy. Conclusions: These data show that a substantial number of pregnant women screened in obstetrics settings have significant symptoms of depression, and most of them are not being monitored in treatment during this vulnerable time. This information may be used to justify and streamline systematic screening for depression in clinical encounters with pregnant women as a first step in determining which women may require further treatment for their mood symptoms. As elevations in depressive symptomatology have been associated with adverse maternal and infant outcomes, further study of the impact of psychiatric treatment in gravid women is essential.

McLean SA; Blow FC; Walton MA; Gregor MA; Barry KL; Maio RF et al. Rates of at-risk drinking among patients presenting to the emergency department with occupational and nonoccupational injury. Academic Emergency Medicine 10(12): 1354-1361, 2003. (31 refs.)

Objectives: To compare the characteristics and rates of at-risk drinking among patients presenting to the emergency department (ED) with occupational and nonoccupational injury. Methods: Cross-sectional survey of injured patients presenting to a university hospital ED. Injured patients were prospectively identified, and consenting patients completed a survey including questions regarding quantity/frequency of alcohol use, TWEAK, CAGE, and work-relatedness of injury. Major trauma and motor-vehicle collisions were excluded. Demographic and injury information was obtained from the medical record. Patients with a TWEAK score greater than or equal to3, CAGE score greater than or equal to2, or who exceeded NIAAA quantity/frequency guidelines were defined as at-risk drinkers. Analysis utilized the Student t-test for continuous variables, and frequency and chi-square analysis for categorical variables. Results: Among 3,476 enrolled patients, 766 (22%) had work injuries and 2,710 (78%) had nonwork injuries. Patients with work injuries were as likely as patients with nonwork injuries to be at-risk drinkers; 35% of patients with an occupational injury and 36% of those with a nonoccupational injury were at-risk drinkers (odds ratio = 0.96). Conclusions: Patients presenting to the ED with an occupational injury have rates of at-risk drinking similar to other injury patients, and may be an important group in which to target brief alcohol interventions.

O'Connor MJ; Whaley SE. Health care provider advice and risk factors associated with alcohol consumption following pregnancy recognition. Journal of Studies on Alcohol 67(1): 22-31, 2006. (61 refs.)

Objective: This study examined the extent to which pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were counseled by their health care providers to stop drinking alcohol during pregnancy A second purpose was to identify characteristics associated with alcohol consumption postrecognition of pregnancy. Method: The sample consisted of 279 women who continued to drink after learning they were pregnant. Measures of provider advice on alcohol consumption, demographic characteristics caffeine intake, smoking, other drug use, alcohol risk (using the TWEAK scale), and depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D) were collected. Results: Sixty-two percent of women had significantly high TWEAK scores, and 60% scored within the clinical range for depression (CES-D >= 16). Sixty percent of sample women had been advised by their care providers not to drink alcohol during pregnancy. Women who were most likely to receive advice were black non-Hispanic and Hispanic, were Spanish speaking, were less educated, were on public assistance, and had a higher number of alcohol-related risk behaviors. Advanced age, public assistance, caffeine use, smoking, and elevated TWEAK and CES-D scores predicted elevations in alcohol consumption rates. Conclusions: Although advice to stop drinking during pregnancy was provided to 60% of this sample, women continued to drink following pregnancy recognition, with alcohol consumption rates highly associated with sociodemographic and psychological factors, namely maternal depression. Because elevations in alcohol consumption during pregnancy are associated with poorer developmental outcomes for children, further efforts are needed to better address social and mental health factors that influence consumption.

O'Connor MJ; Whaley SE. Alcohol use in pregnant low-income women. Journal of Studies on Alcohol 64(6): 773-783, 2003. (46 refs.)

Objective: The present study had two aims: (1) to examine the prevalence rates of prenatal alcohol consumption in a group of women participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Southern California, with special emphasis on Hispanic women, and (2) to identify variables associated with postconception drinking in low-income minority women. Method: The study employed a cross-sectional survey that assessed alcohol use rates, demographic variables, and alcohol risk status. Participants were 826 pregnant women enrolled in the Public Health Foundation Enterprises (PHFE) WIC Program in Los Angeles and Orange counties, California. Pregnant women who enrolled self-administered a specially designed alcohol screener. Results: Findings were that 24% of sample women were consuming alcohol post conception. Of that percentage, approximately two thirds drank prior to pregnancy recognition, and one third continued to drink after pregnancy was confirmed. Approximately 30% of white non-Hispanic, black non-Hispanic and English-speaking Hispanic women were found to drink post conception compared with 15.8% of Spanish-speaking Hispanic women. This finding supported recent research that suggests more acculturated Hispanic women tend to incorporate the drinking patterns of the larger U.S. population to a greater extent than less acculturated Hispanic women. Although a number of demographic variables differentiated women who were abstinent from those who were postconception drinkers, the best predictor of postconception alcohol consumption was the woman's high-risk drinking score as measured by the TWEAK (sensitivity = 70.1%, specificity = 88.5%). Conclusions: Results suggest the importance of screening low-income minority pregnant women in a community setting so that interventions can be initiated to prevent fetal alcohol syndrome and related conditions.

Russell M; Martier SS; Sokol RJ; Mudar P; Jacobson S; Jacobson J. Detecting risk drinking during pregnancy: A comparison of four screening questionnaires. American Journal of Public Health 86(10): 1435-1439, 1996. (21 refs.)

OBJECTIVES. This study investigated the efficacy of screening for risk drinking during pregnancy with two brief questionnaires, TWEAK and T-ACE. Both include an assessment of tolerance based on the number of drinks women report they can hold. METHODS. Subjects were disadvantaged African-American obstetric patients in Detroit, Mich. Traditional alcoholism screens (Michigan Alcohol Screening Test [MAST], CAGE) and the tolerance question were administered (n = 2717); TWEAK and T-ACE were constructed from tolerance and embedded MAST and CAGE items. In a separate sample (n = 1420), only the T-ACE was administered, Periconceptional risk drinking was the gold standard. Screen evaluations were based on receiver-operating characteristic analyses. RESULTS. At the cutpoint of 2, sensitivity/specificity for embedded screens were 91/77 for TWEAK and 88/79 for T-ACE; comparable values for T-ACE alone were 67/86, TWEAK and T-ACE Screened more effectively than CAGE or MAST. CONCLUSIONS. Embedded versions of TWEAK and T-ACE were both highly sensitive to periconceptional risk drinking in this population. Administering T-ACE alone reduced its sensitivity; this suggests that MAST and CAGE administration improves its performance.