Psychiatric Comorbidity, Health Status, and Functional Impairment Associated With Alcohol Abuse and Dependence in Primary Care Patients: Findings of the PRIME MD-1000 Study
Jeffrey G. Johnson
Department of Psychiatry Columbia University
Robert L. Spitzer
Department of Psychiatry Columbia University
Janet B. W. Williams
Department of Psychiatry Columbia University
Department of Medicine Uniformed Health Services University of the Health Sciences
Department of Internal Medicine New England Medical Center
Department of Medicine Mercy Catholic Medical Center
Department of Family Practice University of South Alabama
Department of Primary Care Albert Einstein College of Medicine
Citation: Journal of Consulting and Clinical PsychologyFebruary 1995 Vol. 63, No. 1, 133-140
ABSTRACTThe psychiatric comorbidity, health, and functioning of primary care patients with alcohol abuse and dependence (AAD) were investigated in a sample of 1,000 patients. Psychiatric symptomatology was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic system. Health and functional status was assessed with the Medical Outcomes Study Short Form General Health Survey (SF-20). Results indicated that use of the PRIME-MD system brought about a 71% increase in physician recognition of AAD. AAD patients were diagnosed with substantial psychiatric comorbidity, and they reported poorer health and functioning than did patients without any psychiatric disorders. However, they reported less impairment and psychiatric comorbidity than did patients with other psychiatric disorders. Results also indicated that AAD patients' health and functioning were associated with the presence or absence of psychiatric comorbidity.
This research was supported in part by an unrestricted educational grant from Roerig and Pratt Pharmaceuticals, divisions of Pfizer, Inc. We acknowledge gratefully the valuable comments and suggestions provided by Deborah Hasin and the statistical assistance provided by Mark Davies during the preparation of this article.
Correspondence may be addressed to Jeffrey G. Johnson, Biometrics Research Department, Unit 74, New York State Psychiatric Institute, 722 West 168th Street, New York, New York, 10032.
A number of studies conducted in the past decade have established that alcohol abuse and dependence (AAD) are relatively common in primary care settings, affecting 3% to 20% of primary care patients (e.g., Buchsbaum, Buchanan, Lawton, & Schnoll, 1991 ; Cherpitel, 1991 ; Cleary et al., 1988 ; Coulehan, Zettler-Segal, Block, McClelland, & Schulberg, 1987 ; Cyr & Wartman, 1988 ; Hurt, Morse, & Swenson, 1980 ; Leckman, Umland, & Blay, 1984 ; Powers & Spickard, 1984 ; Rydon, Redman, Sanson-Fisher, & Reid, 1992 ; Von Korff et al., 1987 ). A substantial body of research has also demonstrated that primary care physicians fail to recognize the presence of AAD in between 33% and 90% of their patients who have these disorders ( Borus, Howes, Devins, Rosenberg, & Livingston, 1988 ; Cleary et al., 1988 ; Coulehan et al., 1987 ; Leckman et al., 1984 ; Moore & Malitz, 1986 ; Reid, Webb, Hennrikus, Fahey, & Sanson-Fisher, 1986 ; Rydon et al., 1992 ; see Kamerow, Pincus, & Macdonald, 1986 ; Schulberg & Burns, 1988 ).
Insofar as chronic heavy alcohol consumption has been associated with increased risk for a number of life-threatening illnesses ( Adams, Yuan, Barboriak, & Timm, 1993 ; Eckardt et al., 1981 ; Gorelick, 1990 ; Mendelson, Babor, Mello, & Pratt, 1986 ; Schultz, Rice, & Parker, 1990 ), it has been proposed that researchers should develop methods that may bring about increased recognition of AAD and other psychiatric disorders by primary care physicians (e.g., Cyr & Wartman, 1988 ; Schulberg, 1991 ). Improved recognition of AAD appears to be of particular importance because research has demonstrated that feedback and advice provided by physicians and nurses can contribute to significant reductions in problem drinking (e.g., Anderson, 1993 ; Anderson & Scott, 1992 ; Kristenson, Ohlin, Hulten-Nosslin, Trell, & Hood, 1983 ; see also Babor, Ritson, & Hodgson, 1986 ).
This article presents findings of the PRIME-MD 1000 study ( Spitzer et al., 1992 ) regarding the psychiatric comorbidity, health status, and functional impairment of primary care patients diagnosed with AAD. The PRIME-MD 1000 study was conducted to validate and assess the clinical usefulness of a new diagnostic system, entitled Primary Care Evaluation of Mental Disorders" (PRIME-MD), that was developed for the purpose of facilitating the recognition of a range of psychiatric disorders, including AAD, by primary care physicians.
Although numerous studies have examined the prevalence and recognition of AAD in primary care settings, very little research has investigated the extent to which primary care patients with AAD suffer from comorbid psychiatric disorders, poor health, and impaired functioning (see Wells, Burnam, Benjamin, & Golding, 1990 ). The handful of studies that have addressed these issues in primary care settings have yielded conflicting findings; perhaps this is due in large measure to the use of different definitions and methodologies. Thus, whereas Buchan, Buckley, Deacon, Irvine, and Ryan (1981) reported that primary care patients who were problem drinkers had higher rates of mental and physical illness, as well as more social and marital problems than control-group patients, Tracy, Gorman, and Leventhal (1992) reported conversely that drinkers reported fewer illness symptoms than patients who abstained from alcohol use.
Although previous research indicates that patients in alcohol treatment programs tend to suffer from substantial psychiatric comorbidity and functional impairment (e.g., Mendelson et al., 1986 ; Powell et al., 1992 ; Powell, Penick, Othmer, Bingham, & Rice, 1982 ; Ross, Glaser, & Germanson, 1988 ; Schuckit, 1985 ), it has not been established whether the same is true of the larger population of primary care patients with mild to moderate AAD. A major goal of the present research, therefore, was to assess the psychiatric comorbidity, health status, and functional impairment of primary care patients with AAD.
The mean age of the 1,000 patients who participated in the PRIME-MD 1000 Study was 55 years ( SD = 16.5), with a range of 18 to 91 years; 60% were female, 58% were White, and 28% were college graduates. The most common types of physical disorders were hypertension (48%), arthritis (23%), diabetes (17%), heart disease (15%), and pulmonary disease (8%). Study participants were selected from four academic medical center primary care clinics, each directed by one of the authors: New England Medical Center General Medical Associates (hospital-based group practice); Bronx Municipal Hospital Center, Albert Einstein College of Medicine (city hospital clinic); Walter Reed Army Medical Center General Medicine Clinic (for both active-duty and retired military personnel and their families); and the University of South Alabama College of Medicine (family practice clinic). Participants were excluded from the study if they failed to provide informed consent, were less than 16 years of age, or were too demented or physically ill to participate. The first 369 patients who were entered into the study were selected by convenience but independently of the participating physicians' knowledge or suspicion that a patient had any psychopathology. The remaining 631 participants were either consecutively selected (one site) or selected with a site-specific procedure to ensure random sampling. Within all four sites, the convenience sample and the randomlyselected sample did not differ with respect to age, sex, ethnicity, education, level of functioning, health status, or frequency of PRIME-MD diagnoses. A more detailed description of the sample is provided by Spitzer et al. (1993).
Instruments The PRIME-MD Diagnostic System.
The PRIME-MD Diagnostic System ( Spitzer et al., 1993, in press ) has two components: a one-page screening instrument referred to as the Patient Questionnaire (PQ), which is completed by the patient before seeing the physician, and a Clinician Evaluation Guide (CEG), which is a structured clinical interview administered by the physician to patients who give positive responses on the PQ. The CEG assesses patients for the five groups of mental disorders most commonly encountered in primary care settings: mood, anxiety, alcohol, eating, and somatoform disorders. The PQ includes 26 yes-or-no questions about symptoms and signs experienced during the past month, the following three of which are adapted from the CAGE alcohol screening questionnaire ( Ewing, 1984 ): (a) Have you thought you should cut down on your use of alcohol? (b) Has anyone complained about your drinking? (c) Have you felt guilty or upset about your drinking? A fourth PQ alcohol screening question assesses heavy drinking by asking whether the patient has consumed five or more drinks on a single day during the past month. If any of the four alcohol screening items are checked yes (i.e., the patient screens positive" for AAD), the physician administers the alcohol module of the CEG, beginning with open-ended follow-up questions about each of the endorsed PQ items to determine their clinical significance.
Next, five additional CEG questions are asked, addressing the maladaptive use of alcohol during the past 6 months in the following areas: (a) Continued alcohol use despite being told by a physician to stop drinking because of a health problem; (b) Repeated alcohol use, intoxication, or hangovers while working, going to school, or taking care of other important responsibilities; (c) Repeated missing of work, school, or other important responsibilities because of alcohol use or being hung over; (d) Repeated problems getting along with other people while using alcohol; (e) Repeated automobile driving after having consumed several drinks or drinking too much." Probable alcohol abuse or dependence" is diagnosed if any of these five items is endorsed by the patient, or if the patient's responses to the follow-up questions indicate that the patient's alcohol use has caused clinically significant impairment or distress during the past 6 months. Whereas some CEG items assess symptoms of alcohol abuse in accordance with the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [ DSM-III-R ]; American Psychiatric Association, 1987 ; 4th ed. [ DSM-IV ], American Psychiatric Association, 1993 ), and others assess symptoms of alcohol dependence, the PRIME-MD system does not a yield differential diagnosis of alcohol abuse and alcohol dependence. Furthermore, the diagnosis is considered probable" because further information may in some cases be needed to confirm the diagnosis.
In an assessment of the validity of PRIME-MD diagnoses, a subset of 431 patients, selected regardless of their screening and diagnostic status on the PQ and CEG, were reinterviewed by mental health professionals who were not informed of the PRIME-MD diagnostic findings, using a telephone-administered semistructured psychiatric interview. Reinterview by telephone was used because of its convenience and demonstrated similarity to the findings of face-to-face research interviews ( Potts, Daniels, Burnam, & Wells, 1990 ; Wells, Burnam, Leake, & Robins, 1988 ). To permit assessment of the diagnostic criteria for the disorders assessed by physicians with the CEG, the telephone interview included the same diagnostic criteria used in the alcohol, anxiety, eating, and mood CEG modules. In addition, several open-ended questions from the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon, & First, 1992 ) were also included so as to permit assessment of psychopathology not elicited by the briefer and more structured CEG. Furthermore, as in the standard administration of the SCID, the mental health interviewer was encouraged to ask follow-up questions to clarify ambiguous responses to structured interview items.
Findings generally supported the validity of physician diagnoses obtained using the PRIME-MD system. The specificity and overall predictive power of physician diagnoses were consistently high for specific diagnoses, ranging from .84 to .99. Agreement between physician and mental health professional diagnoses, although modest, approximated the levels of agreement among mental health professionals using structured diagnostic interviews. With regard to AAD, a pairwise kappa of .71 was obtained between physician and mental health professional diagnoses, indicating good chance-corrected agreement. The sensitivity, specificity, and overall accuracy of physician AAD diagnoses using the PRIME-MD system were .81, .98, and .98 respectively, with physicians failing to detect the presence of AAD in 3 patients who were diagnosed with AAD by the mental health professionals and diagnosing AAD in 7 patients who were not diagnosed with AAD by the mental health professionals. The construct validity of the PRIME-MD diagnostic system was also supported by findings that patients who were diagnosed using the PRIME-MD system reported impaired functioning, as well as elevated health care utilization, in comparison with patients who did not receive PRIME-MD diagnoses. Furthermore, the concurrent validity of PRIME-MD was supported by strong relationships that were obtained between PRIME-MD diagnoses of mood, anxiety, and somatoform disorders and corresponding patient self-rated severity scales.
The Medical Outcomes Study Short Form General Health Survey (SF-20).
The SF-20 (Stewart, Hays, & Ware, 1988) is a 20-item self-report questionnaire that assesses six dimensions of health-related quality of life (physical, social, and role functioning, mental health, bodily pain, and general health perceptions). Scores on all six SF-20 scales range from 0 to 100, with higher scores indicating better health and less functional impairment; a 5-point reduction in SF-20 scale scores is generally considered clinically significant. Considerable support for the reliability and validity of the SF-20 has been reported (e.g., Nelson et al., 1983 ; Read, Quinn, & Hoefer, 1987 ; Stewart et al., 1988; Stewart et al., 1989 ).
After providing informed consent, all 1,000 patients completed the PQ; 877 patients completed the SF-20. Then, before they examined each patient's responses to the PQ, participating physicians recorded how well they knew the patient on a 3-point scale ranging from not at all well (1) to fairly well (3), and whether they already knew that the patient was currently suffering from AAD or any other PRIME-MD mental disorder. Next, physicians examined the PQ and administered the CEG to all of their patients who screened positive on the PQ. One hundred twenty-four of the 1,000 patients (71% male; mean age = 49.9) gave affirmative responses to one or more PQ alcohol screening items and were thus administered the CEG alcohol module. After completing the CEG, participating physicians recorded all of the current health problems experienced by the patient, as well as their ratings of the patient's physical health on a 5-point scale ranging from (1) excellent to (5) poor .
Prevalence and Physician Recognition of Alcohol Abuse and Dependence (AAD)
Of the one hundred twenty-four patients who responded affirmatively to one or more PQ screening items, 51 (72% male; mean age = 53.4) were diagnosed by their physicians with AAD on the basis of the information obtained using the CEG. Thus, the overall prevalence of AAD in this sample was 5%, with specific prevalences of 10% in male patients and 2% in female patients. The mean age of the patients diagnosed with AAD was 53.4 years, which did not differ significantly from the mean age of 55.3 years for the remainder of the sample, t (962) = 0.78, p > .05.
A positive association was obtained between the number of PQ alcohol items endorsed by patients and the likelihood of an AAD diagnosis being assigned. Thus, whereas 16 of the 75 patients (21%) who endorsed a single PQ alcohol item were diagnosed with AAD, 20 of the 33 patients (61%) who endorsed two PQ alcohol items and 15 of the 16 patients (94%) who endorsed three or four PQ alcohol items were diagnosed with AAD. The four PQ alcohol screening items varied substantially with regard to their sensitivity (se), specificity (sp), and positive predictive power (ppp): (PQ item 1) Have you thought you should cut down on your use of alcohol?" (se = .76, sp = .96; ppp = .53); (PQ item 2) Has anyone complained about your drinking?" (se = .39, sp = .99; ppp = .91); (PQ item 3) Have you felt guilty or upset about your drinking?" (se = .33, sp = .99; ppp = .77); (PQ item 4) Was there ever a single day in which you had five or more drinks of beer, wine, or liquor?" (se = .62, sp = .95; ppp = .41).
Of the 36 patients who were diagnosed with AAD and who were known somewhat" or fairly well" by their physicians, only 21 (58%) had been identified by their physicians as having a current alcohol problem before the administration of the PRIME-MD system. Insofar as 15 new cases of AAD were thus identified using PRIME-MD as a standard, the PRIME-MD system brought about a 71% increase in the recognition of AAD among patients who had some previous relationship with their physicians.
Table 1 presents the prevalence rates, odds ratios, and results of chi-square tests with regard to the distribution of each disorder diagnosed using the PRIME-MD system in the 51 patients diagnosed with probable alcohol abuse or dependence, in comparison with the remaining 949 patients. Patients with AAD had substantial psychiatric comorbidity, with 47% receiving one or more additional PRIME-MD diagnoses; 33%, 22%, 6%, and 14% of patients with AAD were diagnosed with mood, anxiety, eating, and somatoform disorders, respectively. However, the psychiatric comorbidity rate associated with AAD was somewhat less than the comorbidity rates associated with mood (65%), anxiety (82%), eating (84%), and somatoform (73%) disorders. Of the 949 patients who were not diagnosed with AAD, 35% received one or more PRIME-MD diagnoses, with 26%, 18%, 3%, and 14% diagnosed with mood, anxiety, eating, and somatoform disorders, respectively. Odds ratios and chi-square tests were computed to determine whether patients with AAD would have an elevated likelihood of receiving each of the specific PRIME-MD diagnoses. Odds ratios (OR) are defined as the odds that a case" (of AAD) will be diagnosed with a given disorder, divided by the odds that a control (non-AAD patient) will be so diagnosed. A Bonferroni correction procedure was implemented to control for the probability that multiple comparisons would inflate the likelihood of a Type II error, with a resulting alpha level of .002. Results were that, although the 51 patients with AAD tended to have somewhat higher prevalences of mood, anxiety, and eating disorders than the 949 patients without AAD, only in the case of major depressive disorder without dysthymia was this difference statistically significant (OR = 3.94),
χ2 1, N = 1000= 13.81, p < .0005
Health and Functional Status of Patients With AAD
A series of seven analyses of variance (ANOVAs) were conducted, to compare the health and functional status of primary care patients with AAD with that of two other patient groups: (a) patients with no psychiatric disorders and (b) patients with other psychiatric disorders. As Table 2 indicates, significant overall differences on all six SF-20 scales were obtained among the three groups, with the mean scores of the AAD group in all instances intermediate between the scores of the no-diagnosis group and the other psychiatric diagnosis group. Post hoc Scheffé pairwise comparisons revealed that patients with AAD had significantly lower SF-20 scores, indicating poorer functioning, than patients who had no psychiatric diagnoses on five of the six SF-20 scales, but also revealed that AAD patients had significantly higher scores than patients with other psychiatric diagnoses on four SF-20 scales. Identical findings were obtained when analyses of covariance (ANCOVAs) were conducted, controlling for the effects of age, educational status, minority status, number of types of physical disorders, and site. A seventh ANOVA, conducted to compare physicians' health ratings of patients in these three groups was also statistically significant, F (2, 988) = 51.73, p < .0001. Scheffé post hoc pairwise comparisons revealed that physicians rated the health of patients with no psychiatric disorders ( M = 2.30, SD = 0.96) as significantly better than that of both patients with AAD ( M = 2.86, SD = 1.14) and patients with other psychiatric disorders ( M = 2.94; SD = 0.90).
To determine whether the intermediate health and functional status of AAD patients was associated with the presence or absence of psychiatric comorbidity in these patients, a series of seven ANOVAs was conducted. The following specific research questions were addressed by means of these analyses: (a) Do the health and functional status of AAD patients with co-occurring psychiatric disorders tend to differ from those of patients without any psychiatric disorders? (b) Do the health and functional status of AAD patients without co-occurring psychiatric disorders tend to differ from those of patients without any psychiatric disorders? and (c) Do the health and functional status of AAD patients with co-occurring psychiatric disorders tend to differ from those of AAD patients without co-occurring psychiatric disorders?
As Table 3 indicates, the results of these ANOVAs were that significant overall differences were obtained between the three groups on all six SF-20 scales. Post hoc Scheffé pairwise comparisons revealed that AAD patients without psychiatric comorbidity did not differ with respect to health and functional status from patients who had no psychiatric disorders. By contrast, AAD patients with one or more co-occurring psychiatric disorders had significantly lower scores than patients who had no psychiatric diagnoses on all six SF-20 scales and had lower scores than AAD patients without psychiatric comorbidity on five SF-20 scales. Identical findings were obtained when ANCOVAs were conducted, controlling for the effects of age, educational status, minority status, number of types of physical disorders, and site. A seventh ANOVA, conducted to compare physicians' health ratings of patients in these three groups, was also statistically significant, F (2, 655) = 14.49, p < .0001. Scheffé post hoc pairwise comparisons revealed that physicians rated the health of AAD patients with psychiatric comorbidity ( M = 3.38, SD = 0.97) as significantly poorer than that of both AAD patients without psychiatric comorbidity ( M = 2.38, SD = 1.09) and patients with no psychiatric disorders ( M = 2.30, SD = 0.96).
It was also of interest to determine whether AAD patients with co-occurring psychiatric disorders differed with respect to health and functional status from patients without AAD who were diagnosed with other psychiatric disorders. A series of six t tests were thus conducted to compare the SF-20 scores of these groups. The results were that the two groups did not differ on the SF-20 scales for physical functioning, t (277) = 0.44, p > .05; social functioning, t (277) = 1.13, p > .05; role functioning, t (277) = 0.06, p > .05; mental health, t (277) = 1.00, p > .05; bodily pain, t (277) = 1.31, p > .05; or general health perceptions, t (277) = 1.13, p > .05. The means and standard deviations for the two groups are presented in the third columns of Tables 1 and 2 . Results of a seventh t test indicated that physicians rated the health of AAD patients with psychiatric comorbidity ( M = 3.38, SD = 0.97) as somewhat poorer, t (355) = 2.28, p = .023, than that of patients without AAD who were diagnosed with other psychiatric disorders ( M = 2.94, SD = 0.90), although this difference failed to attain statistical significance when a Bonferroni procedure was used to adjust for the effects of multiple comparisons on the probability of producing a Type I error, which resulted in an alpha level of .007.
Finally, a t test was conducted to determine whether AAD patients with psychiatric comorbidity would report more alcohol-related problems than AAD patients without psychiatric comorbidity. The results were that AAD patients with psychiatric comorbidity reported a mean of 3.79 alcohol-related problems on the PQ and CEG ( SD = 1.82), whereas AAD patients without psychiatric comorbidity reported a mean of 2.89 alcohol-related problems on the PQ and CEG ( SD = 1.09). This difference was statistically significant, t (49) = 2.18, p < .025.
The principal findings of the present research were as follows: (a) Use of the PRIME-MD diagnostic system brought about a 71% increase in physician recognition of AAD. (b) Although nearly half of the 51 patients diagnosed with AAD had co-occurring psychiatric disorders, patients with AAD had fewer co-occurring psychiatric disorders than did patients with mood, anxiety, eating, and somatoform disorders. (c) Furthermore, although patients with AAD reported poorer health and greater functional impairment than did patients without any psychiatric disorders, they reported less impairment than did patients who were diagnosed with other psychiatric disorders. (d) Only those AAD patients who had one or more co-occurring psychiatric disorders reported poorer health and greater functional impairment than that of patients without any psychiatric disorders.
The present findings are consistent with previous findings indicating that primary care patients with AAD are likely to suffer from substantial psychiatric comorbidity and to have poorer health and greater functional impairment than primary care patients with no psychiatric diagnoses (e.g., Buchan et al., 1981 ). The present findings are also consistent with previous reports that individuals with AAD in the general population are at elevated risk for the presence of co-occurring psychiatric disorders (e.g., Regier et al., 1990 ). However, the present findings also indicate that primary care patients with AAD may tend to have fewer co-occurring psychiatric disorders, better health, and less functional impairment than patients with a range of other psychiatric disorders. Furthermore, the present findings suggest that those primary care patients with AAD who have one or more co-occurring psychiatric disorders may be substantially more likely to suffer from poor health and functional impairment than primary care patients with AAD who do not have any co-occurring psychiatric disorders.
It is noteworthy that Powell et al. (1992) have reported, similarly, that inpatients in an alcoholism treatment program who had one or more co-occurring psychiatric disorders reported greater distress and more alcohol-related problems than inpatients in the same treatment program who had no co-occurring psychiatric disorders, although other research has demonstrated that individuals under treatment for alcoholism tend to have poor health and impaired functioning regardless of psychiatric comorbidity (e.g., Mendelson et al., 1986 ; Ross et al., 1988 ; Schuckit, 1985 ). Insofar as the health and functional status of individuals in the general population with AAD has not yet been well investigated ( Wells et al., 1990 ), it will be important for further research to determine whether the present findings, as well as those of Powell et al. (1992) , will be confirmed in samples of individuals with AAD who are not currently under treatment for alcoholism.
It is possible that the widespread belief that people identified as problem drinkers" typically suffer from poor health, impaired functioning, or both has resulted in part from a clinician's illusion" effect ( Cohen & Cohen, 1984 ), whereby conclusions derived from the study of severely disturbed patients-who are most frequently seen in treatment settings-are generalized to patients with less severe conditions (see Rogers et al., 1993 ; Stewart et al., 1993 ). Consistent with this hypothesis, Corrigan et al. (1986) have reported that patients in general hospital medical wards who were identified as suffering from alcoholism were less severely dependent on alcohol than a comparison group of patients, diagnosed with alcoholism, who were admitted for treatment to a psychiatric hospital. Further research should therefore evaluate the short- and long-term consequences of mild, moderate, and severe forms of AAD on health and daily functioning.
A substantial proportion of patients with current drinking problems have only mild to moderate symptoms of alcoholism (e.g., Powers & Spickard, 1984 ; Robins & Regier, 1991 ). As noted earlier, the present findings indicate that primary care AAD patients without co-occurring psychiatric disorders-who have relatively mild cases of AAD-may tend to have relatively few health problems and little functional impairment, compared with primary care patients who have no psychiatric disorders. It is noteworthy that problem drinking tends to be a transient condition that often leads to spontaneous remission (e.g., Hasin, Grant, & Endicott, 1990 ) and that individuals often cease or moderate their drinking when they become aware that they are suffering from the negative consequences of alcohol abuse (see Tracy et al., 1992 ; Wells et al., 1990 ). Nonetheless, because AAD is often a progressive condition that ultimately produces deleterious health consequences (e.g., Hasin et al., 1990 ; Schuckit, Smith, Anthenelli, & Irwin, 1993 ), it is clear that physicians should advise all such patients to cease or moderate their consumption of alcohol.
Fortunately, research has demonstrated that, by providing problem drinkers with information and brief counseling regarding the risks associated with continued heavy drinking, health professionals can contribute to significant reductions in their patients' alcohol consumption (e.g., Anderson, 1993 ; Anderson & Scott, 1992 ; Babor et al., 1986 ; Kristenson et al., 1983 ). The efficacy of such interventions may be due in part to resultant increases in patients' awareness that they are suffering from the effects of alcohol abuse (see Tracy et al., 1992 ; Wells et al., 1990 ). However, increased AAD intervention in primary care settings will be predicated on improved physician recognition of AAD (see Schulberg, 1991 ). Like the findings of previous researchers (e.g., Cleary et al., 1988 ; Cyr & Wartman, 1988 ; Leckman et al., 1984 ; Rydon et al., 1992 ), our findings demonstrate that routine screening can contribute to substantial increases in physician recognition of AAD in primary care settings. By enabling physicians to evaluate and diagnose AAD as well as other treatable psychiatric disorders, the PRIME-MD diagnostic system provides physicians with detailed information that can be used to facilitate intervention efforts.
Interpretation of the present findings should take into account some important considerations. Our finding that AAD patients who had no co-occurring psychiatric disorders did not suffer from significantly impaired health and functioning does not appear to be an artifact brought about by a large number of false-positive diagnoses, for two reasons: (a) the AAD prevalence rate of 5% for this study was relatively low in comparison with other studies that have reported AAD prevalence rates in primary care settings as high as 20% (e.g., Cyr & Wartman, 1988 ) and (b) AAD diagnoses obtained using the PRIME-MD diagnostic system had a very high specificity (.98) when compared with diagnoses of the same patients made by mental health professionals, indicating that participating physicians were unlikely to have made many false- positive diagnoses of AAD. It is also important to note that the PRIME-MD diagnostic system, developed for the purpose of facilitating rapid diagnostic evaluation in primary care settings, does not provide exhaustive evaluations of alcohol abuse or dependence. Clearly, somewhat different findings might have been obtained if the CEG, as well as lengthy structured clinical interviews focusing in greater detail on alcohol-related problems, had been administered to all 1,000 patients by experienced mental health professionals. Furthermore, the possibility cannot be ruled out that a number of patients reporting clinically significant alcohol abuse were not identified by means of the PRIME-MD system. Therefore, further investigations will need to be conducted so that the questions addressed by the present research might be more conclusively studied.
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