Validity of the ADHD module of the Mini International Neuropsychiatric Interview PLUS for screening of adult ADHD in treatment seeking substance use disorder patients: ADHD screening with MINI-Plus

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University of Groningen

Validity of the ADHD module of the Mini International Neuropsychiatric Interview PLUS for

screening of adult ADHD in treatment seeking substance use disorder patients

IASP Research Group; Palma-Álvarez, Raul Felipe; Barta, Csaba; Carpentier, Pieter Jan;

Carruthers, Susan; Crunelle, Cleo L; Demetrovics, Zsolt; Dom, Geert; Faraone, Stephen V;

Franck, Johan

Published in:

Revista de psiquiatria y salud mental

DOI:

10.1016/j.rpsm.2020.04.013

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from

it. Please check the document version below.

Document Version

Version created as part of publication process; publisher's layout; not normally made publicly available

Publication date:

2020

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

IASP Research Group, Palma-Álvarez, R. F., Barta, C., Carpentier, P. J., Carruthers, S., Crunelle, C. L.,

Demetrovics, Z., Dom, G., Faraone, S. V., Franck, J., Johnson, B., Kapitány-Fövény, M., Kaye, S.,

Konstenius, M., Matthys, F., Moggi, F., Møller, M., Schellekens, A., Skutle, A., ... Ramos-Quiroga, J. A.

(2020). Validity of the ADHD module of the Mini International Neuropsychiatric Interview PLUS for

screening of adult ADHD in treatment seeking substance use disorder patients: ADHD screening with

MINI-Plus. Revista de psiquiatria y salud mental. https://doi.org/10.1016/j.rpsm.2020.04.013

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Pleasecitethisarticleinpressas:Palma-ÁlvarezRF,etal.ValidityoftheADHDmoduleoftheMiniInternational Neu-www.elsevier.es/saludmental

ORIGINAL

ARTICLE

Validity

of

the

ADHD

module

of

the

Mini

International

Neuropsychiatric

Interview

PLUS

for

screening

of

adult

ADHD

in

treatment

seeking

substance

use

disorder

patients:

ADHD

screening

with

MINI-Plus

Raul

Felipe

Palma-Álvarez

a,b

,

Csaba

Barta

c

,

Pieter

Jan

Carpentier

d

,

Susan

Carruthers

e

_,

_Cleo

_L.

_Crunelle

f_,g

_,

_Zsolt

_Demetrovics

h

_,

_Geert

_Dom

i_,j

_,

Stephen

V. Faraone

k

_,

_Johan

_Franck

l

_,

_Brian

_Johnson

m

_,

Máté

Kapitány-Fövény

n_,o

_,

_Sharlene

_Kaye

p

_,

_Maija

_Konstenius

l

_,

_Frieda

_Matthys

f

_,

Franz

Moggi

q

_,

_Merete

_Møller

r

_,

_Arnt

_Schellekens

s

_,

_Arvid

_Skutle

t

_,

Geurt

van

de

Glind

u

_,

_Katelijne

_van

_Emmerik-van

_Oortmerssen

v_,w

_,

Soﬁe

Verspreet

j

_,

_Robert

_A.

_Schoevers

w

_,

_Sara

_Wallhed

x

_,

_Frances

_R.

_Levin

y

_,

Lara

Grau-López

a,b

_,

_Miguel

_Casas

a,b

_,

_Wim

_van

_den

_Brink

z

_,

Josep

Antoni

Ramos-Quiroga

a,b,∗

_,

_IASP

_Research

_Group

a_Department_of_Psychiatry,_Hospital_Universitari_Vall_d’Hebron,_Barcelona,_Spain

b_Department_of_Psychiatry_and_Forensic_Medicine,_Universitat_Autònoma_de_Barcelona,_Barcelona,_Spain

c_Institute_of_Medical_Chemistry,_Molecular_Biology,_{Pathobiochemistry,}_Semmelweis_University,_Budapest,_Hungary d_Reinier_van_Arkel_mental_health_institute,_{‘s-Hertogenbosch,}_The_Netherlands

e_National_Drug_Research_Institute,_Curtin_University,_Perth,_Australia

f_Department_of_Psychiatry,_Vrije_Universiteit_Brussel_(VUB),_Universitair_Ziekenhuis_Brussel_(UZ_Brussel),_Brussels,_Belgium g_{Toxicological}_Center,_Antwerp_University,_Antwerp,_Belgium

h_Institute_of_Psychology,_ELTE_Eötvös_Loránd_University,_Budapest,_Hungary

i_Antwerp_University_(UA),_{Collaborative}_Antwerp_Psychiatric_Research_Institute_(CAPRI),_Antwerp,_Belgium j_Psychiatric_Center_Mutiversum,_Boechout,_Belgium

k_Departments_of_Psychiatry_and_of_Neuroscience_and_Physiology,_SUNY_Upstate_Medical_Center,_Syracuse,_NY,_USA l_Department_of_Clinical_{Neuroscience,}_Karolinska_Institutet,_Stockholm,_Sweden

m_Departments_of_Psychiatry_and_of_Anesthesia,_SUNY_Upstate_Medical_Center,_Syracuse,_NY,_USA n_Nyír˝_o_Gyula_National_Institute_of_Psychiatry_and_Addictions,_Budapest,_Hungary

o_Faculty_of_Health_Sciences,_Semmelweis_University,_Budapest,_Hungary

p_National_Drug_and_Alcohol_Research_Center,_University_of_New_South_Wales,_Sydney,_Australia q_University_Hospital_of_Psychiatry_and_{Psychotherapy,}_University_of_Bern,_Switzerland

r_Department_for_Substance_Abuse_Treatment,_Østfold_Hospital_Trust,_Norway

s_Department_of_Psychiatry,_Radboudumc,_Donders_Institute_for_Brain,_Cognition_and_Behavior,_Nijmegen_Institute_for_Scientist

PractitionersinAddiction(NISPA),Nijmegen,TheNetherlands

t_Bergen_Clinics_Foundation,_Bergen,_Norway

∗_{Corresponding}_author.

E-mailaddress:jaramos@vhebron.net(J.A.Ramos-Quiroga).

https://doi.org/10.1016/j.rpsm.2020.04.013

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Pleasecitethisarticleinpressas:Palma-ÁlvarezRF,etal.ValidityoftheADHDmoduleoftheMiniInternational

Neu-ARTICLE IN PRESS

2 R.F.Palma-Álvarezetal.

u_ICASA_Foundation,_University_of_Amsterdam,_Amsterdam,_The_Netherlands v_Arkin_Mental_Health_and_Addiction_Treatment_Center,_Amsterdam,_The_Netherlands w_University_of_Groningen,_University_Medical_Center_Groningen,_Groningen,_The_Netherlands x_Stockholm_Centre_for_Dependency_Disorders,_Sweden

y_Columbia_University,_the_New_York_State_Psychiatric_Institute,_New_York,_NY,_USA

z_Amsterdam_Institute_for_Addiction_Research,_Department_of_Psychiatry,_Academic_Medical_Center,_University_of_Amsterdam,

Amsterdam,TheNetherlands

Received19February2020;accepted18April2020

KEYWORDS ADHD; Comorbidity; Substanceuse disorder; MINI; Psychometrics Abstract

Objective:ThisstudyaimstoassessthevalidityoftheADHDmoduleoftheMini-International

NeuropsychiatricInterview(MINI-Plus)inpatientswithsubstanceusedisorders(SUD),usingthe

Conners’AdultADHDDiagnosticInterviewforDSM-IV(CAADID)astheexternalcriterion.

Method: Across sectionalinternationalmulti-centerstudy in10countrieswasconductedin

treatmentseekingSUDpatients.Asampleof1263patientswithbothMINI-PlusandCAADIDwas

analyzedtodeterminethepsychometricpropertiesoftheMINI-Plus.

Results:AccordingtotheCAADID,179patients(14.2%)metcriteriaforadultADHD,whereas

accordingtotheMINI-Plus227patients(18.0%)wereidentiﬁedashavingadultADHD.Sensitivity

oftheMINI-PlusADHDmodulewas74%,speciﬁcitywas91%,positivepredictivevaluewas60%

andnegativepredictivevaluewas96%.Kappawas0.60.

Conclusion:TheMINI-PlushasacceptablecriterionvalidityforthescreeningofadultADHDin

treatmentseekingSUDpatients.

Scientiﬁcsigniﬁcance: Onthebasisoftheresults,TheMINI-Plusmaybeusedforthescreening

ofADHDinSUDpatients.

openaccessarticleundertheCCBY-NC-NDlicense(

http://creativecommons.org/licenses/by-nc-nd/4.0/). PALABRASCLAVE TDAH; Comorbilidad; Trastornodeconsumo desustancias; MINI; Psicometría

ValidezdelmóduloTDAHdeMini-InternationalNeuropsychiatricInterviewPLUSpara cribarTDAHenadultosenpacientescontrastornosporabusodesustanciasque buscantratamiento

Resumen

Objetivo:ElobjetivodeesteestudioesevaluarlavalidezdelmóduloTDAHdeMINI-Plus

(Mini-InternationalNeuropsychiatricInterview)enpacientescontrastornosporabusodesustancias

(SUD),utilizandoCAADID(EntrevistadiagnósticaConnersparaadultosconTDAHparaDSM-IV)

comocriterioexterno.

Método: Esteestudiointernacionaltransversalmulticéntricorealizadoen10paísesfue

real-izado en los pacientes de SUD que buscan tratamiento. Se analizó una muestra de 1.263

pacientesutilizando MINI-Plus y CAADID, para determinarlaspropiedades psicométricas de

MINI-Plus.

Resultados: ConformealaCAADID,179pacientes(14,2%)cumplieronloscriteriosdeTDAHen

adultos,mientrasque,conformeaMINI-Plusseidentiﬁcaron227pacientes(18%)conTDAHen

adultos.LasensibilidaddelmóduloTDAHdeMINI-Plusfuedel74%,laespeciﬁcidaddel91%,el

valorpredictivopositivodel60%yelvalorpredictivonegativodel96%.Elvalorkappafuede

0,60.

Conclusión:LaMINI-PlustienevalidezdecriteriosaceptableparaelcribadodeTDAHen

adul-tos,enpacientesconSUDquebuscantratamiento.

Signiﬁcacióncientíﬁca:Sobrela basedeestosresultados,puedeutilizarseMINI-Plusparael

cribadodeTDAHenlospacientesconSUD.

art´ıculoOpenAccessbajolalicenciaCCBY-NC-ND(

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Neu-ADHDscreeningwithMINI-Plus 3

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a childhood onset disorder that frequently persists into adulthood characterized by inattention and/or hyperactivity---impulsivity.1---3_In_the_general_population,_the prevalenceof ADHDinadultsrangesbetween2and5%.1,2 ADHDhasbeenassociatedwithmanypsychiatric comorbidi-ties,includingmood disorders,anxiety and substanceuse disorders(SUD).1---4_More_than_30%_of_patients_with_ADHD_also developlifetimeSUD,5_and_ADHD_is_considered_a_risk_factor for the development of SUD.6 _On _the _other _hand, _about 20---25% of adult SUD patients fulfill criteria for ADHD.4 It should be noted, that the prevalence of ADHD in SUD patients varies due to differences between classification systems(DSM-IVvs.DSM-5),diagnosticinstruments,primary substance used(alcohol vs. drugs), andtreatment setting (inpatientsvs.outpatients).7_In_a_{meta-regression}_analysis, a substantial part of the between study heterogeneity of ADHD prevalence in SUD patients was explained by differencesinthediagnosticinstrumentsthatwereused.8

Diagnosing ADHD in SUD patients is a challenge given the overlap of symptoms,9 _and _very _few _diagnostic _and screeninginstrumentsforADHDhavebeenvalidatedinSUD patients.This posesobstaclesfor diagnosisandtreatment ofthesepatients.10 _This_is_a_clinically_urgent_issue_because the correct diagnosis of ADHD in SUD patients provides a targetfortreatment.Currentlymanypatientsremain undi-agnosedand untreated,which hasseriousimplications on theirprognosis.11 _In_past_years,_research_efforts_have_been madetoevaluatescreeninganddiagnosticinstrumentsfor theassessmentofadultADHDinSUDpatients.11---15 _Despite theseefforts,manyquestionsremainandmoreresearchis needed.

TheMini-InternationalNeuropsychiatricInterview (MINI-Plus)isafullystructuredinterviewthatprovidesabriefand accurateassessmentofformerAxis1andsomeAxis2 psy-chiatric disordersin DSM-IVand ICD-10.16,17 _The _MINI-Plus providesan accuratediagnosis in some disorders, using a short-structuredinterviewwhichiswellreceivedbypatients andprofessionals.3,17,18 _Furthermore,_this_interview_can_be performed by lay persons after a brief training.19 Com-parisonsbetweentheMINI-PlusandtheStructuredClinical Interview for DSM-IV-TR axis I disorders (SCID-I)20 _have yieldedkappavaluesof0.70oraboveformostdiagnoses.21 In aclinical study,theMINI-Plus diagnosed comorbidities, including substance dependence, better than a clinical interview.18 _The_MINI-Plus_has_a_speciﬁc_DSM-IV_ADHD mod-ule (for children and adults),but thisinterview does not distinguish between presentations of ADHD (inattentive, hyperactive/impulsive,combined).Itisinterestingtopoint outthat,althoughtheMINI-PlusitemsforADHDarenot iden-ticaltoDSM-5criteria,theMINI-PlusmaybeusedforADHD detection in adults (with 5 criteria as DSM-5 requires) as thisinstrumentcovers the current core ADHDsymptoms.3 The ADHD moduleof the MINI-Plushas neverbeen evalu-atedinpatientswithacomorbidSUDdiagnosisandnodata areavailableaboutitspsychometricfeatures.

Therefore,thepresentstudyaimedtoevaluatethe cri-terionvalidityoftheADHDmoduleoftheMINI-Plusamong treatment-seeking SUD patients, usingthe Conners’ Adult ADHD Diagnostic Interview for DSM-IV (CAADID)22 _as _the

externalcriterion.TheCAADIDisoneofthemostfrequently usedsemi-structureddiagnosticinterviewsforthe classiﬁca-tionoftheDSM-IV-TRdiagnosisadultADHD.22_It_is_clinically useful,23 _and_has _shown_good_concurrent_validity_with_the ADHDmoduleofthePsychiatricResearchInterviewfor Sub-stanceandMentalDisorders(PRISM).24

Methods

We analyzed data from the International ADHD in Sub-stance Use Disorders Prevalence (IASP) study;25 _a _cross sectionalstudycomprising47 addictiontreatment centers from10 countriesacross threecontinents: Australia, Bel-gium, France, Hungary, The Netherlands, Norway, Spain, Sweden, Switzerland and The United States.25 _The _IASP studyusedatwo-stagedstudydesign,includingascreening andadiagnosticstagedirectedatADHDandcomorbid psy-chiatricdisordersintreatment-seekingSUDpatients,7,25_see Fig.1.Thetimebetweenﬁrstandsecondstageswas14days; thedurationoftheﬁrststagewasonehour,whilethesecond stagerequired at least threeconsecutive visits (one-hour session),dependingonthepatient,inordertocompleteall theassessment.25_The_current_validation_study_only_includes IASPparticipants whocompletedboth theMINI-PlusADHD moduleandtheCAADID.Therefore,onlyparticipantsfrom France,Hungary,Norway,The Netherlands,Spain,Sweden andSwitzerland wereincluded.25 _Approval_was_granted_at each center by the local medical ethical committee. All participantsgavewritteninformedconsent.

Participants

TheIASPstudyincludedadults(age18---65years),whowere startinganewtreatmentepisodeinanaddictiontreatment centerbetween July 2008and November2011 (each cen-terrecruitedpatientsforoneyear).Thefollowingexclusion criteriawereapplied:inadequatelanguageskills,cognitive impairment,substanceintoxication,acutepsychiatriccrisis, severesomaticproblemsandunwillingnesstosigninformed consent.Efforts weremade toinclude subjectsthatwere excludedinitially(duetosubstanceintoxication,acute psy-chiatricormedicalproblems)atalaterdate.25

Procedure

Inthetwo-stagedesign,patientsthatparticipatedinstage onewereinvitedtocontinuetostagetwo.Stageonewasa screeningphasethatassessedsociodemographicvariables, substanceuseandscreenedforADHDusingtheAdultADHD Self-ReportScaleV1.1(ASRS).26 _Stage_two_was_a_diagnostic phaseconsistingoftheCAADIDandtheMINI-PlusADHDadult module(5.0version)forthediagnosisof(adult)ADHD.The CAADIDwasused astheGold Standard. Trainedclinicians administeredtheinterviews,theCAADIDandMINI-Pluswere administeredbythesameparson.

Statisticalanalysis

CriterionvalidityoftheMINI-PlusADHDmodulewasassessed bycalculatingthesensitivity,speciﬁcity,positivepredictive

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Neu-ARTICLE IN PRESS

All patients referred to participating site

Selection: random sample, representing population of site. Procedures for randomization differed by site and were related to patient flow and availability of research

staff.

Stage 1: Screening Demographics ADHD - screener: ASRS V 1.1 Substance use questionnaire

Selection : all subjects from stage 1 were asked to participate in stage 2.

Stage 2: Full assessment – included group

2nd screening ADHD: ASRS V 1.1

SUD diagnosis: MINI-Plus modules ADHD diagnosis: CAADID/Mini-Plus modules

Stage 2: Full assessment – drop out group

Control for biases

Figure1 Designofstudy.

value(PPV)andnegativepredictivevalue(NPV)forthe MINI-Plusdiagnosis asapredictor of theCAADID diagnosis. We calculateda95%conﬁdenceintervalforeachvalidity esti-mate.TheKappaindexwascalculatedasaglobalmeasure of chance-corrected agreement. Statistical analyses were performedusingSPSSversion20.0.

Results

Ofthe original IASP sample (N=3558 subjects),27 _data _on bothMINI-PlusADHDmoduleandCAADIDwasavailablefor 1263subjects(ﬁnalsamplefor thepresent study).Table1

showsthesociodemographiccharacteristics:meanage40.0 years(agerange=18---65),male(73.5%),Caucasian(90.3%), single (54.2%), unemployed (38.5%), living alone (41.8%). Themainsubstancesusedwerealcohol(54.2%),stimulants (15.0%),cannabis(10.8%),andopioids(10.8%).

According to the CAADID, 179 patients (14.2%) met criteria for adult ADHD, whereas according to the MINI-Plus 227 patients (18.0%) were identiﬁed as having adult ADHD. The sensitivity of the MINI-PlusADHD module asa predictor of the CAADID was 74.8% (95%CI=[0.68---0.80]). The speciﬁcity was 91.4% (95%CI=[0.90---0.93]). The PPV was 60.0% (95%CI=[0.52---0.65]) and the NPV was 95.6% (95%CI=[0.95---0.97]).Finally,the chance-corrected agree-mentbetweentheMINI-PlusADHDmoduleandtheCAADID showedaKappaindexof0.60(95%CI=[0.53---0.66]).

Discussion

InthecurrentstudyamongtreatmentseekingSUDpatients, theMINI-Plusoverestimatestheprevalenceof adultADHD comparedtotheCAADID:18.0%vs.14.2%.Theseresultsare similartothosereportedbyresearchesthathaveused MINI-Plusfor studyingADHDingeneralpopulation(13.8%).3_Our resultscouldalsoberelatedtothegoodspeciﬁcity(91%)and moderatesensitivity(74%)oftheMINI-Plus.WithitshighNPV

(96%)andmoderatePPV(60%),theMINI-Plusiswell-suited todetectadultADHDpatients,butpatientspositiveforadult ADHD should be clinically assessed to prevent false posi-tivecasesofadultADHDintreatment-seekingSUDpatents. NPVandPPVvaluesmaychangeinsampleswithadifferent prevalenceofADHDprevalence.28_These_results_suggest_that theMINI-Plusmightbemoresuitableasascreenerthanas adiagnostictoolforADHDinSUDpatients.

OurresultswiththeMINI-Plusarebetterthanthosewith otherscreeninginstrumentsforADHDinSUDpatients.Van deGlindetal.(2013)studiedtheASRSasascreening instru-mentforADHDinaSUDpopulationwiththeCAADIDasthe externalcriterion.27_The_ASRS_had_a_similar_NPV_(97%)_but_a muchlowerPPV(26%)inasimilarpopulationwiththesame prevalence.27 _The_ASRS_had_a_higher_sensitivity_(84%)_but_a muchlowerspecificity(66%)comparedwiththeMINI-Plus. Therefore,theMINI-Pluscouldbecautiouslyconsideredas a better instrument than theASRS for ADHD screening in treatmentseekingSUDpatients.Thisisbecause,a screen-ingtestshouldhaveahighsensitivityandgoodspecificity, buthowever,NPVandPPVarekeycharacteristicsduetothe factthattheydescribetheperformanceofatestina spe-cificpopulationwithaspecific,i.e.substantial,prevalence ofADHD.29

According to the Kappa index (0,60), the agreement betweentheCAADIDandMINI-Plusdiagnoseswasmoderate. Previousstudiesonthediagnosticagreementbetween MINI-Plus and other diagnostic instruments (e.g., SCID-I) have shown ahigherKappa indexfor mostdiagnoses,including adultADHD.16,21_One_study_found_major_diagnostic disagree-mentin33%ofcaseswhentheMINI-Pluswasused,butitwas comparedwithanunstructuredinterview18_and_the_study_did notspecifywhetherADHDwasactivelysearchedfor.

SomestudieshaveusedtheMINI-Plustodiagnose adult ADHD in other populations not selected for SUD, such as incarcerated participants,30 _adult _psychiatric outpa-tients without psychotic disorders,31 _patients _with _mood disorders,32 _psychiatric _inpatients,33 _and _patients _in _an

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Table1 Sociodemographicandclinicalcharacteristics.

Variables n=1263 Age(years) M₌39.98(18---65) Gender 73.5%(928)males Socialstatus %(n) Single 54.2(685) Divorced 18.8(237) Married 17.1(216) Livingpartner 8.7(110) Unknown-missing 1.2(15) Laboralstatus %(n) Unemployed 38.5(486) Employed 30.1(210) Sickleave 16.6(210) Disability 12.2(154) Unknown-missing 2.6(33) Housing %(n) Alone 41.8%(528) Withpartner 26.1%(330) Withparents 15.8%(199) Withfriends 4.6%(58) Homeless 4.2%(53) Shelter/healthcare 4.1%(52) Unknown-missing 3.4%(43) Ethnicity %(n) Caucasian 90.3%(1141) Other 9.7%(122) Mainsubstance %(n) Alcohol 54.2%(684) Stimulants 15.0%(190) Cannabis 10.8%(137) Opioids 10.8%(136) Prescriptionmedication 4.6%(58) Other 4.0%(51) Unknown-missing 0.6%(7)

ADHDdiagnosisaccordingtoCAADID %(n)

NoADHDpatients 85.8%(1084)

ADHD 14.2%(179)

ADHDdiagnosisaccordingtoMINI-Plus %(n)

NoADHDpatients 82.0%(1036)

ADHD 18.0%(227)

acutepsychiatricward.34 _Although_DSM-5_criteria_for_ADHD arenotthesametotheMINI-Plusitems,thelatter instru-ment could be used for ADHD detection in adults (with 5 criteria as DSM-5 requires) because this interview cov-ers the current core ADHD symptoms.3 _Moreover, _some researcheshaveused,analyzedandadaptedtheMINI-Plusto fittoDSM-5fivecriteriawithgoodresults.3_To_the_best_of_our knowledge,therearenostudiesinSUDpatientsthat eval-uatedtheMINI-PluspropertiesforADHD.Therefore,thisis thefirststudyofthevalidityoftheADHDmoduleofMINI-Plus inSUDpatients.

AdultADHDinSUDpatientshasalsobeenassessedwith the PRISM,35 _a_diagnostic _instrument _that_was _{speciﬁcally} developed for thispopulation. In a preliminarystudy, the

ADHDsectionofthePRISMshowedhighsensitivityand speci-ﬁcity in SUD patients with clinical diagnosis as external criterion.24 _It _should _be _noted, _however, _that _the _PRISM requiresat leasttwodaystrainingandthatadministration takesabouttwohours.36_In_contrast,_the_MINI-Plus_needs_less trainingandmuchlesstimetoadminister.19,21,30_A_speciﬁc limitationoftheADHD moduleof MINI-Plusisthatit does notdifferentiatebetweenADHDpresentations/subtypes.

Thepresentstudyhasbothstrengthsandlimitations.The mainstrengthsarethe largeand diversesample of treat-ment seeking SUD patients (that represents daily clinical practicein outpatienttreatment centers) and the use of internationallyavailableinstrumentswithinthesamestudy protocolin differentcountriesandtreatment settings.An importantlimitation is the lack of clinical information to checkthevalueoftheCAADIDasexternalcriterion(‘‘gold standard’’).Besides, some authorsdescribe thatlowering theCAADIDcut-offmayincreaseADHDdiagnosis,and there-fore,itmodifiesanycomparisonwithotherinstruments37_; however,inthecurrentwork,weusedthevalidated,more conservativeandrecommendedcut-off.Anotherimportant limitationisthe lack ofdataoncurrent druguse andthe possibleinfluenceofongoingdruguseonthestabilityand validity of an ADHD diagnosis in SUD patients. However, a recent analysis of the ADHD screening data within the current study suggests that this is not a real problem.15 Finally,theadministrationof theCAADIDandMINI-Plusby thesamepersoncouldgenerateaconfirmationbiasduethe evaluator could interpret or assess according to previous information.38

In conclusion, the MINI-Plus has acceptable psychome-tricfeaturesfor thescreening ofadultADHDintreatment seekingSUDpatients.Inordertopreventfalsepositive diag-noses,astructuredclinicalassessmentshouldbeperformed inallpatientswithadultADHDaccordingtotheMINI-Plus.

Conﬂict

of

interest

Aspotentialconflictofinterests,theauthor(s)disclosedthe followingdata:RaulF.Palma-Alvarezhasreceivedfees to give talks for Exeltis, Lundbeck, and Takeda. Lara Grau-López has received fees to give talks for Janssen-Cilag, Lundbeck, Servier, Otsuka, and Pfizer. Miquel Casas has receivedfeestogivetalksforJanssen-Cilag,Bristol-Mayers Squibb,Ferrer-Brainfarma,Pfizer,Reckitt-Benckiser, Lund-beck,Otsuka,Servier, Lilly,Shire, GSK,Rovi andAdamed. Hehasreceivedfinancialcompensationforhisparticipation asamember of theJanssen-Cilag, Lilly, Shire, Lundbeck, Otsuka,FerrerandRoviboard.JosepA.Ramos-Quirogawas onthespeakers’bureauand/oractedasconsultantfor Eli-Lilly, Novartis, Shire, Lundbeck, Ferrer and Rubió in the last3years.Healsoreceivedtravelawards(hotelandair tickets)fortakingpartinpsychiatricmeetingsfromRubió, Ferrer, Shire and Eli-Lilly. The ADHD Program chaired by himreceivedunrestrictededucationalandresearchsupport fromthefollowingpharmaceuticalcompaniesinthelast3 years:Eli-Lilly,Shire,Janssen,Rovi,Lundbeck,andRubió.

Theotherauthorsdonothaveanyconﬂictofinterestto declare.Theauthorsaloneareresponsibleforthecontent andwritingofthispaper.

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Neu-ARTICLE IN PRESS

Acknowledgements

The IASPstudywasfunded by severalinstitutionsin each country. The ICASA Foundation developed the study and coordinatedwitheachinstitutiontheregionalfunding pro-cess.Thefundingsourcesdidnothaveanyinfluenceonthe study(researchprotocol,sampling,issues,analyses, publi-cation).Australia:astrategicgrantfromCurtinUniversityof Technology(Perth,WesternAustralia)fundedtheIAS screen-ingphase.Belgium:theIASPprojectinthiscountryreceived privatefunding.Hungary:Nodirectfundingwasreceived,it wassupportedbyagrantfromTheEuropeanUnionand Euro-peanSocialFund(underagreementtofinancetheproject) no.TÁMOP4.2.1./B-09/1/KMR-2010-0003.TheNetherlands, Amsterdam:noexternalfundingwasobtained.The partici-patinginstitute,Arkin,paidforthecostsinvolved.Norway, BergenClinicsFoundation:50%offundingwasprovidedby theRegional Research Council ForAddiction in West Nor-way(Regionalt kompetansesenterfor rusmiddelforskning I HelseVest(KORFOR);theremaining50%wassupportedby BergenClinics Foundation (Staff and infrastructure). Nor-way, Fredrikstad: The IASP was funded by the hospital (SykehusetØstfoldHF)notwithmoney,butwith50%ofthe salaryoftheparticipants,thenbytwosourcesoutsidethe hospital:TheRegionalcenterofDualDiagnosisandthesocial --- andHealthdirectory.Spain,Barcelona:Financialsupport wasreceivedfromPlanNacionalsobreDrogas,Ministeriode SanidadyPolíticaSocial(PND 0080/2011),theAgènciade SalutPúblicadeBarcelona andtheDepartamentdeSalut, Governmentof Catalonia,Spain. Sweden,Stockholm: The studywasfundedbytheStockholmCenterforDependency Disorders.Switzerland,Berne/Zurich:TheIASPin Switzer-landwasfundedbytheSwissFoundationofAlcoholResearch (Grant # 209). USA, Syracuse: no funding was obtained. The funding sources did not have influence on: who par-ticipatedasanauthorinthisstudy;theresearchprotocol; thesamplingofdata;thetopicschosenforpublications;the analysesofthedata;thecontentofthepublication.

References

1.Asherson P, Buitelaar J, Faraone SV, Rohde LA. Adult attention-deﬁcit hyperactivity disorder: key con-ceptual issues. Lancet Psychiatry. 2016;3:568---78,

http://dx.doi.org/10.1016/S2215-0366(16)30032-3.

2.Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, Ramos-Quiroga JA, et al. Attention-deﬁcit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1(15020),http://dx.doi.org/10.1038/nrdp.2015.20. 3.Barbaresi WJ, Weaver AL, Voigt RG, Killian JM,

Katu-sic SK. Comparing methods to determine persistence of childhood ADHD into adulthood: a prospective population-based study. J Atten Disord. 2018;22:571---80,

http://dx.doi.org/10.1177/1087054715618791.

4.van Emmerik-van Oortmerssen K, van de Glind G, Koeter MW, Auriacombe M, Barta C, Bu ET, et al. Psychiatric comorbidity in treatment-seeking substance use disorder patientswithandwithoutattentiondeﬁcithyperactivity dis-order:resultsoftheIASPstudy.Addiction.2014;109:262---72,

http://dx.doi.org/10.1111/add.12370.

5.Wilens TE, Martelon M, Joshi G, Bateman C, Fried R, Petty C, et al. Does ADHD predict substance-use dis-orders? A 10-year follow-up study of young adults with

ADHD.J AmAcad Child AdolescPsychiatry. 2011;50:543---53,

http://dx.doi.org/10.1016/j.jaac.2011.01.021.

6.VogelT,DomG,vandeGlindG,StuderJ,GmelG,etal.Is atten-tiondeﬁcit/hyperactivitydisorderamongmenassociatedwith initiationorescalation ofsubstanceuseat15-month follow-up?AlongitudinalstudyinvolvingyoungSwissmen.Addiction. 2016;111:1867---78,http://dx.doi.org/10.1111/add.13422. 7.vandeGlindG,KonsteniusM,KoeterMWJ,vanEmmerik-van

Oortmerssen K, Carpentier PJ, Kaye S, et al. Variability in the prevalence of adult ADHD in treatment seek-ing substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria. Drug Alcohol Depend. 2014;134:158---66,

http://dx.doi.org/10.1016/j.drugalcdep.2013.09.026. 8.van Emmerik-van Oortmerssen K, van de Glind G, van

den Brink W, Smit F, Crunelle CL, Swets M, et al. Prevalence of attention-deﬁcit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend. 2012;122:11---9,

http://dx.doi.org/10.1016/j.drugalcdep.2011.12.007. 9.FatseasM,DebrabantR,AuriacombeM.Thediagnostic

accu-racyofattention-deﬁcit/hyperactivitydisorderinadultswith substanceusedisorders.CurrOpinPsychiatry.2012;25:219---25.

10.Matthys F, Soyez V, van den Brink W, Joostens P, Tremmery S, Sabbe B. Barriers to implementation of treatment guidelines for ADHD in adults with sub-stance use disorder. J Dual Diagn. 2014;10:130---8,

http://dx.doi.org/10.1080/15504263.2014.926691.

11.CrunelleCL,vandenBrinkW,MoggiF,KonsteniusM,FranckJ, LevinFR,etal.Internationalconsensusstatementonscreening diagnosisandtreatmentofsubstanceusedisorderpatientswith comorbidattention deﬁcit/hyperactivitydisorder.EurAddict Res.2018;24:43---51,http://dx.doi.org/10.1159/000487767. 12.Chiasson JP, Stavro K, Rizkallah É, Lapierre L,

Dus-sault M, Legault L, et al. Questioning the speciﬁcity of ASRS-v1.1 to accurately detect ADHD in substance abusing populations. J Atten Disord. 2012;16:661---3,

http://dx.doi.org/10.1177/1087054711425768.

13.DaigreC,RonceroC,Rodríguez-CintasL,OrtegaL,Lligo˜naA, FuentesS,etal.AdultADHDscreeninginalcohol-dependent patients using the Wender-Utah Rating Scale and the adult ADHD Self-Report Scale. J Atten Disord. 2015;19:328---34,

http://dx.doi.org/10.1177/1087054714529819.

14.DakwarE,MahonyA, PavlicovaM,GlassA,BrooksD,Mariani JJ,etal. Theutility ofattention-deﬁcit/hyperactivity disor-derscreeninginstrumentsinindividualsseekingtreatmentfor substanceuse disorders.J ClinPsychiatry.2012;73:e1372---8,

http://dx.doi.org/10.4088/JCP.12m07895.

15.van Emmerik-van Oortmerssen K, Vedel E, Kramer FJ, Koeter MW, Schoevers RA, van den Brink W. Diag-nosing ADHD during active substance use: feasible or ﬂawed? Drug Alcohol Depend. 2017;180:371---5,

http://dx.doi.org/10.1016/j.drugalcdep.2017.07.039. 16.LecrubierY,SheehanD,WeillerE,AmorimP,BonoraI,

Shee-hanKH,etal.TheMiniInternationalNeuropsychiatricInterview (MINI).Ashortdiagnosticstructuredinterview:reliabilityand validityaccordingtotheCIDI.EurPsychiatry.1997;12:224---31,

http://dx.doi.org/10.1016/S0924-9338(97)83296-8.

17.Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, WeillerE,etal.TheMini-InternationalNeuropsychiatric Inter-view(M.I.N.I.):thedevelopmentandvalidationofastructured diagnosticpsychiatricinterviewforDSM-IVandICD-10.JClin Psychiatry.1998;59:22---33.

18.PinnintiNR,MadisonH,MusserE,RissmillerD.MINI Interna-tionalNeuropsychiatric Schedule: clinical utility and patient acceptance.EurPsychiatry.2003;18:361---4.

19.BlackDW,ArndtS,HaleN,RogersonR.UseoftheMini Inter-nationalNeuropsychiatricInterview(MINI)asascreeningtool

(8)

inprisons:resultsofapreliminarystudy.JAmAcadPsychiatry Law.2004;32:158---62.

20.FirstMB,SpitzerRL,GibbonM,WilliamsJBW.Structuredclinical interviewforDSM-IVaxisIdisorders-clinicianversion(SCID-CV). WashingtonDC:AmericanPsychiatricPress;1997.

21.SheehanDV,LecrubierY,HarnettSheehanK,JanavsJ,Weiller E,KeskinerA,etal.ThevalidityoftheMiniInternational Neu-ropsychiatricInterview(MINI)accordingtotheSCID-Pand its reliability.EurPsychiatry.1997;12:232---41.

22.Epstein JN, Kollins SH. Psychometric properties of an adult ADHD diagnostic interview. J Atten Disord. 2006;9:504---14,

http://dx.doi.org/10.1177/1087054705283575.

23.Ramos-Quiroga JA, Bosch R, Richarte V, Valero S, Gómez-BarrosN,NogueiraM,etal.Criterionandconcurrentvalidity ofConnersAdultADHDDiagnosticInterviewforDSM-IV (CAA-DID)Spanishversion.RevPsiquiatrSaludMent.2012;5:229---35,

http://dx.doi.org/10.1016/j.rpsm.2012.05.004.

24.Ramos-QuirogaJA,Díaz-DigonL, ComínM,Bosch R,Palomar G,ChalitaJP,et al.Criteriaand concurrentvalidityofadult ADHDsection of the psychiatry research interview for sub-stanceandmentaldisorders.JAttenDisord.2015;19:999---1006,

http://dx.doi.org/10.1177/1087054712454191.

25.vandeGlindG,VanEmmerik-vanOortmerssenK,CarpentierPJ, LevinFR,KoeterMW,BartaC,etal.TheInternationalADHDin SubstanceUseDisordersPrevalence(IASP)study:background, methodsand study population.IntJ Methods PsychiatrRes. 2013;22:232---44,http://dx.doi.org/10.1002/mpr.1397. 26.Kessler RC, Adler L, Ames M, Demler O, Faraone S,

Hiripi E, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35:245---56,

http://dx.doi.org/10.1017/S0033291704002892.

27.van de Glind G, van den Brink W, Koeter MW, Carpen-tier PJ, van Emmerik-van Oortmerssen K, Kaye S, et al. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screenerfor adultADHDintreatmentseekingsubstance use disorder patients. Drug Alcohol Depend. 2013;132:587---96,

http://dx.doi.org/10.1016/j.drugalcdep.2013.04.010. 28.AkobengAK.Understandingdiagnostictests1:sensitivity,

speci-ﬁcity and predictive values. Acta Paediatr. 2007;96:338---41,

http://dx.doi.org/10.1111/j.1651-2227.2006.00180.x.

29.Maxim LD, Niebo R, Utell MJ. Screening tests: a review with examples. Inhal Toxicol. 2014;26:811---28,

http://dx.doi.org/10.3109/08958378.2014.955932.

30.GunterTD,ArndtS,WenmanG,AllenJ,LovelessP,SieleniB, etal.Frequencyofmentalandaddictivedisordersamong320 menandwomenenteringtheIowaprisonsystem:useofthe MINI-Plus.JAmAcadPsychiatryLaw.2008;36:27---34.

31.Almeida Montes LG, Hernández García AO, Ricardo-Garcell J. ADHD prevalence in adult outpatients with nonpsy-chotic psychiatric illnesses. J Atten Disord. 2007;11:150---6,

http://dx.doi.org/10.1177/1087054707304428.

32.McIntyre RS, Kennedy SH, Soczynska JK, Nguyen HT, Bilkey TS,Woldeyohannes HO,et al.Attention-deﬁcit/hyperactivity disorder in adults with bipolar disorder or major depres-sive disorder: resultsfrom the internationalmood disorders collaborative project. Prim Care Companion J Clin Psychi-atry. 2010;12, http://dx.doi.org/10.4088/PCC.09m00861gry, pii:PCC.09m00861.

33.Kumar G, Faden J, Steer RA. Screening for attention-deﬁcit/hyperactivity disorder in adult inpatients with psychiatric disorders. Psychol Rep. 2011;108:815---24,

http://dx.doi.org/10.2466/03.05.09.13.15.PR0.108.3.815-824. 34.Mordal J, Gundersen O, Bramness JG. Norwegian version of the Mini-InternationalNeuropsychiatric Interview:feasibility, acceptabilityandtest---retestreliabilityinanacutepsychiatric ward.EurPsychiatry.2010;25:172---7.

35.Hasin DS, Trautman KD, Miele GM, Samet S, Smith M, Endicott J. Psychiatric Research Interview for Sub-stance and Mental Disorders (PRISM): reliability for substance abusers. Am J Psychiatry. 1996;153:1195---201,

http://dx.doi.org/10.1176/ajp.153.9.1195.

36.Samet S, Waxman R, Hatzenbuehler M, Hasin DS. Assessing addiction: concepts and instruments. Addict Sci Clin Pract. 2007;4:19---31.

37.Solanto MV, Wasserstein J, Marks DJ, Mitchell KJ. Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity? J Atten Disord. 2012;16:631---4,

http://dx.doi.org/10.1177/1087054711416910.

38.NickersonRS.Conﬁrmationbias:aubiquitousphenomenonin manyguises.RevGenPsychol.1998;2:175---220.