1

Consistency of Self-Administered and Interview-Based

Addiction Severity Index Composite Scores

Craig S. Rosen, Ph.D. Brandy R. Henson, B.A.

John W. Finney, Ph.D. Rudolf H. Moos, Ph.D.

Center for Health Care Evaluation

Veterans Affairs Palo Alto Health Care System

and

Stanford University School of Medicine

(2000, Addiction, 95, 419-425)

Correspondence regarding this article should be addressed to Craig S. Rosen, Center for Health Care

Evaluation, VA Palo Alto Health Care System (152-MPD), 795 Willow Road, Menlo Park CA, 94025.

Telephone: 650-493-5000 X 27172. Fax: 650-617-2736. E-mail: crosen@stanford.edu.

 2

Abstract

Aims. This study assesses the viability of a self-administered version of the Addiction Severity

Index (ASI, McLellan et al., 1992) for monitoring substance abuse patients functioning. Design and

measurements. Patients completed the ASI interview and a self-administered questionnaire containing

ASI composite items an average of 4 days apart. Composite scores from both formats were compared

using correlations and mean differences. Participants and setting. Participants were 316 veterans

entering substance abuse treatment in an U.S. Department of Veterans Affairs medical center. Findings.

Alcohol use, drug use, psychiatric, family, legal, and employment problem, composite scores correlated

.59 to .87 across formats. Patients endorsed more drug use and psychiatric symptoms by questionnaire

than by interview. Medical composite scores correlated only .47 across formats. Conclusions. This

study and previous research by Cacciola et al. (1998) suggest that a self-administered questionnaire can

be a feasible alternative to ASI interviews for monitoring substance abuse patients treatment outcomes.
 3

Introduction

This study examines the consistency between responses to Addiction Severity Index (ASI) items

in the standard interview format and in a self-administered questionnaire. The ASI (McLellan, et al.,

1992) assesses seven domains of functioning related to addiction: alcohol use, drug use, medical

problems, psychiatric symptoms, family and social problems, legal problems, and employment problems.

Data supporting the reliability and validity of most of the indices assessed by this instrument have been

obtained in prior studies with VA patients and other populations (Argeriou, et al., 1994; McLellan, et al.,

1985; Stoffelmayr, Mavis & Kasim, 1994; Zanis, et al., 1994).

Clinician-based ASI interviews were conducted recently throughout the Department of Veterans

Affairs (VA) health care system with patients having current substance use disorder diagnoses. However,

face-to-face interviews appear impractical for monitoring patient outcomes on an ongoing basis due to the

burden they impose on clinical staff.

Previous reviews have concluded that patient reports of alcohol and injected drug use are

reasonably reliable and valid when events are recent and patients do not face negative consequences for

their answers (Babor, Stephens, & Marlatt, 1987; Darke, 1998, Midanik, 1988). Studies comparing pencil

and paper questionnaires with interview self-report of substance use have found either similar responses

to both formats or a tendency to endorse more drug use on paper and pencil questionnaires (Aquilino,

1994; Bongers & Van Oers, 1998; Heithoff & Wiseman, 1996; Sobell & Sobell, 1981). This prior

research suggests it may be possible to use a questionnaire to obtain data comparable with the ASI

interview. To gauge the feasibility of using a self-administered ASI-based instrument to assess patients

with substance use disorders, this study investigated the corresponded between composite scores based on

self-administered ASIs and clinician-based ASI interviews. This research expands on a similar study

conducted by Cacciola, McLellan, Alterman, and Mulvaney (1998) with patients at another VA Medical

Center.
 4

Methods

Measures

Patients responded to both the standard ASI interview (McLellan, et al., 1992) and a separate self-

administered questionnaire containing items used to calculate ASI composite scores. Questionnaire items

were based on the text and parenthetical instructions of the interview ASI items, with additional

instructions for only 5 items. The self-administered questionnaire did not include most of the extensive

clarifications and instructions that supplement the ASI interview script. Copies of the self-administered

questionnaire are available from the authors upon request.

Sample

The ASI interview and questionnaire were administered to 341 patients beginning detoxification

(n = 211), residential rehabilitation (n = 73), or outpatient substance abuse treatment (n = 57) at a VA

health care facility from August 1997, through August 1998. Patients were eligible to participate if they

were cognitively and visually capable of responding, were in treatment for at least 3 days, and had not

previously been administered an ASI interview. Our sample represents roughly 55% of eligible patients.

The most common reasons for nonparticipation were patient refusal or being discharged before the

interview was administered.

Another 25 patients were excluded because the interview and self-administered questionnaire

were administered more than 2 weeks apart. Thus, 316 patients responded to both the ASI interview and

self-administered questionnaire within a 14-day time frame (mean 4.0 days apart, S.D. = 3.0). Nearly all

(n = 310) patients provided complete data for items on the alcohol composite, drug composite, and at least

3 of 5 other composites in the interview, whereas only 74% (n = 235) of patients answered all these items

on the questionnaire. All 316 patients were used in our analyses, with missing data deleted pairwise.
 5

Roughly equal numbers of patients first completed the interview (n =160) or self-administered

questionnaire (n =150). Order of administration, although not strictly random, was unrelated to treatment

unit, length of time between administrations, or symptom severity on the ASI interview.

The sample was 99% male. Over half (57%) were White, 25% African-American, 9% Latino,

2% Native American, and 7% were from other ethnic backgrounds. Respondents average age was 47

(S.D. = 8.4), with an average 13.3 years of education (S.D. = 1.8). Fourteen percent were currently

married, 45% were divorced, 15% were separated, 3% were widowed, and 22% were never married.

These characteristics are consistent with those of VA patients who recently completed the ASI nationwide

(Moos et al., 1998), with the exception that more married (22%) and more African-American (36%)

veterans were in the national sample.

Data Analysis

Calculation of five of the seven ASI composites followed standard procedures (McGahan et al.,

1986). To reduce respondent burden on the self-administered questionnaire, this measure assessed use of

specific drugs in the past 30 days dichotomously (yes or no), although it was assessed continuously

(number of days used) on the interview ASI. Interview drug items were dummy-coded to match the self-

administered questionnaire yes/no format and scoring of both the interview and self-administered

questionnaire was adjusted to reflect use of dichotomously coded item responses. Scoring of the self-

administered questionnaire family/social composite was adjusted because two items (conflicts with ones

children and conflicts with close friends) were inadvertently left out of the self-administered

questionnaire. Analyses of item-composite correlations in the interview data indicated that

dichotomization of the drug use items and deletion of the two family composite items did not

significantly alter the factor structure of these composites. Mean family composite scores were not

altered by our item changes, but drug composite scores tended to be higher when items were dummy-

coded.
 6

Consistency of composite scores obtained by interview and self-administered questionnaire was

evaluated at the individual level with Pearson correlation coefficients and at the group level with paired-t

tests. We also compared the internal consistency reliabilities (Cronbachs alpha), item means or

proportions, and item-composite correlations from both forms of administration.

Results

Data comparing composite scores obtained by self-administered questionnaire and interview are

shown on the left side of Table 1. Internal consistency reliability estimates (Cronbachs alphas) for the

self-administered questionnaire composite scores were similar to those for the corresponding interview

composite scores. In both the interview and questionnaire administrations, Cronbachs alphas were

highest (> .77) for the alcohol, drug use, psychiatric and medical composites and somewhat lower (.58 to

.72) for the family/social, legal, and employment composites. Limited internal consistency reliability for

these latter composites has been found in other studies (Alterman, et al., 1998; Zanis et al., 1994).

Composite scores from the self-administered questionnaire and interview-based ASI correlated

.47 to .87, although mean endorsement of problems tended to be somewhat higher by self-administered

questionnaire. Alcohol use composite scores correlated .87 across the two formats, with a slightly (but

significantly) higher mean score by self-administered questionnaire (.49) than by interview (.47, p < .05).

Drug use composite scores correlated .73 between interview and self-administered questionnaire.

However, the mean drug composite score was higher by self-administered questionnaire (.27) than by

interview (.20; p < .01). Mean responses were markedly higher by self-report for 5 of the 13 drug use

composite items, particularly for use of opiates and sedatives.

Psychiatric symptom composite scores correlated .67 between self-administered questionnaire

and interview. However, the mean psychiatric composite score was higher on the self-administered

questionnaire (.36) than in the interview (.27, p < .01). Specifically, endorsement of depression, anxiety,

hallucinations, violent tendencies, and memory/concentration problems were substantially higher by self-

administered questionnaire. Medical composite scores correlated only modestly (r = .47) between the
 7

interview and self-administered questionnaire administrations, although mean composite scores were

comparable across both administrations.

Self-reported family/social scores correlated moderately well (r = .59) with interview composite

scores. Reports of problems were slightly (although significantly) higher by self-administered

questionnaire (mean = .29) than by interview (mean = .25, p < .01). Patients acknowledged having more

conflicts with others on the self-administered questionnaire, but did not report significantly greater

subjective distress or desire for treatment. Legal problem composite scores correlated .71 between the

self-administered questionnaire and interview formats, with only a slightly higher mean score on the self-

administered questionnaire (.16) than in the interview (.13), although this difference was statistically

significant (p < .01). Employment composite scores correlated .86 across the two formats, with no

significant mean difference.

Item-composite correlations and item mean scores were consistent across formats for 20 of 23

items in the alcohol use, medical, family/social, legal, and employment composites, suggesting the

structure of these composites was relatively consistent across formats. Item-composite correlations were

consistent for 8 of 13 items on the psychological composite, although mean scores differed for nearly half

the items as noted above. Item-composite correlations differed for 8 of 13 drug use items. On the

questionnaire, 12 of the 13 drug use items correlated .35 to .53 with the composite score. In contrast,

interview-based item-composite correlations were strong (r > .60) for use of multiple substances, days

experienced problems, subjective distress and desire for treatment, but weak (r < .15) for use of

barbiturates, hallucinogens, sedatives, and street methadone, which were rarely endorsed by interview.

Four post-hoc analyses explored possible explanations for the differences in the mean composite

scores between the self-administered questionnaire and interview. Interviewers confidence ratings were

examined to identify cases where interview results might be distorted by patient misrepresentation or

inability to understand the questions. Only 12 such cases were identified, and their exclusion did not

significantly alter any of the findings. Deleting patients whose ASI questionnaires were only partially
 8

complete (n = 78) also did not significantly change any findings. A third analysis determined that the

length of time between interview and questionnaire administrations did not significantly affect the

consistency of composite scores across formats. A fourth analysis considered whether mean differences

between the interview and self-administered questionnaire depended on which measure was administered

first. Patients who completed the self-administered questionnaire prior to interview had higher mean

composite scores for drug use (.30) and family problems (mean = .32) than patients who completed the

self-administered questionnaire after being interviewed (drug composite mean = .24, t = -2.26, p < .05;

family problems composite mean = .27, t = - 2.07, p < .05). Mean endorsement of psychiatric problems

was consistently higher on the self-administered questionnaire irrespective of which format was

completed first.

Discussion

Results from this study indicate that a self-administered ASI questionnaire elicited information on

substance use-related indices similar to that obtained from the ASI interview. For 6 of 7 ASI composites,

scores obtained from self-administered questionnaires correlated .59 to .87 with those from the ASI

interviews. These correlations are consistent with the findings of Cacciola et al. (1998) among 105 VA

methadone maintenance and alcohol rehabilitation outpatients. Across both studies, the ASI composites

most highly correlated between self-administered questionnaire and interview formats were alcohol use,

drug use, and employment status (r > .73 in both studies). Composites for psychiatric functioning and

legal problems also were generally consistent between self-administered questionnaire and interview (r >

.65 in both studies). Family/social functioning correlated .59 with the interview ASI in the present study.

The strength of correlation between self-administered questionnaire and interview versions of the

ASI is constrained by the test-retest reliability of the ASI interview. Although ASI interview composite

scores are highly reliable under optimal research conditions (Stoffelmayr et al., 1994), their reliability

under clinical field conditions is not known. Although interviewers in the present study all received
 9

two days of training in administering the ASI, frequency of interviewing and interviewer monitoring were

highly variable. Given these conditions, it is notable that correlations between the self-administered

questionnaire and interview for the alcohol use, legal, and family problem composites were comparable to

the test-retest reliability of ASI interviews conducted 3-4 days apart in a homeless veteran sample (Zanis

et al., 1994). The present study and Cacciola et al. (1998) found poor consistency (r < .50) between self-

administered questionnaire and interview-based medical composite scores. Other studies have suggested

responses to medical composite items may be unstable over time (Joyner, Wright, & Devine, 1996; Zanis

et al., 1997).

Mean differences across format. In the present study, patients endorsed more drug use and

psychiatric problems on the self-administered questionnaire than in the interview. Patients also endorsed

significantly more alcohol use, legal problems, and family/social conflicts by self-administered

questionnaire than by interview, but these differences were relatively small. Patients may have indicated

more family or psychiatric problems on the self-administered questionnaire because they did not

appreciate that the items referred to severe problems only. Some patients may have acknowledged having

severe psychiatric symptoms on the self-administered questionnaire even if they were not as severe as

the question intended. On the family composite, interviewers should have been trained to clarify that

items dealing with family conflicts refer only to events that jeopardize the relationship (Fureman et al.,

1990). Difference in family composite scores across formats may have been minimized when the

interview came first, and respondents heard this definition before responding to the questionnaire.

Misunderstanding instructions seems unlikely to explain why reported drug use was higher on the

questionnaire than in the interview. Questions regarding drug use were clear and concrete (e.g., Did you

use cocaine in the last 30 days?). Differences in reported drug use (and perhaps also psychiatric

symptoms) may reflect social desirability concerns. Prior studies suggest patients may endorse more drug

use on a pencil and paper questionnaire than directly to an interviewer (Aquilino, 1994). Responses may

have also reflected differences in response categories, since the self-administered questionnaire asked for
 10

yes/no responses regarding drug use, and the interview ASI asked respondents to report the number of

days in the past month on which they used each substance (recoded to yes/no responses for comparison).

Of course, without objective measures for comparison, we cannot determine whether responses to a self-

administered questionnaire or interview format are more accurate.

The differences we found in mean composite scores between the two forms of administration

suggest that difference scores should only be obtained using the same modality at both intake and follow-

up. Intake data collected by interview can be used as a risk adjustment factor in analyzing later

questionnaire-based reports of functioning, but cannot by themselves provide the basis for an index of

change. Potential drawbacks of a self-administered instrument include possible patient refusal or

incomplete responses. However clinician interviews in field settings also are not immune to such

problems, as suggested by the 74% completion rate among the 46,023 VA patients approached for ASI

interviews nationwide (Moos et al, 1998). It should also be noted that the present data were based on a

sample of treatment-seeking American male veterans, and may not necessarily generalize to other

populations.

In sum, the present study and previous research by Cacciola et al. (1998) suggest that a self-

administered questionnaire version of the ASI is a feasible alternative to the ASI interview for monitoring

patient functioning. Despite some limitations, the consistently high correlations between interview and

self-administered questionnaire composite scores suggest self-administered ASI questions tap dimensions

of functioning similar to those assessed by the ASI interview, with less burden on clinical staff.
 11

References

Aquilino, W. S. (1994). Interview mode effects in surveys of drug and alcohol use: A field experiment.

Public Opinion Quarterly, 58 (2), 210-240.

Argeriou, M., Mcarty, D., Mulvey, K., & Daley, M. (1994). Use of the ASI with homeless substance

abusers. Journal of Substance Abuse Treatment, 11(4), 359-365.

Babor, T. F., Stephens, R. S., & Marlatt, G. A. (1987). Verbal report methods in clinical research on

alcoholism: Response bias and its minimization. Journal of Studies on Alcohol, 48, 410 424.

Cacciola, J. S., McLellan, A. T., Alterman, A. I., & Mulvaney, F. D. (1998). A comparison of a self-

administered ASI with the standard ASI interview. In L. S. Harris (Ed.), Problems of Drug

Dependence, 1997: Proceedings of the 59th Annual Scientific Meeting, The College on Problems of

Drug Dependence, Inc. (NIH Publication No. 98-4305, page 254). Rockville, MD: National Institutes

of Health.

Darke, S. (1998). Self-report among injecting drug users: A review. Drug and Alcohol Dependence, 51,

253-263.

Fureman, B., Parikh, G., Bragg, A., & McLellan, A. T. (1990). Addiction Severity Index Workbook,

Fifth Edition. Pittsburgh, PA: University of Pennsylvania/Veterans Administration Center for Studies

of Addiction.

Heithoff, K. A., & Wiseman, E. J. (1996). Reliability of paper-pencil assessment of drug use severity.

American Journal of Drug and Alcohol Abuse, 22, 109-122.

Joyner, L. M., Wright, J. D., & Devine, J. A. (1996). Reliability and validity of the addiction severity

index among homeless substance misusers. Substance Use and Misuse, 31(6), 729-751.

McGahan, P. L., Griffith, J. A., Parente, R., & McLellan, A. T. (1986). Composite scores from the

Addiction Severity Index. Philadelphia, PA: Department of Veterans Affairs Medical Center.
 12

McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., and Argeriou,

M. (1992). The fifth edition of the addiction severity index. Journal of Substance Abuse Treatment,

9(3), 199-213.

McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H. L., & O'Brien, C. P. (1985).

New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of

Nervous and Mental Disease, 173(7), 412-23

Moos, R. H., Finney, J., Cannon, D., Finkelstein, A, McNicholas, L., McLellan, A. T., & Suchinsky, R.

(1998). Outcomes monitoring for substance abuse patients: I. Patients characteristics and treatment

at baseline. Palo Alto, CA: Veterans Affairs Health Care System, Program Evaluation and Resource

Center, HSR&D Center for Healthcare Evaluation, Center of Excellence in Substance Abuse

Treatment & Education, and Mental Health Strategic Health Group.

Sobell, L. & Sobell, M. (1981). Effects of three interview factors on the validity of alcohol abusers

self-reports. American Journal of Drug and Alcohol Abuse, 8, 225-237.

Stoffelmayr, B. E., Mavis, B. E., & Kasim, R. E. (1994). The longitudinal stability of the ASI. Journal of

Substance Abuse Treatment, 11(4), 373-8.

Zanis, D. A., McLellan, A. T., Cnaan, R. A., & Randall, M. (1994). Reliability and validity of the

Addiction Severity Index with a homeless sample. Journal of Substance Abuse Treatment, 11(6),

541-8.
 13

Acknowledgements

This manuscript was prepared in part for the Substance Abuse Module of the U. S. Department of

Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI). Preparation of this manuscript

was supported by the VA Health Services Research and Development Service, VA Office of Academic

Affiliations, VA Mental Health Strategic Health Group, and VA Sierra-Pacific Network Mental Illness

Research Education and Clinical Center. We are grateful to Lou Moffett, Gary Hartz, and other staff at

the Palo Alto VA Addiction Treatment Services for facilitating data collection. Correspondence

regarding this article should be addressed to Craig Rosen, Center for Health Care Evaluation (152-MPD),

VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025. Electronic mail can be

sent to crosen@stanford.edu.
 1

Table 1

Self-Report vs. Interview ASI Composite Scores

Cronbachs Correspondence Between Number of Meaningful

Alpha Interview and Self-Administered ASI Item-Level Differences

ASI Composite Interview SAQ Item Mean Item-Composite

Scores n Interiew a SAQb r Mean Mean Paired t Differencesc Correlationsd

Alcohol 269 .87 .91 .87 .47 .49 2.46* 2/6 items 1/6 items

Drug Use 272 .77 .81 .73 .20 .27 7.54** 5/13 items 8/13 items

Psychiatric 264 .83 .85 .67 .27 .36 7.17** 5/11 items 3/11 items

Medical 297 .86 .86 .47 .36 .35 -0.42 0/3 items 0/3 items

Family/Social 288 .72 .65 .59 .25 .29 3.50** 1/5 itemse 0/5 items

Legal 302 .62 .58 .71 .13 .16 3.19** 0/5 items 1/5 items

Employment 293 .71 .66 .86 .71 .70 -1.32 0/4 items 1/4 items

a b
Interview ASI. Self-administered questionnaire ASI. cd > .20 for continuous item means, difference > 9 percentage points for reported
d
percentages (all p < .05). q > .15 (small effect size), p < .05 for differences between self-administered and interview item-composite correlation
e
coefficients. Counted as five items because multiple items on conflict with others are summed as one item in computing the composite score.

* p < .05. ** p < .01.