CAGE questionnaire

The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems. The questionnaire takes less than one minute to administer,[1] and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism. The CAGE questionnaire does not have a specific intended population, and is meant to find those who drink excessively and need treatment. The CAGE questionnaire is reliable and valid; however, it is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE questionnaire have been frequently implemented for such a purpose.

CAGE questionnaire
Purposeassessment of problem drinking
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Overview

The CAGE questionnaire asks the following questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?[2]

Two "yes" responses indicate that the possibility of alcoholism should be investigated further.[2]

The CAGE questionnaire, among other methods, has been extensively validated for use in identifying alcoholism.[2] CAGE is considered a validated screening technique with high levels of sensitivity and specificity.[3] It has been validated via receiver operating characteristic analysis, establishing its ability to screen for problem drinking behaviors.[4]

History

The CAGE questionnaire was developed in 1968 at North Carolina Memorial Hospital to combat the paucity of screening measures to detect problem drinking behaviors. The original study, conducted in a general hospital population where 130 patients were randomly selected to partake in an in-depth interview, successfully isolated four questions that make up the questionnaire today due to their ability to detect the sixteen alcoholics from the rest of the patients.[2]

Reliability

Reliability refers to whether the scores are reproducible. Not all of the different types of reliability apply to the way that the CAGE is typically used. Internal consistency (whether all of the items measure the same construct) is not usually reported in studies of the CAGE; nor is inter-rater reliability (which would measure how similar peoples' responses were if the interviews were repeated again, or different raters listened to the same interview).

Rubric for evaluating norms and reliability for the CAGE questionnaire*
CriterionRating (adequate, good, excellent, too good*)Explanation with references
NormsNot applicableNormative data are not gathered for screening measures of this sort
Internal consistencyNot reportedA meta-analysis of 22 studies reported the median internal consistency was

α= 0.74.[5]

Inter-rater reliabilityNot usually reportedInter-rater reliability studies examine whether people's responses are scored the same by different raters, or whether people disclose the same information to different interviewers. These may not have been done yet with the CAGE; however, other research has shown that interviewer characteristics can change people's tendencies to disclose information about sensitive or stigmatized behaviors, such as alcohol or drug use.[6][7]
Test-retest reliability (stability)Not usually reportedRetest reliability studies help measure whether things behave more as a state or trait; they are rarely done with screening measures
RepeatabilityNot reportedRepeatability studies would examine whether scores tend to shift over time; these are rarely done with screening tests

Validity

Validity describes the evidence that an assessment tool measures what it was supposed to measure. There are many different ways of checking validity. For screening measures such as the CAGE, diagnostic accuracy and discriminative validity are probably the most useful ways of looking at validity.

Evaluation of validity and utility for the CAGE questionnaire*
CriterionRating (adequate, good, excellent, too good*)Explanation with references
Content validityAdequateItems are face valid; not clear that they comprehensively cover all aspects of problem drinking
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)GoodMultiple studies show screening and predictive value across a range of age groups and samples[8]
Discriminative validityExcellentStudies not usually reporting AUCs, but combined sensitivity and specificity often excellent
Validity generalizationExcellentMultiple studies show screening and predictive value across a range of age groups and samples[8]
Treatment sensitivityNot applicableCAGE not intended for use as an outcome measure
Clinical utilityGoodFree (public domain), extensive research base, brief.

*Table from Youngstrom et al., extending Hunsley & Mash, 2008;[9] *indicates new construct or category

Limitations

The CAGE is designed as a self-report questionnaire. It is obvious to the person what the questions are about. Because talking about drinking behavior can be uncomfortable or stigmatized, people's responses may be subject to social desirability bias. The honesty and accuracy of responses may improve if the person trusts the person doing the interview or interpreting the score. Responses also may be more honest when the form is completed online, on a computer, or in other anonymous formats.

Alternatives

Some alternatives to the CAGE include:

Test[8] Description[8]
TWEAK A 5-item questionnaire that was originally developed for pregnant women at risk for drinking problems
Michigan Alcoholism Screening Test (MAST) A 25-item scale designed to assess lifetime symptoms of alcoholism with a focus on late-stage symptoms
Brief MAST Shortened 10-item version of the MAST
Short Michigan Alcoholism Screening Test A second shortened version of the MAST that does not include questions pertaining physical symptoms of drinking
Veterans Alcoholism Screening Test A 25-item questionnaire similar to the MAST that distinguishes between current and past symptoms
Alcohol Use Disorders Identification Test (AUDIT) A 10-item scale that focuses on symptoms experienced within the past year
Adolescent Drinking Index A 24-item scale developed specifically to assess the degree of an adolescent (age 12–17) individual's drinking problem

See also

References
  1. Allen, JP; Megan, VN (2003). Assessing alcohol problems : a guide for clinicians and researchers (PDF). Collingdale, PA: Diane Publishing Co. pp. 332–333. ISBN 9780788138294. Retrieved 15 September 2016.
  2. Ewing, John A (1984). "Detecting Alcoholism: The CAGE Questionnaire". JAMA. 252 (14): 1905–1907. doi:10.1001/jama.1984.03350140051025. PMID 6471323.
  3. Bernadt, MW; Mumford, J; Taylor, C; Smith, B; Murray, RM (1982). "Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism". Lancet. 6 (8267): 325–8. doi:10.1016/S0140-6736(82)91579-3. PMID 6120322. S2CID 42263163.
  4. Hemphill-Pearson, Barbara (2008). Assessments in Occupational Therapy Mental Health: An Integrative Approach (2nd ed.). Thorofare, NJ USA: SLACK Incorporated. p. 396. ISBN 978-1-55642-773-2.
  5. Shields, Alan L.; Caruso, John C. (2004-04-01). "A Reliability Induction and Reliability Generalization Study of the Cage Questionnaire". Educational and Psychological Measurement. 64 (2): 254–270. doi:10.1177/0013164403261814. ISSN 0013-1644. S2CID 144398501.
  6. Griensven, Frits van; Naorat, Sataphana; Kilmarx, Peter H.; Jeeyapant, Supaporn; Manopaiboon, Chomnad; Chaikummao, Supaporn; Jenkins, Richard A.; Uthaivoravit, Wat; Wasinrapee, Punneporn (2006-02-01). "Palmtop-assisted Self-Interviewing for the Collection of Sensitive Behavioral Data: Randomized Trial with Drug Use Urine Testing". American Journal of Epidemiology. 163 (3): 271–278. doi:10.1093/aje/kwj038. ISSN 0002-9262. PMID 16357109.
  7. Gribble, James N.; Miller, Heather G.; Cooley, Philip C.; Catania, Joseph A.; Pollack, Lance; Turner, Charles F. (2000-01-01). "The Impact of T-ACASI Interviewing on Reported Drug Use among Men Who Have Sex with Men". Substance Use & Misuse. 35 (6–8): 869–890. doi:10.3109/10826080009148425. ISSN 1082-6084. PMID 10847215. S2CID 26141403.
  8. Allen JP; Maisto SA; Connors GJ (1995-09-11). "SElf-report screening tests for alcohol problems in primary care". Archives of Internal Medicine. 155 (16): 1726–1730. doi:10.1001/archinte.1995.00430160044005. ISSN 0003-9926. PMID 7654105.
  9. Hunsley, John; Mash, Eric (2008). A Guide to Assessments that Work. New York, NY: Oxford Press. pp. 1–696. ISBN 978-0195310641.
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