Validity of the SMAST in Two American Indian Tribal Populations

Abstract

The standardized evaluation of alcoholism and other psychopathologies in minority populations, particularly American Indians, has long been questioned. This study investigated the validity of one of the most commonly applied assessments for alcoholism—the Short Michigan Alcohol Screening Test (SMAST)—in two distinct American Indian tribal groups. We analyzed data collected from 1989 to 1995 from largely community representative samples of 456 Southwestern and 214 Plains Indians ages 21 or older. For comparison, alcohol dependence was diagnosed using Diagnostic and Statistical Manual of Mental Disorders, Third Edition–Revised (DSM-III-R) criteria from a detailed, modified version of the Schedule for Affective Disorders and Schizophrenia—Lifetime (SADS-L). Accuracy of the SMAST was quantified as sensitivity, specificity, likelihood ratios, and the area under the curve for receiver operating characteristics, using the DSM-III-R diagnosis as the reference. The standard SMAST cutoff score of ≥3 had a demonstrated sensitivity 86% to 95%, but did not perform well in terms of specificity (23%–47%). Significantly higher cutoff scores (≥5 for both genders in the Southwestern tribe and 8 and ≥6 for men and women in the Plains tribe) were required to demonstrate acceptable levels of specificity in both tribes. The findings suggest that the SMAST is not a valid tool to screen for alcohol misuse in these two tribal populations. The highly elevated and different thresholds required from one population to the next and from one gender to the next constitute a significant obstacle to the use of the instrument.

• Alcoholism
• American Indian
• Native American
• MAST
• Assessment
• Shame
• Alcohol use screen

Resumen

La evaluación estandarizada para el alcoholismo y otras psicopatologías en poblaciones étnicas minoritarias, particularmente en indígenas norteamericanos, han sido largamente questionadas. Este estudio investigó la validez de una evaluación comúnmente aplicada para el alcoholismo—La prueba corta Michigan para identificación de alcohol (SMAST, por sus siglas en inglés)—en grupos de dos distintivas tribus de indígenas norteamericanos. Utilizando muestras de individuos mayores a 21 años, analizamos los datos de estas muestras representativas de dos grandes comunidades: indígenas de el suroeste de los Estados Unidos (456 individuos) e indígenas simples (214 individuos). Además, para comparar, la dependencia al alcohol fué diagnosticada usando el criterio DSM-III-R de una detallada versión modificada de el catálogo para desórdenes afectivos y esquizofrenia de por vida (SADS-L, por sus siglas en inglés). La precisión de la prueba SMAST fué cuantificada deacuerdo a su sensibilidad, especificidad, probabilidad, y el área bajo la curva para las características de el receptor operario usando el diagnóstico DSM-III-R como referencia. La limitación ≥3 en el resultado de la prueba estándar SMAST había demostrado una sensibilidad de 86–95% pero no tuvo buen desempeño en términos de especificidad (23–47%). Una limitación en los resultados significativamente más altos (≥5 para ambos sexos en la tribu de el Suroeste; 8 y ≥6 para hombres y mujeres en la otra tribu) fué requerida para demostrar niveles aceptables de especificidad en ambas tribus. Los hallazgos sugieren que la prueba SMAST no es una herramienta válida para buscar el mal uso de el alcohol en estas dos poblaciones tribales. El elevado y diferente umbral requerido entre poblaciones y entre sexos constituye un obstáculo significativo para el uso de esta herramienta.

Résumé

La question de l’évaluation standardisée de l’alcoolisme et autres psycho-pathologies dans les populations de minoritées, en particulier les Indiens d’Amérique, a longtemps été un sujet de débat. Cette étude examine la validité de l’une des mesures la plus communément utilisée pour l’alcoolisme, le <<Short Michigan Alcohol Screening Test>> (SMAST), dans deux groupes tribaux distincts d’Indiens d’Amérique. Nous avons analysé des données à partir d’échantillons représentatifs de communautés de 456 Indiens du Sud-Ouest et 214 Indiens des Plaines, âgés de 21 ans ou plus. Pour la comparaison, la dépendance à l’alcool a été diagnostiquée en utilisant le critère DSM-III-R d’une version détaillée et modifiée du <<Schedule for Affective Disorders and Schizophrenia-Lifetime>> (SADS-L). L’exactitude du test SMAST a été quantifiée selon sa sensibilité, sa spécificité, ses taux de probabilité et le secteur sous la courbe ROC (pour <<Receiver-Operating Characteristics>>), en utilisant le diagnostique DMS-III-R comme référence. Au seuil standard ≥3 le test SMAST a une sensibilité significative de 86–95% mais n’est pas très performant en terme de specificité (23–47%). Des seuils significativement plus élevés (≥5 dans les deux sexes pour la tribu du Sud-Ouest, et respectivement 8 et ≥6 pour les hommes et les femmes de la tribu des Plaines) ont été nécessaires pour montrer des niveaux acceptables de spécificité dans les deux tribus. Ces résultats suggèrent que le test SMAST n’est pas un outil valable pour évaluer la consommation abusive d’alcool dans ces deux populations tribales. Les seuils particulièrement élevés et différents requis d’une population à l’autre et d’un sexe à l’autre constituent un obstacle significatif dans l’utilisation de cette mesure.

Additional information

Notes on contributors

Robert W. Robin

Robert Robin, Ph.D., has lived and worked for extended periods of time among indigenous populations, including Papua New Guinea and American Indian and Alaska Native communities. Much of his focus has been directed toward investigating the effects of rapid change and Western influence on traditional societies. He has lent effort to developing a leadership and self-empowerment program for refugee children affected by political torture and violence, and is coordinator for the Barbara Chester Award, an international award given to clinicians and practitioners working with survivors of torture. He currently resides with his sole surviving Bernese Mountain Dog, Loma, on beautiful Baranof Island in Southeast Alaska.

Aramesh Saremi

Aramesh Saremi, M.D., is a Clinical Fellow at the National Institute of Diabetes and Digestive and Kidney Diseases. She received her medical degree from Ludwig-Maximilians University in Munich, Germany, with externship in Internal Medicine and Cardiology at Arizona State University in the United States. Aramesh has researched a range of topics, including late and early complications of liver transplantation, Fibromyalgia syndrome, and diabetes among American Indians. She is multilingual speaking English, German, and Persian, and enjoys hiking in the desert and mountains of Arizona.

Bernard Albaugh

Bernard Albaugh, M.S.W., has collaborated on a variety of clinical, research, preventive, and educational programs with more than 40 American Indian and Alaska Native tribal groups. Employed as a clinician and project officer with the Public Health Service for over 25 years, Bernard co-founded and directed the Center for Human Behavior Studies, one of the few tribally directed research entities in the United States. A Sundance painter, Bernard has participated in the retrieval and restoration of American Indians’ sacred “objects” from museums and other institutions. He and his wife, Patty, have traveled extensively throughout the world, pausing to scuba dive and explore when suitable “terrain” presents itself.

Robert L. Hanson

Robert L. Hanson, M.D., M.P.H., National Institute of Diabetes and Digestive Kidney Diseases, Phoenix, Arizona. No biosketch is available at this time.

Desmond Williams

Desmond Williams, M.B., Ch.B., Ph.D., National Institute of Diabetes and Digestive Kidney Diseases, Phoenix, Arizona. No biosketch is available at this time.

David Goldman

David Goldman, M.D., is Chief, Laboratory of Neurogenetics, NIAAA, NIH. He is a behavioral geneticist whose work includes the study of behavioral variation in so-called normal range traits, such as anxiety, EEG differences, and cognitive differences, as well as genes predisposing to psychiatric diseases, including alcoholism, schizophrenia, OCD, and eating disorders. For analysis of complex traits, his lab studies population isolates in American Indian communities, and uses intermediate phenotypes and functional polymorphisms. Dr. Goldman chairs the NIAAA human research committee and teaches at George Washington University. A Texan, he can often be identified as the guy wearing the hat.