Addiction (2000) 95(2), 245± 250

RESEARCH REPORT

The Severity of Dependence Scale (SDS) as

screening test for benzodiazepine dependence:
SDS validation study

CARLOS DE LAS CUEVAS,1 EMILIO J. SANZ,1

JUAN A. DE LA FUENTE,2 JONATHAN PADILLA3
& JUAN C. BERENGUER3
1
University of La Laguna, 2Mental Health Service, Canary Islands Health Service &
3
Canary Islands Health Service, Santa Cruz de Tenerife, Spain

Abstract
Aims. To assess the validity of the Severity of Dependence Scale (SDS) as a screening test to detect
benzodiazepine dependence in regular benzodiazepine users. Method. One hundred regular benzodiazepine
users, recruited from neurotic benzodiazepine users attending the Mental Health Outpatient Services of the
Canary Islands Health Service, were administered the SDS and responses were compared with the Composite
International Diagnostic Interview (CIDI) diagnosis of benzodiazepine dependence. Receiver Operating
Characteristic (ROC) analysis was used to determine which cut-off score on SDS allowed the best trade-off
between sensitivity and speci® city. Results. SDS was shown to have high diagnostic utility, and a score
higher than six on the scale appears to be an appropriate threshold for problematic benzodiazepine use. The
SDS had a speci® city of 94.2% and a sensitivity of 97.9%, and the area under the curve was of 0.991.
Conclusion. The SDS was found to be a valid brief self-report questionnaire for the assessment of
benzodiazepine dependence in patients using benzodiazepines.

Introduction many as 44% of chronic users become depen-

The appropriate use of benzodiazepines has been
a subject of controversy and concern for many
years. When ® rst introduced, these medications
were viewed as being free of signi® cant prob-
lems, and were prescribed in large quantities for
anxiety, insomnia and other indications.1 How-
ever, it is now widely accepted that humans can
become dependant on benzodiazepines.2, 3 Esti-
mates of the incidence of benzodiazepine depen-
dence indicate that at least 15% and perhaps as
dent.4± 7 Evidence that benzodiazepines could
produce withdrawal symptoms and the con-
clusion that they could produce dependence ® rst
appeared in the early 1970s.8 There are currently
no standardized quantitative methods of assess-
ing the broad construct of benzodiazepine de-
pendence.9 Existing measures either focus on the
presence of withdrawal symptoms or on categor-
ical diagnoses made through interview with a
clinician. Benzodiazepine use needs a sensitive

Correspondence to: Prof. Carlos de las Cuevas Castresana, Mental Health Service, Canary Islands Health Service,
C/. PeÂrez de Rozas, 5± 3°, 38004 Santa Cruz de Tenerife, Spain.
Submitted 5th April 1999; initial review completed 29th June 1999; ® nal version accepted 1st September 1999.

ISSN 0965± 2140 print/ISSN 1360-0443 online/00/020245± 06 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing, Taylor & Francis Ltd

246 C. de las Cuevas et al.

indication of dependence for use clinically and in Table 1. Socio-demographic characteristics of the
sample
research. As Baillie10 has stated, a broad measure
of benzodiazepine dependence may be able to Characteristic % of subjects
predict the success of attempts to cease benzodi-
azepine use, could assist in the understanding of Sex
the processes underlying dependence and could Male 25
Female 75
also assist clinicians to withdraw those patients
whose long-term benzodiazepine use is harmful. Age (years)
18± 20 1
The Severity of Dependence Scale (SDS)11
21± 30 14
was devised to provide a short, easily adminis- 31± 40 26
tered self-report scale which can be used to 41± 50 37
measure the degree of dependence experienced 51± 60 9
by users of different types of drugs. The SDS 61± 70 8
. 70 5
contains ® ve items, all of which are explicitly
concerned with psychological components of de- Marital status
Never married 20
pendence. These items are speci® cally concerned Married 56
with impaired control over drug taking and with Separated 12
preoccupation and anxieties about drug use. Divorced 8
This paper reports a validation study of the Widowed 4
SDS as a screening test of benzodiazepine de- Educational level
pendence in a sample of regular benzodiazepine Can only read and write 3
users attending a Mental Health Outpatient Ser- Elementary school 35
Primary school 28
vice of the Canary Islands Health Service in High school 11
Spain. This study belongs to a broader research University studies 23
project aimed at estimating the prevalence of Employment status
benzodiazepine use in Canary Islands citizens, Employed 57
prescription patterns and the level of dependence Student 2
on these drugs among chronic users. Housekeeper 26
Unemployed 6
Retired 9

Materials and methods

Patients
One hundred consecutive neurotic patients
(ICD-10, F4 category) attending a Mental
Health Outpatient Service in the Canary Islands
who were currently receiving benzodiazepine
treatment for 3 months or longer (mean
22 6 31.5 months, range 3± 240 months) partici-
pated in this study between 1997 and 1998.
To be enrolled in the study, patients were
required to meet the following criteria: age
range, 18± 75 years; continuous daily use of a
benzodiazepine for a minimum of 3 months; and
a stable maintenance dosage of their benzodi-
azepine at the time of the study entry; in
the range of 5± 50 mg/day of diazepam or its
equivalent.
Patients were excluded if they (1) had a cur-
rent diagnosis of schizophrenia or organic brain
syndrome; (2) had any recent history (in the past
12 months) of alcoholism or other substance
abuse; (3) had any acute or unstable medical or
psychiatric condition, and (4) had any problem
that could interfere with understanding of the
test.
The socio-demographic characteristics of the
sample studied are shown in Table 1. The most
common benzodiazepines used in the sample
were: alprazolam in 36% of the cases, clo-
razepate in 20%, diazepam in 11%, bromazepam
in 11% and lorazepam in 9% of the sample. The
doses of benzodiazepines equivalent to 5 mg of
diazepam considered were: alprazolam (0.5 mg);
clorazepate (5 mg); bromazepam (3 mg) and
lorazepam (1 mg).
Method
The wording of the original SDS items was
adapted to cover benzodiazepines as drugs used.
Basically, the original word ª drugº was substi-
tuted by ª tranquillizerº . The SDS includes in-
structions that responses are to refer to

behaviour and experiences during a speci® c pe-
riod of time that in our study was ª during the
last monthº . The items are:
· Did you think your use of tranquillizers was
out of control?
· Did the prospect of missing a dose make you
anxious or worried?
· Did you worry about your use of tranquilliz-
ers?
· Did you wish you could stop?
· How dif® cult would you ® nd it to stop or go
without your tranquillizers?
Each of the items is scored on a four-point
scale (0, never/almost never; 1, sometimes; 2,
often; 3, always/nearly always for items 1± 4; and
0, not dif® cult; 1, quite dif® cult; 2, very dif® cult;
3, impossible for item 5). A total SDS score can
be obtained by addition of scores for all items
(range 0± 15) with higher total scores indicating
higher levels of dependence.
All subjects completed the Severity of Depen-
dence Scale, in a symptom-free period, and were
asked to give a global rating of their addiction or
dependence on benzodiazepines. The patients’
self-report their level of dependence using a four-
point scale (1 5 ª not dependentº ; 2 5 ª may beº
dependent; 3 5 ª a littleº dependent and 4 5 ª a
lotº dependent).
The substance use section of the Composite
International Diagnostic Interview (CIDI)12 was
administered to all patients by a single psy-
chiatrist who was blind to the SDS results. A
current diagnoses of benzodiazepine dependence
was given if three or more symptoms occurred in
the last month.
The Composite International Diagnostic In-
terview is a comprehensive, fully standardized
interview that can be used to assess mental disor-
ders according to the de® nitions and criteria of
ICD-10 and DSM-IV. It was developed as a
collaborative project between the World Health
Organization and the US National Institutes of
Health. It is the most widely used structured
diagnostic interview in the world. The CIDI has
been designed for use in a variety of cultures and
settings. It is primarily intended for use as an
epidemiological tool, but can be used for other
research and clinical tasks. The interview is mod-
ular and presently covers somatoform disorders,
anxiety disorders, depressive disorders, mania,
schizophrenia, eating disorders, cognitive impair-
ment and substance use disorders. The reliability
Benzodiazepine dependence screening 247
of the CIDI has been demonstrated in a major
international ® eld trial of the instrument13, 14 and
in other studies.15 The validity of the CIDI has
also been established.15, 16
In analysing the power of a test the prevalence
of the disease being assessed in the population is
crucial, since a high prevalence rate means that
the questionnaire has a better chance of identify-
ing cases. We used a prevalence rate of 30% to
compute the predictive power of the SDS. This
prevalence ® gure was obtained from previous
studies in the same setting17, 18 and is in accord-
ance with ® gures from other authors.7
The relationship between the true-positive and
false-positive rates is demonstrated in a ROC
curve, which is a plot of these two rates for a
range of cut-off values. If the test does not
provide any information regarding ª casenessº ,
the relationship between true positives and true
negatives for any given cut-off score will result in
a diagonal line (line of ª no informationº ) where
the test is no better than chance at discriminat-
ing between cases and non-cases. In such cases,
the true-positive rate (correct identi® cation)
equals the false-positive rate (incorrect
identi® cation). The method described by Hanley
& McNeil19 was used to estimate the area under
the ROC curve with an associated 95%
con® dence interval.
Results
The patients had little dif® culty completing the
SDS and rarely asked for assistance in under-
standing the items. None of the 100 patients
refused to answer any of the items comprising
SDS.
Forty-eight per cent received a CIDI diagnosis
of current benzodiazepine dependence. The
prevalence of benzodiazepine dependence was
similar between both sexes (52% for men and
46.7% for women). Age, marital status, educa-
tional level or employment were not signi® cantly
associated with prevalence.
By self-report, 38% of the patients thought
they were not dependent on benzodiazepines,
27% thought that they may be dependent, 22%
that they were ª a littleº dependent and 13%
described their dependence on benzodiazepines
as ª a lotº or a great deal. The average rating was
2.1, which lies very close to ª may beº . Table 2
shows the patients’ self-ratings in relation with
CIDI diagnoses. Although the correlation be-
248 C. de las Cuevas et al.

Table 2. Self-reported benzodiazepine dependenc e and CIDI diagnoses of

benzodiazepine dependenc e

CIDI diagnoses
Not dependent Current dependent
Self-reported dependence n % n %
Not dependent 32 61.5 6 12.5
ª Maybeº dependent 14 26.9 12 27.1
ª A littleº dependent 6 11.5 16 33.3
ª A lotº dependent 0 0 13 27.1

tween self-rated dependence and ICD-10 diag-
nosis of dependence made with CIDI was statis-
tically signi® cant, 39.6% of the patients with a
CIDI diagnosis of dependence considered them-
selves free of such dependence while 11.5% of
those without dependence believed that they
were dependent.
The average score of the SDS was 6.4
(SD 5 3.8 range 0± 15), 6.7 6 3.9 for men and
6.3 6 3.8 for women. There were no signi® cant
differences in respect of age.
Choosing a cut-off of 7, the overall sensitivity
(the percentage of patients diagnosed as having a
benzodiazepine dependence scoring above the
threshold on the scale, or rate of true positives)
was 97.9%. For the same cut-off, the overall
speci® city (the percentage of patients without
benzodiazepine dependence who scored low in
the scale, or rate of true negatives) was 94.2%.
There was very little misclassi® cation of pa-
tients. Only 2.08% of the patients who had a
CIDI diagnosis of benzodiazepine dependence
registered SDS scores lower than the cut-off of 7;
only 5.77% of patients that registered SDS
scores equal or higher than the cut-off of 7 did
not receive a CIDI diagnosis of benzodiazepine
dependence.
The positive predictive value of the test (i.e.
the probability that, if someone is scored as a
case according to the test, they actually are a
case) was 94%, while the negative predictive
value (i.e. if someone is classi® ed as not being a
case, the probability that indeed they are not)
was 98%.
For all possible cut-off scores, the sensitivity,
speci® city and rates of false positives and nega-
tives were calculated for the SDS. A ROC Curve
was then constructed (Fig. 1). The AUC was

Area under ROC curve = 0.9910

1.00

0.75
Sensitivity

0.50

0.25

0.00
0.00 0.25 0.50 0.75 1.00
1 – Specificity

Figure 1. ROC curve for the Severity of Dependence Scale as screening test for CIDI diagnoses of benzodiazepine
dependence.

0.991, indicating that the SDS can correctly
discriminate patients who would attain a CIDI
diagnosis of benzodiazepine dependence in 99%
of cases.
The internal consistency of the scale was ex-
amined by calculating correlations (Spearman)
between each item and the total score of the
remaining items in the scale. The correlations
registered ranged from 0.45 (question 4) to 0.69
(question 2) being statistically signi® cant in all
cases (p , 0.01). The results of the reliability
analysis using covariance matrix shown an alpha
value of 0.813 (standardized item alpha: 0.814).
Discussion
Although the SDS was originally designed by
Gossop11 to measure the degree of dependence
experienced by users of different types of illicit
drugs, the results of the present paper shows
that, with few modi® cations in the wording of
items, this instrument could work as a precise
and useful screening test for benzodiazepine de-
pendence. The SDS is easy to understand and
can be completed by most benzodiazepine users
in less than 3 minutes.
This study was potentially limited by the fact
that the sample studied is representative of neur-
otic patients attending at an outpatient mental
health service from the Canary Islands Health
Service and may not be analogous to other kind
of benzodiazepine users. The major limitation on
the use of any instrument is the generalizability
or representativeness of the sample on which the
measure was developed.
Although this scale should not supplant the
usual history-taking by an experienced doctor it
could be useful in aiding general practitioners
and other non-psychiatrist physicians in the
recognition of benzodiazepine dependence. This
scale could be extremely useful in surveys requir-
ing a screening test for benzodiazepine depen
dence or a measure of the severity of such depen-
dence if no psychiatrist were available to admin-
ister standardized research interviews. Scores
could also be used as a quantitative measure to
examine the correlation with other such mea-
sures. Another application would be to use the
proportion of patients using benzodiazepines
with scores above the cut-off scores as an indi-
cator or the prevalence of benzodiazepine depen-
dence. The scale could also be administered to
Benzodiazepine dependence screening 249
make doctors more aware of the risks of the
long-term treatments with benzodiazepines.
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