See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/7457952

The Severity of Dependence Scale (SDS) in an adolescent population of

cannabis users: Reliability, Validity and Diagnostic Cut Off

Article in Drug and Alcohol Dependence · July 2006

DOI: 10.1016/j.drugalcdep.2005.10.014 · Source: PubMed

CITATIONS READS

130 488

4 authors:

Greg Martin Jan Copeland

Victoria University of Wellington UNSW Sydney
20 PUBLICATIONS 554 CITATIONS 192 PUBLICATIONS 5,043 CITATIONS

SEE PROFILE SEE PROFILE

Peter Gates Stuart Gilmour

Macquarie University St. Luke's International University
35 PUBLICATIONS 752 CITATIONS 150 PUBLICATIONS 5,544 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Cannabis use and brief intervention with young people View project

Systematic Literature Review and Meta Analysis of Medication Error-Related Harms in Paediatrics View project

All content following this page was uploaded by Greg Martin on 15 August 2018.

The user has requested enhancement of the downloaded file.

 Drug and Alcohol Dependence 83 (2006) 90–93

Short communication

The Severity of Dependence Scale (SDS) in an adolescent population of

cannabis users: Reliability, validity and diagnostic cut-off
Greg Martin ∗ , Jan Copeland, Peter Gates, Stuart Gilmour
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
Received 10 August 2005; received in revised form 25 October 2005; accepted 26 October 2005

Abstract
The Severity of Dependence Scale (SDS) is a five-item scale that has been reported to be a reliable and valid screening instrument for dependence
and a measure of dependence severity in adults across several substance classes. To date no data have been reported on its performance in a population
of adolescent cannabis users. The current study assessed the psychometric properties of the SDS in a community sample of 14–18-year-old adolescent
cannabis users (n = 100). Internal consistency (α = 0.83) and test–retest coefficients (ICC = 0.88) were high and a principal components analysis of
the scale found all items to load on a single factor. Total SDS score correlated significantly with frequency of cannabis use and number of DSM-IV
dependence criteria met, indicating good concurrent validity. Receiver Operating Characteristic curve analysis was used to determine the most
appropriate SDS cut-off score for use as an indicator of cannabis dependence, with optimal discrimination at an SDS score of 4. These findings
indicate that the SDS is a reliable and valid measure of severity of cannabis dependence among adolescents, has high diagnostic utility, and that
an SDS score of 4 may be indicative of cannabis dependence.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Cannabis; Adolescents; Dependence; Psychometrics

1. Introduction
The Severity of Dependence Scale (SDS) was originally
developed to provide a brief, easily administered measure of
the psychological aspects of dependence experienced by users
of various types of illicit drugs (Gossop et al., 1995). The SDS is
a measure of compulsive use; its five items relate to an individ-
ual’s preoccupation and anxieties about their own drug taking,
and feelings of impaired control over their drug use.
The psychometric properties of the SDS have been well
established in adult populations of illicit drug and alcohol users
(Gossop et al., 1995, 1997, 2002; Ferri et al., 2000), and empir-
ically derived cut-off scores indicative of substance dependence
have been reported for amphetamine, cocaine, benzodiazepine
and cannabis use in adults (Topp and Mattick, 1997; Kaye and
Darke, 2002; De La Cuevas et al., 2000; Swift et al., 1998).
To date, however, no data have been reported on the perfor-
mance of the SDS in a population of adolescent cannabis users.
Given the high prevalence of cannabis use and cannabis depen-
∗ Corresponding author. Tel.: +61 2 93850260; fax: +61 2 93850222.
E-mail address: g.martin@unsw.edu.au (G. Martin).
dence among young people (AIHW, 2005; Coffey et al., 2002)
it is important to have valid and reliable instruments for screen-
ing, assessment and outcome measurement appropriate to this
population.
It is not necessarily the case that adult assessment instru-
ments can be generalised to an adolescent population. Different
developmental stages, patterns of use, family and peer issues,
problem recognition and level of self-insight may influence an
instrument’s psychometric properties (Winters, 2003; Leccese
and Waldron, 1994). The aims of the current study were to
assess the reliability and validity of the SDS within a popu-
lation of young cannabis users, and determine the optimal SDS
cut-off score indicative of a DSM-IV diagnosis of cannabis
dependence.
2. Method
2.1. Participants
A convenience sample of 100 young people was recruited.
To meet inclusion criteria participants were required to be aged
14–18 years, and to have used cannabis at least once in the past
90 days. Although using a sample of convenience, recruitment

0376-8716/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.drugalcdep.2005.10.014
 G. Martin et al. / Drug and Alcohol Dependence 83 (2006) 90–93
processes ensured that it was stratified with regard to age, gender,
and frequency of cannabis use. Participants were recruited from
tertiary education institutions and local youth centres. Further
recruitment came via word-of-mouth, fliers, and advertisement
on community radio.
2.2. Materials
Participants completed two interviews approximately 1 week
apart. During both interviews the SDS was administered for the
period of the last 3 months.
The SDS items adapted for cannabis are:
1. Did you ever think your use of cannabis was out of control?
2. Did the prospect of missing a smoke make you very anxious
or worried?
3. Did you worry about your use of cannabis?
4. Did you wish you could stop?
5. How difficult would you find it to stop or go without
cannabis?
Each item is scored on a four-point scale: for items 1, 2, 4
(0 = never or almost never; 1 = sometimes; 2 = often; 3 = always
or nearly always), item 3 (0 = not at all; 1 = a little; 2 = quite a lot;
3 = a great deal) and item 5 (0 = not difficult; 1 = quite difficult;
2 = very difficult; 3 = impossible). Item scores are added to give
a total SDS score, which can range from 0 to 15. The first inter-
view also included questions relating to participant demographic
information, quantity and frequency of cannabis use, age of initi-
ation of cannabis use, and other drug use. DSM-IV diagnoses of
cannabis abuse and dependence were obtained using the Com-
posite International Diagnostic Interview (CIDI) (World Health
Organisation, 1997). The second interview involved a repeat
administration of the SDS.
2.3. Procedure
Ethical approval to conduct the study was granted by the
University of New South Wales Human Research Ethics Com-
mittee. A waiver of parental consent was obtained to ensure
participant confidentiality. At the initial interview participants
provided written informed consent. Interviewers were two social
science graduates trained in the use of the CIDI and the current
protocol. The two interviews were conducted a mean of 6.85
(S.D. 1.93; range 5–14) days apart, in most cases by the same
interviewer. On completion of the second interview participants
were given two movie vouchers.
2.4. Data analysis
The analyses were performed using SPSS for Windows (Ver-
sion 12.0.1). Means are reported for normally distributed contin-
uous data, and categorical variables are described in percentages.
The data from the first administration of the SDS were anal-
ysed by principal components analysis (PCA) to assess the
dimensionality and construct validity of the scale. Internal con-
sistency of the scale was assessed by Chronbach’s alpha; and
91
test–retest reliability via the intraclass correlation coefficient
(ICC) of total SDS score at time 1 and time 2, and individual
item ICCs between the two time points. A Receiver Operat-
ing Characteristic (ROC) analysis was used to determine the
optimal SDS cut-off score for distinguishing between cannabis
dependence and non-dependence. This analysis compared the
performance of the SDS against the “gold standard” measure
of DSM-IV cannabis dependence obtained from the CIDI. The
ROC curve demonstrates the relationship between sensitivity
(the proportion of true positives) and specificity (proportion of
true-negatives) across the full range of SDS values. Chi-square
values were obtained for each score to determine which provided
the best balance between sensitivity and specificity, as indicated
by the largest χ2 -value.
3. Results
3.1. Participants
Participants were 100 young people aged 14–18 with a mean
age of 16.1 years (S.D. 1.1). The sample was almost evenly
divided by gender with 46% females. The majority (95%) were
non-indigenous Australians. The mean age of first cannabis use
was 13.7 years (S.D. 1.4; range 10–18). Frequency of use varied
widely with 31% of the sample reporting daily use; 35% report-
ing more than weekly but less than daily use; 8% reporting less
than weekly but more than monthly use; and 25% using less than
monthly. The mean number of days on which cannabis was used
in the past 90 days was 33.7 (S.D. 33.4; range 1–90).
Just under half of the sample (45%) met DSM-IV criteria for
cannabis dependence. The total sample mean number of depen-
dence symptoms was 2.8 (S.D. 2.4; range 0–7).
The range of number of dependence symptoms was: 23%
reported no symptoms; 32% reported one to two symptoms;
25% reported three to five symptoms; and 20% reported six or
seven symptoms. Of the total sample, 14% met cannabis abuse
criteria and 18% reported one or two dependence symptoms
but did not report any abuse symptoms, leaving them “diagnos-
tic orphans” (Deas et al., 2005). Mean Severity of Dependence
Scale score was 3.4 (S.D. 3.7; range 0–15) with a median of 2.
The distribution of SDS scores was positively skewed with 21%
of participants scoring zero.
3.2. Reliability
The internal consistency of the SDS was good with a Cron-
bach’s alpha of 0.83. Test–retest reliability (as measured by
intraclass correlation coefficient) between time 1 and time 2
for total SDS score was 0.88. Individual items ICCs compared
between the two time points ranged from 0.69 to 0.85 (see
Table 1).
3.3. Validity
The construct validity of the scale was assessed by principal
components analysis. As expected, the PCA of the five SDS
items revealed a single factor, which accounted for 60% of the
92 G. Martin et al. / Drug and Alcohol Dependence 83 (2006) 90–93

Table 1 Table 2
Severity of Dependence Scale: principal components analysis factor loadings Sensitivity, specificity and χ2 -values of the SDS at each cut-off point when
and test–retest intraclass correlation coefficients discriminating between adolescent cannabis users with and without DSM-IV
cannabis dependence diagnoses
Item Factor loading Intraclass correlation
coefficient SDS score Sensitivity (%) Specificity (%) Chi-square

Over the last 3 months 0 100 0.00 –

Did you ever think your use 0.80 0.76 1 95.3 35.8 13.5
of cannabis was out of 2 81.4 69.8 25.0
control? 3 72.1 81.1 27.5
Did the prospect of missing a 0.87 0.81 4 65.1 94.3 38.4
smoke make you very 5 55.8 96.2 32.6
anxious or worried? 6 46.5 98.1 27.7
Did you worry about your 0.75 0.69 7 41.9 98.1 23.9
use of cannabis? 8 39.5 98.1 22.1
Did you wish you could stop? 0.70 0.69 9 30.2 100 18.5
How difficult would it be to 0.74 0.85 10 25.6 100 15.3
stop or go without? 11 14.0 100 7.9
Total SDS score 0.88 12 9.3 100 5.2
13 4.7 100 2.5
14 2.3 100 1.3
15 0.0 100 –
total variance in scores. The factor loadings ranged from 0.70 to
0.87 (see Table 1).
As an indication of concurrent validity the total SDS score
which indicates the level at which a test would discriminate
would be expected to be significantly associated with increased
between the presence or absence of a diagnosis of depen-
exposure to cannabis use (e.g. daily use) and the number of
dence at the level of chance. The AUC value in the current
DSM-IV criteria endorsed. Pearson correlation between the
analysis was 0.85, which indicates that the SDS can cor-
total SDS score and number of DSM-IV cannabis depen-
rectly discriminate between adolescents who would or would
dence symptoms was 0.76 (p < 0.01), and between total SDS
not receive a diagnosis of cannabis dependence in 85% of
score and frequency of use in the past 90 days was 0.67
cases.
(p < 0.01).
A list of the sensitivity, specificity and χ2 -values for each
cut-off point is presented in Table 2. The greatest value of χ2
3.4. ROC analysis
was at the cut-off score of 4 (χ2 = 38.4) which suggests that this
is the score which best discriminates between the presence and
The ROC curve is presented as Fig. 1. The area under
absence of cannabis dependence in this population.
the ROC curve (AUC) summarises the diagnostic utility of
a test. The straight diagonal line represents an AUC of 0.5
4. Discussion

The SDS is a short, easily administered instrument for mea-

Fig. 1. Receiver Operating Characteristic (ROC) curve for the SDS. Diagonal
segments are produced by ties.
suring the degree of subjective sense of dependence experienced
by substance users. It has strong empirical support for its psy-
chometric properties in adult populations of substance users (e.g.
Gossop et al., 1995, 1997; Ferri et al., 2000). The purpose of
the current study was to determine the reliability, validity and
diagnostic utility of the SDS within an adolescent population of
cannabis users. The stratified sample of 100 participants had a
mean age of 16.1 years with just under half being female. Almost
half (45%) of the sample met DSM-IV criteria for a diagnosis
of cannabis dependence.
The results indicate that the SDS is a reliable and valid mea-
sure of the severity of adolescent cannabis dependence with high
test–retest correlations and good internally consistency. A prin-
cipal components analysis showed the SDS to be a unidimen-
sional scale with all items loading on a single factor. Evidence
of concurrent validity was found in the significant correlations
between the total SDS score and both frequency of cannabis
use and the number of dependence criteria met. As one would
expect, a greater severity of dependence (a measured by SDS
score) is significantly associated with more frequent cannabis
 G. Martin et al. / Drug and Alcohol Dependence 83 (2006) 90–93
use and the presence of a larger number of DSM-IV dependence
symptoms. These findings are consistent with earlier work with
adult substance users.
The ROC analysis showed the SDS to be of high diagnos-
tic utility which performed well against the “gold standard” of
cannabis dependence diagnosis derived from the CIDI. A cut-off
of 4 was found to discriminate optimally between cases and non-
cases of cannabis dependence, although with this value 35% of
dependence cases were not identified. As pointed out by Rey et
al. (1992), however, any cut-off point is a trade off between sensi-
tivity and specificity, where increased specificity is gained at the
expense of decreased sensitivity. The choice of cut-off depends
on which aspect is the most important to the task at hand. Using
the SDS as a screening tool for example it may be preferable
to sacrifice specificity (i.e. use a lower cut-off) to maximise the
ability to detect young people who may be cannabis dependent,
and thus be able to provide timely intervention. In epidemiolog-
ical or descriptive studies, where the aim is to obtain an accurate
estimate of the prevalence of adolescent cannabis use, it may be
more appropriate to use the empirically derived optimal cut-off
score. The full range of sensitivity/specificity values has been
included to allow researchers and clinicians to make their own
decisions, as appropriate.
The current study has a number of limitations. The sample
size was relatively small at 100 participants; further study with a
larger sample of young people would allow for subgroup analy-
sis. The current study used a self-selected community sample of
convenience. The results of this group may not generalise well
to adolescent treatment-seeking populations. Despite these lim-
itations the SDS has been shown to reliable and valid measure
of cannabis dependence in a diverse population of young people
who use cannabis.
Acknowledgement
This research was supported by the National Illicit Drug Strat-
egy of the Australian Government Department of Health and
Ageing.
View publication stats
93
References
Australian Institute of Health and Welfare, 2005. 2004 National Drug Strategy
Household Survey: First Results (Drug Statistics Series No. 13). AIHW,
Canberra.
Coffey, C., Carlin, J.B., Degenhardt, L., Lynskey, M., Sanci, L., Patton, G.C.,
2002. Cannabis dependence in young adults: an Australian population
study. Addiction 97, 187–194.
De La Cuevas, C., Sanz, E.J., De La Fuente, J.A., Padilla, J., Berenguer, J.C.,
2000. The Severity of Dependence Scale as a screening test for benzodi-
azepine dependence: SDS validation study. Addiction 95, 245–250.
Deas, D., Roberts, J.S., Grindlinger, D., 2005. The utility of DSM-IV criteria
in diagnosing substance abuse/dependence in adolescents. J. Subst. Use
10, 10–21.
Ferri, C.P., Marsden, J., De Araujo, M., KLaranjeira, R.R., Gossop, M., 2000.
Validity and reliability of the Severity of Dependence Scale (SDS) in a
Brazilian sample of drug users. Drug Alcohol Rev. 19, 451–455.
Gossop, M., Best, D., Marsden, J., Strang, J., 1997. Test–retest reliability of
the Severity of Dependence Scale. Addiction 92, 353–354.
Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W., Strang, J.,
1995. The Severity of Dependence Scale (SDS): psychometric properties
of the SDS in English and Australian samples of heroin, cocaine and
amphetamine users. Addiction 90, 607–614.
Gossop, M., Marsden, J., Stewart, D., 2002. Dual dependence: assessment of
dependence upon alcohol and illicit drugs, and the relationship of alcohol
dependence among drug misusers to patterns of drinking, illicit drug use
and health problems. Addiction 97, 169–178.
Kaye, S., Darke, S., 2002. Determining a diagnostic cut-off on the Severity of
Dependence Scale (SDS) for cocaine dependence. Addiction 97, 727–731.
Leccese, M., Waldron, H.B., 1994. Assessing adolescent substance use: a
critique of current measurement instruments. J. Subst. Abuse Treat. 6,
553–563.
Rey, J.M., Morris-Yates, A., Stanislaw, H., 1992. Measuring the accuracy
of diagnostic tests using receiver operating characteristic (ROC) analysis.
Int. J. Methods Psychiatr. Res. 2, 1–11.
Swift, W., Copeland, J., Hall, W., 1998. Choosing a diagnostic cut-off for
cannabis dependence. Addiction 93, 1681–1692.
Topp, L., Mattick, R., 1997. Choosing a cut-off on the Severity of Dependence
Scale for amphetamine users. Addiction 92, 839–845.
Winters, K., 2003. Assessment of alcohol and other drug use behaviours
among adolescents. In: Allen, J.P., Wilson, V.B. (Eds.), Assessing Alcohol
Problems, second ed. NIH Publication No. 03-3745. National Institute on
Alcohol Abuse and Alcoholism, Bethseda, pp. 101–123.
World Health Organisation, 1997. Composite International Diagnostic Inter-
view (CIDI)—Core Version 2.1. World Health Organisation, Geneva.