Are subthreshold alcohol dependence symptoms a risk factor for developing DSM-IV alcohol use disorders? A three-year prospective study of 'diagnostic orphans' in a national sample

The impact of DSM classification changes on the prevalence of alcohol use disorder and 'diagnostic orphans' in Lebanese college youth: Implications for epidemiological research, health practice, and policy

Background

Studies comparing prevalence of alcohol use disorder (AUD) using DSM-IV and DSM-5 diagnostic criteria in college students are limited. This study examines changes in AUD prevalence estimates using DSM-IV versus DSM-5 and characterizes the profile of DSM-5 “diagnostic orphans.”

Methods and findings

A college student sample (n = 1,155; mean age: 21 ±1.97) selected conveniently from six large private and public universities in Greater Beirut, Lebanon completed an anonymous survey in May 2016. The study response rate was 83.1%. Data on DSM-IV and DSM-5 AUD criteria were gathered from 582 past-year drinkers, of which 377 (65%) were screened to have DSM-IV abuse/dependence, and 203 (35%) to have any DSM-5 AUD (58% mild, 21% moderate, and 21% severe). Overall percent agreement between measures was 68% (kappa = 0.41). One hundred and ninety-one students met one DSM-5 AUD criterion only (i.e. “diagnostic orphans,” herein DOs), of which the majority (82%) endorsed “hazardous use.” Compared to past-year drinkers with zero-endorsed DSM-5 criteria, DOs were more likely to be aged 21 or above [OR = 1.57(1.21–2.03)], less likely to perceive their socioeconomic status (SES) as poorer vs. same as others [OR = 0.17(0.07–0.43)], more likely to drink 1–2 times/week vs. ≤3 times per month [OR = 2.24(1.44–3.49)], and more likely to report past-year cigarette smoking [OR = 2.16(1.10–4.24)]. When compared to past-year drinkers with DSM-5 AUD, DOs were more likely to be pursuing a graduate or medical degree (vs. undergraduate degree) [2.06 (1.09–3.89)], and to be living with parents most of the time vs. not [OR = 2.68(1.14–6.31)]. DOs (versus drinkers with AUD) were less likely to drink at a high frequency (3–4 times /week or more vs.≤3 times per month) [OR = 0.15(0.05–0.48)], and to report past-year waterpipe smoking [OR = 0.54(0.34–0.85)], but more likely to report past-year marijuana use [1.89(1.10–3.23)]. The findings are subject to recall bias and under-reporting and the study could not infer causality because temporality of associations cannot be established in a cross-sectional study design.

Conclusions

DSM-IV abuse/dependence prevalence rate was higher than DSM-5 AUD prevalence mainly due to the high percentage of students who engaged in “hazardous use”. The DO screen might capture a young person in transition between non-drinking/occasional drinking to drinking frequently/developing an AUD. The prevention, identification, and management of DOs may be critical components of a national alcohol harm-reduction policy.

Characterizing a Hidden Group of At-Risk Drinkers: Epidemiological Profiles of Alcohol-Use Disorder Diagnostic Orphans

BACKGROUND

Drinkers who report some symptoms of alcohol-use disorder (AUD) but fail to meet full criteria are "diagnostic orphans." To improve risk-reduction efforts, we sought to develop better epidemiologic profiles of this underrecognized subgroup.

METHODS

This study estimated the population prevalence and described AUD symptoms of diagnostic orphans using the 2012-2013 National Epidemiological Survey of Alcohol and Related Conditions-III. Multivariate logistic regression was used to model odds of being a diagnostic orphan or meeting mild, moderate, and severe AUD criteria versus no AUD symptoms. Models were adjusted for the complex survey design using sampling weights and survey procedures (e.g., proc surveylogistic).

RESULTS

Among drinkers, 14% of men and 11% of women were classified as diagnostic orphans. The most common symptoms were drinking more or for longer periods than intended, wanting or trying unsuccessfully to quit or cut back, and drinking in ways that increased risk of injury. We noted broad similarities between diagnostic orphans and mild/moderate AUD groups. There were no differences in odds of diagnostic orphans status by race/ethnicity; however, female gender was associated with lower odds of diagnostic orphan status and all levels of AUD. Individual history of AUD, family history of problem drinking, concurrent smoking, and concurrent marijuana use were associated with greater odds of problem drinking, with stronger associations as AUD severity increased.

CONCLUSIONS

Diagnostic orphans remain a sizeable and overlooked population of problem drinkers. Clarifying the array of symptoms and cooccurring disorders can improve screening and facilitate alcohol risk-reduction intervention efforts.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings

PURPOSE

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking.

METHOD

NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized.

RESULT

The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers.

CONCLUSIONS

Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Latent class analysis of DSM-5 criteria for opioid use disorders: results from the Iranian National Survey on Mental Health

BACKGROUND

Assessments of DSM-IV and DSM-5 criteria with sample populations of opioid users are limited. This study aimed to determine the number of latent classes in opioid users and assessment of the proposed revisions to the DSM-5 opioid use disorder (OUD) criteria.

METHODS

Data came from the 2011 Iranian National Mental Health Survey (IranMHS) on 7,886 participants aged 15-64 years living in Iran. We used the Composite International Diagnostic Interview (CIDI) version 2.1 in all respondents who indicated using opioids at least 5 times in the previous 12 months (n = 236).

RESULTS

A three-class model provided the best fit of all the models tested. Classes showed a spectrum of severity that was compatible with the DSM-5 classification. 'Legal problems' and 'desire to cut down' showed poor discrimination between classes. The weighted prevalence of OUD using DSM-5 was 20.7% higher than with DSM-IV.

CONCLUSIONS

RESULTS support the grouping based on severity of symptoms, combining abuse and dependence into a single diagnosis, omitting legal problems, and addition of craving as a new criterion.

Characteristics of developmentally early alcohol use disorder symptom reports: a prospective-longitudinal community study

BACKGROUND

There is little prospective-epidemiological information on symptoms of DSM-IV-alcohol use disorder (alcohol abuse and dependence; AUD) that may be typical for early AUD stages or the developmental periods of adolescence and early adulthood.

AIMS

To investigate AUD symptoms (AUDS) cross-sectionally at three subsequent assessment waves regarding prevalence rates, symptom counts, associated drinking patterns, positive predictive values (PPV) for DSM-IV-alcohol dependence (AD), and AUDS stability over time.

METHODS

N=2039 community subjects (baseline age 14-24 years) participated in a baseline and two follow-up assessment(s) over up to ten years. DSM-IV-AUDS, DSM-IV-AUD and craving were assessed with the DSM-IV/M-CIDI.

RESULTS

Over the assessment waves, tolerance and much time were most and role obligations and withdrawal least frequent. Most subjects with DSM-IV-AUDS reported only one symptom (47.2-55.1%). PPV for DSM-IV-AD only exceeded 70% for activities, problem, withdrawal, and desired control; PPV were lowest for tolerance and hazardous use. For most AUDS, AUDS report compared to non-report was associated with elevated drinking frequency and amounts. Stability of baseline AUDS at four-year and ten-year follow-up did not exceed 36.4% for any symptom.

CONCLUSIONS

The overall pattern of most/least frequent AUDS reported in adolescence and early adulthood resembles findings in older adults and does not suggest a developmentally specific symptom pattern. Moderate AUDS-stability and considerable remission rates indicate that AUDS in this age group are transient for a considerable proportion of subjects. However, the associations with elevated consumption indicate that AUDS reports early in life need to be taken seriously in prevention and intervention.

Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders

OBJECTIVES

The present study examined the compatibility of the current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders (CUD) among state prison inmates, and evaluated the diagnostic utility of the proposed criteria in accounting for DSM-IV "diagnostic orphans" (i.e., individuals who meet one or two of the diagnostic criteria for substance dependence yet fail to report indications of substance abuse).

METHOD

Data were derived from routine clinical assessments of adult male inmates (N=6871) recently admitted to the Minnesota Department of Corrections state prison system from 2000 to 2003. An automated (i.e., computer-prompted) version of the Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV; Hoffmann & Harrison, 1995) was administered to all inmates as part of routine assessments. DSM-IV and DSM-5 criteria were coded using proposed guidelines.

RESULTS

The past 12-month prevalence of DSM-IV CUDs was 12.7% (Abuse, 3.8%, Dependence, 8.9%), while 11.0% met past 12-month DSM-5 criteria for a CUD (Moderate [MCUD], 1.7%; Severe [SCUD], 9.3%). When DSM-5 criteria were applied, 11.8% of the DSM-IV diagnostic orphans received a MCUD diagnosis. The vast majority of those with no diagnosis (99.6%) continued to have no diagnosis, and a similar proportion who met dependence criteria (98.4%) met SCUD criteria of the proposed DSM-5. Most of the variation in diagnostic classifications was accounted for by those with a current abuse diagnosis.

CONCLUSIONS

The proposed DSM-5 criteria perform similarly to DSM-IV criteria in terms of the observed past 12-month CUD prevalence and diagnostic classifications. The proposed criteria appear to account for diagnostic orphans that may warrant a diagnosis. DSM-IV abuse cases were most affected when DSM-5 criteria were applied. Additional criteria, beyond those included in the proposed DSM-5 changes, concerning use to relieve emotional stress and preoccupation with use were frequently endorsed by those with a proposed DSM-5 diagnosis.

Ten-year stability and variability, drinking patterns, and impairment in community youth with diagnostic orphan status of alcohol dependence

OBJECTIVE

Some adolescents and young adults who do not fulfill criteria for DSM-IV alcohol abuse (AA) report symptoms of DSM-IV alcohol dependence (AD) below the diagnostic threshold (diagnostic orphans, DOs; 1 or 2 symptoms). Contemporarily, little is known on the long-term stability, risk of progression to AD, impairment, and drinking patterns possibly associated with this status in the first decades of life.

AIM

(1) To identify prevalence rates of the DO status from adolescence to early adulthood. To investigate (2) stability and variability of the DO status over time and (3) associations between DO status, drinking patterns and impairment in comparison to subjects with AA, with AD, or without any symptoms.

METHOD

N=2039 community subjects (aged 14-24 years at baseline) were assessed at baseline and at about four and ten years after baseline. DSM-IV AUD diagnoses were obtained with the DIA-X/M-CIDI.

RESULTS

About 11-12% of the sample was classified as DOs at all waves. Over a period of ten years, 18% of DOs were stable in their diagnosis and additional 10% progressed to AD. DOs were comparable to subjects with AA in drinking patterns, impairment and stability of diagnostic status. DOs progressed to AD significantly more often than AA. AD was associated with highest levels in all outcomes of interest.

CONCLUSIONS

The DO status in adolescence and early adulthood is associated with considerable stability, risk of progression and problematic alcohol intake. In consequence, it can be meaningful for the timely identification of early stages of clinically relevant alcohol problems. For subjects with DO status early specific interventions are required.

Alcohol research: past, present, and future

Created forty years ago, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has played a major role in the great strides made in the understanding, treatment, prevention, and public acceptance of alcohol-use disorders. Throughout most of U.S. history "habitual drunkenness" was viewed as a problem of moral degeneracy or character flaw inherent in the individual. However, the wealth of scientific evidence amassed throughout NIAAA's history has established alcoholism as a medical condition, that is, as a disease for which affected individuals should feel no shame or be treated with disdain. We look at the developments in alcohol epidemiology, typology, etiology, prevention, and treatment research over the past 40 years. We also discuss how NIAAA addresses alcohol disorders from a life-course framework, affecting all stages of the lifespan, from fetus through child, adolescent, and young adult, to midlife/senior adult, with each stage involving different risks, consequences, prevention efforts, and treatment strategies.

Three (or more) alcohol-dependence symptoms but not clustered in the same 12 months: diagnostic orphans from a longitudinal perspective

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), currently uses a polythetic classification system for defining alcohol use disorders (AUD; alcohol abuse and dependence). This classification results in individuals who are subthreshold for an official AUD diagnosis but still endorse one or two criteria of dependence: so-called "diagnostic orphans." To our knowledge, however, there has been no attention given to diagnostic orphans from a lifetime perspective. The goal of the current article was to compare various diagnostic groups based on lifetime reports of abuse and dependence symptoms on a range of outcomes.

METHOD

Data taken from the National Epidemiological Survey of Alcohol and Related Conditions study were used to form seven mutually exclusive diagnostic groups based on lifetime abuse and dependence symptomatology.

RESULTS

Diagnostic groups that experienced extensive dependence symptoms, regardless of past-12-month clustering (i.e., formal diagnostic criteria), tended to exhibit poorer outcomes compared with participants that met formal lifetime diagnosis for an AUD through abuse alone. It is notable that a significant group of individuals who failed to meet formal lifetime AUD diagnosis, but who endorsed a number of dependence symptoms, consistently demonstrated more problematic outcomes on a range of measures compared with individuals who never reported dependence symptoms but who were formally diagnosed with lifetime AUD through alcohol abuse.

CONCLUSIONS

DSM-IV lifetime diagnostic criteria may exclude individuals with a history of extensive dependence symptomatology. Implications regarding lifetime diagnosis conceptualization are discussed.