Concordance between DSM-III-R and DSM-IV diagnoses of substance use disorders in adolescents

Except for cannabis and alcohol, concordance between DSM-III-R and DSM-IV substance use disorder diagnoses has not been reported in adolescents. We assessed a clinical sample of 102 adolescents using CIDI-SAM. Prevalence of either an abuse or dependence diagnosis was lower with DSM-IV than DSM-III-R except for cannabis and alcohol, and concordance rates were better for dependence than for abuse. For most substances, rates of DSM-IV withdrawal were lower than in DSM-III-R, but rates of DSM-IV physiological dependence remained high. Changes in DSM-IV criteria appear to have impacted diagnoses in these adolescents, particularly for the substances they use most--i.e. alcohol, tobacco, and cannabis.     

Drinking patterns among individuals with and without DSM-IV alcohol use disorders

OBJECTIVE: The purpose of this study was to compare alcohol consumption patterns among individuals with and without alcohol use disorders, using a representative sample of the general population that would not exaggerate differences as a result of selection biases associated with treatment for alcohol problems. METHOD: Based on data from 18,352 past-year drinkers selected from a nationally representative sample of U.S. households, 11 measures of past-year alcohol consumption were compared for three diagnostic groups: (1) individuals who did not meet the criteria for either alcohol abuse or dependence, i.e., those without a DSM-IV alcohol use disorder (AUD); (2) those classified with abuse only; and (3) those classified with alcohol dependence, with or without abuse. RESULTS: For all measures reflecting frequency and quantity of drinking, frequency of heavy drinking and intoxication, and frequency of atypical temporal drinking patterns, the values for abusers lay midway between those for individuals without an AUD and those with dependence. Individuals with alcohol use disorders drank a greater proportion of their ethanol intake in the form of beer and a lower proportion in the form of wine than did those without an AUD. Of all the consumption measures considered, frequency of intoxication showed the strongest association with the probability of having an AUD, followed by frequency of drinking 5 + drinks, prevalence of morning drinking and total volume of intake. The ratios of consumption measures for individuals with disorders relative to those without an AUD showed relatively little significant variation across demographic subgroups of the population. CONCLUSIONS: The findings supported the distinction between the disorders of alcohol abuse and dependence, and implicated loss of control as an important element of this distinction. They also indicated that even among individuals with alcohol use disorders, demographic differentials reflecting cultural, physiological and normative forces were maintained and should be considered in approaches to treatment.     

Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR,CIDI and SCAN

This study was designed to examine the agreement of DSM-IV alcohol and drug use disorder diagnoses generated by three WHO/NIH diagnostic instruments, the AUDADIS-ADR, the CIDI, and the SCAN. This substudy, conducted in three countries, Greece, Luxembourg, and the United States, was part of the larger joint project on diagnosis and classification of mental disorders and alcohol and drug-related problems, which was initiated to evaluate the cross-cultural applicability of the instruments and the criteria. Overall, concordance among the three assessments was good for alcohol and opiate dependence, fair to good for cocaine and sedative dependence, and low for amphetamine dependence. Cannabis dependence concordance was significantly more discrepant than any other substance. Agreement on abuse was low for all substances examined. In addition, the concordance of DSM-IV criteria for each substance was examined. Finally, reasons for discrepancies in responses among assessments were examined, based on discrepancy interview protocol methodology. Further investigation will help to refine these instruments in order to provide a more thorough understanding of alcohol and drug abuse diagnoses.     

Diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders

The diagnostic concordance of DSM-III-R, DSM-IV, and ICD-10 inhalant use disorders was assessed using the sample of lifetime inhalant users (n=76) participating in the DSM-IV Field Trial for Substance Use Disorders. Substantially smaller proportions of lifetime inhalant users met DSM-IV inhalant abuse or dependence criteria than met comparable DSM-III-R or ICD-10 criteria. DSM-III-R and ICD-10 performed similarly, although DSM-III-R tended to be more inclusive vis-à-vis diagnoses of inhalant dependence. Kappa coefficients indicated a moderate degree of concordance between the three nosologies for inhalant use disorder diagnosis rates. Inclusion of possible withdrawal symptomatology criteria (that are not normally included) in the DSM-IV and ICD-10 criteria sets for inhalant dependence exerted little effect on diagnosis rates.     

The DSM-IV criteria for adolescent alcohol and cannabis use disorders.

OBJECTIVE: The aims of this study are to compare DSM-IV criteria for alcohol and cannabis use disorders with its predecessor, DSM-III-R, and to examine the validity of the new criteria in an adolescent drug clinic sample. METHOD: During evaluation, a sample of 772 adolescents (63% boys, 77% white) were administered a structured interview of diagnostic symptoms and additional problem severity measures. Independent staff ratings of problem severity and treatment referral were collected as well. RESULTS: Compared to its predecessor, DSM-III-R, application of the DSM-IV criteria for alcohol and cannabis users resulted in more abuse assignments and fewer dependence assignments. The shift in assignments appeared to be largely due to a lowering of the abuse threshold, rather than to a tightening of the dependence criteria. The external validity data generally supported the DSM-IV abuse and dependence distinction in adolescents, and the newer criteria were as valid as the older criteria. CONCLUSIONS: In contrast to DSM-III-R, the DSM-IV system yields more abuse cases and fewer dependence cases among adolescent alcohol and cannabis abusers. Validity evidence for the new criteria are defensible, yet the findings are seen as a starting point for discussing the need for tailoring substance use disorder criteria for adolescents.     

DSM-IV alcohol and substance abuse and dependence in homeless youth

OBJECTIVE: The purpose of this study is to describe endorsement rates of substance use criteria among homeless adolescents and to evaluate the reliability of diagnostic formulations among a group of adolescents who use more frequently and more heavily than other samples of adolescents. METHOD: Substance use rates and DSM-IV abuse and dependence criteria were assessed among 198 (109 male) homeless youths between the ages of 13 and 19, as part of a larger study. Endorsement rates and reliability analyses were completed for diagnostic criteria assessed for alcohol, marijuana, amphetamines and heroin. RESULTS: Consistent with other studies of homeless youth, data revealed high rates of substance use and high rates of substance dependence. Both dependence and abuse diagnoses were associated with greater rates of use. DSM-IV criteria showed acceptable internal reliability, although variability was observed when applied to different substances. Of the drugs assessed, problems with heroin use appeared to be best, and marijuana use least, represented by dependence criteria. Criteria pertaining to continued use despite interference with role obligations and the experience of craving were consistently related to other dependence criteria. CONCLUSIONS: DSM-IV substance dependence criteria appear to have good internal reliability within a sample of adolescents who use at extremely high rates. Continued development of diagnostic systems for adolescent substance use should consider the social context of use, differential patterns of symptoms across different substances and the inclusion of additional criteria found reliable among adolescent samples.     

The reliability and validity of the Alcohol,Smoking and Substance Involvement Screening Test (ASSIST) in first-episode psychosis

Aims

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a brief, easily administered, valid and reliable screening instrument for all psychoactive substances in drug treatment and primary care settings. This study aims to determine the reliability and validity of the ASSIST for detecting substance use disorders in first-episode psychosis.

Participants

Participants were 214 first-episode psychosis patients attending the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.

Measurements

Participants were administered the ASSIST, Alcohol Use Disorders Identification Test (AUDIT), the Severity of Dependence Scale (SDS) and the Brief Psychiatric Rating Scale (BPRS). Presence of DSM-IV substance abuse and dependence disorders in the previous 12 months was assessed using the Structured Clinical Interview for DSM-IV (SCID-IV).

Findings

The ASSIST total substance involvement (TSI) score and specific substance involvement (SSI) scores for cannabis, alcohol and amphetamine use demonstrated high levels of internal consistency and acceptable levels of concurrent and discriminative validity. Individuals with cutoff scores of ≥ 2, 4 and 1 on the ASSIST cannabis, alcohol and amphetamine SSI scores were 5 to 6 times more likely to meet the diagnostic criteria for these substance use disorders.

Conclusions

The ASSIST is a psychometrically sound measure of cannabis, alcohol and amphetamine use disorders in first-episode psychosis.     

Reliability of DSM-IV diagnostic criteria using the semi-structured assessment for drug dependence and alcoholism (SSADDA)

The semi-structured assessment for drug dependence and alcoholism (SSADDA) yields reliable DSM-IV diagnoses for a variety of psychiatric disorders, including alcohol and drug dependence. This study examines the reliability of individual DSM-IV criteria for lifetime substance dependence diagnoses and the impact of those criteria on diagnostic reliability. METHODS: Two hundred ninety-three subjects (52.2% women; 38.2% African American, 46.8% European American, 7.5% Hispanic) were interviewed twice over a 2-week period to examine the inter-rater reliability (n=173) or test-retest reliability (n=120) of the SSADDA. Cohen's kappa-statistic and its confidence interval were used to assess the reliability of individual diagnostic criteria. RESULTS: Overall, the inter-rater reliability estimates were excellent for individual DSM-IV criteria for nicotine and opioid dependence; good for alcohol and cocaine dependence, and fair for dependence on cannabis, sedatives and stimulants. The impact of any individual criterion on diagnostic reliability was minimal, consistent with the notion that the DSM-IV diagnosis of substance dependence measures an underlying construct that is relatively consistent across specific groups of substances. CONCLUSIONS: These results, combined with results from a study of the SSADDA's diagnostic reliability [Pierucci-Lagha, A., Gelernter, J., Feinn, R., Cubells, J.F., Pearson, D., Pollastri, A., Farrer, L., Kranzler, H.R., 2005. Diagnostic reliability of the semi-structured assessment for drug dependence and alcoholism (SSADDA). Drug Alcohol Depend. 80, 303-312], show that the instrument can be used reliably to assess substance dependence.     

Substance Dependence Severity Scale: reliability and validity for ICD-10 substance use disorders.

The Substance Dependence Severity Scale (SDSS) is a semistructured interview that assesses the severity of the DSM-IV diagnoses of dependence and abuse and the ICD-10 diagnoses of substance dependence and harmful use across a wide range of substances. Previous research has demonstrated that the SDSS' DSM-IV dependence scales are reliable and valid indicators of diagnostic severity. However, the ICD-10 scales have not been psychometrically tested. This study investigated the test-retest reliability, internal consistency, diagnostic concordance, and concurrent validity of the SDSS' ICD-10 dependence and harmful use scales in 180 (112 male and 68 female) treated substance users. Test-retest reliabilities for the ICD-10 dependence scales ranged from good to excellent for alcohol, cocaine, heroin, and cannabis. Test-retest reliabilities for the SDSS' ICD-10 harmful use scales were in the good range for alcohol, cocaine, and heroin and the poor to fair range for cannabis. Internal consistency, diagnostic concordance, and concurrent validity results were comparable to the test-retest findings. These results support the use of the SDSS for assessing the severity of the ICD-10 dependence and harmful use diagnoses.     

The latent structure of marijuana and cocaine use disorders: results from the National Longitudinal Alcohol Epidemiologic Survey (NLAES)

To better understand the underlying concepts of substance dependence and abuse, the present study examines the factor structure of DSM-IV lifetime criteria for cannabis and cocaine use disorders. Data for this study were drawn from the National Longitudinal Alcohol Epidemiologic Survey (NLAES), a large nationally representative U.S. sample aged 18 years and older. Exploratory factor analysis (EFA) examined the factor structure for each substance and the factors were related to background covariates using latent variable modeling techniques. Separate analyses were conducted for lifetime marijuana and cocaine users. A two-factor solution was identified for each substance and was similar to DSM-IV abuse and dependence. The factors were highly correlated for both cannabis (r=0.73) and cocaine (r=0.77). Background variables accounted only for a modest amount of factor variance. In conjunction with the findings in alcohol use disorders, these results support the use of consistent criteria across substances in DSM-IV and ICD-10, and suggest that the consistent finding of two correlated factors across substances needs to be better understood.     

DSM-IV alcohol dependence and abuse: further evidence of validity in the general population

BACKGROUND: In order to understand the validity of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) alcohol abuse and dependence diagnoses, studies are needed in both clinical and general population samples. The purpose of this study was to examine the construct and criterion-oriented validity of DSM-IV alcohol dependence and abuse in the general population with respect to factor structure and their relationship to family history of alcoholism, treatment utilization, and psychiatric comorbidity. METHODS: This analysis is based on data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), in which nationally representative data were collected in personal interviews conducted with one randomly selected adult in each sample household or group quarters. A subset (n=26,946) of the NESARC sample (total n=43,093) who reported drinking one or more drinks during the year preceding the interview formed the basis of analyses. Latent variable modeling was used to assess the concurrent validity of DSM-IV alcohol abuse and dependence symptom items. RESULTS: The latent variable modeling yielded one major factor related to alcohol dependence, a second factor related to alcohol abuse and a third smaller factor defined by tolerance. The validity of alcohol dependence in general population samples was further supported by statistically significant associations with family history of alcoholism, treatment utilization, and psychiatric and medical comorbidities. CONCLUSIONS: The factor structure and relationship to external criterion variables observed in the study provide support for the further validity of DSM-IV alcohol dependence in the general population, whereas support for the validity of DSM-IV abuse was equivocal.     

Diagnostic orphans for alcohol use disorders in a treatment-seeking psychiatric sample

Individuals who endorse one or two of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criterion items for alcohol dependence but do not meet criteria for either alcohol abuse or dependence have been referred to in the literature as "diagnostic orphans." The goal of the present study is to compare diagnostic orphans for alcohol use disorders (AUD) to patients with lifetime DSM-IV alcohol abuse, alcohol dependence, and those with no-AUD symptoms on a series of demographic, diagnostic, and clinical measures. Participants were treatment-seeking psychiatric outpatients (n=1793; 61.5% women) who completed an in-depth, face-to-face diagnostic evaluation for DSM-IV axis I and axis II disorders. Results revealed that diagnostic orphans were younger, had a higher frequency of family history positive for alcoholism, and higher rates of cannabis dependence, as compared to the no-AUD symptoms group. Diagnostic orphans differed significantly from patients with alcohol abuse and dependence on a number of demographic, diagnostic, and clinical measures. Most notably, on a lifetime basis, diagnostic orphans were less likely to meet diagnostic criteria for various substance use disorders, as compared to individuals with alcohol abuse and dependence. Taken together, these results generally do not support combining diagnostic orphans to individuals with alcohol abuse.     

Symptom endorsement of alcohol and other substance abuse and dependence criteria among American-Indian adolescents in residential substance abuse treatment

OBJECTIVE: This study addresses the prevalence of DSM-IV substance abuse and dependence and the endorsement of specific symptoms of these disorders among American Indian adolescents admitted to a residential substance abuse treatment program. METHOD: We interviewed 89 American Indian adolescents using the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). RESULTS: The most frequent diagnoses included marijuana dependence (51.7%), followed by alcohol abuse and dependence (33.7% each) and marijuana abuse (32.6%). Among the three substances with the highest prevalence of any use disorder (alcohol, marijuana and stimulants), the most frequently endorsed abuse criterion was Impaired Role Obligations. The two most frequently endorsed dependence criteria were Use Despite Substance-Related Psychological/Physical Problems and Unsuccessful Attempts to Quit/Cut down on substance use. CONCLUSIONS: These American Indian adolescents presented to a residential substance abuse treatment program with serious, highly complex substance use disorders that represent substantial challenges to effective treatment.     

DSM-IV criteria-based clinical subtypes of cannabis use disorders: results from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC)

Prior research documented high homogeneity of alcohol use disorders (AUDs) as clinical entities. However, it is unknown whether this finding extends to other substance use disorders. We investigated this by examining the prevalence of all possible DSM-IV criteria-based clinical subtypes of current and lifetime cannabis use disorders in the general population. The number of possible (i.e., theoretical) clinical subtypes of cannabis abuse and dependence based on different combinations of the DSM-IV criteria was calculated using the combinatorial function. This number was compared with the subtypes actually observed in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large U.S. national sample (N=43,093). Clinical and demographic correlates of the subtypes were examined with chi2 tests whose target population was the United States civilian non-institutionalized population. All DSM-IV cannabis abuse and dependence criteria were assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). Of all possible cannabis dependence subtypes, 29 (69%) were observed in the 12-month timeframe, and 41 (98%) in the lifetime timeframe. The corresponding numbers of subtypes for cannabis abuse were 12 (75%), current and 15 (100%), lifetime. These findings suggest that, in contrast to alcohol disorders, cannabis use disorders were highly heterogeneous. Future research should investigate whether there are differences in the course and treatment response of these clinical subtypes of cannabis use disorders, and the heterogeneity of other substance use disorders.     

Substance use disorders among inhalant users: results from the National Epidemiologic Survey on alcohol and related conditions

OBJECTIVE: To assess the prevalence, correlates, and age of onset of DSM-IV substance use disorders (SUDs) among adult inhalant users. METHODS: Analyses were based on structured psychiatric interviews of a nationally representative sample of 43,093 US adults. RESULTS: The lifetime prevalence of SUDs among adult inhalant users was 96%. Alcohol (87%), marijuana (68%), nicotine (58%), cocaine (35%), hallucinogen (31%), and stimulant (28%) use disorders were more prevalent than inhalant use disorders (19%). An estimated 62% of inhalant users met criteria for a past-year SUD. Less education, residence in non-metropolitan areas, early onset of inhalant use, and a history of substance abuse treatment were associated with increased odds of having an inhalant use disorder. Inhalant users who were under age 30 or who were members of families with low incomes had increased odds of having nicotine dependence and an alcohol or drug use disorder in the past year. Compared with substance users without a history of inhalant use, inhalant users, on average, initiated use of cigarettes, alcohol, and almost all other drugs at younger ages, and had a higher lifetime prevalence of nicotine, alcohol, and any drug use disorder. CONCLUSIONS: Lifetime and past-year SUDs are prevalent among adults with a history of inhalant use.     

Nosological comparisons of alcohol and drug diagnoses: a multisite,multi-instrument international study

International nosological research was conducted to determine cross-system agreement on alcohol and drug dependence and harmful use (abuse). ICD-10, DSM-IV and DSM-III-R diagnoses were compared in 1811 subjects from a variety of treatment and other types of settings from 12 sites around the world. Three diagnostic instruments were used: the Alcohol Use Disorders and Associated Disabilities Interview Schedule—Alcohol/Drug-Revised (AUDADIS-ADR), the composite international diagnostic interview (CIDI), and the schedules for clinical assessment in neuropsychiatry (SCAN). At seven of the study sites, two or more of these instruments were used. Results for dependence diagnoses showed excellent cross-system agreement across sites and instruments, especially for current diagnoses. Cross-system agreement for harmless use (abuse) was much lower and less consistent. Geographic location or culture appeared to have little influence on the results for either dependence or harmful use.     

The dimensionality of alcohol abuse and dependence: a multivariate analysis of DSM-IV symptom items in the National Longitudinal Survey of Youth

OBJECTIVE: This article examines the factor structure of 22 symptom items used to configure the criteria of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) alcohol abuse and dependence and relates the factor structure to background characteristics. METHOD: Data for this study were drawn from the National Longitudinal Study of Labor Market Experience in Youth (NLSY). The symptom items were related to the covariates using the statistical technique of structural equation modeling generalized to dichotomous outcomes. The present model is a special case of structural equation modeling, a multiple causes and multiple indicators (MIMIC) model, in which one or more latent variables (i.e., alcohol abuse and dependence) intervene between a set of observed background variables predicting a set of observed response variables (i.e., DSM-IV symptom items). RESULTS: The results of the structural equation analysis provide further support for two dimensions underlying the DSM-IV symptom items. Although the two-factor dimension bore a strong resemblance to the DSM-IV conceptions of abuse and dependence, there were notable differences in the item content of the symptom items for each dimension. The dependence dimension drew upon items related to the abuse criteria for continued drinking despite social problems and recurrent drinking resulting in failure to fulfill role obligations. The abuse dimension drew upon items related to the abuse criterion for hazardous drinking and the dependence criterion for larger amounts over time. The two factors were shown to have different relationships to the background variables. Alcohol dependence was related to family history of alcoholism and educational status. Age was not related to dependence and inversely related to alcohol abuse. CONCLUSIONS: Findings from this study replicate the two-dimensional model for DSM-IV criteria found in other studies and provide further support for the validity of alcohol dependence in general population samples. A major implication of the factor structure in the present study relates to the different classification of cases that would otherwise be obtained with DSM-IV criteria. These departures were shown to affect abuse, which retained only 40% of DSM-IV diagnoses, more strongly than dependence, which retained 91% of DSM-IV diagnoses.     

Alcohol use disorders in adolescents: epidemiology,diagnosis, psychosocial interventions,and pharmacological treatment

Alcohol (ethanol) abuse and dependence are the most common substance use disorders among adolescents. Binge drinking occurs in up to one-third of adolescents, and alcohol use disorders occur in about 6% of this age group. Adolescents with alcohol use disorders also typically have problems with other substances and comorbid mental disorders. Validated measures are available for the clinical detection and diagnosis of adolescent alcohol use disorders and related problems. Psychosocial interventions promoting abstinence are the most common treatments for alcohol use disorders, with empirical support particularly strong for family-based approaches. Pharmacological interventions may diminish the effects of alcohol withdrawal, prevent a return to alcohol consumption, or treat comorbid mental disorders. In this population, pharmacological interventions require further investigation and, where indicated, are generally considered to be supplementary to psychosocial approaches.     

The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002

BACKGROUND: Alcohol abuse and dependence can be disabling disorders, but accurate information is lacking on the prevalence of current DSM-IV alcohol abuse and dependence and how this has changed over the past decade. The purpose of this study was to present nationally representative data on the prevalence of 12-month DSM-IV alcohol abuse and dependence in 2001-2002 and, for the first time, to examine trends in alcohol abuse and dependence between 1991-1992 and 2001-2002. METHODS: Prevalences and trends of alcohol abuse and dependence in the United States were derived from face-to-face interviews in the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC: n = 43, 093 ) and NIAAA's 1991-1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES: n= 42, 862 ). RESULTS: Prevalences of DSM-IV alcohol abuse and dependence in 2001-2002 were 4.65 and 3.81%. Abuse and dependence were more common among males and among younger respondents. The prevalence of abuse was greater among Whites than among Blacks, Asians, and Hispanics. The prevalence of dependence was higher in Whites, Native Americans, and Hispanics than Asians. Between 1991-1992 and 2001-2002, abuse increased while dependence declined. Increases in alcohol abuse were observed among males, females, and young Black and Hispanic minorities, while the rates of dependence rose among males, young Black females and Asian males. CONCLUSIONS: This study underscores the need to continue monitoring prevalence and trends and to design culturally sensitive prevention and intervention programs.