Cross system agreement for substance use disorders: DSM-III-R, DSM-IV and ICD-10

This report presents results of a field trial of Substance Use Disorders as defined by DSM-III-R, DSM-IV (proposed) and ICD-10. Diagnoses based on the three systems were derived from interviews using the Composite International Diagnostic Interview (CIDI) in a heterogeneous sample of 521 adults drawn from clinical and community settings. Two issues are addressed: (1) cross system agreement; and (2) syndrome coherence of proposed criterion sets for Substance Dependence in each of the three systems. Findings were as follows: (1) Cross system agreement for Dependence was generally high, especially between DSM-III-R and DSM-IV. (2) Cross system agreement was lower for DSM-III-R and DSM-IV Abuse and very low for DSM-IV Abuse and ICD-10 Harmful Use. (3) Agreement varied across drug categories with lowest DSM-III-R/DSM-IV agreement for alcohol abuse and DSM-IV/ICD-10 agreement for marijuana use disorders. (4) Overall prevalence differed for the three systems with DSM-IV yielding highest rates followed by DSM-III-R and ICD-10 in that order. (5) Factor analysis of Dependence criteria showed high loadings of all items on a single factor across the three diagnostic systems and for all categories of drugs. Implications for validity of the dependence syndrome construct and for revisions in DSM-IV are discussed.     

A new measure of the alcohol dependence syndrome: the severity scale of alcohol dependence

The purpose was to develop a diagnostic instrument of the Alcohol Dependence Syndrome defined by Edwards and Gross (1976) since comparable scales show some limitations. The methods include three studies carried out in order to develop the SEverity Scale of Alcohol dependence (SESA; total n = 774 alcohol-dependent patients), and three further studies served for validation (total n = 603 alcohol dependents). The findings reveal that the SESA, a 33-item questionnaire including 7 subscales which cover the criteria of the Alcohol Dependence Syndrome, proved to be internally consistent. The subscales are correlated with respective information from internationally validated interview instruments for the diagnosis of alcohol dependence according to DSM and ICD (CIDI, SCAN): six subscales are correlated with six of eight CIDI items and with eight of nine SCAN items selected for the purpose of validation. In addition, there are positive correlations with the Munich Alcoholism Test, the Michigan Alcoholism Test as well as single items of the WHO Alcohol Use Disorders Identification Test. It is concluded from the results that the SESA shows good validity.     

Primary Syndromes of Alcohol Abuse: Their Measurement and Correlates

A factor analysis of the Alcohol Use Inventory identified four major syndromes of alcohol abuse in a clinical sample of N = 274 individuals. The first factor, labelled Alcohol Dependence, was characterized by loss of behavioural control when drinking, alcohol withdrawal symptoms, repeated attempts to stop drinking, and a compulsive drinking style. This factor was correlated with chronic social debilitation and various aspects of psychopathology. Factor I provided empirical evidence for the alcohol dependence syndrome described by Edwards and Gross. The second factor, termed Perceived Benefits From Drinking, was defined by a sustained drinking style and belief that alcohol use facilitates social and mental functioning. A correlation with anxiety symptoms indicated that drinking may be used to cope with stressful situations, especially in social interactions. The third factor was Marital Discord and encompassed drinking problems that either instigated or resulted from marital difficulties. The fourth factor, Polydrug Abuse, was marked by the use of illicit drugs in conjunction with a gregarious style of drinking. High scorers on this factor tended to be younger, socially deviant and rebellious. The results from this study supported a quantitative, multiple syndrome conception of alcohol abuse. Individuals may be ordered along several dimensions according to their level of problem severity.     

Alcohol dependence and abuse diagnoses: concurrent validity in a nationally representative sample

The Alcohol Dependence Syndrome concept has had a widespread influence on the major nosological classification systems, most recently with its operationalization as DSM-IV alcohol dependence. Although many studies have provided evidence of the validity of the Alcohol Dependence Syndrome in clinical samples, little validation work has been conducted in general population samples on DSM-IV alcohol dependence or the distinction of DSM-IV alcohol dependence from DSM-IV alcohol abuse. We therefore examined the cross-sectional validity of DSM-IV alcohol dependence and abuse in 27,616 household residents who participated in a 1992 national survey on alcohol use disorders. Validity was investigated by testing the association of a set of five "criterion" variables, external to the alcohol diagnostic criteria, with dependence and abuse diagnoses. Results indicated that dependence diagnoses were significantly associated with all criterion variables when compared with those with no diagnosis and also when compared with alcohol abuse. This supported the separation of dependence from abuse. Abuse diagnoses were associated with some, but not all, criterion variables when compared with subjects with no diagnosis. This report replicates many aspects of a similar investigation in a community sample of household residents. Implications for the next steps in research are discussed.     

A Comparison of ICD-10 and DSM-III-R Criteria for Substance Abuse and Dependence

As part of DSM-IV field trials for substance use disorders, 100 inpatients from two psychiatric substance abuse units were interviewed using a modified version of the Substance Abuse Module (SAM) to ascertain substance use diagnoses according to ICD-10 and DSM-III-R criteria. Both criteria sets developed from the theoretical framework presented by Gross and Edwards (1976) and thus, they should demonstrate close concurrence in diagnoses of dependence and abuse/harmful use. The kappa scores obtained in these analyses demonstrate good to excellent agreement on the diagnoses of dependence across substances. There was poor agreement between DSM-III-R and ICD-10 for abuse/harmful use diagnoses. Although there is generally good agreement between DSM-III-R and ICD-10 for substance dependence diagnoses, important differences exist between the two criteria sets both for the diagnoses of abuse and harmful use, and for the diagnosis of marijuana dependence. These differences are primarily due to the inclusion of social problems and repeated use of substances in hazardous situations as DSM-III-R criteria.     

Trends in alcohol services utilization from 1991-1992 to 2001-2002: ethnic group differences in the U.S. population

Background: During the early 1990s in the United States, changes to the provision and financing of alcohol treatment services included reductions in inpatient treatment services and in private sector spending for treatment. We investigated trends in alcohol services utilization over the 10‐year period from 1991–1992 to 2001–2002 among U.S. whites, blacks, and Hispanics. Methods: Data come from 2 household surveys of the U.S. adult population. The 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted face‐to‐face interviews with a multistage cluster sample of individuals 18 years of age and older in the continental United States. Treatment utilization represented both total utilization and the use of alcohol services. Data analyses were prevalence rates and multivariate logistic regressions for lifetime utilization with drinkers and individuals with alcohol use disorders (AUDs). Results: From 1991–1992 to 2001–2002, drinking‐related emergency room and human services use increased for drinkers, while total utilization and the use of private health professional services and mutual aid decreased for individuals with AUDs. In drinkers and individuals with AUDs, blacks and Hispanics were less likely than whites to use private health professional care. Hispanics with AUDs were less likely than whites with AUDs to use alcohol or drug programs. Ethnicity interacted with alcohol severity to predict alcohol services utilization. At higher levels of alcohol severity, blacks and Hispanics were less likely than whites to ever use treatment and to use alcohol services (i.e., human services for Hispanic drinkers, mental health services for blacks with AUDs, and mutual aid for Hispanics with AUDs). Conclusions: Our findings showed increases from 1991–1992 to 2001–2002 in alcohol services utilization for drinkers, but reductions in utilization for individuals with AUDs. Blacks and Hispanics, particularly those at higher levels of alcohol severity, underutilized treatment services compared to whites. These utilization trends for blacks and Hispanics may reflect underlying disparities in healthcare access for minority groups, and language and logistical barriers to utilizing services.     

Alcohol screening in young persons attending a sexually transmitted disease clinic

OBJECTIVE: To compare the ability of 3 brief alcohol screens (Alcohol Use Disorders Identification Test [AUDIT], CRAFFT, and CAGE) to identify adolescents and young adults with a current alcohol use disorder (AUD) and to determine whether there are gender-based or race-based differences in screening performance. DESIGN, PARTICIPANTS, AND SETTING: Cross-sectional study of 358 young persons (55% males; 49% blacks; age range, 15-24 years; mean age, 20.6 years) who were attending an urban clinic for sexually transmitted diseases and reported alcohol use during the past year. MEASUREMENTS: Receiver operating characteristic (ROC) curve analysis was used to determine the ability of the 3 screens to discriminate between participants with and without AUDs detected in the Structured Clinical Interview for DSM-IV (SCID). RESULTS: One third (33%) of participants met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for a current AUD (24% with alcohol abuse and 9% with alcohol dependence). The AUDIT performed best at a cut score of 9 (sensitivity, 0.76; specificity, 0.79), CRAFFT at a cut score of 2 (sensitivity, 0.94; specificity, 0.33), and CAGE at a cut score of 1 (sensitivity, 0.69; specificity, 0.63). The AUDIT had the best overall performance (area under the curve [AUC], 0.84), followed closely by CRAFFT (AUC, 0.79) and then CAGE (AUC, 0.70). Performance of screens did not differ by gender. The AUDIT performed slightly better in whites than blacks, but no race-based differences were observed for the CAGE or CRAFFT. CONCLUSIONS: Clinicians should use the AUDIT or CRAFFT, rather than the CAGE, to screen young persons for AUDs. The AUDIT performs best, but its length may limit its utility in this setting. The CRAFFT is a suitable alternative, with excellent sensitivity and no gender-based or race-based differences.     

Factor analysis of ICD-10 symptom items in the 1988 National Health Interview Survey on Alcohol Dependence

The present paper analyzes data from the 1988 National Health Interview Survey (NHIS88) of US adults. This general population survey is important in that it is the largest survey to date that collects detailed information on alcohol consumption and alcohol problems. The NHIS88 is a multi-stage complex sample household study with a sample size of about 44 000 adults of which about 20 000 reported that they were current drinkers. Symptom items were used for classification of individuals into categories of alcohol abuse and alcohol dependence based on the DSM-III-R, DSM-IV, and ICD-10 classification. The present analyses are based on 20 items corresponding to the ICD-10 classification, the elements of which are closely related to the Edwards–Gross alcohol dependence syndrome concepts. A single dimension corresponding to alcohol problems in general accounted for much of the correlations among these items, but additional dimensions of interest were also identified. Of the ICD-10 elements only Impaired Control, Tolerance, and Withdrawal could be identified as separate dimensions.     

Concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT zones in defining levels of severity among out-patients with alcohol dependence in the COMBINE study

AIMS: To examine among alcohol-dependent out-patient clients the concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) total score and 'zones' suggested by the World Health Organization for defining levels of severity of alcohol use problems. DESIGN: Participants were classified into AUDIT zones (AUDIT total score = 8-15, 16-19, 20-40) and compared on measures of demographics, treatment goals, alcohol consumption, alcohol-related consequences, severity of dependence, physiological dependence, tolerance, withdrawal and biomarkers of alcohol use. SETTING: Eleven out-patient academic clinical research centers across the United States. Participants Alcohol dependent individuals (n = 1335) entering out-patient treatment in the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study. MEASUREMENTS: The AUDIT was administered as part of an initial screening. Baseline measures used for concurrent validation included the Structured Clinical Interview for Diagnostic and Statistical Manual, 4th edition (DSM-IV) Disorders, the Alcohol Dependence Scale, the Drinker Inventory of Consequences, the Obsessive-Compulsive Drinking Scale, the University of Rhode Island Change Assessment, the Thoughts about Abstinence Scale, the Form-90, %carbohydrate-deficient transferrin and gamma-glutamyl transferase. Findings Indicators of severity of dependence and alcohol-related problems increased linearly with total score and differed significantly across AUDIT zones. The highest zone, with scores of 20 and above, was markedly different with respect to severity from the other two zones and members of this group endorsed an abstinence goal more strongly. CONCLUSIONS: The AUDIT total score is a brief measure that appears to provide an index of severity of dependence in a sample of alcohol-dependent individuals seeking out-patient treatment, extending its potential utility beyond its more traditional role as a screening instrument in general populations.     

An evaluation of the psychoactive substance dependence syndrome in its application to opiate users

The Psychoactive Substance Abuse and Dependence (PSDA) section of the revised, 3rd edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-III-R) bears a close correspondence to the conceptualization of a dependence syndrome as posited by Edwards, Arif & Hodgson (1981). Further, DSM-III-R represents a major shift in psychodiagnostics. The present study investigated hypothesized properties of the dependence syndrome and examined the characteristics of DSM-III-R criteria with a sample of opiate users. Findings indicated general support for the unidimensional postulate of the dependence syndrome but did not support the weighting of syndrome elements within DSM-III-R. The implications of such findings for the proposed DSM-IV are discussed.     

Alcohol Use Disorders in ICD‐11: Past,Present, and Future

The Eleventh Revision of the International Classification of Diseases (ICD‐11) was formally published in May 2019. Alcohol use disorders form a key part of the section of Disorders due to Substance Use and Addictive Behaviours. This review describes and discusses the alcohol diagnoses within this section of ICD‐11, including Alcohol Dependence, Harmful Pattern of Use of Alcohol, and entities such as Alcohol Intoxication, Alcohol Withdrawal, and several alcohol‐induced mental disorders, and briefly covers Hazardous Alcohol Use, which is listed separately as a health risk factor. We summarize the historical background to the development of these diagnoses, including work within the World Health Organization since the 1970s, and the corresponding diagnoses in the current ICD‐10. The process by which ICD‐11 diagnoses have been made is described and may be summarized as a conceptual–pragmatic–confirmatory one. The available empirical data supporting the ICD‐11 diagnoses are presented, particularly in relation to the diagnostic guidelines for Alcohol Dependence. Comparison is made with the corresponding diagnoses in ICD‐10 and their nearest counterparts in the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders. Field testing of the ICD‐11 diagnoses is currently in progress. A plea is made for matching of diagnoses, diagnostic guidelines/criteria, and the assessment tools intended to capture these diagnoses.     

Alcoholism Diagnoses for Convicted Drinking Drivers Referred for Alcoholism Evaluation

The types and extent of alcohol-related problems were determined for a sample of 461 convicted drinking drivers who were referred to an alcoholism treatment facility for evaluation and possible treatment. Using responses to questionnaire and structured interview questions on alcohol-related problems, DSM III diagnoses are constructed; approximately three-quarters of the sample are diagnosed with sufficient severity for a DSM III diagnosis of abuse or dependence. Self-reported consumption levels and drinking/driving incidents increase as the level of the alcohol problem increases; persons in the Alcohol Abuse category are heavier consumers and drive more frequently after drinking than are persons who are not diagnosed by the DSM III as having an alcohol problem. Persons in the Alcohol Dependence category are heavier consumers than either the Alcohol Abuse or Undiagnosed Problem categories and report more drinking/driving incidents. The DSM III provides useful subcategories of convicted drinking drivers referred for alcoholism evaluation and distinguishes groups differing in quality, frequency, and self-reported DWI measures, independent of basic demographics. These analyses suggest that drinking/driving countermeasures should include intervention efforts to address alcohol-related problems. Serious alcohol problems exist among some drinking drivers, and drinking/driving incidents are more frequent among these individuals.     

Comparison of the Alcohol Dependence Scale and Diagnostic Interview Schedule in Homeless Women

The Alcohol Dependence Scale (ADS) is a 25 item self-report instrument designed to evaluate the degree of severity of alcohol dependence. Although previous studies have reported on the validity of the ADS, no studies using the ADS have been done on the homeless population, a special and rapidly growing population. To assess the utility of the ADS in a population of homeless, substance-abusing women, the ADS questionnaire was compared with the DSM-III-R alcohol use disorder diagnosis as measured by the Diagnostic Interview Schedule (DIS). Both the ADS and the DIS were administered to 149 homeless, substance-abusing women by trained, lay interviewers. There was good agreement between the ADS and the past-year DIS diagnosis of alcohol use disorder. The level of agreement between the ADS and DIS, as well as sensitivity and specificity, for various ADS cutoff scores are reported to facilitate selection of cutoff scores by clinicians and future researchers.     

Age and ethnic differences in the onset, persistence and recurrence of alcohol use disorder

Aims To estimate ethnic differences in three components of alcohol use disorder and alcohol dependence course (onset, persistence and recurrence) in a developmental framework. Design Longitudinal data from The National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), collected using face‐to‐face interviews. Setting Civilian non‐institutionalized US population aged 18 years and older, with oversampling of Hispanics, blacks and those aged 18–24 years. Participants Individuals who completed both NESARC assessments, were not life‐long abstainers and were either white (n = 17 458), black (n = 4995), US‐born Hispanic (n = 2810) or Hispanic‐born outside the United States (n = 2389). Measurements Alcohol dependence (AD) and alcohol use disorder (AUD; abuse or dependence) onset, persistence and recurrence were examined using the Alcohol Use Disorders and Associated Disabilities Interview Schedule, DSM‐IV version. Findings Among men: relative to whites aged 18–29, AUD onset and persistence were elevated only in US‐born Hispanics aged 40 years and older; odds were reduced for all non‐US‐born Hispanics, older whites, most blacks and US‐born Hispanics aged 30–39. For AD, onset risk was elevated for all younger minority men and only reduced among non‐US‐born aged Hispanics 40 or older. For women: compared to young whites, non‐US‐born Hispanics were at decreased AUD and AD onset risk; AUD and AD onset and persistence were increased for older blacks and US‐born Hispanics. Conclusions In the United States, ethnic differences in alcohol disorder transitions (onset, persistence, and recurrence) vary across age, gender and whether a broad (alcohol use disorder) or narrow (alcohol dependence) alcohol definition is used. Evidence of increased risk for some transitions in minority groups suggests that attention should be paid to the course of alcohol use disorders, and that differences in prevalence should not be assumed to reflect differences in specific transitions.     

Alcoholism and Occupations: A Review and Analysis of 104 Occupations

A review of the many attempts to establish an association between occupations and alcoholism reveals that most do not deal with data about clinically defined alcoholism but instead use data about cirrhosis mortality, self-reported alcohol problems, and frequent and heavy drinking. The present study establishes an association between occupations and diagnoses of Alcohol Dependence Disorder and Alcohol Abuse Disorder, using data from a large population-based household interview study. Statistical adjustment using logistic methods reveals that apparent associations between occupations and alcohol-related disorders previously reported in the literature are due to characteristics of those employed in various occupations. The prevalence of alcohol dependence and abuse in two high risk industries, construction and transportation, is confirmed. More than one in four construction laborers and one in five skilled construction trades workers received a DIS/DSM-III diagnosis related to alcohol abuse. In the transportation industry one in six heavy truck drivers and material movers received an alcohol diagnosis. Analyses of the data from individuals currently employed and not employed in their occupation reveals reduction in risk for those who leave some occupations and increased risk for those who leave other occupations. Evidence is presented that employment in some occupations may be protective for Alcohol Dependence. The findings support the view that occupation may be associated with Alcohol Dependence and Alcohol Abuse independent of demographic variations. Previously proposed explanatory models for associations between occupations and alcohol problems are called into question because they do not take into account the demographic characteristics and employment status of workers.     

Health problems in adolescents with alcohol use disorders: self-report, liver injury, and physical examination findings and correlates

BACKGROUND: Although adolescent alcohol consumption has been found to be positively correlated with self-reported health problems, few studies have examined other health indicators. This study compared adolescents with alcohol use disorders (AUDs) and a community reference group on self-reported health problems, serum liver enzymes, and physical examination findings. The relevance of negative emotionality to understanding these health problems was also investigated. METHODS: The subjects were adolescents with AUDs recruited from clinical programs and classified as having DSM-IV alcohol dependence (n = 71) or alcohol abuse (n = 57) and reference adolescents without AUDs recruited from community sources (n = 131). The assessment of health status included self-reported health problems in 15 areas; serum liver enzyme assays, including gamma-glutamyl transpeptidase, alanine aminotransferase, and aspartate aminotransferase; and physical examination findings. Negative emotionality was determined by systematically combining scores from the Hamilton Anxiety Rating Scale, the Beck Depression Inventory, the Child Behavior Checklist, and the Multidimensional Personality Questionnaire. RESULTS: Adolescent AUDs were associated with more self-reported health problems, higher gamma-glutamyl transpeptidase and alanine aminotransferase levels, and more physical examination abnormalities. Negative emotionality was highly correlated with self-reported health problems, mediated the relationship between AUDs and self-reported health problems, and was not correlated with serum liver enzyme levels or physical examination abnormalities. CONCLUSIONS: These results indicated that AUDs during adolescence were associated with health problems, including modest but demonstrable liver injury. Self-reported health problems were probably best understood, in this context, as a negative emotionality manifestation.     

Validity of the bi-axial dependence concept: a test in the US general population

According to the “bi-axial” concept of alcohol dependence, the Alcohol Dependence Syndrome (ADS) constitutes an axis or dimension of alcohol difficulties, while other alcohol-related problems (social, legal, etc.) constitute one or more separate dimensions. The validity of the bi-axial distinction was investigated in a stratified probability sample of 3212 US current drinkers who were interviewed in their households. Indicators of the Alcohol Dependence Syndrome and potentially distinct alcohol-related problems were covered in a structured interview administered by carefully trained interviewers. This interview provided extensive coverage of drinking patterns and problems. Aspects of the ADS covered included narrowing, salience, tolerance, withdrawal, withdrawal relief/avoidance and compulsion/control. Other alcohol problems included difficulties with work, health, the law, general social difficulties and problems in marriage/home life. Confirmatory and exploratory factor analyses were used to determine whether a single factor (dimension) or two or more factors fit the data best. Using all methods, we found that one general factor explained the structure of the data better than a two-factor model or other models for males, females, blacks and whites. Thus, the utility of this approach to distinguishing between types of alcohol problems was challenged, raising some questions about abuse/dependence distinctions in various nomenclatures.     

Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: results from the 2001 National Household Survey on Drug Abuse

BACKGROUND: Studies of the prevalence of DSM-IV alcohol use disorders (AUDs) in general population samples of adolescents and adults are rare. Comparisons of the prevalence of alcohol abuse and dependence in adolescent surveys with the prevalence in adult general population surveys are confounded by differences in survey design and measurement, thereby reducing their validity. The purpose of the present study was to examine the effects of age, sex, race/ethnicity, and drinking status on the prevalence of DSM-IV alcohol abuse and dependence (including diagnostic orphans) and associated diagnostic criteria among adolescents and adults aged 12-65 years in a single representative sample of the US population. METHODS: This study was based on data from the 2001 National Household Survey on Drug Abuse public use file. Of the 55,561 subjects in the survey, 33,576 (60.5%) reported alcohol use in the past year and provided information on DSM-IV AUD criteria. DSM-IV AUD criteria were assessed by questions related to specific symptoms occurring during the past 12 months. RESULTS: Overall, the most prevalent criteria of DSM-IV alcohol dependence were "tolerance" and "time spent obtaining alcohol, drinking, or getting over its effects." The most prevalent criterion of DSM-IV alcohol abuse was "hazardous use." The prevalence of alcohol abuse only and of dependence with and without abuse was highest among respondents aged 18-23 years, followed by respondents aged 12-17 years, and lowest among respondents aged 50 years and older. Among subgroups of current and heavier drinkers, differences between adolescents and young adults were less pronounced, especially among females. For each age group, the prevalence of alcohol abuse only was greater than the prevalence of dependence (with or without abuse). The abuse-to-dependence ratios also were generally consistent across age groups and slightly higher among males (2.1:1.0) than females (1.6:1.0). CONCLUSIONS: The higher prevalence for some dependence criteria among adolescents and young adults as measured in the present study may blur the distinction between symptom reports associated with the normative development of drinking patterns and clinically relevant aspects of DSM-IV alcohol dependence.     

Naltrexone versus acamprosate in the treatment of alcohol dependence: A multi-centre, randomized, double-blind, placebo-controlled trial

AIM: To compare the efficacy of acamprosate and naltrexone in the treatment of alcohol dependence. DESIGN: A double-blind, placebo-controlled trial. SETTING: Three treatment centres in Australia. PARTICIPANTS: A total of 169 alcohol dependent subjects were given naltrexone (50 mg/day), acamprosate (1998 mg/day) or placebo for 12 weeks. INTERVENTION: All subjects were offered manualized compliance therapy, a brief intervention that targets problems that may affect treatment compliance such as ambivalence and misperceptions about medication. MEASUREMENTS: Time to the first drink, time to first relapse, drinks per drinking day and cumulative abstinence. FINDINGS: In intention-to-treat analyses, there were no differences between groups on outcome measures of drinking, craving or biochemical markers. Similarly, analyses of the 94 subjects that completed the study in full and demonstrated 80% compliance, revealed no significant treatment effects. Differential treatment effects were identified after stratification according to scores on the Alcohol Dependence Scale (ADS) and Depression Anxiety and Stress Scale (DASS). A significant beneficial treatment effect on time to first relapse was revealed for subjects with 'no depression' allocated to naltrexone (n = 56; P < 0.01). In addition, a significant beneficial treatment effect was revealed in subjects with 'low dependence' allocated to naltrexone (n = 34; P < 0.05). CONCLUSIONS: The results of this study support the efficacy of naltrexone in the relapse prevention of alcoholism amongst those with low levels of clinical depression and alcohol dependence severity. No effect of acamprosate was found in our sample.     

A Rasch model analysis of DSM-IV Alcohol abuse and dependence items in the National Epidemiological Survey on Alcohol and Related Conditions

BACKGROUND: Questions persist about the diagnoses of alcohol abuse and alcohol dependence as defined by Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV). These questions center around the performance of individual alcohol use disorder (AUD) criteria and the nature of items used to assess them. In this study, we conduct in-depth analyses of interview items used to assess alcohol abuse and dependence. METHOD: We conducted Rasch model analyses of responses to 33 items assessing alcohol abuse and dependence criteria in the National Epidemiological Survey on Alcohol and Related Conditions, a nationally representative sample of 34,550 participants. We also examined whether items performed differentially by gender, race/ethnicity, age, education, and time frame of assessment (i.e., past year vs lifetime). RESULTS: A single latent dimension explained the vast majority of shared variance among the items. Abuse symptoms were not of consistently lower severity than dependence symptoms, and some were consistently prone to differential functioning across subgroups. Items related to tolerance also functioned differentially across subgroups especially in the comparison of past-year symptoms between young adults (ages 18-24) and older adults. Items differed widely in their empirically estimated severity, even when they were intended to assess the same DSM-IV criterion. CONCLUSIONS: The use of Rasch model analyses demonstrated the essential unidimensionality of AUD criteria and the lack of hierarchical ordering between abuse and dependence criteria, as well as potential sources of bias in the abuse diagnosis and the tolerance criterion. Results highlight that the prevalence and even the meaning of AUD criteria can differ substantially depending on the wording of items used to assess them. Implications for assessment of specific DSM criteria and for development of DSM-V are discussed.