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.     

Alcohol,Tobacco, and Nonmedical Drug Use in Older U.S. Adults: Data from the 2001/02 National Epidemiologic Survey of Alcohol and Related Conditions

OBJECTIVES: To examine the prevalence and sociodemographic and health‐related correlates of substance use, including alcohol, tobacco, and nonmedical drug use, in adults aged 65 and older. DESIGN: Cross‐sectional, retrospective survey of a population‐based sample, the 2001/02 National Epidemiologic Survey on Alcohol and Related Conditions. SETTING: United States. PARTICIPANTS: Eight thousand two hundred five U.S. adults aged 65 and older. MEASUREMENTS: Prevalence of lifetime and previous‐12‐month alcohol, tobacco, and nonmedical drug use and associations between substance use and sociodemographic and health‐related factors. RESULTS: Almost 80% of older adults had used any of the three substances over their lifetimes, and more than 50% reported such use over the previous 12 months. Alcohol was the most commonly used substance over the lifetime (74%) and in the previous 12 months (45%), followed by tobacco (52% lifetime; 14% previous 12 months); far fewer reported nonmedical use of drugs (5% lifetime; 1% previous 12 months). In general, being younger, male, and divorced or separated were factors consistently associated with use of any of the three substances. CONCLUSION: Most older adults had used substances over their lifetimes and in the previous 12 months. Alcohol is the substance of choice for this age group, followed by tobacco; few report nonmedical drug use.     

Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions

Aim To estimate the general and racial/ethnic specific cumulative probability of remission from nicotine alcohol cannabis or cocaine dependence, and to identify predictors of remission across substances. Design Data were collected from structured diagnostic interviews using the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM‐IV version. Setting The 2001–2002 National Epidemiological Survey of Alcohol and Related Conditions (NESARC) surveyed a nationally representative sample from US adults (n = 43 093) selected in a three‐stage sampling design. Participants The subsamples of individuals with life‐time DSM‐IV diagnosis of dependence on nicotine (n = 6937), alcohol (n = 4781), cannabis (n = 530) and cocaine (n = 408). Measurements Cumulative probability estimates of dependence remission for the general population and across racial/ethnic groups. Hazard ratios for remission from dependence. Findings Life‐time cumulative probability estimates of dependence remission were 83.7% for nicotine, 90.6% for alcohol, 97.2% for cannabis and 99.2% for cocaine. Half of the cases of nicotine, alcohol, cannabis and cocaine dependence remitted approximately 26, 14, 6 and 5 years after dependence onset, respectively. Males, Blacks and individuals with diagnosis of personality disorders and history of substance use comorbidity exhibited lower hazards of remission for at least two substances. Conclusions A significant proportion of individuals with dependence on nicotine, alcohol, cannabis or cocaine achieve remission at some point in their life‐time, although the probability and time to remission varies by substance and racial/ethnic group. Several predictors of remission are shared by at least two substances, suggesting that the processes of remission overlap. The lower rates of remission of individuals with comorbid personality or substance use disorders highlight the need for providing coordinated psychiatric and substance abuse interventions.     

Classification of alcohol use disorders among nightclub patrons: associations between high-risk groups,sociodemographic factors and illicit drug use

Background: Nightclubs are favorable environments for alcohol abuse and the use of other drugs among patrons. Objective: To identify patterns of alcohol use in a high-risk population and their relationship with sociodemographic factors and illicit drug use. Methods: A portal survey technique was used to recruit patrons in 31 nightclubs in the city of São Paulo, Brazil. A two stage sampling method allowed the selection of nightclubs and patrons within a nightclub. A total of 1057 patrons answered to a three stages-survey (nightclub entrance and exit face-to-face interviews and a day-after online questionnaire). Entrance survey offered information on sociodemographic data and history of drug use. The day-after survey used the Alcohol Use Disorders Identifications Test (AUDIT) that identified patterns of alcohol abuse disorders. Data were modeled using an ordered logit regression analysis, considering sample weights. Results: Almost half of the nightclub patrons presented any alcohol use disorder (AUDIT score ≥8). Being male (OR?=?1.68; 95% CI?=?1.09–2.60) and single (OR?=?1.71; 95% CI?=?1.05–2.76) increased the chances for more severe alcohol use disorders. Having a graduate degree (OR?=?0.57; 95% CI?=?0.38–0.87) and age ≥35 years (OR?=?0.48; 95% CI?=?0.27–0.85) decreased the chances of patrons’ alcohol use disorders. The prevalence rates of past-year marijuana, cocaine and inhalants use increased with the increased level of alcohol use disorders. Conclusions: Patrons of nightclubs show higher prevalence rates for any alcohol use disorders than the general population. Patrons could benefit from governmental brief intervention or referral to treatment for alcohol used disorders disclosed in nightclubs.     

A comparison of the latent class structure of cannabis problems among adult men and women who have used cannabis repeatedly

BACKGROUND: Little empirical evidence exists to determine if there are alternative classification schemes for cannabis abuse and dependence beyond the definitions provided by Diagnostic and Statistical Manual (DSM) criteria. Current evidence is not conclusive regarding gender differences for cannabis use, abuse and dependence. It is not known if symptom profiles differ by gender. METHODS: Latent class analysis (LCA) was used to assess whether cannabis abuse and dependence symptom patterns suggest a severity spectrum or distinct subtypes and to test whether symptom patterns differ by gender. Data from 3312 men and 2509 women in the National Longitudinal Alcohol Epidemiologic Survey (NLAES) who had used cannabis 12 + times life-time were included in the present analyses. The comparability of the solutions for men and women was examined through likelihood ratio chi(2) tests. RESULTS: Based on the Bayesian information criterion and interpretability, a four-class solution was selected, and the classes were labeled as 'unaffected/mild hazardous use', 'hazardous use/abuse', 'abuse/moderate dependence' and 'severe abuse/dependence'. The solutions were generally suggestive of a severity spectrum. Compared to men, women were more likely to be in the 'unaffected/mild hazardous use' class and less likely to be in the 'abuse/moderate dependence' or 'severe abuse/dependence' classes. The results were generally similar for men and women. However, men had consistently and substantially higher endorsements of hazardous use than women, women in the 'abuse/moderate dependence' class had moderately higher rates for four dependence symptoms, and women in two of the classes were more likely to endorse withdrawal. CONCLUSION: Our findings generally support the severity dimension for DSM-IV cannabis abuse and dependence symptomatology for both men and women. While our results indicate that public health messages may have generic and not gender-specific content, treatment providers should focus more effort on reducing hazardous use in men and alleviating withdrawal in women.     

Gender and racial/ethnic differences in patterns of adolescent alcohol use and associations with adolescent and adult illicit drug use

Objectives: The study objective was to use latent class analyses (LCAs) to identify gender- and racial/ethnic-specific groups of adolescent alcohol users and associations between alcohol use group and adolescent and adulthood illicit drug use in a nationally-representative US sample. Methods: We used Wave I (1994–1995, adolescence) of the National Longitudinal Study of Adolescent Health to conduct LCAs by gender and race/ethnicity and measure associations between class membership and Wave I and Wave III (2001–2002, young adulthood) drug use. Participants included white (n?=?9548), African American (n?=?4005) and Hispanic (n?=?3184) participants. LCAs were based on quantity and frequency of adolescent alcohol use; physiological and social consequences of use; and peer use. Results: Males and females were characterized by different alcohol use typologies and consequences. Males in the highest severity class (i.e. drank both heavily and frequently) experienced disproportionate risk of alcohol-related consequences compared with abstainers and other alcohol-using groups. Females who drank heavily when drinking even if only occasionally, experienced high risk of alcohol-related consequences. Substantial proportions of males reported diverse alcohol-related problems, whereas females most commonly reported alcohol-related problems with dating and sexual experiences. Though levels of alcohol use and report of problems associated with use were higher among white versus minority populations, other racial/ethnic differences in patterns of alcohol use were minimal. Classification in any drinking class was a strong risk factor for adolescent and adulthood illicit drug use, with heavy drinkers at greatest risk of drug use. Conclusions: Gender-specific adolescent alcohol and substance use prevention programs are warranted.     

Probability and Predictors of Transition from Abuse to Dependence on Alcohol,Cannabis, and Cocaine: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

Background: Little is known about the transition from substance abuse to substance dependence. Objectives: This study aims to estimate the cumulative probability of developing dependence and to identify predictors of transition to dependence among individuals with lifetime alcohol, cannabis, or cocaine abuse. Methods: Analyses were done for the subsample of individuals with lifetime alcohol abuse (n = 7802), cannabis abuse (n = 2832), or cocaine abuse (n = 815) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Estimated projections of the cumulative probability of transitioning from abuse to dependence were obtained by the standard actuarial method. Discrete-time survival analyses with time-varying covariates were implemented to identify predictors of transition to dependence. Results: Lifetime cumulative probability estimates indicated that 26.6% of individuals with alcohol abuse, 9.4% of individuals with cannabis abuse, and 15.6% of individuals with cocaine abuse transition from abuse to dependence at some point in their lives. Half of the transitions of alcohol, cannabis, and cocaine dependence occurred approximately 3.16, 1.83, and 1.42 years after abuse onset, respectively. Several sociodemographic, psychopathological, and substance use-related variables predicted transition from abuse to dependence for all of the substances assessed. Conclusion: The majority of individuals with abuse do not transition to dependence. Lifetime cumulative probability of transition from abuse to dependence was highest for alcohol, followed by cocaine and lastly cannabis. Time from onset of abuse to dependence was shorter for cocaine, followed by cannabis and alcohol. Although some predictors of transition were common across substances, other predictors were specific for certain substances.     

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

Aims The study investigates severity of alcohol dependence among drug misusers. Specifically, it investigates the inter‐relationship of alcohol and drug dependence and associations with alcohol consumption, drug consumption and substance‐related problems. Design, setting, participants The sample comprised 735 people seeking treatment for drug misuse problems, who were current (last 90 days) drinkers. Measurements Data were collected by structured face‐to‐face interviews. Dependence upon illicit drugs and upon alcohol was measured by the Severity of Dependence Scale (SDS). Findings Three groups of drinkers were identified: non‐alcohol‐dependent drug misusers (63%); low‐dependence (19%); and high‐dependence (18%). Many drug misusers were drinking excessively and alcohol dependence was related to patterns of alcohol and drug consumption. High‐dependence drinkers were more likely to drink extra‐strength beer; they were less frequent users of heroin and crack cocaine but more frequent users of benzodiazepines, amphetamines and cocaine powder; they reported more psychological and physical health problems. The SDS was found to have good reliability and validity as a measure of alcohol dependence. SDS scores for alcohol and drug dependence were unrelated. Conclusions Alcohol use is an important and under‐rated problem in the treatment of drug misusers. A comprehensive assessment of alcohol use among drug misusers should include separate assessments of alcohol consumption, alcohol‐related problems and severity of alcohol dependence.     

A taxometric study of alcohol abuse and dependence in a general population sample: evidence of dimensional latent structure and implications for DSM-V

Aims   To explore, with the aid of taxometric analysis, whether alcohol abuse and alcohol dependence are each conceptualized most effectively as single latent dimensions or distinct latent categories.
Design   Data were taken from a nationally representative cross-sectional epidemiological survey of psychiatric and substance use disorders.
Setting   General population of Australia.
Participants   A subsample of all respondents who had consumed at least 12 drinks in the year prior to the survey and who had consumed at least three drinks on at least one single day ( n  = 4920 of a possible 10 641).
Measurements   DSM-IV criteria for alcohol abuse and dependence were assessed with the Composite International Diagnostic Interview, version 2.1. Two independent taxometric procedures, MAXimum EIGenvalue (MAXEIG) and mean above minus below a cut (MAMBAC), together with analysis of simulated dimensional and categorical data sets, were carried out.
Findings   Consistent evidence was found for a single latent dimension underlying the symptoms of alcohol dependence. Less consistent evidence of dimensionality was found for the symptoms of alcohol abuse.
Conclusions   These findings support the growing consensus regarding the need for continuous measures of alcohol use disorders to complement the traditional categorical representations in upcoming versions of the major psychiatric classification systems.     

Antisocial behavioral syndromes and DSM-IV alcohol use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: Antisocial personality disorder (ASPD), syndromal adult antisocial behavior (AABS) without conduct disorder (CD) before age 15, and CD without progression to ASPD ("CD only") are highly prevalent among adults with alcohol use disorders (AUDs). Among patients in AUD treatment, antisocial behavioral syndromes are associated with more severe AUDs and poorer treatment outcomes. Comparative data concerning associations of antisocial syndromes with clinical characteristics of AUDs and the sociodemographic and clinical correlates of these syndromes among general population adults with AUDs have not previously been available. This study examines prevalences and correlates of antisocial syndromes among adults with lifetime Diagnostic and Statistical Manual--Version IV (DSM-IV) AUDs, and describes associations of these syndromes with clinical characteristics of AUDs, in the general U.S. population. METHODS: This report is based on the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (n=43,093, response rate=81%). Respondents (n=11,843) with lifetime AUDs were classified according to whether they met criteria for ASPD, AABS, "CD only," or no antisocial syndrome. Correlates of antisocial syndromes were examined using contingency table approaches and normal theory analyses of variance. Associations of antisocial syndromes with clinical characteristics of AUDs, including number of lifetime episodes, duration of longest or only episode, and alcohol consumption during period of heaviest drinking were examined using normal theory and logistic regression. RESULTS: Sociodemographic and clinical correlates of antisocial syndromes among respondents with AUDs were consistent with results from prior studies. Antisocial syndromes were significantly associated with phenomenology of AUDs, particularly ASPD with the most severe clinical presentations. Associations with AABS were similar to but more modest than those with ASPD; those with "CD only" were weaker and less consistent. Patterns of associations between antisocial syndromes and clinical characteristics of AUDs were generally similar between men and women. CONCLUSIONS: Antisocial syndromes, particularly ASPD, appear to identify a more pernicious clinical profile of AUDs among adults in the general U.S. population.     

Classifying patients by their characteristics and clinical presentations; the use of latent class analysis

In this article, we introduce the general statistical analysis approach known as latent class analysis and discuss some of the issues associated with this type of analysis in practice. Two recent examples from the respiratory health literature are used to highlight the types of research questions that have been addressed using this approach.