ADD5107: Week 10 Discussion 1: Categories of Addiction

Brief Report: Agreement Between DSM-IV and DSM-5 Criteria for Alcohol Use Disorder Among Outpatients Suffering From Depressive and Anxiety Disorders

Francesco Bartoli, MD, PhD,1 Giuseppe Carr�a, MD, MSc, PhD,1,2,3 Enrico Biagi, MD,2

Cristina Crocamo, MSc,2 Antonios Dakanalis, PsyD, MSc, PhD,1 Francesco Di Carlo, MD,1

Francesca Parma, MSc,4 Anna Paola Perin, MD,5 Ester Di Giacomo, MD,1,2

Luigi Zappa, MD,2 Fabio Madeddu, MD,4 Fabrizia Colmegna, MD,2

Massimo Clerici, MD, PhD1,2

1Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy 2Department of Mental Health, San Gerardo Hospital, Monza, Italy 3Division of Psychiatry, University College London, London, UK 4Department of Psychology, University of Milano-Bicocca, Milano, Italy 5Department of Psychiatry, University of Brescia, Milano, Italy

Background and Objectives: Since significant differences have been reported, we estimated agreement betweenDSM-5 andDSM-IV criteria for alcohol use disorder (AUD). Methods:We assessed 327 outpatients (mean age: 45.2� 13.4) with depressive or anxiety disorders. Results: Absolute differences in prevalence rates between DSM-5 and DSM-IV AUD ranged from �1.1% (subjects with anxiety disorders) to þ1.8% (tobacco smokers). The agreement was excellent (k¼ 0.88), also accounting for specific subgroups (relevant k coefficients >0.80). Discussion and Conclusions: DSM-5 criteria did not inflate AUD rates. Scientific Significance: Our results have epidemiological signifi- cance since, unlike previous reports, we found diagnostic stability between new and old AUD criteria in this clinical population. (Am J Addict 2017;26:53–56)

INTRODUCTION

Alcohol use disorder (AUD) is a chronic illness associated with a high burden of disease,1 often comorbid with other mental disorders.2 In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) made several changes to diagnostic criteria and classifications of AUD.3 First, abuse/dependence criteria were merged into a

single diagnostic category requiring that at least two criteria weremet. Second, the alcohol-related legal problems criterion, representing one of the four used for DSM-IV alcohol abuse, was dropped. Third, the craving criterion, ie, the strong desire or urge to use alcohol, was added. Finally, the new classification has traced the transition from a categorical to a dimensional diagnosis, identifying a severity grade of the disorder (mild, moderate, severe), according to the number of criteria met.

All individuals with a diagnosis of DSM-IV alcohol dependence, but only a portion of those with DSM-IV alcohol abuse, thus reach the DSM-5 diagnostic threshold for AUD. On the other hand, a portion of so-called DSM-IV “diagnostic orphans”, ie, people meeting one or two criteria for alcohol dependence, but none for alcohol abuse, are diagnosed with AUD according to DSM-5 criteria. Therefore, based onDSM-5 criteria, some AUD cases are lost and other gained, implying potential epidemiological variations. Indeed, a previous systematic overview4 showed that DSM-5 criteria might significantly inflate AUD rates in general population. Never- theless, there is a lack of data exploring this issue in particularly vulnerable populations. For example, AUD is frequently associated with an unfavorable prognosis among subjects with depressive and anxiety disorders.5 Thus, it seems important to test if there are AUD epidemiological variations, due to DSM-5 new set of criteria, also among subjects with depressive and anxiety disorders. To our knowledge, there are no studies exploring this topic so far. In order to overcome limitations of previous research, we aimed at estimating differences in prevalence, as well as agreement, between DSM-5 and DSM-IV criteria for AUD in a sample of

Received July 25, 2016; revised November 18, 2016; accepted December 4, 2016.

Address correspondence to Dr. Bartoli, Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza (MB), Italy. E-mail: [email protected]

The American Journal on Addictions, 26: 53–56, 2017 Copyright © 2016 American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12482

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individuals with depressive and anxiety disorders. We hypothesized that DSM-5 diagnostic criteria would increase AUD rates as compared with those based on DSM-IV criteria.

METHODS

This study was drawn up according to “The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement”.6 STROBE Statement developed recommendations on items that should be included in accurate and complete reports of observational studies.

Setting and Eligibility Criteria We included individuals older than 18 years of age,

consecutively admitted, in a 12-month period from January to December 2015, to San Gerardo Hospital outpatient clinic (“Ambulatorio Vademecum”) and suffering from a depressive or anxiety disorder. The setting, sampling strategies and inclusion/exclusion criteria are fully described elsewhere.7

San Gerardo University Hospital of Monza covers a comprehensive range of medical and surgical inpatient and outpatient services, serving a catchment area of 319,000 inhabitants.8

Data Collection and Measures Standard socio-demographic and clinical characteristics

were collected for descriptive purposes. The Italian version of the K-6 scale was used to measure individual psychological distress.9 We used the Mini- International Neuropsychiatric Interview (MINI)—alcohol module, to assess current DSM-IV and DSM-5 AUDs. Since DSM-5 includes the additional craving criterion, we implemented the interview with an item derived from the Composite International Diagnostic Interview (CIDI), assessing strong desire and urge to drink alcohol. Individuals were diagnosed with a current DSM-IV AUD if, in a 12-month period, criteria for DSM-IV abuse or dependence were met. On the other hand, subjects were diagnosed with a current DSM-5 AUD if, equally in a 12-month period, at least two out of the eleven criteria were met. Fully trained consultant psychia- trists sequentially administered, along with other routine screening questionnaires, the MINI/CIDI alcohol module. All data were recorded anonymously in a dataset not allowing identification of subjects included in this study. The protocol was submitted to, and approved by, the ethic committee of San Gerardo University Hospital.

Data Analysis In order to estimate variations attributable to DSM-5

criteria as compared with DSM-IV ones, we calculated absolute differences (increase/decrease) in prevalence rates. Cohen’s Kappa coefficients (k), with relevant Pr(a) (relative observed agreement) and Pr(e) (chance agreement), were used to measure the agreement between the different diagnostic systems. We chose the conventional cut-offs to indicate

poor (�0.20), fair (0.21–0.40), moderate (0.41–0.60), sub- stantial (0.61–0.80), and excellent (0.81–1.00) agreement.4

Relevant subgroup analyses, accounting for age, gender, diagnosis, psychological distress score, and smoking status, were tested to verify variability of k coefficients across different characteristics of subjects.

Statistical analyses were performed using Stata for Windows, version 13.1.

RESULTS

Four hundred and twenty-six individuals were consecu- tively admitted to the San Gerardo Hospital outpatient clinic for depressive and anxiety disorders during the index period. Among these, 83 subjects were excluded because they did not suffer from depressive or anxiety disorders, while other 16 were excluded because they refused to be screened (n¼ 10) or had a mental status or physical conditions not allowing the screening (n¼ 6). Thus, 327 subjects (mean age: 45.2� 13.4; women/men ratio: 1.51) were assessed for DSM-IV/DSM-5 alcohol use disorders using the MINI/CIDI interview. The mean K-6 psychological distress score was 10.9 (5.6), and most of subjects suffered from an anxiety disorder (58.3%).

Prevalence rates for DSM-IV and DSM-5 AUDs were identical, both corresponding to 11.3% (37/327) in the overall sample, and to 15.3% (37/242) among alcohol users. The absolute differences were generally low and homogenous also across relevant subgroups, ranging from �1.1% among subjects suffering from anxiety disorders, to þ1.8% among tobacco smokers. A high level of diagnostic stability was found since DSM-5 AUD was present in most people with DSM-IV AUD (89.2%) and absent in almost all subjects without DSM-IV AUD diagnosis (98.6%). The overall agreement between DSM-IV and DSM-5 criteria was excellent (k¼ 0.88). Excellent values (k> 0.80) were found also considering the subsample of alcohol users, and accounting for age, gender, diagnosis, psychological distress, apart from non-smokers where the k coefficient (0.79) was slightly below the relevant threshold, probably because of the limited proportion of AUD cases. Detailed findings are summarized in Table 1.

DISCUSSION

To our knowledge, this is the first empirical study addressing the epidemiological impact of DSM-5 diagnostic criteria on AUD rates among subjects suffering from depressive or anxiety disorders. We tested a clinical sample of 327 subjects consecutively admitted to a hospital outpatient service. We found that DSM-5 diagnostic criteria, as compared with DSM-IV ones, did not increase expected AUD prevalence rates. DSM-IV and DSM-5 showed comparable rates of AUD in our clinical sample. We also found a high level of diagnostic stability, highlighting that

54 From DSM-IV to DSM-5 Rates of Alcohol Use Disorder January 2017

most of the subjects with DSM-IV, had also DSM-5 AUDs. This was confirmed by the excellent overall agreement, verified also by subgroup analyses, with k values generally remaining above 0.80 also accounting for alcohol use, age, gender, diagnosis, psychological distress score, and smoking status. Thus, despite previous concerns on potential epidemiological impact of DSM-5 criteria,4 DSM-5 does not seem to produce several AUD new cases (also called DSM-IV “diagnostic orphans”10) in this clinical population. Therefore, the additional epidemiological burden of dual diagnosis after DSM-5 could be considered minimal if any, at least among subjects suffering from depressive or anxiety disorders.

Nevertheless, this study has some potential limitations that should be taken into account.7 First, the small sample sizemight have reduced the statistical power of our findings. However, it seems unlikely that the magnitude of overlapping in AUD rates between DSM-IV and DSM-5 might be entirely due to the reduced sample size. Second, it should be considered the potential lack of representativeness of our sample. As previously reported,4 individuals identified in clinical settings may not necessarily share identical characteristics of the general population. Furthermore, we recruited subjects from an outpatient clinic, receiving referrals fromprimary care services. Service users included in our study might be considerably different to those from caseloads of community mental health services.11 Finally, since we excluded from analyses a substantial pool of individuals without depressive and anxiety disorders, we cannot exclude that our findings are valid only for subjects with a confirmed clinical diagnosis.

Although some open questions regarding, especially, reliability and validity of diagnostic criteria12,13 still remain, DSM is considered worldwide a key tool for diagnosing mental disorders. Thus, our observational study has important implications for AUD assessment and treatment. There is a large diagnostic stability between new and old

AUD criteria, at least in the specific clinical population we assessed, suggesting it is unlikely that DSM-5 diagnostic criteria may inflate the size of AUD cases. Nevertheless, further research is needed to estimate epidemiological trends also for illicit substance use disorders whose criteria had similar changes in DSM-5.3

Declaration of Interest The authors report no conflicts of interest. The authors

alone are responsible for the content and writing of this paper.

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TABLE 1. Agreement between DSM-IV and DSM-5 alcohol use disorders across participant characteristics

DSM-IV AUD DSM-5 AUD

Cases Prevalence (%) Cases Prevalence (%) Absolute difference (%) Pr(a) Pr(e) k

Overall sample (n¼ 327) 37 11.3 37 11.3 0.0 0.98 0.80 0.88 Alcohol users (n¼ 242) 37 15.3 37 15.3 0.0 0.97 0.74 0.87 Men (n¼ 130) 23 17.7 22 16.9 �0.8 0.96 0.71 0.87 Women (n¼ 196) 14 7.1 15 7.6 +0.5 0.98 0.86 0.89 Age <30 years (n¼ 58) 13 22.4 13 22.4 0.0 1.00 0.65 1.00 Age >30 years (n¼ 269) 24 8.9 24 8.9 0.0 0.97 0.84 0.82 Depressive disorder (n¼ 133) 16 12.0 18 13.5 +1.5 0.97 0.78 0.87 Anxiety disorder (n¼ 186) 20 10.8 18 9.7 �1.1 0.98 0.82 0.88 K6< 7 (n¼ 89) 5 5.6 5 5.6 0.0 1.00 0.89 1.00 K6> 7 (n¼ 238) 32 13.4 32 13.4 0.0 0.97 0.77 0.86 Tobacco smoker (n¼ 112) 26 23.2 28 25.0 +1.8 0.96 0.63 0.90 Non-tobacco smoker (n¼ 214) 11 5.1 9 4.2 �0.9 0.98 0.91 0.79

AUD, alcohol use disorder; Pr(a), relative observed agreement; Pr(e), chance agreement; k, Cohen’s kappa coefficient.

Bartoli et al. January 2017 55

9. Carr�a G, Sciarini P, Segagni-Lusignani G, et al. Do they actually work across borders? Evaluation of two measures of psychological distress as screening instruments in a non Anglo-Saxon country. Eur Psychiatry. 2011;26:122–127.

10. McBride O, Adamson G, Bunting BP, et al. Characteristics of DSM-IV alcohol diagnostic orphans: Drinking patterns, physical illness, and negative life events. Drug Alcohol Depend. 2009;99:272–279.

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13. Luciano M, Sampogna G, Del Vecchio V, et al. Critical evaluation of current diagnostic classification systems in psychiatry: The case of DSM-5. Riv Psichiatr. 2016;51:116–121.

56 From DSM-IV to DSM-5 Rates of Alcohol Use Disorder January 2017

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