Clinical and public health significance of the proposed changes to the diagnosis of alcohol abuse and dependence in DSM-5
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1 Clinical and public health significance of the proposed changes to the diagnosis of alcohol abuse and dependence in DSM-5 Dr Tim Slade, Senior Research Fellow, National Drug and Alcohol Research Centre, University of New South Wales
2 Classification of mental disorders
3 DSM Alcohol Use Disorders Criterion Major role Hazard Legal Social Tolerance Withdrawal Larger Cut down Time spent Give up Continue Craving Description Recurrent use despite the inability to fulfil major role obligations at work, school or home Recurrent use in physically dangerous situations Recurrent use despite substance-related legal problems Recurrent use despite substance-related social or interpersonal problems Tolerance Withdrawal Taking more of the substance or for longer than intended Desire or unsuccessful efforts to cut down A great deal of time obtaining, using or recovering from the effects of the substance Reduction in important activities because of substance use Continued use despite knowing it is causing a significant problem Craving or a strong desire for a substance
4 Alcohol Use Disorders in DSM-IV Criterion Major role Clinical description Recurrent use despite the inability to fulfil major role obligations at work, school or home Hazard Legal Recurrent use in physically dangerous situations Recurrent use despite substance-related legal problems Threshold for Alcohol Abuse: 1 criterion Social Tolerance Withdrawal Larger Cut down Time spent Give up Continue Craving Recurrent use despite substance-related social or interpersonal problems Tolerance Withdrawal Taking more of the substance or for longer than intended Desire or unsuccessful efforts to cut down A great deal of time obtaining, using or recovering from the effects of the substance Reduction in important activities because of substance use Continued use despite knowing it is causing a significant problem Craving or a strong desire for a substance
5 Alcohol Use Disorders in DSM-IV Criterion Major role Hazard Legal Social Tolerance Withdrawal Clinical description Recurrent use despite the inability to fulfil major role obligations at work, school or home Recurrent use in physically dangerous situations Recurrent use despite substance-related legal problems Recurrent use despite substance-related social or interpersonal problems Tolerance Withdrawal Larger Cut down Taking more of the substance or for longer than intended Desire or unsuccessful efforts to cut down Threshold for Alcohol Dependence: 3 criteria Time spent Give up Continue Craving A great deal of time obtaining, using or recovering from the effects of the substance Reduction in important activities because of substance use Continued use despite knowing it is causing a significant problem Craving or a strong desire for a substance
6 Alcohol Use Disorders in DSM-5* Criterion Major role Hazard Legal Social Clinical description Recurrent use despite the inability to fulfil major role obligations at work, school or home Recurrent use in physically dangerous situations Recurrent use despite substance-related legal problems Recurrent use despite substance-related social or interpersonal problems Tolerance Withdrawal Larger Cut down Tolerance Withdrawal Taking more of the substance or for longer than intended Desire or unsuccessful efforts to cut down Threshold for Alcohol Use Disorder: 2-3 criteria moderate 4 criteria severe Time spent Give up Continue Craving A great deal of time obtaining, using or recovering from the effects of the substance Reduction in important activities because of substance use Continued use despite knowing it is causing a significant problem Craving or a strong desire for a substance * According to the proposed diagnostic criteria (
7 Summary of proposed changes* 1. Eliminate distinction between abuse and dependence 2. Remove substance-related legal problems criterion 3. Add craving or strong desire criterion 4. Change threshold for diagnosis * According to the proposed diagnostic criteria (
8 Summary of proposed changes* 1. Eliminate distinction between abuse and dependence 2. Remove substance-related legal problems criterion 3. Add craving or strong desire criterion 4. Change threshold for diagnosis * According to the proposed diagnostic criteria (
9 Prevalence of DSM-IV vs DSM-5 AUD Prevalence % (SE) Kappa* DSM-IV abuse or dependence 6.0 (0.2) - DSM-5 ( 2 criteria) 9.7 (0.4) 0.65 * Indicates agreement between DSM-IV any alcohol use disorder and DSM-5 alcohol use disorder. Adapted from Mewton et al. (2010) This equates to roughly 592,000 more people in the general population meeting criteria for an alcohol use disorder
10 Prevalence of DSM-IV vs DSM-5 AUD Prevalence % (SE) Kappa* DSM-IV abuse or dependence 6.0 (0.2) - DSM-5 ( 2 criteria) 9.7 (0.4) 0.65 DSM-5 ( 3 criteria) 5.2 (0.2) 0.84 DSM-5 ( 4 criteria) 3.0 (0.2) 0.65 * Indicates agreement between DSM-IV any alcohol use disorder and DSM-5 alcohol use disorder made at indicated threshold. Adapted from Mewton et al. (2010)
11 Prevalence of DSM-IV vs DSM-5 AUD Prevalence % (SE) Kappa* DSM-IV abuse or dependence 6.0 (0.2) - DSM-5 ( 2 criteria) 9.7 (0.4) 0.65 DSM-5 ( 3 criteria) 5.2 (0.2) 0.84 DSM-5 ( 4 criteria) 3.0 (0.2) 0.65 * Indicates agreement between DSM-IV any alcohol use disorder and DSM-5 alcohol use disorder made at indicated threshold. Adapted from Mewton et al. (2010)
12 and in more detail No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
13 DSM-5 No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria
14 DSM-5 No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria
15 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
16 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
17 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
18 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
19 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
20 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
21 No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
22 What are the clinical implications? DSM committees are committed to enhancing clinical utility, i.e. the ability to: Communicate between clinicians, clients, families etc. select effective interventions predict course, prognosis and future management needs differentiate disorder from non-disorder for the purposes of determining who might benefit from treatment
23 Non-convertors versus Convertors No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
24 Non-convertors versus Convertors Symptoms DSM-IV orphans who remain noncases (n=939) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Tolerance 24.0% 46.6% 2.8** ( ) Withdrawal 3.1% 7.0% 2.3* ( ) Larger 38.9% 67.0% 3.2** ( ) Cut down 29.4% 55.5% 3.0** ( ) Time spent 0.9% 3.8% 4.5* ( ) Give up 0.4% 0.9% 2.1 ( ) Continue 3.3% 12.1% 4.1** ( ) * p<0.05 ** p<0.001
25 Non-convertors versus Convertors Symptoms DSM-IV orphans who remain noncases (n=939) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Tolerance 24.0% 46.6% 2.8** ( ) Withdrawal 3.1% 7.0% 2.3* ( ) Larger 38.9% 67.0% 3.2** ( ) Cut down 29.4% 55.5% 3.0** ( ) Time spent 0.9% 3.8% 4.5* ( ) Give up 0.4% 0.9% 2.1 ( ) Continue * p< % 12.1% 4.1** ( ) ** p<0.001
26 Non-convertors versus Convertors Clinical characteristics DSM-IV orphans who remain noncases (n=939) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Weekly drinking 77.7% 83.6% 1.5* ( ) Risky drinking (5+) 32.4% 44.1% 1.6* ( ) Used services 10.5% 17.1% 1.8* ( ) Suicidal ideation (LT) 12.8% 14.9% 1.2 ( ) 1+ days out of role 30.2% 33.5% 1.2 ( ) High K10 (22+) 7.7% 12.2% 1.7* ( ) Comorbid mood dis. 6.3% 10.4% 1.7* ( ) Comorbid anxiety dis. 7.9% 11.0% 1.4 ( ) Comorbid drug dis. 4.2% 6.2% 1.5 ( ) * p<0.05 ** p<0.001
27 Non-convertors versus Convertors Clinical characteristics DSM-IV orphans who remain noncases (n=939) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Weekly drinking 77.7% 83.6% 1.5* ( ) Risky drinking (5+) 32.4% 44.1% 1.6* ( ) Used services 10.5% 17.1% 1.8* ( ) Suicidal ideation (LT) 12.8% 14.9% 1.2 ( ) 1+ days out of role 30.2% 33.5% 1.2 ( ) High K10 (22+) 7.7% 12.2% 1.7* ( ) Comorbid mood dis. 6.3% 10.4% 1.7* ( ) Comorbid anxiety dis. 7.9% 11.0% 1.4 ( ) Comorbid drug dis. 4.2% 6.2% 1.5 ( ) * p<0.05 ** p<0.001
28 Existing cases versus Convertors No criteria Diagnostic Orphans* DSM-IV Abuse Dependence Total DSM-5 n % # n % # n % # n % # n No criteria One criterion Moderate AUD (2-3 criteria) Severe AUD (4+ criteria) Total * Defined as individuals who endorse at least one but no more than two DSM-IV dependence criteria and no abuse criteria # Percentages represent weighted prevalence of each DSM-5 diagnostic sub-group amongst those individuals in each DSM-IV diagnostic sub-group
29 Existing cases versus Convertors Symptoms DSM-IV cases who remain DSM-5 cases (n=249) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Tolerance 54.0% 46.6% 0.8 ( ) Withdrawal 13.6% 7.0% 0.5* ( ) Larger 78.6% 67.0% 0.6* ( ) Cut down 52.4% 55.5% 1.1 ( ) Time spent 9.5% 3.8% 0.4* ( ) Give up 0.7% 0.9% 1.3 ( ) Continue 18.8% 12.1% 0.6* ( ) * p<0.05 ** p<0.001
30 Existing cases versus Convertors Symptoms DSM-IV cases who remain DSM-5 cases (n=249) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Tolerance 54.0% 46.6% 0.8 ( ) Withdrawal 13.6% 7.0% 0.5* ( ) Larger 78.6% 67.0% 0.6* ( ) Cut down 52.4% 55.5% 1.1 ( ) Time spent 9.5% 3.8% 0.4* ( ) Give up 0.7% 0.9% 1.3 ( ) Continue 18.8% 12.1% 0.6* ( ) * p<0.05 ** p<0.001
31 Existing cases versus Convertors Clinical characteristics DSM-IV cases who remain DSM-5 cases (n=249) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Weekly drinking 85.5% 83.6% 0.9 ( ) Risky drinking (5+) 44.7% 44.1% 1.0 ( ) Used services 15.6% 17.1% 1.1 ( ) Suicidal ideation (LT) 13.9% 14.9% 1.1 ( ) 1+ days out of role 37.3% 33.5% 0.8 ( ) High K10 (22+) 15.9% 12.2% 0.7 ( ) Comorbid mood dis. 12.1% 10.4% 0.8 ( ) Comorbid anxiety dis. 11.6% 11.0% 0.9 ( ) Comorbid drug dis. 14.0% 6.2% 0.4* ( ) * p<0.05 ** p<0.001
32 Existing cases versus Convertors Clinical characteristics DSM-IV cases who remain DSM-5 cases (n=249) DSM-IV orphans who convert to DSM-5 cases (n=464) OR (95%CI) Weekly drinking 85.5% 83.6% 0.9 ( ) Risky drinking (5+) 44.7% 44.1% 1.0 ( ) Used services 15.6% 17.1% 1.1 ( ) Suicidal ideation (LT) 13.9% 14.9% 1.1 ( ) 1+ days out of role 37.3% 33.5% 0.8 ( ) High K10 (22+) 15.9% 12.2% 0.7 ( ) Comorbid mood dis. 12.1% 10.4% 0.8 ( ) Comorbid anxiety dis. 11.6% 11.0% 0.9 ( ) Comorbid drug dis. 14.0% 6.2% 0.4* ( ) * p<0.05 ** p<0.001
33 Summary of findings The prevalence of alcohol use disorder would increase by 62% with the proposed DSM-5 criteria This increase is mostly accounted for by DSM-IV diagnostic orphans converting to DSM-5 moderate AUD However, the new DSM-5 cases are more like existing cases and less like non-cases
34 Conclusions The proposed threshold for DSM-5 alcohol use disorders may be set too low This raises doubts about the sensitivity and specificity of the new diagnosis Diagnosis versus need for treatment?
35 Acknowledgements Thanks to Louise Mewton for helping with data analysis This was funded in part by NHMRC project grant (no ) Tim Slade, p: , e:
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