Diagnosis & Assessment of Alcohol Dependence 2006 RSA Lecture Series

1. Diagnosis & Assessment of Alcohol Dependence2006 RSA Lecture Series Deborah Hasin, Ph.D. Columbia University New York State Psychiatric Institute

2. Importance to different types of research • Treatment: inclusion and exclusion criteria for studies of behavioral & pharmacological interventions • Etiologic: phenotypes in genetic studies, defines case and control groups in other studies • Epidemiology: defines conditions to determine rates in populations and subgroups • Policy: determines & documents services needs

3. Importance of diagnosis and assessment in treatment • Formulation of treatment plans • Facilitates communication between clinicians • Teaching tool • Justifies third-party payment

4. DSM-IV/V importance in treatment • Formulation of treatment plans • Communication between clinicians with different training or experience • Justifying 3rd party payment • Teaching and training

5. Before “Alcohol Dependence…” • Ongoing debate over “alcoholism” vs. “alcohol problems” • 12-step(AA) philosophy vs. social science vs. psychoanalysis • Little conceptual agreement • Assessments not standardized

6. Isn’t “alcoholism” obvious? Don’t you “know one when you see one?” Not necessarily… • Concepts of what constitutes an alcohol disorder vary by culture, training, and personal experience • Non-standardized assessments yield inconsistent coverage • Variation in concepts and coverage lead to poor reliability (agreement) and validity

7. What is reliability? • Reliability: between-rater agreement on presence, absence, or level of a diagnosis • Joint rating design sometimes used • Test-retest more common, informative design • Reliability coefficients • Kappa (K) most common for binary diagnoses • Intraclass correlation coefficient (ICC) most common for continuous • Interpretation: > .75 excellent, .60 - .74 good, .40 - .59 fair, <.40 poor

8. What is validity? • This indicates that the condition (diagnosis) being measured is the condition of interest and not something else • No single “validity coefficient” or “gold standard” • Validity of diagnosis often indicated by comparison to more authoritative evaluation • Single biological indicators for alcohol dependence or abuse do not exist • Usual design compares diagnosis to expert judgment based on longitudinal course, family history, multiple informants, etc.

9. The need for good reliability and validityled (in steps) to DSM-IV • Concern over inconsistent concepts of psychiatric disorders led to specific diagnostic criteria • Concern over inconsistent and incomplete assessment led to standardized diagnostic interviews

10. Alcohol Dependence Syndrome(Edwards and Gross, 1976) • Dependence concept based on close observation of patients • The concept: a combination of physiological and psychological processes • Dimensional rather than yes or no • Bi-axial distinction of core alcohol dependence syndrome from its consequences the basis for dependence/abuse

11. DSM-IV Alcohol Dependence Maladaptive drinking leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period: • Drinking more or longer than intended • Persistent desire or unsuccessful efforts to cut down or stop • A great deal of time spent on drinking or getting over its effects • Important activities given up or reduced because of drinking • Continued drinking despite knowledge of a serious physical or psychological problem • Tolerance • Withdrawal, or drinking to avoid or relieve drinking

12. DSM-IV Alcohol Dependence – Physiological subtype • Includes tolerance and/or withdrawal • DSM-IV withdrawal criteria: cessation/reduction in heavy, prolonged use & within several hours to a few days • 2 or more withdrawal symptoms, including: • Autonomic hyperactivity (sweating or rapid pulse) • Hand tremor • Insomnia • Nausea or vomiting • Transient hallucinations or illusions • Psychomotor agitation • Anxiety • Seizures

13. DSM-IV Alcohol Abuse Not dependent, and maladaptive drinking leading to clinically significant impairment or distress, shown by 1 + of the following: • Continued use despite social/interpersonal problems • Hazardous use (e.g., driving when impaired by alcohol) • Frequent drinking leading to failure to function in major roles • Legal problems

14. DSM-III-R, DSM-IV, ICD-10 DSM-III-R Dependence: 3 out of 9 Criteria Abuse: 1 out of 2 Criteria, no dependence ICD-10 Dependence: 3 out of 6 Criteria Harmful use: Mental, physical, social harm to user, no dependence DSM-IV Dependence: 3 out of 7 Criteria Abuse: 1 out of 4 Criteria, no dependence

15. Reliability and validity evidence Although developed in patient samples: • DSM-III-R, DSM-IV and ICD-10 alcohol dependence highly reliable in general population, medical and other populations in the U.S. and elsewhere • Dependence valid in many designs • Reliability and validity less consistent for abuse • Abuse criteria themselves fairly reliable • When diagnosed “hierarchically” as required in DSM-IV, reliability is lower

16. How diagnostic criteria ascertained in different types of assessments • Fully structured: close-ended questions read to participants exactly as worded. Usually more than one question (“item”) per diagnostic criterion. • Semi-structured: initial questions provided, but interviewer expected to ask additional questions to clarify responses • Unstructured: interviewers ask their own questions to determine diagnostic criteria

17. Structured Clinical Interview for DSM-IV (SCID)Williams et al., Arch Gen Psychiatry 1992 • Designed for clinicians, often administered by research assistants • Reliance on clinical judgment for many ratings • Reliability of alcohol abuse/dependence: excellent, validity good (Kranzler et al., 1996) • Used mainly in clinical studies to determine inclusion, • exclusion criteria • Semi-structured: initial questions included, interviewer then • adds own probes if more information needed • Major Axis I disorders, SCID-II for Axis II disorders

18. Psychiatric Research Interview for Substance & Mental Disorder (PRISM)Hasin et al., Am J Psychiatry 1996; 2006 • Mainly clinical studies where differentiating primary and substance-induced psychiatric disorders important • Semi-structured • Major Axis I disorders, Antisocial and Borderline PD • Designed for clinicians or research assistants • Specified guidelines provided for most ratings • Test-retest reliability of DSM-IV alcohol dependence excellent, alcohol abuse fair (non-hierarchical, excellent)

19. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2001-2002 • National sample • N= 43,093 • NIAAA & NIDA sponsored • Household, group residents • Oversampled Blacks, Hispanics, adults 18-24 yrs • DSM-IV diagnoses

20. Alcohol Use Disorders and Associated Disabilities Interview Schedule(AUDADIS)Grant et al., Drug Alcohol Depend 1995; 2003 • Used mainly in large-scale epidemiologic studies • Fully structured • Designed for lay interviewers • Major Axis I disorders, Axis II disorders • Test-retest reliability of DSM-IV alcohol abuse/dependence excellent • Validity excellent via psychiatrist re-appraisal and other designs

21. Semi-Structured Assessment for the Genetics of Alcoholism(SSAGA) Bucholz et al., J Stud Alcohol 1994; 2006 • Mainly used in genetics studies • Semi-structured • Major Axis I disorders, Antisocial PD • Designed for non-clinicians with supervision from an editor • Test-retest reliability of DSM-IV alcohol dependence excellent, alcohol abuse fair to very good

22. National Comorbidity Study – Replication (NCS-R) 2001-2002 • National sample • N= 9,282 • NIMH sponsored • Household participants 18+yrs • DSM-IV diagnoses • WHO-CIDI

23. The Composite International Diagnostic Interview (CIDI) • Used mainly in epidemiologic and clinical studies • Fully structured, designed for lay interviewers • Early versions such as CIDI-SAM (substance abuse module) similar to other interviews • Recent versions (NCS-R, WMH Survey) skipped dependence questions in respondents with no abuse symptoms • Agreement with SCID for alcohol dependence fair

24. NESARC findings, current dependence with and without abuse – alcoholHasin et al., Arch Gen Psychiatry, 2004

25. NESARC findings, lifetime dependence with and without abuse – alcoholHasin et al., Arch Gen Psychiatry, 2005

26. Designs for Validity Research • Longitudinal – course stays “true” over time, and/or is consistent with theoretical prediction • Multi-method comparison – methods agree because they measure a consistent underlying construct • Construct – Conditions associated (or not) with external variables in theoretically predicted patterns • Factor/latent class analysis – criteria cluster in theoretically predicted patterns

27. Longitudinal course:Dependence and Abuse distinctly different • Hasin et al.NationalAm J Psychiatry 1990 • Hasin et al.Community heavy J Subst Abuse 1997 drinkers • Grant et al.National J Subst Abuse 2001 • Schuckit et al.UCSD male Am J Psychiatry 2000 volunteers • Schuckit et al.COGA Am J Psychiatry 2001

28. Multi-Method ComparisonDependence: ExcellentAbuse hierarchical: LowAbuse non-hierarchical: Better* • Rounsaville et al. Clinical Addiction 1993 • Schuckit et al. COGA Addiction 1994 • Hasin et al. Community * Addiction 1996 • Grant National Alch Clin Exp Res 1996 • Hasin et al.WHO Int’l Drug Alch Depend 1997 • Pull et al. WHO Int’l * Drug Alch Depend 1997 • Cottler et al. WHO Int’l * Drug Alch Depend 1997

29. Construct Validation: DependenceDrinkers from a community and national sample

30. Construct Validation: AbuseCommunity Heavy Drinkers and NLAES drinkers

31. Factor analyses:Dependence and Abuse • Harford, MuthenU.S. national, NLSY 2 factors • Muthen et al.U.S. national, NHIS 2 factors • Proudfoot et al.Australian, National 1 factor • Saha et al.U.S. NESARC 1 factor

32. DSM-V issues concerning dependence • Alcohol dependence is a highly reliable, valid alcohol diagnosis, however: • Should a severity indicator of dependence be added, as has been used in small-sample/low-frequency genetics studies (Hasin et al., 2002; Heath et al., 2001)? • Should drinking level be added as a criterion or as an extra requirement, e.g., Project COMBINE? (Anton et al., 2006) • Can biological endophenotypes be identified that would aid in the diagnosis, e.g., the COGA study? (Hesselbrock et al., 2001; Edenberg et al., 2004) • Can the relationship of substance and psychiatric disorders be specified better than the current primary/substance-induced differentiation?

33. DSM-V issues concerning abuse • Alcohol abuse is less clear • Keep abuse as it is now? • Diagnose it independently from dependence? • Add a severity indicator? • Combine abuse and dependence criteria? • Rename? • Drop category entirely?

34. Clinical assessment and diagnosis • NIAAA Clinician’s Guide • http://pubs.niaaa.nih.gov/publications/ Practitioner/CliniciansGuide2005/guide.pdf

38. Acknowledgements • K05 AA014223, R01 AA008159, AA008910, DA008409DA010919 DA018652 • New York State Psychiatric Institute • Presentation: Valerie Richmond, M.A. • Contact: dsh2@columbia.edu