A five-year prospective study of diagnostic orphans for alcohol use disorders

Substance use and addictive disorders in DSM-5 and ICD 10 and the draft ICD 11

PURPOSE OF REVIEW

The present review compares and contrasts the diagnostic entities and taxonomy of substance use and addictive disorders in the beta draft of the Eleventh Revision of the International Classification of Diseases (ICD 11), which was released in November 2016, and the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published in mid-2013. Recently published papers relevant to these two classification systems are examined. New initiatives in diagnosis and assessment including the addictions neuroclinical assessment are noted.

RECENT FINDINGS

The draft ICD 11 retains substance dependence as the 'master diagnosis' in contrast to the broader and heterogeneous concept of substance use disorder in DSM-5 and there is empirical support for the coherence of substance dependence for alcohol, cannabis, and prescribed opioids. Both systems now include gambling disorder in the addictive disorders section, with it being transferred from the impulse control disorders section. The new diagnosis of Internet gaming disorder is included in DSM-5 as a condition for further study, and gaming disorder is grouped with the substance and gambling disorders in the draft ICD 11. Initiatives from the U.S. National Institutes of Health (NIH) are highlighting the importance of capturing the neurobiological phases of the addictive cycle in clinical diagnosis and assessment.

SUMMARY

Although most of the changes in the draft ICD 11 and DSM-5 are incremental, the contrast between DSM-5 substance use disorder and substance dependence in the draft ICD 11, and the inclusion of gambling disorder and gaming disorder will generate much discussion and research.

An Online Intervention for Co-Occurring Depression and Problematic Alcohol Use in Young People: Primary Outcomes From a Randomized Controlled Trial

BACKGROUND

Depression and problematic alcohol use represent two of the major causes of disease burden in young adults. These conditions frequently co-occur and this is associated with increased harm and poorer outcomes than either disorder in isolation. Integrated treatments have been shown to be effective; however, there remains a significant gap between those in need of treatment and those receiving it. The increased availability of eHealth programs presents a unique opportunity to treat these conditions.

OBJECTIVE

This study aimed to evaluate the feasibility and preliminary efficacy of an automated Web-based self-help intervention (DEAL Project) in treating co-occurring depressive symptoms and problematic alcohol use in young people.

METHODS

Young people (aged 18 to 25 years) with moderate depression symptoms and drinking at hazardous levels (recruited largely via social media) were randomly allocated to the DEAL Project (n=60) or a Web-based attention-control condition (HealthWatch; n=44). The trial consisted of a 4-week intervention phase with follow-up assessment at posttreatment and at 3 and 6 months postbaseline. The primary outcomes were change in depression severity according to the Patient Health Questionnaire-9 as well as quantity and frequency of alcohol use (TOT-AL).

RESULTS

The DEAL Project was associated with statistically significant improvement in depression symptom severity (d=0.71) and reductions in alcohol use quantity (d=0.99) and frequency (d=0.76) in the short term compared to the control group. At 6-month follow-up, the improvements in the intervention group were maintained; however, the differences between the intervention and control groups were no longer statistically significant, such that between-group effects were in the small to moderate range at 6 months (depression symptoms: d=0.39; alcohol quantity: d=-0.09; alcohol frequency: d=0.24).

CONCLUSIONS

Overall, the DEAL Project was associated with more rapid improvement in both depression symptoms and alcohol use outcomes in young people with these co-occurring conditions relative to an attention-control condition. However, long-term outcomes are less clear.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000033741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363461 (Archived by WebCite at http://www.webcitation.org/6fpsLEGOy).

College students who endorse a sub-threshold number of DSM-5 alcohol use disorder criteria: alcohol, tobacco, and illicit drug use in DSM-5 diagnostic orphans

OBJECTIVES

Diagnostic orphans (DOs) represent a group of individuals with no formal diagnosis, despite endorsing some criteria of an alcohol use disorder (AUD). Prior research has indicated that rates of DSM-IV DOs in college are high and closely resemble those with an alcohol abuse diagnosis across pertinent alcohol use risk factors. However, significant changes to the DSM-IV AUD criteria have been made for the current DSM-5 manual, which may impact how DOs are classified. This study examined the unique alcohol and illicit drug use characteristics of a group of 2,620 DSM-5 DOs in college and tested whether DOs differed from those with and without a DSM-5 AUD across pertinent alcohol and drug use risk factors.

METHODS

Participants were 2,620 DSM-5 DO undergraduate college students, between the ages of 18 and 30, recruited from three public universities in the Southeastern, United States.

RESULTS

Diagnostic orphans represented 19.6% (n = 506) of the sample; with the most frequently endorsed criteria being tolerance and consuming alcohol in hazardous situations. DOs reported significantly greater alcohol consumption, alcohol and drug related problems, and illicit drug use compared to those with no DSM-5 AUD diagnosis. Alternatively, DOs reported significantly lower alcohol use and illicit drug use compared to those with a DSM-5 AUD.

CONCLUSION

The present findings indicate that DSM-5 DOs in college represent a distinct group of drinkers relative to those with and without a DSM-5 AUD. Current screening initiatives should target this group to prevent future escalation of problem drinking.

Drinking correlates of DSM-IV alcohol use disorder diagnostic orphans in college students

One major limitation of the DSM-IV criteria for alcohol abuse and dependence is that a cluster of individuals who endorse a subthreshold number of dependence criteria and no abuse criteria do not receive a formal diagnosis; despite elevated risk for alcohol-related problems relative to those with an abuse diagnosis. These individuals have been referred to as diagnostic orphans. The primary aim of this study was to examine alcohol use correlates of a group of diagnostic orphans in a sample of 396 nontreatment seeking college students who reported drinking on at least one occasion in the last 90 days. DSM-IV criteria were assessed using a modified version of the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). Diagnostic orphans represented 34.1% (n = 135) of the original sample who did not receive a formal diagnosis; with the most frequently endorsed dependence criteria being tolerance and drinking larger/longer amounts than intended. Diagnostic orphans reported a range of alcohol-related negative consequences and reported greater frequencies of social and enhancement drinking motives in comparison to coping motives. They were similar to alcohol abusers and dissimilar to those with dependence or those without a diagnosis on alcohol consumption, alcohol problem severity, drinking motives and restraint variables. The present findings indicate that diagnostic orphans in college students represent a distinct group of drinkers who may be at risk for the development of alcohol use disorders and may be in need of intervention, given their similarity to those with an abuse diagnosis. Prevention and intervention efforts across college campuses should target this group to prevent escalation of alcohol problem severity.

The role of ANKK1 and TTC12 genes on drinking behaviour in tobacco dependent subjects

OBJECTIVES

Alcohol use disorders (AUD) act as a risk factor for smoking relapse, and tobacco dependent (TD) subjects with comorbid AUD experience more withdrawal symptoms compared to TD subjects without AUD or other psychiatric comorbidities. Our aim was to investigate whether drinking behaviour in the past 12 months and smoking relapse due to alcohol use in TD subjects was associated with polymorphisms flanking the TTC12/ANKK1/DRD2 region since associations have been found between these genes and AUD and TD as separate disorders.

METHODS

380 TD subjects were assessed for alcohol use and relapse to smoking. Subjects were genotyped for polymorphisms located in the TTC12/ANKK1/DRD2 region.

RESULTS

Associations were found between ANKK1 haplotype rs4938015C_rs11604671A and age of onset of daily smoking, as well as with hazardous drinking. No genetic association was found with smoking relapse due to alcohol consumption.

CONCLUSIONS

Our findings suggest that TD subjects who present earlier age at onset and carry this haplotype may have a higher risk for developing an alcohol use disorder.

The epidemiology of alcohol use disorders and subthreshold dependence in a middle-aged and elderly community sample

OBJECTIVE

To estimate 1-year prevalence and correlates of alcohol abuse, dependence, and subthreshold dependence (diagnostic orphans) among middle-aged and elderly persons in the United States.

DESIGN

2005-2007 National Surveys on Drug Use and Health.

METHOD

Sample included 10,015 respondents aged 50-64 years and 6,289 respondents older than 65 years. Data were analyzed by bivariate and multinomial regression analyses.

MEASUREMENTS

Sociodemographic variables; alcohol use; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition abuse and dependence; major depression; nicotine dependence; illicit drug use; and nonmedical use of prescription drugs.

RESULTS

Fifty-one percent of the sample used alcohol during the past year (56% in the 50-64 age group and 43% in the older than 65 age group). Overall, 11% (dependence 1.9%, abuse 2.3%, and subthreshold dependence 7.0%) of adults aged 50-64 and about 6.7% (dependence 0.6%, abuse 0.9%, and subthreshold dependence 5.2%) of those older than 65 reported alcohol abuse, dependence or dependence symptoms. Among past-year alcohol users, 20% (dependence 3.4%, abuse 4.0%, and subthreshold dependence 12.5%) of adults aged 50-64 and 15.4% (dependence 1.3%, abuse 2.1%, and subthreshold dependence 12.0%) of those older than 65 endorsed alcohol abuse or dependence symptoms. "Tolerance" (48%) and "time spent using" (37%) were the two symptoms most frequently endorsed by the subthreshold group. Compared with alcohol users without alcohol abuse or dependence symptoms, blacks or Hispanics and those who had nicotine dependence or used nonmedical prescription drugs had increased odds of subthreshold dependence. Diagnostic orphans also were more likely to engage in binge drinking than the asymptomatic group.

CONCLUSIONS

Diagnostic orphans among middle-aged and elderly community adults show an elevated rate for binge drinking and nonmedical use of prescription drugs that require attention from healthcare providers.

Ten-year trends (1992 to 2002) in sociodemographic predictors and indicators of alcohol abuse and dependence among whites, blacks, and Hispanics in the United States

BACKGROUND

The objective of this paper is to examine 10-year trends (1992 to 2002) in the number and type of indicators of DSM-IV abuse and dependence among whites, blacks, and Hispanics in the United States.

METHODS

Data are from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES; n = 42,862) and the 2001 to 2002 National Epidemiologic Study on Alcohol and Related Conditions (NESARC; n = 43,093). Both surveys used multistage cluster sample procedures to select respondents 18 years of age and older from the U.S. household population.

RESULTS

Increases in the prevalence of alcohol abuse between 1992 and 2002 seem associated with a rise in the prevalence of the indicator for "hazardous use." which usually means reports of driving after drinking. The decrease in dependence was not associated with changes in a particular indicator. In addition, both in 1992 and 2002, 12.3 to 15.4% of the men and 5.2 to 7.9% of the women were diagnostic "orphans." These respondents reported 1 or 2 indicators of alcohol dependence as present.

CONCLUSIONS

The observed trends in number and types of indicators of DSM-IV alcohol abuse and dependence were probably triggered by a complex interplay between individuals' volume and pattern of drinking and reactions from the drinkers' social environment. The close association between hazardous use of alcohol and the prevalence of abuse deserves further discussion. A medical diagnostic category should not be so dependent on a criterion that may be influenced by social situations. It is necessary to understand more about diagnostic "orphans" to better design interventions to address their problems.

Chronology of alcohol dependence: implications in prevention

Background:

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us design strategies for the prevention for ADS, which aims at reducing the occurrence of ADS.

Objective:

To study the age-wise and order-wise chronologies of ICD-10 (DCR) dependence criteria in individuals with ADS.

Materials and Methods:

Consecutively admitted and consenting inpatients with ICD-10 (DCR) diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II.

Results:

The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion and International Statistical Classification of Diseases and Related Health Problems 10^th Revision (ICD-10) dependence was 18.72 years (SD, 6.84), 24.33 years (SD, 9.21) and 27.51 years (SD, 9.28), respectively. In age-wise chronology, tolerance, loss of control and craving were present in 97.53%, 80.24% and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%) or loss of control (18.5%) was observed in the first criterion in 55.5% of the subjects.

Conclusions:

Knowledge of chronology, its frequencies and time duration between various milestones in the development of the dependence criteria may enable the selection of the target population at an early stage. The pattern of development of dependence may provide us with an opportunity for interventions to reduce the incidence of ADS, as a step toward primary prevention. Adequate training of the primary care personnel and early psychiatric referral may help in the reduction in the incidence of ADS.

Prevention of alcohol dependence: strategies for selective, indicated, and universal prevention

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us to design strategies for the prevention for ADS, which takes into account primary prevention (indicated, selective, and universal prevention) approaches and aims at reducing the occurrence of ADS. The objective of this work is to study the age-wise and order-wise chronologies of International Classification of Diseases Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR) dependence criteria in individuals with ADS. Consecutively admitted and consenting inpatients with ICD-10 DCR diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion, and ICD-10 dependence was 18.72 years (SD: 6.84), 24.33 years (SD: 9.21), and 27.51 years (SD: 9.28), respectively. In age-wise chronology, tolerance, loss of control, and craving were present in 97.53%, 80.24%, and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%), or loss of control (18.5%) was observed as the first criterion in 55.5% of the subjects. Indicated prevention may be attempted by enquiring about craving, tolerance, and loss of control and use of anticraving medications or behavioral strategies. Selective prevention by using naltrexone for those genetically inclined and universal prevention by use of "clinical" labeling on alcoholic beverages can also be attempted.

Are subthreshold alcohol dependence symptoms a risk factor for developing DSM-IV alcohol use disorders? A three-year prospective study of 'diagnostic orphans' in a national sample

AIMS

Research suggests that diagnostic orphans (i.e., individuals experiencing only 1-2 criteria for DSM-IV alcohol dependence) may be at increased risk for developing more severe alcohol problems. This study aimed to: (i) investigate the course of diagnostic orphans in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and (ii) explore whether a specific symptom endorsement pattern(s) could identify diagnostic orphans at Wave 1 who remitted or progressed to alcohol dependence at Wave 2.

METHODS

Current drinkers (n = 15,751) were divided into diagnostic groups at Waves 1 and 2: no-alcohol use disorder (AUD); one-criterion orphans, two-criterion orphans, alcohol abuse, or alcohol dependence. Multinomial logistic regression analysis explored the association between diagnostic status at Wave 1 and Wave 2. Chi-square tests investigated differences in the criteria endorsement patterns of diagnostic orphans.

RESULTS

Compared to the no-AUD group, one-criterion orphans at Wave 1 were twice as likely to be in the abuse group and four times more likely to be dependent at Wave 2. Two-criterion orphans were three times more likely to be in the abuse group and eight times more likely to have progressed to dependence. Criterion endorsement patterns of diagnostic orphans at baseline did not significantly differentiate between those who remitted and those who progressed to dependence at follow-up.

CONCLUSIONS

Like previous research, diagnostic orphans are at increased for developing to more severe alcohol problems. Relying solely on the DSM-IV AUD diagnostic criteria, however, may not be sufficient to identify those diagnostic orphans who are at risk for progressing to dependence.

The five-year diagnostic utility of "diagnostic orphans" for alcohol use disorders in a national sample of young adults

OBJECTIVE

This study was conducted to assess the association of "diagnostic orphans" at baseline and subsequent development of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol use disorders (AUDs) 5 years later.

METHOD

A sample of 8,534 respondents was drawn from the National Longitudinal Survey of Youth for the years 1989 and 1994. Diagnostic orphans were defined as respondents who met one or two alcohol dependence symptom criteria but did not meet the criteria for a diagnosis of alcohol abuse or dependence. Using multinomial logistic regression analysis, 1994 assessments of DSM-IV AUD were regressed on 1989 baseline assessments of diagnostic orphan status and DSM-IV AUD. In addition to demographic characteristics, other background variables included heavy episodic drinking at baseline and early problem behaviors (antisocial behaviors, illicit substance use, and age at onset of alcohol use).

RESULTS

Findings from this 5-year prospective study indicate that diagnostic orphan status at baseline was predictive of DSM-IV AUD at follow-up. These associations remained significant when other early behavioral problems were included in the models.

CONCLUSIONS

The present findings have important diagnostic implications for the proposed DSM-V, particularly for a dimensional diagnosis incorporating less severe forms of alcohol dependence.

Why do we Need to Control Alcohol Use Through Legislative Measures? A South East Asia Perspective?

BACKGROUND

Even though prevalence of alcohol use in the world is very high, it has not been brought under legal control in several countries, contrary to other controlled substances like opium, cocaine, cannabis, and so on.

AIM

To demonstrate the similarities in both alcohol and opioid dependence by comparing and contrasting the course of clinical dependence for both substances.

PATIENTS AND METHODS

Consecutively admitted patients during the period August 2005 to May 2006, in the Center for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India, with ICD-10 (DCR) diagnosis of alcohol dependence syndrome or opioid dependence syndrome were recruited for the study and administered the alcohol or other drug (opioid) section of SSAGA-II, respectively, and the data was entered in the corresponding tally sheet.

RESULTS

The total sample size was 150, of which 112 consented to participate. Eighty-one (72%) were alcohol-dependent and 31 (28%) were opioid-dependent. Mean ages of the patients of alcohol dependence for opioid dependence was 35.16 +/- 10.2 compared to 26.09 +/- 5.65. Mean age of onset of alcohol and opioid use were similar (18.72 +/- 6.84 and 20.73 +/- 3.93 years, respectively). Patterns of dependence were also similar for both substances, from the first criteria to dependence (0.49 years for alcohol versus 0.64 years for opioids), and from the appearance of the second criteria to dependence (0.24 years versus 0.28 years).

CONCLUSION

This study recommends alcohol to be treated on par with opioids and calls for legislations for the control of alcohol, uniformly, across the world, as a public health policy, on the lines of the Framework Convention for Tobacco Control.

Hallucinogen-related disorders in a national sample of adolescents: the influence of ecstasy/MDMA use

AIMS

To present the prevalence and correlates of hallucinogen use disorders (HUDs: abuse or dependence) and subthreshold dependence.

METHODS

The study sample included adolescents aged 12-17 years (N=55,286) who participated in the National Survey on Drug Use and Health (2004-2006). Data were collected with a combination of computer-assisted personal interviewing and audio computer-assisted self-interviewing.

RESULTS

The overall prevalence of HUDs among adolescents was low (<1%). However, more than one in three (38.5%) MDMA users and nearly one in four (24.1%) users of other hallucinogens reported HUD symptoms. MDMA users were more likely than users of other hallucinogens to meet criteria for hallucinogen dependence: 11% (95% confidence interval [CI]: 8.24-14.81) vs. 3.5% (95% CI: 2.22-5.43). Compared with hallucinogen use only, subthreshold dependence was associated with being female (adjusted odds ratio [AOR]=1.8 [95% CI: 1.08-2.89]), ages 12-13 years (AOR=3.4 [1.64-7.09]), use of hallucinogens > or = 52 days (AOR=2.4 [1.66-6.92]), and alcohol use disorder (AOR=1.8 [1.21-2.77]). Compared with subthreshold dependence, abuse was associated with mental health service use (AOR=1.7 [1.00-3.00]) and opioid use disorder (AOR=4.9 [1.99-12.12]); dependence was associated with MDMA use (AOR=2.2 [1.05-4.77]), mental health service use (AOR=2.9 [1.34-6.06]), and opioid use disorder (AOR=2.6 [1.01-6.90]). MDMA users had a higher prevalence of most other substance use disorders than users of non-hallucinogen drugs.

CONCLUSIONS

Adolescent MDMA users appear to be particularly at risk for exhibiting hallucinogen dependence and other substance use disorders.

Characteristics of DSM-IV alcohol diagnostic orphans: drinking patterns, physical illness, and negative life events

BACKGROUND

Interest in subthreshold psychiatric disorders has increased recently. Diagnostic orphans experience one to two criteria of alcohol dependence but do not meet the diagnostic criteria for a DSM-IV alcohol use disorder (AUD). This study investigated the impact of subthreshold alcohol symptoms on three domains: physical illness, drinking patterns, and the occurrence of negative life events.

METHOD

Current drinkers (n=26,946) in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were divided into five diagnosis groups: no-AUD; one-criterion orphans (reference group), two-criterion orphans, alcohol abuse, and alcohol dependence. Exploratory factor analysis examined the factor structure of items in the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS-IV) relating to each life domains. Factors were related to the diagnosis groups and background covariates using latent variable modeling.

RESULTS

One-criterion orphans did not differ from the other groups with regards to physical illness. One- and two-criterion orphans differed significantly in relation to drinking patterns, with the latter group engaging in hazardous drinking behaviours more frequently. The dependence group were more likely to experience higher estimates of social problems compared to one-criterion orphans. One-criterion orphans were more likely than the abuse group to experience financial problems but less likely than the dependence group to experience family-related legal problems.

CONCLUSIONS

Diagnostic orphans were more impaired than those with no-AUD or alcohol abuse in specific life domains; however, diagnostic orphans were significantly less impaired than those with alcohol dependence. Diagnostic orphans may be an important group for early case identification and intervention.

How should we revise diagnostic criteria for substance use disorders in the DSM-V?

This article reviews literature on the validity and performance characteristics of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for substance use disorders (SUDs) and recommends changes in these criteria that should be considered for the next edition of the DSM (DSM-V). Substantial data indicate that DSM-IV substance abuse and substance dependence are not distinct categories and that SUD criteria are best modeled as reflecting a unidimensional continuum of substance-problem severity. The conceptually and empirically problematic substance abuse diagnosis should be abandoned in the DSM-V, with substance dependence defined by a single set of criteria. Data also indicate that various individual SUD criteria should be revised, dropped, or considered for inclusion in the DSM-V. The DSM-V should provide a framework that allows the integration of categorical and dimensional approaches to diagnosis. Important areas for further research are noted.

The prognostic implications of DSM-IV abuse criteria in drinking adolescents

BACKGROUND

The validity of the DSM-IV diagnostic criteria for alcohol abuse has been questioned, and additional issues have been raised regarding the performance of this label in adolescents. While future diagnostic manuals might alter the approach to abuse, it is worthwhile to evaluate the implications of the current definition that has been in place since 1994.

METHODS

Six hundred and sixteen 12-19-year-old subjects (mean 16.5 years) were offspring identified in the Collaborative Study on the Genetics of Alcoholism (COGA) protocol who had ever consumed a full drink and who were followed up 5 years later using age-appropriate semi-structured interviews. Following the guidelines for evaluating the utility of the diagnostic labels of Robins and Guze [Robins, E., Guze, S.B., 1970. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am. J. Psychiat. 126, 983-987], the subjects with alcohol abuse were compared with other groups regarding clinical validators and clinical course.

RESULTS

At initial interview, the pattern of most alcohol use and problem variables were least severe for teenagers with no diagnosis, intermediate for those with abuse, and the highest for individuals with alcohol dependence. At follow-up, 50% of those with initial abuse maintained that diagnosis, 19% developed dependence, and 31% had no DSM-IV diagnosis. Baseline alcohol abuse predicted follow-up diagnosis even when evaluated along with initial demographic and substance use characteristics.

CONCLUSIONS

These results support some assets for the DSM-IV alcohol abuse criteria in these adolescents, including indications of both cross-sectional and predictive validities. Additional studies will need to compare the current abuse label with other possible approaches.

Diagnostic orphans for alcohol use disorders in a treatment-seeking psychiatric sample

Individuals who endorse one or two of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criterion items for alcohol dependence but do not meet criteria for either alcohol abuse or dependence have been referred to in the literature as "diagnostic orphans." The goal of the present study is to compare diagnostic orphans for alcohol use disorders (AUD) to patients with lifetime DSM-IV alcohol abuse, alcohol dependence, and those with no-AUD symptoms on a series of demographic, diagnostic, and clinical measures. Participants were treatment-seeking psychiatric outpatients (n=1793; 61.5% women) who completed an in-depth, face-to-face diagnostic evaluation for DSM-IV axis I and axis II disorders. Results revealed that diagnostic orphans were younger, had a higher frequency of family history positive for alcoholism, and higher rates of cannabis dependence, as compared to the no-AUD symptoms group. Diagnostic orphans differed significantly from patients with alcohol abuse and dependence on a number of demographic, diagnostic, and clinical measures. Most notably, on a lifetime basis, diagnostic orphans were less likely to meet diagnostic criteria for various substance use disorders, as compared to individuals with alcohol abuse and dependence. Taken together, these results generally do not support combining diagnostic orphans to individuals with alcohol abuse.

Clinical implications of tolerance to alcohol in nondependent young drinkers

BACKGROUND

Ten percent of teenagers and young adults with no alcohol diagnosis and a third of those with alcohol abuse report tolerance to alcohol. However, relatively few data are available on the clinical implications of tolerance in nondependent men and women.

METHODS

Data were gathered from 649 18-to-22-year-old drinking offspring from the Collaborative Study on the Genetics of Alcoholism (COGA) families. The prevalence and clinical correlates of tolerance were evaluated across subjects with no DSM-IV alcohol abuse and no tolerance, similar individuals with tolerance, subjects with alcohol abuse but no tolerance, and individuals with both alcohol abuse and tolerance.

RESULTS

Tolerance was associated with an almost doubling of the number of drinks needed to feel alcohol's effects, and correlated with additional alcohol-related problems. In regression analyses, the most consistent and robust correlates of tolerance were the maximum number of drinks and alcohol problems, and tolerance remained informative after covarying for drinking quantity.

CONCLUSIONS

Tolerance to alcohol may be a useful concept regarding nondependent drinkers that is not just a proxy for alcohol quantity but also reflects the presence of additional problems.

Are diagnostic orphans at risk of developing cannabis abuse or dependence? Four-year follow-up of young adult cannabis users not meeting diagnostic criteria

OBJECTIVE

To examine the characteristics of "diagnostic orphans" among cannabis users - those who report one or two symptoms of DSM-IV dependence but do not meet diagnostic criteria for DSM-IV abuse or dependence - 4 years post-assessment.

METHOD

Data were collected from a representative population cohort of young Australian adults. Those who reported that they had used cannabis at least weekly at some point within the past year were assessed for symptoms of DSM-IV cannabis abuse and dependence using the Composite International Diagnostic Interview at age 20-21 years. The entire sample was followed up 4 years later. At age 24-25 years, cannabis use and cannabis diagnostic category were examined according to diagnostic category at age 20-21 years.

RESULTS

Diagnostic orphans at age 20-21 years were more likely than non-problem cannabis users at that age to be using cannabis, and to meet criteria for cannabis abuse or dependence 4 years later. Those who had met criteria for cannabis abuse or dependence, however, appeared to be at greater risk relative to non-problematic users and diagnostic orphans of meeting criteria for cannabis abuse and dependence at follow-up.

CONCLUSIONS

Young adult diagnostic orphans for cannabis use appear to be at lower risk of meeting full (or partial) diagnostic criteria after a 4-year follow-up, compared to those who had met criteria for cannabis abuse or dependence. This suggests that there is prognostic diagnostic utility in the threshold for dependence symptoms among young adult cannabis users. Diagnostic orphans did appear to be at greater risk than non-problem users for developing dependent and daily cannabis use, however, suggesting that clinicians would do well to intervene with this group.

Psychometric properties of DSM assessments of illicit drug abuse and dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

DSM-IV criteria for illicit drug abuse and dependence are largely based on criteria developed for alcohol use disorders and there is a lack of research evidence on the psychometric properties of these symptoms when applied to illicit drugs.

METHOD

This study utilizes data on abuse/dependence criteria for cannabis, cocaine, stimulants, sedatives, tranquilizers, opiates, hallucinogens and inhalants from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC, n=43 093). Analyses included factor analysis to explore the dimensionality of illicit drug abuse and dependence criteria, calculation of item difficulty and discrimination within an item response framework and a descriptive analysis of 'diagnostic orphans': individuals meeting criteria for 1-2 dependence symptoms but not abuse. Rates of psychiatric disorders were compared across groups.

RESULTS

Results favor a uni-dimensional construct for abuse/dependence on each of the eight drug classes. Factor loadings, item difficulty and discrimination were remarkably consistent across drug categories. For each drug category, between 29% and 51% of all individuals meeting criteria for at least one symptom did not receive a formal diagnosis of either abuse or dependence and were therefore classified as 'orphans'. Mean rates of disorder in these individuals suggested that illicit drug use disorders may be more adequately described along a spectrum of severity.

CONCLUSIONS

While there were remarkable similarities across categories of illicit drugs, consideration of item difficulty suggested that some alterations to DSM regarding the relevant severity of specific abuse and dependence criteria may be warranted.

Welfare receipt and substance-abuse treatment among low-income mothers: the impact of welfare reform

OBJECTIVES

We explored changing relations between substance use, welfare receipt, and substance-abuse treatment among low-income mothers before and after welfare reform.

METHODS

We examined annual data from mothers aged 18 to 49 years in the 1990-2001 National Household Survey of Drug Abuse and the 2002 National Survey of Drug Use and Health. Logistic regression was used to examine determinants of treatment receipt.

RESULTS

Among low-income, substance-using mothers, the proportion receiving cash assistance declined from 54% in 1996 to 38% in 2001. The decline was much smaller (37% to 31%) among low-income mothers who did not use illicit substances. Low-income, substance-using mothers who received cash assistance were much more likely than other low-income, substance-using mothers to receive treatment services. Among 2002 National Survey of Drug Use and Health respondents deemed "in need" of substance-abuse treatment, welfare recipients were significantly more likely than nonrecipients to receive such services (adjusted odds ratio=2.31; P<.05). Controlling for other factors, welfare receipt was associated with higher prevalence of illicit drug use. Such use declined among both welfare recipients and other mothers between 1990 and 2001.

CONCLUSIONS

Welfare is a major access point to identify and serve low-income mothers with substance-use disorders, but it reaches a smaller proportion of illicit drug users than it did prereform. Declining welfare receipt among low-income mothers with substance abuse disorders poses a new challenge in serving this population.

Substance dependence and non-dependence in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD): can an identical conceptualization be achieved?

BACKGROUND

This review summarizes the history of the development of diagnostic constructs that apply to repetitive substance use, and compares and contrasts the nature, psychometric performance and utility of the major diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) diagnostic systems.

METHODS

The available literature was reviewed with a particular focus on diagnostic concepts that are relevant for clinical and epidemiological practice, and so that research questions could be generated that might inform the development of the next generation of DSM and ICD diagnoses.

RESULTS

The substance dependence syndrome is a psychometrically robust and clinically useful construct, which applies to a range of psychoactive substances. The differences between the DSM fourth edition (DSM-IV) and the ICD tenth edition (ICD-10) versions are minimal and could be resolved. DSM-IV substance abuse performs moderately well but, being defined essentially by social criteria, may be culture-dependent. ICD-10 harmful substance use performs poorly as a diagnostic entity.

CONCLUSIONS

There are good prospects for resolving many of the differences between the DSM and ICD systems. A new non-dependence diagnosis is required. There would also be advantages in a subthreshold diagnosis of hazardous or risky substance use being incorporated into the two systems. Biomedical research can be drawn upon to define a psychophysiological 'driving force' which could underpin a broad spectrum of substance use disorders.

Stability and instability in alcohol diagnosis from ages 18 to 21 and ages 21 to 25 years

BACKGROUND

Only in recent years have longitudinal studies of adolescents diagnosed alcohol use disorders and these have not distinguished between abuse and dependence. This study describes the course of disorder from age 18 to age 25 for abuse and dependence and investigates the extent to which continuities in disorder can be explained by background factors.

METHODS

A birth cohort of 1,265 individuals from Christchurch, New Zealand, followed annually to age 16 years then at 18, 21 and 25 years (1,003 at age 25). DSM-IV diagnoses were made from reports of alcohol symptoms at 18, 21 and 25 years.

RESULTS

The most stable diagnosis was that of no diagnosis, with 83-91% staying the same from one interview to the next. There were high rates of remission to no disorder; 57-75% for those with initial abuse and 50-54% of those with initial dependence. Nonetheless prior diagnosis was a strong predictor of subsequent diagnosis (ORs of 3.7-27.6). Adjustment for background risk factors reduced these odds ratios but all remained significant and substantial (minimum 2.6).

CONCLUSIONS

The dual finding of substantial discontinuity and substantial continuity indicates that both public health and treatment interventions are warranted.

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.

Welfare reform and substance abuse

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed the nature, purpose, and financing of public aid. Researchers, administrators, and policymakers expressed special concern about the act's impact on low-income mothers with substance use disorders. Before PRWORA's passage, however, little was known about the true prevalence of these disorders among welfare recipients or about the likely effectiveness of substance abuse treatment interventions for welfare recipients. Subsequent research documented that substance abuse disorders are less widespread among welfare recipients than was originally thought and are less common than other serious barriers to self-sufficiency. This research also showed significant administrative barriers to the screening, assessment, and referral of drug-dependent welfare recipients. This article summarizes current research findings and examines implications for welfare reform reauthorization.

Testing the level of response to alcohol: social information processing model of alcoholism risk--a 20-year prospective study

BACKGROUND

The low level of response (LR) to alcohol is a genetically influenced characteristic associated with an enhanced risk for alcohol use disorders (AUDs). An optimal understanding of how this intermediate phenotype relates to the AUD risk requires evaluation of the milieu in which LR operates, and this study tested an LR/social information processing model in adult men.

METHODS

Almost 300 Caucasian males (97% of those eligible, to date) from the San Diego Prospective Study participated in an alcohol challenge at approximately age 20 and were evaluated with a structural equation model regarding their expectations of the effects of alcohol, drinking among peers, use of alcohol to cope with stress, and alcohol-related problems during follow-up.

RESULTS

The direct paths in the structural equation model in these 40-year-old men explained 58% of the variance of the alcoholic outcome at age 40 and 35% at age 35 while demonstrating good fitness characteristics. The LR to alcohol was related to the family history of AUDs and to the alcoholic outcome; the latter primarily operated through the use of alcohol to cope with stress. Although drinking in peers and expectations of the effects of alcohol both contributed to the model in these 40-year-old men, they were not directly related to LR.

CONCLUSIONS

The results continue to support the importance of the low LR to alcohol as a predictor of AUDs, even when evaluated in the context of additional relevant characteristics. Future evaluations of adolescent and young adult subjects will also explore the potential importance of expectations of the effects of alcohol and drinking among peers as mediators or moderators of alcoholism risk among subjects with a low LR.