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Article Excerpt
THE AMERICAN PSYCHIATRIC ASSOCIATION publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), which provides diagnostic categories and criteria for their diagnoses. Substance abuse and substance dependence criteria were differentiated in 1980 (American Psychiatric Association, 1980) and further refined in 1987 (American Psychiatric Association, 1987). In 1994 the criteria were readjusted (American Psychiatric Association, 1994). It is recognized that the diagnostic criteria for any disorder is subject to change as the understanding of the disorder process is further elucidated over time. These changing criteria pose problems, however, for researchers undertaking longitudinal studies of groups of individuals at high risk for developing alcohol problems or investigators who wish to compare the prevalence of disorders across populations. Researchers who painstakingly determined the psychiatric status of a given cohort using the DSM, Third Edition, Revised (DSM-III-R; American Psychiatric Association, 1987), taxonomy are faced with a conundrum when planning follow-up studies. Now that the DSM, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), defines alcohol abuse and dependence differently, what criteria should be used to define alcohol-use disorders?
Some scientists have resolved the dilemma by continuing to use DSM-III-R criteria for their longitudinal studies (Breslau et al. 2003; Compton et al., 2003), and some scientists have retired their DSM-III-R data. However, if DSM-III-R criteria are used in the present environment, the diagnoses are not accurate with respect to current thinking about diagnostic criteria for alcohol abuse and dependence. Conversely, if DSM-IV criteria are used, the question is how baseline and follow-up diagnoses can be compared. Any difference noted may be attributable to a difference in the actual syndrome, in reporting inconsistencies, or merely differences in the definition of the disorder.
Four studies addressed the DSM-III-R to DSM-IV changes by comparing the two sets of criteria. One study (Schuckit et al., 1994) used the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA; Bucholz et al., 1994) interview, a detailed research instrument that gathers information applicable to multiple diagnostic systems. The other three (Grant and Hasin, 1990; Hasin et al., 1996a,b) used the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS; Grant and Hasin, 1990), a fully structured psychiatric interview with questions that operationalized the DSM-IV, DSM-III-R, and International Classification of Diseases, Tenth Revision (World Health Organization, 1992), substance-abuse criteria. The AUDADIS was explicitly designed to measure DSM-IV alcohol- and drug-use disorders (Grant, 1996). The SSAGA was developed specifically to select probands and assess their relatives using DSM-III-R criteria for alcohol-and drug-use disorders. Substance-use disorder criteria for the DSM-IV were developed by extracting items for the SSAGA that approximated the DSM-IV classification (Grant, 1996). All these studies reported that the prevalence of lifetime alcohol abuse is greater for the DSM-IV than the DSM-III-R and that the proportion of individuals diagnosed with lifetime dependence by DSM-IV is lower than that observed in DSM-III-R. Kappa values comparing DSM-IV and DSM-III-R are generally in the good-to-excellent range for lifetime alcohol dependence and in the fair-to-good range for lifetime alcohol abuse.
Some studies were of the general population (Grant, 1996), some focused on individuals who drink heavily (Hasin et al., 1996a,b), and some on patients diagnosed with alcohol-use disorders (Schuckit et al., 1994). Two standardized instruments were used, the SSAGA and the AUDADIS, administered by clinicians (SSAGA) and nonclinicians (AUDADIS). None of these studies assessed the agreement between the DSM-III-R and DSM-IV with data gathered by the Diagnostic Interview Schedule (DIS), an extensively used diagnostic instrument.
The DIS is a fully structured instrument that has been translated into at least 30 other languages, has been used worldwide, and is an established clinical and research tool (Helzer and Canino, 1992). Development of the DIS began in 1978 at the request of the National Institute of Mental Health (NIMH). At that time, the NIMH Division of Biometry and Epidemiology was beginning to organize its Epidemiological Catchment Area Program and needed a comprehensive diagnostic instrument to conduct surveys that would provide the prevalence and incidence of specific psychiatric disorders in the general population and which could be administered by trained lay interviewers (Regier et al., 1984). The DIS requires relatively little judgment from the interviewer by specifying each question to be asked. It sets requirements for clinical significance, and it distinguishes psychiatric symptoms from those caused by physical illness or...
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