Megan Brooks

May 17, 2011

May 17, 2011 (Honolulu, Hawaii) — The prevalence of alcohol use disorders will increase substantially if proposed revisions to diagnostic criteria for alcohol abuse and dependence contained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are adopted, a new study suggests.

"Our analyses show that the proposed changes would lead to about a 60% increase in the diagnosis of alcohol use disorders in Australia, from 6.0% to 9.7%," Louise Mewton, from the National Drug and Alcohol Research Center, University of New South Wales in Sydney, told Medscape Medical News.

Presented here at the American Psychiatric Association 2011 Annual Meeting, the study showed the number of people meeting criteria for alcohol use disorder proposed revisions to the APA's DSM-IV would likely increase in other countries as well. Whether this would be helpful or not is not known. "Our analyses cannot be used to determine whether this increase is 'good or bad,' Ms. Mewton emphasized.

The study was also published in the journal Addiction.

Four Major Changes

Now in its fourth edition, the DSM is currently being revised, with publication of the DSM-5 anticipated for release in May 2013. DSM-5 includes 4 major changes.

Dr. Louise Mewton

First, 2 separate categories of "alcohol abuse" and "alcohol dependence" under DSM-IV would be collapsed into a single "alcohol use disorder" (of graded severity) under DSM-5.

The rationale for combining the 2 DSM-IV disorders into 1 DSM-5 alcohol use disorder comes from several lines of evidence, Ms. Mewton explained.

"The reliability and validity of the alcohol abuse diagnosis was consistently low, especially when compared with the alcohol dependence diagnosis, which performed well. Statistical analyses of these 2 disorders also indicated that these 2 disorders were statistically indistinguishable."

The structure of the alcohol use disorders in DSM-IV also created "diagnostic orphans" — people who report 1 or 2 dependence criteria but no abuse criteria.

"According to DSM-IV, these people received no alcohol use disorder diagnosis. However, research has shown that this group of people experience clinically meaningful alcohol-related problems and experience significant impairment, sometimes more so than those diagnosed with alcohol abuse. The combining of the 2 DSM-IV disorders overcomes these problems," Ms. Mewton said.

Second, new diagnostic thresholds have been proposed. DSM-5 includes thresholds for a moderate alcohol use disorder (2 or 3 criteria) and a severe alcohol use disorder (≥4 criteria).

"These cutoff points were chosen because analyses of large US databases indicated that they yielded similar prevalence and high concordance with the combined DSM-IV substance abuse and dependence diagnoses.

"However, our study of the Australian general population is not entirely consistent with this conclusion and the American findings," she added.

Third, criterion of alcohol-related legal problems, contained in DSM-IV, is not in DSM-5.

"The substance-related legal problems criterion was removed because it was very rare, even amongst those seeking treatment," Ms. Mewton said. "The legal problems criterion is also heavily dependent on things like state legislature, which are unrelated to alcohol use disorders per se."

Fourth, a new criterion representing "craving" — or a strong desire for alcohol — has been added. "The craving criterion was included due to evidence indicating it is a key clinical feature of problematic alcohol use," she explained.

"Some of these changes are based on our own Australian-based research, so we strongly support the continued improvement of the criteria."

60% Increase in Cases, Implications Unclear

Ms. Mewton and colleagues applied the proposed DSM-5 alcohol use criteria to a sample made up of 10,641 Australian adults 18 years and older. Of these, 7746 (about 73%) reported having at least 12 drinks in the past year. Data on these individuals came from the 1997 Australian National Survey of Mental Health and Well-Being.

The researchers say their analysis supports the proposed introduction of a single alcohol use disorder.

"DSM-5 criteria were all indicators of a single underlying disorder," they report.

However, under DSM-5, the number of people who would qualify for an alcohol use disorder diagnosis would increase by 61.7% when compared with those whose conditions were diagnosed under DSM-IV criteria. But again, the implications of this remain unclear.

"Further research needs to be done to determine whether or not those diagnosed with a DSM-5 alcohol use disorder experience clinically meaningful alcohol-related problems," Ms. Mewton said. "If those diagnosed with a DSM-5 alcohol use disorder experience substantial disability and impairment, then diagnosis, early intervention, and further treatment would be appropriate.

"Our results indicate that the increase in the prevalence of alcohol use disorders is likely to be the result of those with a diagnostic orphan status under DSM-IV who are now being diagnosed with a moderate alcohol use disorder in DSM-5. Given the evidence that suggests that diagnostic orphans experience significant alcohol-related problems, their recognition under DSM-5 may be warranted," said Ms Mewton.

On the basis of their analysis, the researchers say the "2+ threshold" for diagnosis of alcohol use disorder, as well as the inclusion of a craving criterion, "may be problematic." For a variety of reasons, they say a "3+ threshold" for diagnosis of alcohol use disorder may be better, and they urge further research on the usefulness of the craving criterion before adopting it.

Summing up, Ms. Mewton noted that alcohol use disorders are "common and disabling and highly stigmatized, and we need better recognition, better prevention, and better treatment. The DSM-5 is attempting to improve our recognition and definition of the problem."

She added that this study highlights the need to evaluate the proposed changes in cultural settings outside the United States.

"Hopefully, the results of our study will encourage further research of the proposed DSM-5 alcohol use disorder criteria," she said.

The study authors have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2011 Annual Meeting: Abstract NR08-10. Presented May 17, 2011.

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