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Diagnosis & Assessment of Alcohol Dependence 2006 RSA Lecture Series Deborah Hasin, Ph.D. Columbia University New York State Psychiatric Institute.

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Presentation on theme: "Diagnosis & Assessment of Alcohol Dependence 2006 RSA Lecture Series Deborah Hasin, Ph.D. Columbia University New York State Psychiatric Institute."— Presentation transcript:

1 Diagnosis & Assessment of Alcohol Dependence 2006 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 3 rd 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 validity led (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 M aladaptive drinking leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period: 1. Drinking more or longer than intended 2. Persistent desire or unsuccessful efforts to cut down or stop 3. A great deal of time spent on drinking or getting over its effects 4. Important activities given up or reduced because of drinking 5. Continued drinking despite knowledge of a serious physical or psychological problem 6. Tolerance 7. 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 N ot dependent, and maladaptive drinking leading to clinically significant impairment or distress, shown by 1 + of the following: 1. Continued use despite social/interpersonal problems 2. Hazardous use (e.g., driving when impaired by alcohol) 3. Frequent drinking leading to failure to function in major roles 4. 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 A lthough 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 – alcohol Hasin et al., Arch Gen Psychiatry, 2004 Proportion of Sample TotalDependence with abuse Dependence without abuse % alcohol dependence cases missed All women1.231.0546.1 African American1.231.1648.5 Hispanic.0871.0755.2 All men3.801.5529.0 African American2.902.1943.0 Hispanic3.572.3339.5

25 NESARC findings, lifetime dependence with and without abuse – alcohol Hasin et al., Arch Gen Psychiatry, 2005 Proportion of Sample TotalDependence with abuse Dependence without abuse % alcohol dependence cases missed All women6.111.7129.1 African American3.601.4324.8 Hispanic4.171.7129.1 All men15.441.7410.1 African American10.662.0416.1 Hispanic10.522.5019.2

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. National Am 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 Comparison Dependence: Excellent Abuse hierarchical: Low Abuse 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: Dependence Drinkers from a c ommunity and national sample

30 Construct Validation: Abuse Community Heavy Drinkers and NLAES drinkers

31 Factor analyses: Dependence and Abuse Harford, Muthen U.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

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38 Acknowledgements K05 AA014223, R01 AA008159, AA008910, DA008409 DA010919 DA018652 New York State Psychiatric Institute Presentation: Valerie Richmond, M.A. Contact: dsh2@columbia.edu

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