Validity of the DSM-5 tobacco use disorder diagnostics in adults with problematic substance use.

BACKGROUND: DSM-5 tobacco use disorder (TUD) nosology differs from DSM-IV nicotine dependence (ND) by including craving and DSM-IV abuse criteria, a lower threshold (≥ 2 criteria), and severity levels (mild; moderate; severe). We assessed concurrent and prospective validity of the DSM-5 TUD diagnosis and severity and compared validity with DSM-IV ND diagnosis. METHODS: The sample included U.S. adults with current problematic substance use and past year cigarette smoking (N = 396). Baseline assessment collected information on DSM-IV ND and DSM-5 TUD criteria, smoking-related variables, and psychopathology. Over the following 90 days, electronic daily assessments queried smoking and cigarette craving. Variables expected to be related to TUD were validators: cigarette consumption, cigarette craving scale, Fagerström Test for Nicotine Dependence, and psychiatric disorders. Regression models estimated the association of each validator with DSM-5 TUD and severity levels, and differential association between DSM-5 TUD and DSM-IV ND diagnoses. RESULTS: DSM-5 TUD and DSM-IV ND were associated with most baseline validators (p-values < 0.05), with significantly stronger associations with DSM-5 TUD for number of days smoked (p = 0.023) and cigarette craving scale (p = 0.007). Baseline DSM-5 TUD and DSM-IV ND predicted smoking and craving on any given day during follow-up, with stronger associations for DSM-5 TUD (association difference [95% CI%]: any smoking, 0.53 [0.27, 0.77]; number of cigarettes smoked, 1.36 [0.89, 1.78]; craving scale, 0.19 [0.09, 0.28]). Validators were associated with TUD severity in a dose-dependent manner. CONCLUSION: DSM-5 TUD diagnostic measures as operationalized here demonstrated concurrent and prospective validity. Inclusion of new criteria, particularly craving, improved validity and clinical relevance.

Test-retest reliability of DSM-5 substance disorder measures as assessed with the PRISM-5, a clinician-administered diagnostic interview.

AIM: In DSM-5, the definitions of substance use disorders (SUD) were changed considerably, yet little is known about the reliability of DSM-5 SUD and its new features. METHODS: The test-retest reliability of DSM-5 SUD and DSM-IV substance dependence (SD) was evaluated in 565 adult substance users, each interviewed twice by different clinician interviewers using the semi-structured Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 version (PRISM-5). DSM-5 SUD and DSM-IV SD criteria were assessed for past year and lifetime, yielding diagnoses and severity levels for alcohol, tobacco, cannabis, cocaine, heroin, opioids, sedatives, hallucinogen, and stimulant use disorders. Cohen's and intraclass correlation coefficients (ICC) assessed reliability for categorical and graded outcomes, respectively. Factors potentially influencing reliability were explored, including inpatient vs. community participant, days between interviews gender, age, race/ethnicity, and SUD severity. RESULTS: DSM-5 SUD diagnoses had substantial to excellent reliability for most substances (κ = 0.63-0.94), and moderate for others (hallucinogens, stimulants, sedatives; κ = 0.50-0.59). For graded outcomes (DSM-5 SUD mild, moderate, severe; criteria count 0-11), reliability was substantial to excellent (ICC = 0.74-0.99). Comparisons of DSM-5 SUD and DSM-IV SD reliability showed few significant differences. Reliability of the DSM-5 craving criterion was excellent for heroin (κ = 0.84-0.95) and moderate to substantial for other substances (κ = 0.49-0.76). The only factor influencing reliability of SUD was severity, with milder disorders significantly more likely to be discordant between the interviews. CONCLUSION: Reproducibility is crucial to good measurement. In a large sample using rigorous methodology, diagnoses and dimensional measures from clinician-administered interviews for DSM-5 SUD were generally highly reliable.

Effects of independent and substance-induced major depressive disorder on remission and relapse of alcohol, cocaine and heroin dependence.

AIMS: Little is known about the differential effects of independent and substance-induced major depression on the longitudinal course of alcohol, cocaine and heroin disorders when studied prospectively. DESIGN: Consecutively admitted in-patients, evaluated at baseline, 6-, 12- and 18-month follow-ups. SETTING: Baseline evaluations in a short-stay in-patient urban community psychiatric hospital unit. PARTICIPANTS: Adults (n = 250) with current DSM-IV cocaine, heroin and/or alcohol dependence at baseline. MEASUREMENTS: The Psychiatric Research Interview for Substance and Mental Disorders (PRISM), used to evaluate independent and substance-induced major depression, alcohol, cocaine and heroin dependence, and other psychiatric disorders. Outcomes for each substance: (i) time (weeks) from hospital discharge to first use; (ii) time from discharge to onset of sustained (≥26 weeks) remission from dependence; (iii) time from onset of sustained remission to relapse. FINDINGS: Substance-induced major depression significantly predicted post-discharge use of alcohol, cocaine and heroin (hazard ratios 4.7, 5.3 and 6.5, respectively). Among patients achieving stable remissions from dependence, independent major depression predicted relapse to alcohol and cocaine dependence (hazard ratios 2.3 and 2.7, respectively). CONCLUSIONS: Substance-induced and independent major depressions were both related to post-discharge use of alcohol, cocaine and heroin. The findings suggest the importance of clinical attention to both types of depression in substance abusing patients.

Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders.

CONTEXT: Little is known about the role of a broad range of personality disorders in the course of substance use disorder (SUD) and whether these differ by substance. The existing literature focuses mostly on antisocial personality disorder and does not come to clear conclusions. OBJECTIVE: To determine the association between the 10 DSM-IV personality disorders and the persistence of common SUDs in a 3-year prospective study of a national sample. DESIGN: Data were drawn from participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) who had alcohol dependence (n = 1172), cannabis use disorder (n = 454), or nicotine dependence (n = 4017) at baseline and who were reinterviewed 3 years later. Control variables included demographic characteristics, family history of substance disorders, baseline Axis I disorders and treatment status, and prior SUD duration. Main Outcome Measure  Persistent SUD, defined as meeting full criteria for the relevant SUD throughout the 3-year follow-up period. RESULTS: Persistent SUD was found among 30.1% of participants with alcohol dependence, 30.8% with cannabis use disorder, and 56.6% with nicotine dependence at baseline. Axis I disorders did not have strong or consistent associations with persistent SUD. In contrast, antisocial personality disorder was significantly associated with persistent alcohol, cannabis, and nicotine use disorders (adjusted odds ratios, 2.46-3.51), as was borderline personality disorder (adjusted odds ratios, 2.04-2.78) and schizotypal personality disorder (adjusted odds ratios, 1.65-5.90). Narcissistic, schizoid, and obsessive-compulsive personality disorders were less consistently associated with SUD persistence. CONCLUSIONS: The consistent findings on the association of antisocial, borderline, and schizotypal personality disorders with persistent SUD indicates the importance of these personality disorders in understanding the course of SUD. Future studies should examine dimensional representations of personality disorders and the role of specific components of these disorders, biological and environmental contributors to these relationships, and potential applications of these findings to treatment development.

Nicotine dependence, abuse and craving: dimensionality in an Israeli sample.

AIMS: Evidence-based changes planned for Diagnostic and Statistical Manual 5th edition (DSM-5) substance use disorders (SUDs) include combining dependence and three of the abuse criteria into one disorder and adding a criterion indicating craving. Because DSM-IV did not include a category for nicotine abuse, little empirical support is available for aligning the nicotine use disorder criteria with the DSM-5 criteria for other SUDs. DESIGN: Latent variable analyses, bootstrap tests and likelihood ratio tests were used to explore the unidimensionality, psychometric properties and information of the nicotine criteria. SETTING AND PARTICIPANTS: A sample of household residents selected from the Israeli population register yielded 727 life-time cigarette smokers. MEASUREMENTS: DSM-IV nicotine dependence criteria and proposed abuse and craving criteria, assessed with a structured interview. FINDINGS: Three abuse criteria (hazardous use, social/interpersonal problems and neglect roles) were prevalent among smokers, formed a unidimensional latent trait with nicotine dependence criteria, were intermixed with dependence criteria across the severity spectrum and significantly increased the diagnostic information over the dependence-only model. A craving criterion was shown to fit well with the other criteria. CONCLUSION: Similar to findings from research on other substances, nicotine dependence, abuse and craving criteria appear to derive from a common underlying dimension. The results support alignment of nicotine criteria with those for alcohol and drug use disorders in Diagnostic and Statistical Manual 5th edition.