Concordance between the diagnostic guidelines for alcohol and cannabis use disorders in the draft ICD-11 and other classification systems: analysis of data from the WHO's World Mental Health Surveys.

BACKGROUND AND AIMS: The World Health Organization's (WHO's) proposed International Classification of Diseases, 11th edition (ICD-11) includes several major revisions to substance use disorder (SUD) diagnoses. It is essential to ensure the consistency of within-subject diagnostic findings throughout countries, languages and cultures. To date, agreement analyses between different SUD diagnostic systems have largely been based in high-income countries and clinical samples rather than general population samples. We aimed to evaluate the prevalence of, and concordance between diagnoses using the ICD-11, The WHO's ICD 10th edition (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 4th and 5th editions (DSM-IV, DSM-5); the prevalence of disaggregated ICD-10 and ICD-11 symptoms; and variation in clinical features across diagnostic groups. DESIGN: Cross-sectional household surveys. SETTING: Representative surveys of the general population in 10 countries (Argentina, Australia, Brazil, Colombia, Iraq, Northern Ireland, Poland, Portugal, Romania and Spain) of the World Mental Health Survey Initiative. PARTICIPANTS: Questions about SUDs were asked of 12 182 regular alcohol users and 1788 cannabis users. MEASUREMENTS: Each survey used the World Mental Health Survey Initiative version of the WHO Composite International Diagnostic Interview version 3.0 (WMH-CIDI). FINDINGS: Among regular alcohol users, prevalence (95% confidence interval) of life-time ICD-11 alcohol harmful use and dependence were 21.6% (20.5-22.6%) and 7.0% (6.4-7.7%), respectively. Among cannabis users, 9.3% (7.4-11.1%) met criteria for ICD-11 harmful use and 3.2% (2.3-4.0%) for dependence. For both substances, all comparisons of ICD-11 with ICD-10 and DSM-IV showed excellent concordance (all κ ≥ 0.9). Concordance between ICD-11 and DSM-5 ranged from good (for SUD and comparisons of dependence and severe SUD) to poor (for comparisons of harmful use and mild SUD). Very low endorsement rates were observed for new ICD-11 feature for harmful use ('harm to others'). Minimal variation in clinical features was observed across diagnostic systems. CONCLUSIONS: The World Health Organization's proposed International Classification of Diseases, 11th edition (ICD-11) classifications for substance use disorder diagnoses are highly consistent with the ICD 10th edition and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Concordance between ICD-11 and the DSM 5th edition (DSM-5) varies, due largely to low levels of agreement for the ICD harmful use and DSM-5 mild use disorder. Diagnostic validity of self-reported 'harm to others' is questionable.

Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys.

CONTEXT: The scarcity of cross-national reports and the changes in Diagnostic and Statistical Manual version 5 (DSM-5) regarding panic disorder (PD) and panic attacks (PAs) call for new epidemiological data on PD and PAs and its subtypes in the general population. OBJECTIVE: To present representative data about the cross-national epidemiology of PD and PAs in accordance with DSM-5 definitions. DESIGN AND SETTING: Nationally representative cross-sectional surveys using the World Health Organization Composite International Diagnostic Interview version 3.0. PARTICIPANTS: Respondents (n = 142,949) from 25 high, middle, and lower-middle income countries across the world aged 18 years or older. MAIN OUTCOME MEASURES: PD and presence of single and recurrent PAs. RESULTS: Lifetime prevalence of PAs was 13.2% (SE 0.1%). Among persons that ever had a PA, the majority had recurrent PAs (66.5%; SE 0.5%), while only 12.8% fulfilled DSM-5 criteria for PD. Recurrent PAs were associated with a subsequent onset of a variety of mental disorders (OR 2.0; 95% CI 1.8-2.2) and their course (OR 1.3; 95% CI 1.2-2.4) whereas single PAs were not (OR 1.1; 95% CI 0.9-1.3 and OR 0.7; 95% CI 0.6-0.8). Cross-national lifetime prevalence estimates were 1.7% (SE 0.0%) for PD with a median age of onset of 32 (IQR 20-47). Some 80.4% of persons with lifetime PD had a lifetime comorbid mental disorder. CONCLUSIONS: We extended previous epidemiological data to a cross-national context. The presence of recurrent PAs in particular is associated with subsequent onset and course of mental disorders beyond agoraphobia and PD, and might serve as a generic risk marker for psychopathology.

Alcohol as a trigger for medical emergencies.

In this paper, our goal is to report relative risks of the impact of alcohol consumption 6 hours prior to medical emergencies presenting in the emergency department for 8,346 patients in seven countries using data from the Emergency Room Collaborative Alcohol Analysis Project. We found that alcohol increased the risk of a medical emergency by 2.17 times (confidence interval: 1.78-2.65), and those without a regular pattern of heavy drinking and those younger showed a greater risk. Acute alcohol is associated not only with injury but also with medical emergencies. More studies are needed on the acute role of alcohol in medical emergencies, preferably with data on the type of medical emergencies.

Scaling properties of the combined ICD-10 dependence and harms criteria and comparisons with DSM-5 alcohol use disorder criteria among patients in the emergency department.

OBJECTIVE: The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), alcohol use disorders (AUDs) classifications offer competing and somewhat overlapping diagnostic tools for assessing alcohol dependence and harms/abuse. Both systems are in active stages of development in anticipation of their next respective iterations. Although much psychometric work has been done studying DSM-IV criteria, efforts toward the ICD-11 have been less prevalent. METHOD: Data from 3,191 drinkers in seven emergency department sites in four countries (United States, Mexico, Argentina, and Poland) were used to study the psychometric properties of the combined ICD-10 dependence and harms criteria. Comparisons with the proposed set of DSM-5 criteria and diagnostic thresholds are also included. RESULTS: Item response theory analyses of the combined ICD-10 dependence and harms criteria suggested a single underlying factor, both overall and for each site separately, with only moderate differential item functioning across sites. Overall agreement between the summative combined ICD-10 dependence and harms criteria and the proposed 11-criteria DSM-5 scale was very high (r = .97), as was agreement between proposed diagnostic threshold levels of 0-1 (negative AUD), 2-3 (moderate AUD), and 4 or more (severe AUD) criteria endorsed (κ = .84). Although disagreement between the two three-level diagnoses was only 5.5% of the sample, a majority of these were because of differences between endorsement rates of abuse versus harms criteria. CONCLUSIONS: Although there is support for efforts to align the two schemes, results are consistent with other studies finding the largest differences between the two systems emanating from differences between the abuse and harms domains. More research is needed before differences between the two systems can be reconciled.

Threshold and optimal cut-points for alcohol use disorders among patients in the emergency department.

BACKGROUND: Current research suggests that Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV alcohol abuse and dependence form a unidimensional continuum in emergency department (ED) patients in 4 countries: Argentina, Mexico, Poland, and the United States. In this continuum of alcohol use disorder (AUD), there are no clear-cut distinctions between the criteria for dependence and abuse in the severity dimension based on prior results from item response theory (IRT) analysis. Nevertheless, it is desirable to find a threshold for identifying cases for clinical practice and cut-points of clinical utility in this continuum to distinguish between patients more or less affected by an AUD, using a scale of symptoms count. METHODS: Data from 5,193 patients in 7 ED sites in the same 4 countries (3,191 current drinkers) were used to study the structure, threshold, and possible cut-points for the diagnoses of AUD. RESULTS: The proposed changes in the DSM-V, dropping the abuse item "legal problems" and adding an item on "craving," did not impact the IRT performance and unidimensionality of AUD in this sample. With a total set of 11 items (deleting "legal problems" and adding "craving" to the current set of DSM criteria), an endorsement of 2 or more criteria can be used as the threshold to define those with an AUD in clinical practice. Furthermore, we can distinguish at least 2 levels of clinical severity, 2 to 3 criteria (moderate), and 4 or more criteria (severe). CONCLUSIONS: A dimensional approach to AUD using the proposed new set of criteria for the DSM-V can be used to propose a threshold and levels of severity. More research in different populations and countries is needed to further substantiate a threshold and cut-points that could be used in new formulations of substance use disorders.

Performance of a craving criterion in DSM alcohol use disorders.

OBJECTIVE: Adding a craving criterion--presently in the International Classification of Diseases, 10th Revision, diagnosis of alcohol dependence--has been under consideration as one possible improvement to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and was recently proposed for inclusion by the DSM Substance-Related Disorders Work Group in the Fifth Revision of diagnostic criteria for alcohol use disorders. To inform cross-cultural applicability of this modification, performance of a craving criterion was examined in emergency departments in four countries manifesting distinctly different culturally based drinking patterns (Mexico, Poland, Argentina, United States). METHOD: Exploratory factor analysis and item response theory were used to examine psychometric properties and individual item characteristics of the 11 DSM-IV abuse and dependence criteria with and without craving for each country separately. Differential item functioning analysis was performed to examine differences in the difficulty of endorsement (severity) and discrimination of craving across countries. RESULTS: Exploratory factor analysis found craving fit well within a one-dimensional solution, and factor loadings were high across all countries. Results from item-response theory analyses indicated that both discrimination and difficulty estimates for the craving item were located in the middle of the corresponding discrimination and difficulty ranges for the other 11 items for each country but did not substantially increase the efficiency (or information) of the overall diagnostic scheme. Across the four countries, no differential item functioning was found for difficulty, but significant differential item functioning was found for discrimination (similar to other DSM-IV criteria). CONCLUSIONS: Findings suggest that, although craving performed similarly across emergency departments in the four countries, it does not add much in identification of individuals with alcohol use disorders.

The dimensionality of alcohol use disorders and alcohol consumption in a cross-national perspective.

AIMS: To replicate the finding that there is a single dimension trait in alcohol use disorders and to test whether the usual 5+ drinks for men and 4+ drinks for women and other measures of alcohol consumption help to improve alcohol use disorder criteria in a series of diverse patients from emergency departments (EDs) in four countries. DESIGN: Cross-sectional surveys of patients aged 18 years and older that reflected consecutive arrival at the ED. The Composite International Diagnostic Interview Core was used to obtain a diagnosis of DSM-IV alcohol dependence and alcohol abuse; quantity and frequency of drinking and drunkenness as well as usual number of drinks consumed during the last year. SETTING: Participants were 5195 injured and non-injured patients attending seven EDs in four countries: Argentina, Mexico, Poland and the United States (between 1995-2001). FINDINGS: Using exploratory factor analyses alcohol use disorders can be described as a single, unidimensional continuum without any clear-cut distinction between the criteria for dependence and abuse in all sites. RESULTS: from item response theory analyses showed that the current DSM-IV criteria tap people in the middle-upper end of the alcohol use disorder continuum. Alcohol consumption (amount and frequency of use) can be used in all EDs with the current DSM-IV diagnostic criteria to help tap the middle-lower part of this continuum. Even though some specific diagnostic criteria and some alcohol consumption variables showed differential item function across sites, test response curves were invariant for ED sites and their inclusion would not impact the final (total) performance of the diagnostic system. CONCLUSIONS: DSM-IV abuse and dependence form a unidimensional continuum in ED patients regardless of country of survey. Alcohol consumption variables, if added, would help to tap patients with more moderate severity. The DSM diagnostic system for alcohol use disorders showed invariance and performed extremely well in these samples.

Acute alcohol use and the risk of non-fatal injury in sixteen countries.

AIMS: To determine the relative risk (RR) of non-fatal injury associated with alcohol consumption in a series of emergency departments (EDs), possible effect modifiers and the impact of contextual variables on differences across sites. DESIGN: The case-crossover method was used to obtain RR estimates of the effect of alcohol on non-fatal injuries. Meta-analysis was used to evaluate the consistency and magnitude of RR across sites, and the extent to which contextual variables explain differences in effect sizes. PARTICIPANTS: Probability samples of 11,536 injured patients attending 28 EDs studies in 16 countries (1984-2002). The majority of the sample was male (65%) and > 30 years old (53%). MEASUREMENTS: Exposed cases where those that consumed alcohol 6 hours prior to the injury. Usual alcohol consumption served as the control period. FINDINGS: Drinking within 6 hours prior to the injury was reported by 21% of the sample. The estimated (random) pooled relative risk for patients who reported alcohol use within 6 hours prior to injury was 5.69 (95% confidence interval = 4.04-8.00), ranging from 1.05 in Canada to 35.00 in South Africa. Effect size was not homogeneous across studies, as societies with riskier consumption patterns had a higher relative risk for injury. Heavier drinkers also showed lower RR. CONCLUSIONS: Acute alcohol was a risk factor for non-fatal injuries in most sites. Policy measures addressed to the general population are recommended, especially in societies with riskier consumption patterns.