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Letters to the Editor   |    
The DSM-5 Field Trials and Reliability of Alcohol Use Disorder
Deborah S. Hasin, Ph.D.; Marc Auriacombe, M.D.; Guilherme Borges, Ph.D.; Kathleen Bucholz, Ph.D.; Alan Budney, Ph.D.; Thomas Crowley, M.D.; Bridget F. Grant, Ph.D., Ph.D.; Charles O’Brien, M.D., Ph.D.; Nancy M. Petry, Ph.D.; Marc Schuckit, M.D.; Melanie M. Wall, Ph.D.
Am J Psychiatry 2013;170:442-443. doi:10.1176/appi.ajp.2013.13010032
View Author and Article Information

Dr. Auriacombe has received research and educational grants from Reckit Benkiser and advisory board fees from D&A Pharma and Mundipharma. Dr. Budney has received consulting fees from G.W. Pharmaceuticals. Dr. O'Brien has been an occasional consultant to companies that are conducting research to develop new medications for the treatment of addictive disorders. All authors have received travel expenses from APA for DSM work group meetings.

From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute/Columbia University, New York; the Department of Addiction Psychiatry, Bordeaux Segalen University, Bordeaux, France; National Institute of Psychiatry, Mexico City; Washington University, St. Louis; the Center for Addiction Research, Department of Psychiatry, Dartmouth University, University of Colorado School of Medicine, Aurora; National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md.; the Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia; the Department of Psychiatry, University of Connecticut Health Center, Farmington; the Department of Psychiatry, San Diego VA Medical Center; and the Department of Psychiatry, College of Physicians and Surgeons, Columbia University.

Copyright © 2013 by the American Psychiatric Association

Accepted February , 2013.

To the Editor: The DSM-5 criteria incorporate many changes to improve psychiatric diagnosis compared with DSM-IV. While test-retest reliability was not a major DSM-5 focus, valid measurement requires adequate reliability (1). For alcohol use disorders, a 2006 review (2) indicated good to excellent reliability of the DSM-IV criteria for alcohol dependence (kappa values, 0.66–0.82). Reliability of DSM-IV alcohol abuse was lower, but the criteria were more reliable when analyzed independently of dependence (2). In the DSM-5 field trial, alcohol use disorder reliability was much lower (kappa=0.40) (1). Why the precipitous drop in reliability?

We considered three explanations. First, compared with DSM-IV, DSM-5 field trial cases could have been more complex because of comorbidity that reduced reliability. This appears unlikely, however, because the DSM-IV studies did not exclude comorbid cases, and they recruited participants from settings in which comorbidity was common. Second, DSM-IV kappas could have been inflated because multisite studies did not adjust for data pooled across sites. The reanalysis of data from one of the studies (3) after making this adjustment (4) suggests that this is also unlikely. After pooling data from sites with more than 50 patients, the unadjusted and adjusted kappas did not differ dramatically (Table 1).

Anchor for Jump
TABLE 1.Test-Retest Reliability of Pooled Data From DSM-IV Trial Sites With >50 Patients (N=257)a
Table Footer Note

a Data from Hasin et al. (3)

Third, error variance could have differed between the DSM-IV studies and the DSM-5 field trial. Two main types of error variance reduce reliability (57): criterion variance and information variance. Criterion variance is minimized by having clear guidelines to evaluate symptoms. Information variance is minimized by standardizing 1) content, through fully or semistructured interviews, and 2) procedures, such as investigator training in the use of the interviews. While information variance can never be eliminated completely, studies using standard methodology (structured interviews and training) (7) to control information variance provide more information on criterion variance than studies that do not.

In terms of criterion variance, did the DSM-5 criteria for alcohol use disorder become less clear than those in DSM-IV? This appears unlikely, since the biggest change in alcohol use disorder from DSM-IV to DSM-5 was the combination of dependence and abuse criteria into a single disorder. Except for the addition of craving (new to DSM-5) and the deletion of legal problems, the alcohol use disorder criteria are identical in DSM-IV and DSM-5.

Did information variance increase in the DSM-5 field trial compared with studies in the 2006 review (2)? Here, the answer appears to be yes. All DSM-IV reliability studies reviewed in 2006 used standard methodology to minimize information variance. The DSM-5 field trials were very different (1, 4). After a brief introduction to DSM-5 criteria, clinicians conducted unstructured diagnostic interviews, rating criteria checklists for any disorder they deemed appropriate. Because clinician training was minimal and diagnostic assessment and checklist selection were unstructured, information variance in the DSM-5 alcohol use disorder field trial was not controlled.

Given the design differences in the DSM-IV studies and the DSM-5 field trial, the reliability of DSM-5 alcohol use disorder cannot be directly compared with DSM-IV; studies of DSM-5 alcohol use disorder that minimize information variance are needed. We think such a study should be conducted to accurately make comparisons between the DSM-IV and DSM-5 criteria for alcohol use disorder.

Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Hasin  D;  Hatzenbuehler  ML;  Keyes  K;  Ogburn  E:  Substance use disorders: Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases, tenth edition (ICD-10).  Addiction 2006; 101(suppl 1):59–75
[CrossRef] | [PubMed]
 
Hasin  D;  Samet  S;  Nunes  E;  Meydan  J;  Matseoane  K;  Waxman  R:  Diagnosis of comorbid psychiatric disorders in substance users assessed with the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV.  Am J Psychiatry 2006; 163:689–696
[CrossRef] | [PubMed]
 
Clarke  DE;  Narrow  WE;  Regier  DA;  Kuramoto  SJ;  Kupfer  DJ;  Kuhl  EA;  Greiner  L;  Kraemer  HC:  DSM-5 field trials in the United States and Canada, part I: study design, sampling strategy, implementation, and analytic approaches.  Am J Psychiatry 2013; 170:43–58
[CrossRef] | [PubMed]
 
Spitzer  RL;  Endicott  J;  Robins  E:  Clinical criteria for psychiatric diagnosis and DSM-III.  Am J Psychiatry 1975; 132:1187–1192
[PubMed]
 
Spitzer  RL;  Fleiss  JL:  A re-analysis of the reliability of psychiatric diagnosis.  Br J Psychiatry 1974; 125:341–347
[CrossRef] | [PubMed]
 
Endicott  J;  Spitzer  RL:  A diagnostic interview: the schedule for affective disorders and schizophrenia.  Arch Gen Psychiatry 1978; 35:837–844
[CrossRef] | [PubMed]
 
References Container
Anchor for Jump
TABLE 1.Test-Retest Reliability of Pooled Data From DSM-IV Trial Sites With >50 Patients (N=257)a
Table Footer Note

a Data from Hasin et al. (3)

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References

Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Hasin  D;  Hatzenbuehler  ML;  Keyes  K;  Ogburn  E:  Substance use disorders: Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases, tenth edition (ICD-10).  Addiction 2006; 101(suppl 1):59–75
[CrossRef] | [PubMed]
 
Hasin  D;  Samet  S;  Nunes  E;  Meydan  J;  Matseoane  K;  Waxman  R:  Diagnosis of comorbid psychiatric disorders in substance users assessed with the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV.  Am J Psychiatry 2006; 163:689–696
[CrossRef] | [PubMed]
 
Clarke  DE;  Narrow  WE;  Regier  DA;  Kuramoto  SJ;  Kupfer  DJ;  Kuhl  EA;  Greiner  L;  Kraemer  HC:  DSM-5 field trials in the United States and Canada, part I: study design, sampling strategy, implementation, and analytic approaches.  Am J Psychiatry 2013; 170:43–58
[CrossRef] | [PubMed]
 
Spitzer  RL;  Endicott  J;  Robins  E:  Clinical criteria for psychiatric diagnosis and DSM-III.  Am J Psychiatry 1975; 132:1187–1192
[PubMed]
 
Spitzer  RL;  Fleiss  JL:  A re-analysis of the reliability of psychiatric diagnosis.  Br J Psychiatry 1974; 125:341–347
[CrossRef] | [PubMed]
 
Endicott  J;  Spitzer  RL:  A diagnostic interview: the schedule for affective disorders and schizophrenia.  Arch Gen Psychiatry 1978; 35:837–844
[CrossRef] | [PubMed]
 
References Container
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