Abstract
Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.
Highlights
AND CONCEPTUAL BACKGROUND In this paper, we provide a novel reanalysis of prevalence rates for alcohol use disorder (AUD) in two major epidemiological surveys
We use the harmful dysfunction (HD)-derived criteria to recalculate AUD prevalence rates in the surveys, comparing the results to the prevalences yielded by the DSM-based criteria originally used in the studies, and to the prevalences yielded by the new DSM-5 criteria
We examine whether the HD analysis might explain the puzzlingly high rate of spontaneous remission among adolescents with apparent AUD, a finding often cited by those who argue that addiction is not really a disorder at all but a normal choice process [4, 5]
Summary
AND CONCEPTUAL BACKGROUND In this paper, we provide a novel reanalysis of prevalence rates for alcohol use disorder (AUD) in two major epidemiological surveys. We examine the degree to which each criteria set addresses the longstanding puzzle of divergent prevalence rates of AUD across surveys, a problem tackled in classic papers by Regier et al [2] and Narrow et al [3] but which they failed to resolve. We use the HD analysis to provide estimates of unmet need for treatment of AUD that are dramatically different from standard estimates and address the paradox of enormous rates of apparent AUD but without any felt need for treatment
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