Elsevier

Drug and Alcohol Dependence

Volume 126, Issue 3, 1 December 2012, Pages 384-388
Drug and Alcohol Dependence

Short communication
Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders

https://doi.org/10.1016/j.drugalcdep.2012.05.029Get rights and content

Abstract

Objective

Under the proposed DSM-5 revision to the criteria for alcohol use disorder (AUD), a substantial proportion of DSM-IV AUD cases will be lost or shifted in terms of severity, with some new cases added. Accordingly, the performance of the AUDIT-C in screening for DSM-IV AUD cannot be assumed to extend to DSM-5 AUD. The objective of this paper is to compare the AUDIT-C in screening for DSM-IV and DSM-5 AUD.

Methods

Using a broad range of performance metrics, the AUDIT-C was tested and contrasted as a screener for DSM-IV AUD (any AUD, abuse and dependence) and DSM-5 AUD (any AUD, moderate AUD and severe AUD) in a representative sample of U.S. adults aged 21 and older and among past-year drinkers.

Results

Optimal AUDIT-C cutpoints were identical for DSM-IV and DSM-5 AUD: ≥4 for any AUD, ≥3 or ≥4 for abuse/moderate AUD and ≥4 or ≥5 for dependence/severe AUD. Screening performance was slightly better for DSM-5 severe AUD than DSM-IV dependence but did not differ for other diagnoses. At optimal screening cutpoints, positive predictive values were slightly higher for DSM-5 overall AUD and moderate AUD than for their DSM-IV counterparts. Sensitivities were slightly higher for DSM-5 severe AUD than DSM-IV dependence. Optimal screening cutpoints shifted upwards for past-year drinkers but continued to be identical for DSM-IV and DSM-5 disorders.

Conclusions

Clinicians should not face any major overhaul of their current screening procedures as a result of the DSM-5 revision and should benefit from fewer false positive screening results.

Introduction

The AUDIT-C, comprising the first three questions of the Alcohol Use Disorders Identification Test (Saunders et al., 1993), is a brief screener for alcohol use disorder (AUD) commonly used in general medical and emergency department settings. Its screening utility has been demonstrated among patients in Veterans Affairs (Bush et al., 1998, Bradley et al., 2003), primary care (Aertgeerts et al., 2001, Gual et al., 2001, Gordon et al., 2001, Bradley et al., 2007), emergency department (Kelly et al., 2009), occupational care (Kaarne et al., 2010), and prenatal (Burns et al., 2010) settings, as well as in the general population (Dawson et al., 2005a, Dawson et al., 2005b, Nayak et al., 2009, Rumpf et al., 2002). It also shows promise for telephone screening (McPherson et al., 2010), and its screening performance approaches that of the full AUDIT (Aertgeerts et al., 2001, Gordon et al., 2001, Nayak et al., 2009, Rumpf et al., 2002).

No study to date has evaluated the AUDIT-C with respect to the proposed DSM-5 criteria for AUD (http://www.dsm5.org), which differ in several ways from the DSM-IV criteria (American Psychiatric Association, 1994). Under the proposed revision, the criterion of alcohol-related legal problems has been dropped, and a new craving criterion has been added. DSM-IV abuse and dependence are based on separate sets of diagnostic criteria, with endorsement of ≥1 of four abuse criteria required for an abuse diagnosis and ≥3 of seven dependence criteria required for a dependence diagnosis. In contrast, all 11 DSM-5 criteria apply toward a unitary construct of AUD, with endorsement of 2–3 criteria representing moderate AUD and ≥4 criteria representing severe AUD. Accordingly, cases of AUD have been gained, lost and shifted in terms of severity (Agrawal et al., 2011, Dawson et al., 2012). As per Supplementary Table 1, 3.3% of individuals negative for any DSM-IV AUD qualify for DSM-5 moderate AUD; these comprise former diagnostic orphans (Hasin and Paykin, 1998) who endorsed two of the DSM-IV dependence criteria (or one plus craving). Only 58% of individuals with DSM-IV abuse are classified with the corresponding DSM-5 diagnosis of moderate AUD; 36% who endorsed a single DSM-IV abuse criterion (or two including legal) do not qualify for any DSM-5 AUD, and 6.0% whose DSM-5 criteria count reaches 4+ by combining former abuse and dependence criteria and craving qualify for DSM-5 severe AUD. Finally, 19.5% of individuals with DSM-IV dependence, those with just three dependence criteria, no abuse criteria (or legal only) and no craving, are downshifted into DSM-5 moderate rather than severe AUD. As a result, the performance of the AUDIT-C in screening for DSM-IV AUD cannot be assumed to extend to DSM-5 diagnoses.

In light of the widespread use of the AUDIT-C, it is of critical importance to clinicians to document its screening ability for DSM-5 AUD. This analysis was designed to provide this missing information. It utilizes data from a representative sample of the U.S. adult population to compare the relationship of the AUDIT-C with DSM-IV and DSM-5 AUD in the total population and among past-year drinkers who consumed any alcohol in the year preceding alcohol screening.

Section snippets

Sample

This study uses data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the 3-year follow-up of a nationally representative sample of U.S. adults 18 and older living in households and noninstitutional group quarters, originally interviewed in 2001–2002. At the 2004–2005 Wave 2 follow-up, 34,653 of the 43,093 Wave 1 respondents were reinterviewed, 86.7% of those eligible for reinterview, for a cumulative response rate of 70.2% (Grant et al., 2003a, Grant

Results

AUDIT-C screening performance was similar for DSM-IV and DSM-5 AUD in the total population. A cutpoint of ≥4 optimized the combined values of sensitivity and specificity for the diagnosis of any AUD under both the DSM-IV and DSM-5, and AUC values were virtually identical, 0.914 and 0.915 (left panel of Table 1). However, at this optimal cutpoint, the PPV was significantly higher for DSM-5 than DSM-IV AUD, 36.9%, versus 33.7%. When comparing DSM-IV abuse and DSM-5 moderate AUD (middle panel), a

Discussion

The AUDIT-C cutpoints that optimally screen for DSM-IV AUD will also optimize screening for DSM-5 AUD; thus, clinicians should not face any major overhaul of their current screening procedures as a result of the revision. However, the AUDIT-C will do a somewhat better job of screening for DSM-5 than DSM-IV disorders, yielding slightly higher PPV for any AUD and moderate AUD and slightly higher sensitivity and AUC for severe AUD. Thus, clinicians should benefit from fewer false positive

Role of funding source

The study on which this paper is based, the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), is sponsored by the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, U.S. Department of Health and Human Services, with supplemental support from the National Institute on Drug Abuse. This research was supported in part by the Intramural Program of the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism.

Contributors

Dr. Dawson planned the study, executed the SUDAAN and SAS statistical analyses and prepared the first draft of the manuscript. Dr. Smith calculated the positive likelihood ratios and provided revisions to the manuscript. Dr. Saha and Ms. Rubinsky worked on estimation of the AUROC values and provided revisions to the manuscript. Dr. Grant reviewed the study design and statistical approaches and provided revisions to the manuscript.

The views and opinions expressed in this paper are those of the

Conflict of interest

None of the authors has any financial conflict of interest to report.

Acknowledgment

None.

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    Supplementary material can be found by accessing the online version of this paper at http://dx.doi.org/10.1016/j.drugalcdep.2012.05.029

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