Will it be Easier to Diagnose Alcohol Dependency in the Future?
About the author:
Director, Clinical Health Promotion Centre, Bispebjerg & Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.
Professor at Lund University, Skåne University Hospital, Malmö, Sweden
Professor, University of Southern Denmark
CEO, International HPH Secretariat
A medical student once said that unhealthy alcohol consumption is defined by an alcohol intake higher than the doctor’s consumption. And one way or the other, there seems to be an attitude of ‘us and them’, in that we only drink socially, while the others seem to be drinking a lot more. However, more specified definitions exist. Some are based on drinking a certain amount of alcohol exceeding (different) national limits, while others are more related to the mental and behavioral symptoms, such as dependence.
On one hand, a definition that clearly categorize the dependent and the non-dependent drinkers separately may seem attractive from a treatment and prognostic perspective (1;2). Then the patients with dependency can be offered specialized care in addiction centers, while the others can receive intervention in the generalized care. On the other hand, this simplification does not always portray reality, as unhealthy alcohol consumption reflects a continuum rather than clearly separated categories. As an example, about one third of emergency patients undergoing ankle fracture surgery who also had a high alcohol intake were simultaneously diagnosed with syndrome of dependence (3).
Are you familiar with the new dependence terminology and criteria of ICD-11?
In the latest version of the International Classification of Diseases (ICD-11) version from April 2019, a new classification related to alcohol and other psychoactive substances was released. An important aim was to make diagnosing easier in both primary and secondary healthcare. Consequently, the number of symptoms related to alcohol dependence were collapsed from 6 to now only 3 (Table 1).
The new criteria for the dependence diagnosis including having at least two symptoms daily or almost daily within the last month or to have at least two symptoms repeated several times during the last year. However, the numbers are not quite clear in the updated browser for clinical use; “the features of dependence are usually evident over a period of at least 12 months, but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least 1 month”.
Interestingly, this may lead to a higher prevalence of the dependence diagnosis compared to using the previous Diagnostic and Statistical Manual: Mental Disorders (DSM-4) and ICD-10 criteria, as well as by using the updated DSM-5 criteria for moderate or severe alcohol use disorder (AUD). The young adults with ICD11 diagnosed dependence most often had symptoms of tolerance and of spending much time on drinking or recovering afterwards (5).
What about the terminology and criteria of DSM-5?
Already in 2013, the American Psychiatric Association (APA) released the updated DSM–5 with an integration of the two previous diagnoses (alcohol abuse and alcohol dependence) into a single alcohol use disorder (AUD) (6). It now includes 11 symptoms (Table 1) and the criteria for the AUD diagnosis are to have at least two of the symptoms during the past year. Based on the number of co-existing symptoms three groups have been proposed representing mild, moderate, and severe AUD.
All clinicians and many other health professionals will from time to time meet patients, who drink too much, and they may even have symptoms of dependence.
Maybe such meetings take place more often than realized, because diagnosing alcohol dependency is often forgotten or directly neglected in healthcare. The neglection has serious consequences for the individual, the family, the workplace, the health care, and the society at large, as unhealthy alcohol consumption (with or without dependence) is an important risk factor adding significantly to the burden of diseases and early death (7).
Table 1 Comparing the symptoms of alcohol abuse, alcohol dependence and alcohol use disorder (AUD) based on the updated and previous DSM and ICD versions
Has it become easier to identify alcohol dependence in primary and secondary care?
Yes and no. Yes, because the revisions of the ICD and the DSM criteria have made them more understandable. No, because they are not in agreement and no longer based on a similar basic understanding of alcohol use disorder. The ICD has kept alcohol dependence as a separate diagnosis and even reduced the number of criteria. Thus, it may be easier to get the diagnosis of dependence – at least among young persons. In contrast, the DSM reflects a larger bit of the continuum by considering symptoms of both abuse and dependence as parts of the broader understanding of the term alcohol use disorder. This may, however, be challenging for the alcohol intervention – at least until the term has become routine.
There is a call for new research considering cultural and social differences around the world . However, give it a try, and hopefully the patient, family, workplace, health care and society will gain from the improved efforts aiming at opening the door to an increased focus on unhealthy alcohol intake. Both WHO and APA welcome feedback on the use of the updated diagnoses.
More to come
Overall, we need more models and tools that has proven effective in putting new evidence into practice. This might be the reason that the development and evaluation of the new model for fast-track implementation (FAST-IM) in the HPH Network has been warmly welcomed, when presented at international health forums for managers, clinicians, public health professionals, health planners and other groups. It took place at 38 HPH member hospitals in 8 European and Asian areas, and the results are in the final step of the editorial process for publication. The managers, clinicians and patients reported positive experiences from the process (12). More evidence will be collected in the nearest future as several study protocols have been published, so hopefully we will soon be able to accelerate the implementation using effective tools and models based on solid evidence.
(1) The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization,1993.
(2) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-4). https://www.psychiatry.org/psychiatrists/practice/dsm 1994.
(3) Egholm JWM. Scand-Ankle: Alcohol intervention in acute surgery of ankle fracture. Clin Health Promot 2018;8(4):1-53.
(4) The ICD-11 Geneva: World Health Organization; 2018. Latest revision April 2019 available at https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1676588433.
(5) Chung T, Cornelius J, Clark D, Martin C. Greater Prevalence of Proposed ICD-11 Alcohol and Cannabis Dependence Compared to ICD-10, DSM-IV, and DSM-5 in Treated Adolescents. Alcohol Clin Exp Res. 2017 Sep;41(9):1584-1592. doi: 10.1111/acer.13441.
(6) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. https://www.psychiatry.org/psychiatrists/practice/dsm 2013.
(7) GBD 2016 Alcohol and Drug Use Collaborators. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018 Dec;5(12):987-1012. doi: 10.1016/S2215- 0366(18)30337-7. Erratum in: Lancet Psychiatry. 2019 Jan;6(1):e2.
(8) Basu D, Ghosh A. Substance use and other addictive disorders in International Classification of Diseases-11, and their relationship with diagnostic and statistical manual-5 and International Classification of Diseases-10. Indian J Soc Psychiatry 2018;34:S54-62.