The impact of DSM classification changes on the prevalence of alcohol use disorder and 'diagnostic orphans' in Lebanese college youth: Implications for epidemiological research, health practice, and policy

Abstract

Background Studies comparing prevalence of alcohol use disorder (AUD) using DSM-IV and DSM-5 diagnostic criteria in college students are limited. This study examines changes in AUD prevalence estimates using DSM-IV versus DSM-5 and characterizes the profile of DSM-5 “diagnostic orphans.” Methods and findings A college student sample (n = 1,155; mean age: 21 ±1.97) selected conveniently from six large private and public universities in Greater Beirut, Lebanon completed an anonymous survey in May 2016. The study response rate was 83.1%. Data on DSM-IV and DSM-5 AUD criteria were gathered from 582 past-year drinkers, of which 377 (65%) were screened to have DSM-IV abuse/dependence, and 203 (35%) to have any DSM-5 AUD (58% mild, 21% moderate, and 21% severe). Overall percent agreement between measures was 68% (kappa = 0.41). One hundred and ninety-one students met one DSM-5 AUD criterion only (i.e. “diagnostic orphans,” herein DOs), of which the majority (82%) endorsed “hazardous use.” Compared to past-year drinkers with zero-endorsed DSM-5 criteria, DOs were more likely to be aged 21 or above [OR = 1.57(1.21-2.03)], less likely to perceive their socioeconomic status (SES) as poorer vs. same as others [OR = 0.17(0.07-0.43)], more likely to drink 1-2 times/week vs. ≤3 times per month [OR = 2.24(1.44-3.49)], and more likely to report past-year cigarette smoking [OR = 2.16(1.10-4.24)]. When compared to past-year drinkers with DSM-5 AUD, DOs were more likely to be pursuing a graduate or medical degree (vs. undergraduate degree) [2.06 (1.09-3.89)], and to be living with parents most of the time vs. not [OR = 2.68(1.14-6.31)]. DOs (versus drinkers with AUD) were less likely to drink at a high frequency (3-4 times /week or more vs.≤3 times per month) [OR = 0.15 (0.05-0.48)], and to report past-year waterpipe smoking [OR = 0.54(0.34-0.85)], but more likely to report past-year marijuana use [1.89(1.10-3.23)]. The findings are subject to recall bias and under-reporting and the study could not infer causality because temporality of associations cannot be established in a cross-sectional study design. Conclusions DSM-IV abuse/dependence prevalence rate was higher than DSM-5 AUD prevalence mainly due to the high percentage of students who engaged in “hazardous use”. The DO screen might capture a young person in transition between non-drinking/occasional drinking to drinking frequently/developing an AUD. The prevention, identification, and management of DOs may be critical components of a national alcohol harm-reduction policy. Copyright: © 2020 Ghandour et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.