Brief Report: Agreement Between DSM-IV and DSM-5
Criteria for Alcohol Use Disorder Among Outpatients
Suffering From Depressive and Anxiety Disorders

Francesco Bartoli, MD, PhD,1 Giuseppe Carr�a, MD, MSc, PhD,1,2,3 Enrico Biagi, MD,2

Cristina Crocamo, MSc,2 Antonios Dakanalis, PsyD, MSc, PhD,1 Francesco Di Carlo, MD,1

Francesca Parma, MSc,4 Anna Paola Perin, MD,5 Ester Di Giacomo, MD,1,2

Luigi Zappa, MD,2 Fabio Madeddu, MD,4 Fabrizia Colmegna, MD,2

Massimo Clerici, MD, PhD1,2

1Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
2Department of Mental Health, San Gerardo Hospital, Monza, Italy
3Division of Psychiatry, University College London, London, UK
4Department of Psychology, University of Milano-Bicocca, Milano, Italy
5Department of Psychiatry, University of Brescia, Milano, Italy

Background and Objectives: Since significant differences have
been reported, we estimated agreement betweenDSM-5 andDSM-IV
criteria for alcohol use disorder (AUD).
Methods:We assessed 327 outpatients (mean age: 45.2� 13.4) with
depressive or anxiety disorders.
Results: Absolute differences in prevalence rates between DSM-5
and DSM-IV AUD ranged from �1.1% (subjects with anxiety
disorders) to þ1.8% (tobacco smokers). The agreement was
excellent (k¼ 0.88), also accounting for specific subgroups (relevant
k coefficients >0.80).
Discussion and Conclusions: DSM-5 criteria did not inflate AUD
rates.
Scientific Significance: Our results have epidemiological signifi-
cance since, unlike previous reports, we found diagnostic stability
between new and old AUD criteria in this clinical population. (Am J
Addict 2017;26:53–56)

INTRODUCTION

Alcohol use disorder (AUD) is a chronic illness associated
with a high burden of disease,1 often comorbid with other
mental disorders.2 In 2013, the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) made
several changes to diagnostic criteria and classifications of
AUD.3 First, abuse/dependence criteria were merged into a

single diagnostic category requiring that at least two criteria
weremet. Second, the alcohol-related legal problems criterion,
representing one of the four used for DSM-IV alcohol abuse,
was dropped. Third, the craving criterion, ie, the strong desire
or urge to use alcohol, was added. Finally, the new
classification has traced the transition from a categorical to
a dimensional diagnosis, identifying a severity grade of the
disorder (mild, moderate, severe), according to the number of
criteria met.

All individuals with a diagnosis of DSM-IV alcohol
dependence, but only a portion of those with DSM-IV alcohol
abuse, thus reach the DSM-5 diagnostic threshold for AUD. On
the other hand, a portion of so-called DSM-IV “diagnostic
orphans”, ie, people meeting one or two criteria for alcohol
dependence, but none for alcohol abuse, are diagnosed with
AUD according to DSM-5 criteria. Therefore, based onDSM-5
criteria, some AUD cases are lost and other gained, implying
potential epidemiological variations. Indeed, a previous
systematic overview4 showed that DSM-5 criteria might
significantly inflate AUD rates in general population. Never-
theless, there is a lack of data exploring this issue in particularly
vulnerable populations. For example, AUD is frequently
associated with an unfavorable prognosis among subjects
with depressive and anxiety disorders.5 Thus, it seems
important to test if there are AUD epidemiological variations,
due to DSM-5 new set of criteria, also among subjects with
depressive and anxiety disorders. To our knowledge, there are
no studies exploring this topic so far. In order to overcome
limitations of previous research, we aimed at estimating
differences in prevalence, as well as agreement, between
DSM-5 and DSM-IV criteria for AUD in a sample of

Received July 25, 2016; revised November 18, 2016; accepted
December 4, 2016.

Address correspondence to Dr. Bartoli, Department of Medicine
and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900
Monza (MB), Italy. E-mail: [email protected]

The American Journal on Addictions, 26: 53–56, 2017
Copyright © 2016 American Academy of Addiction Psychiatry
ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1111/ajad.12482

53

individuals with depressive and anxiety disorders. We
hypothesized that DSM-5 diagnostic criteria would increase
AUD rates as compared with those based on DSM-IV criteria.

METHODS

This study was drawn up according to “The Strengthening
the Reporting of Observational Studies in Epidemiology
(STROBE) Statement”.6 STROBE Statement developed
recommendations on items that should be included in accurate
and complete reports of observational studies.

Setting and Eligibility Criteria
We included individuals older than 18 years of age,

consecutively admitted, in a 12-month period from January to
December 2015, to San Gerardo Hospital outpatient clinic
(“Ambulatorio Vademecum”) and suffering from a depressive
or anxiety disorder. The setting, sampling strategies and
inclusion/exclusion criteria are fully described elsewhere.7

San Gerardo University Hospital of Monza covers a
comprehensive range of medical and surgical inpatient and
outpatient services, serving a catchment area of 319,000
inhabitants.8

Data Collection and Measures
Standard socio-demographic and clinical characteristics

were collected for descriptive purposes. The Italian version
of the K-6 scale was used to measure individual
psychological distress.9 We used the Mini- International
Neuropsychiatric Interview (MINI)—alcohol module, to
assess current DSM-IV and DSM-5 AUDs. Since DSM-5
includes the additional craving criterion, we implemented
the interview with an item derived from the Composite
International Diagnostic Interview (CIDI), assessing strong
desire and urge to drink alcohol. Individuals were diagnosed
with a current DSM-IV AUD if, in a 12-month period,
criteria for DSM-IV abuse or dependence were met. On the
other hand, subjects were diagnosed with a current DSM-5
AUD if, equally in a 12-month period, at least two out of the
eleven criteria were met. Fully trained consultant psychia-
trists sequentially administered, along with other routine
screening questionnaires, the MINI/CIDI alcohol module.
All data were recorded anonymously in a dataset not
allowing identification of subjects included in this study.
The protocol was submitted to, and approved by, the ethic
committee of San Gerardo University Hospital.

Data Analysis
In order to estimate variations attributable to DSM-5

criteria as compared with DSM-IV ones, we calculated
absolute differences (increase/decrease) in prevalence rates.
Cohen’s Kappa coefficients (k), with relevant Pr(a) (relative
observed agreement) and Pr(e) (chance agreement), were used
to measure the agreement between the different diagnostic
systems. We chose the conventional cut-offs to indicate

poor (�0.20), fair (0.21–0.40), moderate (0.41–0.60), sub-
stantial (0.61–0.80), and excellent (0.81–1.00) agreement.4

Relevant subgroup analyses, accounting for age, gender,
diagnosis, psychological distress score, and smoking status,
were tested to verify variability of k coefficients across
different characteristics of subjects.

Statistical analyses were performed using Stata for
Windows, version 13.1.

RESULTS

Four hundred and twenty-six individuals were consecu-
tively admitted to the San Gerardo Hospital outpatient clinic
for depressive and anxiety disorders during the index period.
Among these, 83 subjects were excluded because they did not
suffer from depressive or anxiety disorders, while other 16
were excluded because they refused to be screened (n¼ 10) or
had a mental status or physical conditions not allowing the
screening (n¼ 6). Thus, 327 subjects (mean age: 45.2� 13.4;
women/men ratio: 1.51) were assessed for DSM-IV/DSM-5
alcohol use disorders using the MINI/CIDI interview. The
mean K-6 psychological distress score was 10.9 (5.6), and
most of subjects suffered from an anxiety disorder (58.3%).

Prevalence rates for DSM-IV and DSM-5 AUDs were
identical, both corresponding to 11.3% (37/327) in the overall
sample, and to 15.3% (37/242) among alcohol users. The
absolute differences were generally low and homogenous also
across relevant subgroups, ranging from �1.1% among
subjects suffering from anxiety disorders, to þ1.8% among
tobacco smokers. A high level of diagnostic stability was
found since DSM-5 AUD was present in most people with
DSM-IV AUD (89.2%) and absent in almost all subjects
without DSM-IV AUD diagnosis (98.6%). The overall
agreement between DSM-IV and DSM-5 criteria was
excellent (k¼ 0.88). Excellent values (k> 0.80) were found
also considering the subsample of alcohol users, and
accounting for age, gender, diagnosis, psychological distress,
apart from non-smokers where the k coefficient (0.79) was
slightly below the relevant threshold, probably because of the
limited proportion of AUD cases. Detailed findings are
summarized in Table 1.

DISCUSSION

To our knowledge, this is the first empirical study
addressing the epidemiological impact of DSM-5 diagnostic
criteria on AUD rates among subjects suffering from
depressive or anxiety disorders. We tested a clinical sample
of 327 subjects consecutively admitted to a hospital
outpatient service. We found that DSM-5 diagnostic criteria,
as compared with DSM-IV ones, did not increase expected
AUD prevalence rates. DSM-IV and DSM-5 showed
comparable rates of AUD in our clinical sample. We also
found a high level of diagnostic stability, highlighting that

54 From DSM-IV to DSM-5 Rates of Alcohol Use Disorder January 2017

most of the subjects with DSM-IV, had also DSM-5 AUDs.
This was confirmed by the excellent overall agreement,
verified also by subgroup analyses, with k values generally
remaining above 0.80 also accounting for alcohol use, age,
gender, diagnosis, psychological distress score, and smoking
status. Thus, despite previous concerns on potential
epidemiological impact of DSM-5 criteria,4 DSM-5 does
not seem to produce several AUD new cases (also called
DSM-IV “diagnostic orphans”10) in this clinical population.
Therefore, the additional epidemiological burden of dual
diagnosis after DSM-5 could be considered minimal if any,
at least among subjects suffering from depressive or anxiety
disorders.

Nevertheless, this study has some potential limitations that
should be taken into account.7 First, the small sample sizemight
have reduced the statistical power of our findings. However, it
seems unlikely that the magnitude of overlapping in AUD rates
between DSM-IV and DSM-5 might be entirely due to the
reduced sample size. Second, it should be considered the
potential lack of representativeness of our sample. As
previously reported,4 individuals identified in clinical settings
may not necessarily share identical characteristics of the general
population. Furthermore, we recruited subjects from an
outpatient clinic, receiving referrals fromprimary care services.
Service users included in our study might be considerably
different to those from caseloads of community mental health
services.11 Finally, since we excluded from analyses a
substantial pool of individuals without depressive and anxiety
disorders, we cannot exclude that our findings are valid only for
subjects with a confirmed clinical diagnosis.

Although some open questions regarding, especially,
reliability and validity of diagnostic criteria12,13 still remain,
DSM is considered worldwide a key tool for diagnosing
mental disorders. Thus, our observational study has
important implications for AUD assessment and treatment.
There is a large diagnostic stability between new and old

AUD criteria, at least in the specific clinical population we
assessed, suggesting it is unlikely that DSM-5 diagnostic
criteria may inflate the size of AUD cases. Nevertheless,
further research is needed to estimate epidemiological trends
also for illicit substance use disorders whose criteria had
similar changes in DSM-5.3

Declaration of Interest
The authors report no conflicts of interest. The authors

alone are responsible for the content and writing of this paper.

REFERENCES

1. Rehm J, Mathers C, Popova S, et al. Global burden of disease and injury
and economic cost attributable to alcohol use and alcohol-use disorders.
Lancet. 2009;373:2223–2233.

2. Carr�a G, Crocamo C, Borrelli P, et al. Correlates of dependence and
treatment for substance use among people with comorbid severe mental
and substance use disorders: Findings from the “Psychiatric andAddictive
Dual Disorder in Italy (PADDI)” study. Compr Psychiatry. 2015;58:
152–159.

3. Hasin DS, O’Brien CP, Auriacombe M, et al. DSM-5 criteria for
substance use disorders: Recommendations and rationale.Am JPsychiatry.
2013;170:834–851.

4. Bartoli F, Carr�aG, CrocamoC, et al. FromDSM-IV toDSM-5 alcohol use
disorder: An overview of epidemiological data. Addict Behav. 2015;41:
46–50.

5. Boschloo L, Vogelzangs N, van den BrinkW, et al. Alcohol use disorders
and the course of depressive and anxiety disorders. Br J Psychiatry. 2012;
200:476–484.

6. von Elm E, Altman DG, EggerM, et al. The strengthening the reporting of
observational studies in epidemiology (STROBE) statement: Guidelines
for reporting observational studies. J Clin Epidemiol. 2008;61:344–349.

7. Bartoli F, Crocamo C, Biagi E, et al. Clinical utility of a single-item test
for DSM-5 alcohol use disorder among outpatients with anxiety and
depressive disorders. Drug Alcohol Depend. 2016;165:283–287.

8. Carr�a G, Bartoli F, Carretta D, et al. The prevalence of metabolic
syndrome in people with severe mental illness: A mediation analysis. Soc
Psychiatry Psychiatr Epidemiol. 2014;49:1739–1746.

TABLE 1. Agreement between DSM-IV and DSM-5 alcohol use disorders across participant characteristics

DSM-IV AUD DSM-5 AUD

Cases Prevalence (%) Cases Prevalence (%) Absolute difference (%) Pr(a) Pr(e) k

Overall sample (n¼ 327) 37 11.3 37 11.3 0.0 0.98 0.80 0.88
Alcohol users (n¼ 242) 37 15.3 37 15.3 0.0 0.97 0.74 0.87
Men (n¼ 130) 23 17.7 22 16.9 �0.8 0.96 0.71 0.87
Women (n¼ 196) 14 7.1 15 7.6 +0.5 0.98 0.86 0.89
Age <30 years (n¼ 58) 13 22.4 13 22.4 0.0 1.00 0.65 1.00
Age >30 years (n¼ 269) 24 8.9 24 8.9 0.0 0.97 0.84 0.82
Depressive disorder (n¼ 133) 16 12.0 18 13.5 +1.5 0.97 0.78 0.87
Anxiety disorder (n¼ 186) 20 10.8 18 9.7 �1.1 0.98 0.82 0.88
K6< 7 (n¼ 89) 5 5.6 5 5.6 0.0 1.00 0.89 1.00
K6> 7 (n¼ 238) 32 13.4 32 13.4 0.0 0.97 0.77 0.86
Tobacco smoker (n¼ 112) 26 23.2 28 25.0 +1.8 0.96 0.63 0.90
Non-tobacco smoker (n¼ 214) 11 5.1 9 4.2 �0.9 0.98 0.91 0.79

AUD, alcohol use disorder; Pr(a), relative observed agreement; Pr(e), chance agreement; k, Cohen’s kappa coefficient.

Bartoli et al. January 2017 55

9. Carr�a G, Sciarini P, Segagni-Lusignani G, et al. Do they actually work
across borders? Evaluation of two measures of psychological distress as
screening instruments in a non Anglo-Saxon country. Eur Psychiatry.
2011;26:122–127.

10. McBride O, Adamson G, Bunting BP, et al. Characteristics of DSM-IV
alcohol diagnostic orphans: Drinking patterns, physical illness, and
negative life events. Drug Alcohol Depend. 2009;99:272–279.

11. Carr�a G, Clerici M. Dual diagnosis-policy and practice in Italy. Am J
Addict. 2006;15:125–130.

12. Hasin D. DSM-5 SUD diagnoses: Changes, reactions, remaining open
questions. Drug Alcohol Depend. 2015;148:226–229.

13. Luciano M, Sampogna G, Del Vecchio V, et al. Critical evaluation of
current diagnostic classification systems in psychiatry: The case of
DSM-5. Riv Psichiatr. 2016;51:116–121.

56 From DSM-IV to DSM-5 Rates of Alcohol Use Disorder January 2017

Copyright of American Journal on Addictions is the property of Wiley-Blackwell and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.