Case ascertainment of alcohol dependence in general population surveys: ‘gated’ versus ‘ungated’ approaches

Abstract

Social role impairment and other forms of maladaptation are referenced explicitly in the case definitions for the drug use disorders within DSM-IV-TR, but there is continuing debate about whether and how to include these manifestations of 'clinical significance' in diagnostic criteria and assessment protocols. When a 'gated' approach (based on impairment or other maladaptation) has been taken during recent large scale psychiatric surveys with coverage of drug dependence (e.g. to reduce participant fatigue or burden), the net effect may include (a) a reduced number of identified cases, and (b) biases in the estimates of association linked to the occurrence of drug dependence. In this report focused on alcohol dependence, we probe these issues, making use of data from the cross-sectional US National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a household survey with 44,093 adult participants. NESARC alcohol dependence assessments were 'ungated', but allowed simulation of a 'gated' approach; the end result was a robust decrement in the estimated prevalence of this condition. Nonetheless, patterns of association linking suspected background characteristics to prevalence of alcohol dependence were not appreciably different when the gated and ungated estimates were contrasted. In summary, there are reasons to take the ungated approach in detailed research on alcohol use and dependence. Nevertheless, in panoramic mental health surveys, the inefficiency of an ungated approach must be balanced against the anticipated yield of cases who have experienced alcohol dependence without alcohol related social role impairments or other maladaptation, particularly when the dependence syndromes without these consequences are sometimes thought to lack clinical significance.

Violations of the Usual Sequence of Drug Initiation: Prevalence and Associations With the Development of Dependence in the New Zealand Mental Health Survey

“…(The 34% missed that was quoted by Grant et al [2007] is not relevant because it concerns current symptoms of abuse in those with current dependence.) Degenhardt et al (2007aDegenhardt et al ( ,b, 2008a have used data from the U.S. National Epidemiologic Survey on Alcohol and Related Conditions, a survey without gating, to assess the impact for dependence estimates. They did fi nd that imposing gating lowered the 12-month prevalence estimate for alcohol dependence (3.8% down to 2.5%; Degenhardt et al, 2007a) but had little impact on the prevalence for cannabis dependence (Degenhardt et al, 2007b) or cocaine dependence (Degenhardt et al, 2008a), nor were associations with correlates affected.…”

“…Degenhardt et al (2007aDegenhardt et al ( ,b, 2008a have used data from the U.S. National Epidemiologic Survey on Alcohol and Related Conditions, a survey without gating, to assess the impact for dependence estimates. They did fi nd that imposing gating lowered the 12-month prevalence estimate for alcohol dependence (3.8% down to 2.5%; Degenhardt et al, 2007a) but had little impact on the prevalence for cannabis dependence (Degenhardt et al, 2007b) or cocaine dependence (Degenhardt et al, 2008a), nor were associations with correlates affected. Therefore, although the prevalence of alcohol dependence in New Zealand may be slightly underestimated, it seems unlikely that models of progression from use to dependence will be biased.…”

Childhood Physical Punishment and Later Alcohol Drinking Consequences: Evidence From a Chinese Context

“…A major assumption was made in the WMH-CIDI assessment of alcohol-dependence problems: If an individual never had experienced socially maladaptive or hazard-laden drinking, the WMH-CIDI measurement assumption was that the drinker could never fully qualify for the DSM-IV diagnostic criteria for "clinically signifi cant alcohol dependence" as explained elsewhere (e.g., see Degenhardt et al, 2007). This measurement assumption will be addressed in the Discussion section as a potential limitation of this research, but the assumption is not operative with respect to the majority of drinking outcomes under study (e.g., early involvement, heavier drinking).…”

“…With respect to the assessment of outcomes, our major concern is the self-report character of the survey data, but in large-scale epidemiological survey research, there are few alternatives to the self-report approach when the research task concerns cumulative occurrence and lifetime history of alcohol outcomes. With respect to the alcohol-dependence outcomes (but not with respect to the many other alcohol outcomes under study), the "gated" approach described in the Method section deserves mention as a limitation, as our research group has previously examined thoroughly (e.g., Degenhardt et al, 2007). This type of measurement assumption is quite common in contemporary alcohol-dependence research.…”

“…This type of measurement assumption is quite common in contemporary alcohol-dependence research. Available evidence suggests that the WMH-CIDI "gating approach" may yield attenuated estimates of the population prevalence of alcohol dependence as defi ned in terms of DSM-IV standards, to the extent that the "gate" based on history of socially maladaptive and hazard-laden drinking may exclude some mildly impaired dependent individuals who have experienced no alcohol-associated social maladaptation (e.g., Degenhardt et al, 2007;Hasin and Grant, 2004). One might speculate that this "gating approach" also differentially fi lters out alcohol-dependent persons who have no background history of CPP, although we are aware of no evidence on this form of bias.…”