Practical assessment of DSM‐5 alcohol use disorder criteria in routine care: High test‐retest reliability of an Alcohol Symptom Checklist

Abstract

Background Alcohol use disorder (AUD) is underdiagnosed and undertreated in medical settings, in part due to a lack of AUD assessment instruments that are reliable and practical for use in routine care. This study evaluates the test‐retest reliability of a patient‐report Alcohol Symptom Checklist questionnaire when it is used in routine care, including primary care and mental health specialty settings. Methods We performed a pragmatic test‐retest reliability study using electronic health record (EHR) data from Kaiser Permanente Washington, an integrated health system in Washington state. The sample included 454 patients who reported high‐risk drinking on a behavioral health screen and completed two Alcohol Symptom Checklists 1 to 21 days apart. Subgroups of these patients who completed both checklists in primary care (n = 271) or mental health settings (n = 79) were also examined. The primary measure was an Alcohol Symptom Checklist on which patients self‐reported whether they experienced each of the 11 AUD criteria within the past year, as defined by the Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5). Results Alcohol Symptom Checklists completed in routine care and documented in EHRs had excellent test‐retest reliability for measuring AUD criterion counts (ICC = 0.79, 95% CI: 0.76 to 0.82). Test‐retest reliability estimates were also high and not significantly different for the subsamples of patients who completed both checklists in primary care (ICC = 0.82, 95% CI: 0.77 to 0.85) or mental health settings (ICC = 0.74, 95% CI: 0.62 to 0.83). Test‐retest reliability was not moderated by having a past two‐year AUD diagnosis, nor by the age or sex of the patient completing it. Conclusions Alcohol Symptom Checklists can reliably and pragmatically assess AUD criteria in routine care among patients who screen positive for high‐risk drinking. The Alcohol Symptom Checklist may be a valuable tool in supporting AUD‐related care and monitoring AUD criteria longitudinally in routine primary care and mental health settings.

An Alcohol Symptom Checklist identifies high rates of alcohol use disorder in primary care patients who screen positive for depression and high-risk drinking

“…Endorsing 2–3 criteria, 4–5 criteria, or 6–11 criteria is consistent with DSM-5 definitions for mild, moderate, or severe AUD, respectively. Psychometric analyses have supported the reliability [ 39 ] and validity [ 38 ] of the Alcohol Symptom Checklist, showing that it measures AUD criteria consistently over time [ 39 ], along a unidimensional continuum of severity (consistent with DSM-5 conceptualization) [ 38 , 39 ], and similarly across sex, age, race, and ethnicity subgroups when it is completed in routine care by patients with high-risk drinking [ 38 ].…”

“…In KPWA, primary care patients with high-risk drinking are asked to complete an Alcohol Symptom Checklist as part of routine care to assess whether symptoms of AUD are also present [31,37]. The Alcohol Symptom Checklist [38,39] is an 11-item self-report questionnaire that asks patients whether they have experienced each of the 11 AUD criteria within the past year. Each of the 11 items on the Alcohol Symptom Checklist maps onto one the 11 criteria for AUD as currently defined by the DSM-5 [40].…”

Integrating Alcohol-Related Prevention and Treatment Into Primary Care

“…Systematic assessment, diagnosis, and initiation of treatment in primary care may be more effective. Therefore, in SPARC, when patients reported high-risk drinking, the EHR prompted medical assistants to administer an Alcohol Symptom Checklist . Patient responses on the Alcohol Symptom Checklist provided clinicians with timely information on the presence and severity of 11 DSM-5 AUD symptoms to aid engagement (for example, “you indicated you tried to cut down but been unable, can you tell me about that?”) and patient-centered shared decision-making .…”

“…The SPARC intervention was designed to implement the following clinical care: population-based annual alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C), brief intervention for patients who screened positive (AUDIT-C ≥ 3 for women; AUDIT-C ≥ 4 for men), assessment with an Alcohol Symptom Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ) AUD if high-risk drinking (AUDIT-C ≥ 7), shared decision-making about AUD treatment options with a primary care practitioner or integrated licensed social worker, and support for initiation and engagement in AUD treatment (Figure 1; eAppendix 2 in Supplement 1). The intervention included 3 evidence-based implementation strategies (eAppendix 1 in Supplement 1).…”

Evidence-Based Assessment of Substance Use Disorder

“…The Substance Dependence Severity Scale, a semi-structured interview, has shown good reliability and validity (Miele et al, 2000, 2001), and of note, it was developed to measure changes in diagnostic severity over time. Finally, the Alcohol Use Disorder symptom checklist was developed as a brief self-report instrument that has good reliability for assessment in primary care settings (Hallgren, Matson, Oliver, Caldeiro, et al, 2022; Hallgren, Matson, Oliver, Witkiewitz, et al, 2022). Initial validation on a Substance Use Disorder checklist for primary care was also recently completed (Matson et al, 2023).…”