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ICD-10, DSM-5 differ in criteria for mild, moderate alcohol abuse disorders

While alcohol use disorder criteria of the DSM-5 and the ICD-10 demonstrate a high level of concordance in patients with very severe alcohol use disorder and in those that would not receive a diagnosis, these criteria exhibit important differences for patients with mild or moderate alcohol use disorder, according to recent findings.

“The ICD-10 and DSM-5 converge for cases who would not receive a diagnosis and those who manifest the most severe forms of alcohol use disorder," researcher Norman G. Hoffmann, PhD, adjunct professor of psychology at Western Carolina University, said in a press release. “There is more discrepancy between the two, however, for more mild and moderate cases of alcohol use disorder. This has significant implications not only for diagnosis, but also for the development and application of treatment services.”

The DSM-5 and ICD-10 both have formulated diagnostic criteria for alcohol abuse disorders.  Although clinicians frequently use the DSM for this purpose, CMS has recently asked for clinicians to bill for services using ICD-10 codes. Given the potential impact of eligibility or ineligibility for alcohol use disorder treatment, Hoffmann and colleagues sought to analyze the discrepancies between the two diagnostic approaches for mild and moderate alcohol use disorders.

“Although the clinical use of the DSM classification system remains commonplace - at least in the U.S. - with the forthcoming federal mandate that all U.S. health care settings transition to ICD-10 billing codes, empirical evidence is necessary to determine if the DSM-5 does in fact facilitate a cross-walk to the new ICD-10 coding system,” Steven L. Proctor, psychology postdoctoral fellow with the Addictive Disorders Treatment Program at the G.V. (Sonny) Montgomery VA Medical Center, said in the press release. “The implications derived from such work not only inform future research efforts, but they directly impact all facets of substance use disorder treatment – whether assessment, diagnosis, selection of appropriate treatment interventions, billing or reimbursement.”

The researchers evaluated data from state prison admissions, consisting of a population of 6,871 men and 801 women. All inmates were between the ages of 18 and 65 years of age, and slightly more than half were white. Of the minority inmates, African Americans comprised the largest proportion (31.5 men and 21.5% women), followed by Native Americans (7.7% men and 13.2% women). The researchers used data from this population to compare the DSM-5 severity index for alcohol use disorder to the ICD-10 clinical and research formulations for harmful use and dependence.

The researchers found a high level of concordance between the two diagnostic approaches in patients with severe alcohol use disorder and those that did not receive a diagnosis. Almost all (99.4%) of those diagnosed with an alcohol use disorder under the DSM would get an ICD alcohol dependence diagnosis. In addition, 65% of those with a moderate DSM-5 diagnosis and nearly 10% of those with a mild diagnosis would be diagnosed with dependence based on the clinical ICD-10 criteria. Similarly, a substantial percentage (96.4%) of patients who did not receive a DSM-5 diagnosis would not be diagnosed under the ICD-10.

However, slightly more than one-third (35.9%) of patients deemed mild under the DSM-5 would not receive a diagnosis under the ICD-10, and 1.5% of DSM-5 moderate patients would not receive a diagnosis based on the ICD-10.

“Roughly one-third of DSM-5 mild cases would not receive a diagnosis per the ICD-10 clinical version, which in turn translates to reduced access to treatment services for a fairly large number of individuals,” he said. “When the research version criteria are applied, we see this number rise to nearly one-half of all mild cases.”

According to Proctor, these findings could have implications for treatment coverage and outcomes.

“Considering the wide variation in the specific criteria or symptoms used to arrive at a diagnosis between systems, additional research is necessary to identify relevant prognostic factors and determine the clinical course for these two groups,” Proctor said in the press release.

Disclosure: Hoffman reports acting as President of Evince Clinical Assessments and receiving compensation from the sale of his diagnostic instruments. Kopak reports no relevant financial disclosures.