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Diagnosing comorbidity: concepts, criteria, and methods

Published online by Cambridge University Press:  24 June 2014

S. Samet,
E. V. Nunes and
D. Hasin
S. Samet*
Affiliation:
New York State Psychiatric Institute
E. V. Nunes
Affiliation:
New York State Psychiatric InstituteCollege of Physicians and Surgeons, Department of Psychiatry, Columbia University
D. Hasin
Affiliation:
New York State Psychiatric InstituteMailman School of Public Health, Division of Epidemiology, Columbia University, New York, NY
*
Sharon Samet, MSW, Columbia University/New York State Psychiatric Institute, 1051 Riverside Drive, Box 123, New York, NY 10032. E-mail: ss1456@columbia.edu
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Abstract

Background:

The clinical and etiologic implications of comorbid psychiatric and substance-use disorders are relevant across countries and cultures. The DSM-IV now places greater emphasis on the clinical and research utility of the substance-induced disorders classification, and clarifies several important diagnostic issues specific to primary and substance-induced disorders. However, no research consensus exists over the core problem of identifying and differentiating the drug and alcohol intoxication and withdrawal symptoms that can mimic psychiatric symptoms in heavy drinkers and drug users.

Objective:

To investigate how various diagnostic instruments have measured comorbid psychiatric and substance-use disorders and how each instrument operationalizes the DSM-IV classification.

Method:

We review the evolution of the concept of comorbidity beginning with its formalization as the ‘primary–secondary’ distinction in the Feighner Criteria. We address the ‘organic–non-organic’ distinction found in the RDC, DSM-III, and DSM-III-R; and finally, review the ‘primary’ and ‘substance-induced’ categories of DSM-IV, DSM-IV-TR and ICD-10. We describe how these distinctions have been operationalized in widely used diagnostic instruments.

Conclusion:

Further understanding of these classifications and the relationship of co-occurring psychiatric and substance disorders can be accomplished with the range of available measures, particularly the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), which reliably utilizes and refines DSM-IV classification distinctions.

Keywords

substance-induced disordersdiagnostic interviewspsychiatric comorbiditydual diagnosisdiagnostic criteria

Information

Type
Research Article
Information
Acta Neuropsychiatrica , Volume 16 , Issue 1 , February 2004, pp. 9 - 18
Copyright
Copyright © 2004 Blackwell Munksgaard

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References

Hesselbrock, VM, Stabenau, J, Hesselbrock, M, Mirkin, P, Meyer, R. A comparison of two interview schedules. The Schedule for Affective Disorders and Schizophrenia-Lifetime and the National Institute for Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 1982;39: 674–677.CrossRefGoogle ScholarPubMed
Hasin, D, Endicott, J, Lewis, C. Alcohol and drug abuse in patients with affective syndromes. Compr Psychiatry 1985;26: 283–295.CrossRefGoogle ScholarPubMed
Hasin, D, Grant, BF, Endicott, J. Lifetime psychiatric comorbidity in hospitalized alcoholics: subject and familial correlates. Int J Addictions 1988;23: 827–850. CrossRefGoogle ScholarPubMed
Merikangas, KR, Gerlernter, C. Comorbidity for alcoholism and depression. Psychiatr Clin North Am 1990;13: 613–632.Google ScholarPubMed
Rounsaville, BJ, Anton, SF, Carroll, K, Budde, D, Prusoff, BA, Gawin, F. Psychiatric diagnoses of treatment-seeking cocaine abusers. Arch Gen Psychiatry 1991;48: 43–51.CrossRefGoogle ScholarPubMed
Hasin, D, Nunes, E. Comorbidity of alcohol, drug and psychiatric disorders: epidemiology. In: Kranzler, HR, Rounsaville, BJ, eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York, NY: Marcel Dekker, Inc., 1997: 1–31. Google Scholar
Schneider, U, Altmann, A, Baumann, Met al. Comorbid anxiety and affective disorder in alcohol-dependent patients seeking treatment: the first multicentre study in Germany. Alcohol Alcohol 2001;36: 219–223.CrossRefGoogle ScholarPubMed
Melartin, TK, Rytsala, HJ, Leskela, US, Lestela-Mielonen, PA, Sokero, TP, Isometsa, ET. Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study. J Clin Psychiatry 2002;63: 126–134.CrossRefGoogle ScholarPubMed
Hannesdottir, H, Tyrfingsson, T, Piha, J. Psychosocial functioning and psychiatric comorbidity among substance-abusing Icelandic adolescents. Nord J Psychiatry 2001;55: 43–48.Google ScholarPubMed
Moggi, F, Brodbeck, J, Koltzsch, K, Hirsbrunner, HP, Bachmann, KM. One-year follow-up of dual diagnosis patients attending a 4-month integrated in-patient treatment. Eur Addiction Res 2002;8: 30–37. CrossRefGoogle Scholar
Parrott, AC, Milani, RM, Parmar, R, Turner, JD. Recreational ecstasy/MDMA and other drug users from the UK and Italy: psychiatric symptoms and psychobiological problems. Psychopharmacology (Berl) 2001;159: 77–82.CrossRefGoogle ScholarPubMed
Marsden, J, Gossop, M, Stewart, D, Rolfe, A, Farrell, M. Psychiatric symptoms among clients seeking treatment for drug dependence. Intake data from the National Treatment Outcome Research Study. Br J Psychiatry 2000;176: 285–289.CrossRefGoogle ScholarPubMed
Ahmadi, J, Fakoor, A, Pezeshkian, P, Khoshnood, R, Malekpour, A. Substance use among Iranian psychiatric in-patients. Psychol Rep 2001;89: 363–365.CrossRefGoogle Scholar
Ahmad, B, Mufti, KA, Farooq, S. Psychiatric comorbidity in substance abuse (opioids). J Pak Med Assoc 2001;51: 183–186.Google Scholar
Lin, CC, Bai, YM, Hu, PG, Yeh, HA. Substance use disorders among in-patients with bipolar disorder and major depressive disorder in a general hospital. Gen Hosp Psychiatry 1998;20: 98–101.CrossRefGoogle Scholar
Chen, CC, Tsai, SY, Su, LW, Yang, TW, Tsai, CJ, Hwu, HG. Psychiatric co-morbidity among male heroin addicts: differences between hospital and incarcerated subjects in Taiwan. Addiction 1999;94: 825–832.CrossRefGoogle ScholarPubMed
Rabinowitz, J, Mark, M, Popper, M, Slyuzberg, M. Reported comorbidity of mental disorders with substance abuse among psychiatric in-patients in Israel. J Ment Health Adm 1996;23: 471–478.CrossRefGoogle Scholar
Regier, D, Farmer, M, Rae, D, Locke, B, Keith, S, Judd, L, Goodwin, F. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 1990; 264: 2511–2518.CrossRefGoogle ScholarPubMed
Grant, BF, Harford, TC. Comorbidity between DSM-IV alcohol use disorder and DSM-IV major depression: results of a national survey. Drug Alcohol Depend 1995;39: 197–206.CrossRefGoogle ScholarPubMed
Kessler, RC, Crum, RM, Warner, LA, Nelson, CB, Schulenberg, J, Anthony, JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry 1997;54: 313–321.CrossRefGoogle ScholarPubMed
De Graaf, R, Bijl, R, Smit, F, Vollebergh, W A, Spijker, J. Risk factors for 12-month comorbidity of mood, anxiety, and substance use disorders: findings from the Netherlands Mental Health Survey and Incidence Study. Am J Psychiatry 2002;159: 620–629.CrossRefGoogle ScholarPubMed
Farrell, M, Howes, Set al. Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a national household survey. Br J Psychiatry 2001;179: 432–437.CrossRefGoogle ScholarPubMed
Aalto-Setala, T, Marttunen, M, Tuulio-Hendriksson, A, Poikolainen, K, Lonnqvist, J. One-month prevalence of depression and other DSM-IV disorders among young adults. Psychol Med 2001;31: 791–801.CrossRefGoogle ScholarPubMed
Kringlen, E, Togersen, S, Cramer, V. A Norwegian psychiatric epidemiological study. Am J Psychiatry 2001;158: 1091–1098.CrossRefGoogle ScholarPubMed
Chong, MY, Chan, KW, Cheng, AT. Substance use disorders among adolescents in Taiwan: prevalence, sociodemographic correlates and psychiatric co-morbidity. Psychol Med 1999;29: 1387–1396.CrossRefGoogle ScholarPubMed
Abou-Saleh, MT, Ghubash, R, Daradkeh, TKA, AL Ain Community Psychiatric Survey., I. Prevalence and socio-demographic correlates. Soc Psychiatry Psychiatr Epidemiol 2001;36: 20–28.CrossRefGoogle ScholarPubMed
Pakriev, S, Vasar, V, Aluoja, A, Shlik, J. Prevalence of ICD-10 harmful use of alcohol and alcohol dependence among the rural population in Udmurtia. Alcohol Alcohol 1998;33: 255–264.CrossRefGoogle ScholarPubMed
Hasin, DS, Grant, BF. Assessment of specific drug disorders in a sample of substance abuse patients. a comparison of the DIS and the SADS-L procedures. Drug Alcohol Depend 1987;19: 167–176. CrossRefGoogle Scholar
Hasin, D, Grant, BF. Diagnosing depressive disorders in patients with alcohol and drug problems. a comparison of the SADS-L and the DIS. J Psychiatric Res 1987; 21: 301–311. CrossRefGoogle ScholarPubMed
Weiss, RD, Mirin, S, Griffin, M. Methodological considerations in the diagnosis of coexisting psychiatric disorders in substance abusers. Br J Addiction 1992;87: 179–187. CrossRefGoogle Scholar
Spitzer, RL, Endicott, J, Robins, E. Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry 1978;35: 773–782.CrossRefGoogle ScholarPubMed
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. Washington, D.C.: American Psychiatric Association, 1980. Google ScholarPubMed
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. Rev. (DSM-III-R). Washington, D.C.: American Psychiatric Association, 1987. Google ScholarPubMed
American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). Washington, D.C.: American Psychiatric Association, 1994. Google ScholarPubMed
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, D.C.: American Psychiatric Association, 2000. Google ScholarPubMed
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioral Disorders. Geneva: World Health Organization, 1992. Google ScholarPubMed
Feighner, JP, Robins, E, Guze, SB, Woodruff, RAJ, Winokur, G, Munoz, R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 1972;26: 57–63.CrossRefGoogle ScholarPubMed
World Health Organization (WHO). ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization, 1993. Google ScholarPubMed
First, MB, Gibbon, M, Spitzer, RL, Williams, JB. Users guide for the Structured Clinical Interview for DSM-IV-TR Axis I Disorders – research version – (SCID-I for DSM-IV-TR. February 2001 revision.Google Scholar
Williams, JB, Gibbon, M, First, MBet al. Multisite test-retest reliability. Arch Gen Psychiatry 1992;49: 198–205. Google ScholarPubMed
Bryant, KJ, Rounsaville, BJ, Spitzer, RL, Williams, J B. Reliability of dual diagnosis: substance dependence and psychiatric disorders. J Nerv Ment Dis 1992;180: 251–257.CrossRefGoogle ScholarPubMed
Ross, HE, Swinson, R, Doumani, S, Larkin, EJ. Diagnosing comorbidity in substance abusers: a comparison of the test-retest reliability of two interviews. Am J Drug Alcohol Abuse 1995;21: 167–185.CrossRefGoogle ScholarPubMed
Kranzler, HR, Kadden, R, Burleson, JA, Babor, TF, Apter, A, Rounsaville, BJ. Validity of psychiatric diagnoses in patients with substance use disorders: is the interview more important than the interviewer. Compr Psychiatry 1995;36: 278–288.CrossRefGoogle Scholar
Kranzler, HR, Kadden, R, Babor, TF, Tennen, H, Rounsaville, BJ. Validity of the SCID in substance abuse patients. Addiction 1996;91: 859–868.CrossRefGoogle ScholarPubMed
Bucholz, KK, Cadoret, R, Cloninger, CRet al. A new, semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA. J Stud Alcohol 1994;55: 149–158.CrossRefGoogle ScholarPubMed
Hesselbrock, M, Easton, C, Bucholz, KK, Schuckit, M A, Hesselbrock, VM. A validity study of the SSAGA-a comparison with the SCAN. Addiction 1999;94: 1361–1370.CrossRefGoogle Scholar
Janca, A, Ustun, TB, Sartorius, N. New versions of World Health Organization instruments for the assessment of mental disorders. Acta Psychiatr Scand 1994;90: 73–83.CrossRefGoogle ScholarPubMed
Regier, DA, Myers, JK, Kramer, Met al. The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 1984;41: 934–941.CrossRefGoogle ScholarPubMed
Myers, JK, Weissman, MM, Tischler, Get al. Six-month prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry 1984;41: 959–967.CrossRefGoogle ScholarPubMed
Robins, LN, Helzer, JE, Weissman, MM, Orvaschel, H, Gruenberg, E, Burke, J, Regier, D. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984;41: 949–958.CrossRefGoogle ScholarPubMed
Wing, J, Babor, TF, Brugha, Tet al. Schedules for Clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990;47: 589–593.CrossRefGoogle ScholarPubMed
Silverstone, PH. SCAN accurately gives diagnoses according to DSM-III-R criteria: validation in psychiatric patients using SADS. Int J Meth Psychiatric Res 1993;3: 209–213. Google Scholar
Endicott, J, Spitzer, RL. A diagnostic interview. the Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 1978;35: 837–844.CrossRefGoogle Scholar
Robins, LN, Wing, J, Wittchen, HUet al. The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry 1988;45: 1069–1077.CrossRefGoogle ScholarPubMed
World Health Organization (WHO). Composite International Diagnostic Interview (cIdI). Chapter 4, Probing. Composite International Diagnostic Interview (CIDI): Core, Version 2.1. Interviewer's Manual 23. 1-1-1997. Available at Http://www.Who.International/Msa/Cidi.Accessedjanuary6, 2002. Google Scholar
Verheul, R, Hartgers, C, Van Den Brink, W, Koeter, M WJ. The effect of sampling, diagnostic criteria and assessment procedures on the observed prevalence of DSM-III-R personality disorders among treated alcoholics. J Stud Alcohol 1998;59: 227–236.CrossRefGoogle ScholarPubMed
Hasin, D, Trautman, K, Miele, G, Samet, S, Smith, M, Endicott, J. Psychiatric Research Interview for Substance and Mental Disorders (PRISM): Reliability for substance abusers. Am J Psychiatry 1996;153: 1195–1201.Google ScholarPubMed
Hasin, D, Trautman, K, Endicott, J. Psychiatric research interview for substance and mental disorders: phenomenologically-based diagnosis in patients who abuse alcohol or drugs. Psychopharmacol Bull 1998; 34: 3–8.Google ScholarPubMed
Caton, C, Samet, S, Hasin, D. When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders. J Psychiatric Prac 2000;6: 256–266. CrossRefGoogle ScholarPubMed
Schuckit, MA. Genetic and clinical implications of alcoholism and affective disorder. Am J Psychiatry 1986;143: 140–147.Google ScholarPubMed
Hasin, DS, Grant, BF. Major depression in 6,050 former drinkers: association with past alcohol dependence. Arch Gen Psychiatry 2002;59: 794–800.CrossRefGoogle Scholar
Hasin, D, Liu, X, Nunes, E, McCloud, S, Samet, S, Endicott, J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry 2002;59 (375):380. CrossRefGoogle ScholarPubMed
Aharonovich, E, Liu, X, Nunes, E, Hasin, D. Suicide attempts in substance abusers: effects of major depression in relation to substance use disorders. Am J Psychiatry 2002;169: 1600–1602. CrossRefGoogle Scholar