The 5-year course of alcohol abuse among young adults

Abstract

Purpose: This study describes the course of alcohol abuse among a nationally representative sample of young adults over a 5-year time period for the purpose of examining the validity of the DSM-IV alcohol abuse category. Methods: DSM-IV diagnoses of alcohol abuse at baseline and follow-up were examined using logistic regression analyses. Results: Alcohol abuse and dependence were shown to have different courses. Very few abusers at Time 1 became dependent at Time 2, suggesting that abuse is not merely prodromal to dependence. Females, Blacks, and high school dropouts were less likely to receive an abuse diagnosis at baseline. Marital status, family history, earlier onset of drinking, and heavy drinking were also related to abuse at baseline. Alcohol abuse at baseline, in addition to gender, marital status, family history, early onset drinking, and heavy drinking, predicted abuse at follow-up. Exclusion of the hazardous criterion item “driving after drinking too much” from the abuse diagnosis yielded similar results. Discussion: The DSM-IV alcohol abuse category was shown to have some diagnostic utility.

Introduction

Current diagnostic criteria for alcohol use disorders, published by the American Psychiatric Association (1994) in its Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV), distinguish between alcohol abuse and alcohol dependence. The definition of alcohol dependence draws heavily upon the alcohol dependence syndrome (Edwards & Gross, 1976) and the validity of the concept has now been well established (Helzer, 1994). The conceptual basis of alcohol abuse, other than the need for a diagnosis when alcohol use leads to impairment, has not received comparable attention (Langenbucher & Martin, 1996). Alcohol abuse is diagnosed only in the absence of dependence and is characterized by meeting one of four criteria: (1) recurrent use of alcohol in hazardous situations; (2) recurrent alcohol-related legal problems; (3) continued use despite social or interpersonal problems; or (4) failure to fulfill major role obligations.

A study of symptom onset in 369 clinical cases revealed the presence of three discrete stages, with alcohol abuse as a discrete first illness phase (Langenbucher & Chung, 1995). Hasin, Grant, and Endicott (1990) argued that if abuse constitutes a mild condition prodromal to dependence then the validity of the distinction between abuse and dependence is challenged, since it would represent an early manifestation of dependence.

There have been few longitudinal studies in the general population on the course of alcohol abuse and its relationship to alcohol dependence. Drawing upon a 1973 follow-up of a 1969 national survey of men, Hasin et al. (1990) found that 24% of the respondents reported indicators of alcohol abuse 4 years later, 46% were in remission, and 30% reported indicators of alcohol dependence. While the findings showed that the longitudinal course of alcohol abuse was significantly different from dependence, the study was restricted to men and used an earlier definition of alcohol abuse based on the then-current Third Edition Revision of the DSM, (DSM-III-R: American Psychiatric Association, 1994) that yielded a low prevalence of abuse. A subsequent study with a community sample of heavy-drinking men and women used DSM-IV diagnostic criteria with a 1-year follow-up and revealed that the course of alcohol abuse differed from that of dependence (Hasin, Van Rossem, McCloud, & Endicott, 1997). While the majority of respondents with dependence at baseline remained dependent at follow-up (67%), only 6% of respondents with abuse at baseline became dependent at follow-up, a rate comparable to that of respondents who had no alcohol diagnosis at baseline (7%).

In a related analysis of data from this community study, Hasin and Paykin (1999) used a subset of respondents who never met the criteria for DSM-IV alcohol dependence at baseline to examine the validity of the DSM-IV alcohol abuse category. Comparisons between abusers and respondents with no diagnosis indicated that abusers were younger and White, and reported higher frequencies of heavy, episodic drinking in the past year. Unlike dependence, alcohol abuse was not related to family history of alcoholism or alcohol problems. Respondents with a baseline diagnosis of alcohol abuse were six times more likely to receive a diagnosis of abuse at follow-up when compared to those with no diagnosis at baseline. Despite the fact that DSM-IV diagnosis of abuse involves four criteria, only one criterion must be met, and the majority of respondents in this study met the diagnosis based on the hazardous use criterion, which was nearly always driving after drinking too much. Given the short length of follow-up in this study, the authors suggested that further study with longer term information about the course of abuse in the general population is warranted.

The objective of the present study is to describe the course of alcohol abuse among a nationally representative sample of young adults aged 25 through 32 years in 1989 at baseline and aged 30 through 37 years 5 years later at reinterview. In addition to the demographic characteristics of age, gender, and race, the present study also compares abusers and those with no diagnosis at baseline with respect to several other characteristics associated with alcohol use disorders: family history of alcoholism, heavy episodic drinking, age at onset of alcohol use, educational status, and marital disruption. The longitudinal framework for the measures of family history and age at onset overcomes some of the limitations imposed by the cross-sectional designs of earlier studies. A second advantage in the present study is the use of a large nationally representative sample of young adults at an age when the prevalence of alcohol abuse is high. The large sample provides a unique opportunity to examine the contribution of the high-prevalence abuse item related to drinking and driving to the course of alcohol abuse.