Addressing the Underdiagnosis of Alcohol Use Disorder: A Simple Symptom Checklist Can Assist Diagnosis and Monitoring in Routine Medical Care

Newswise — Symptoms of alcohol use disorder (AUD) can be reliably assessed with an Alcohol Symptom Checklist during routine care among patients who screen positive for high-risk drinking, according to a study in Alcoholism: Clinical and Experimental Research. The checklist can be easily administered in primary care settings, and can help providers diagnose AUD, determine its severity, and monitor changes in symptoms over time. To date, a lack of practical tools to reliably assess AUD symptoms has contributed to the underdiagnosis and undertreatment of AUD, despite the availability of effective treatments. Brief screening questionnaires can identify people with high-risk drinking and are increasingly used, but these do not assess symptoms required for an AUD diagnosis or the number of AUD symptoms present (required for determining the severity of a diagnosis). Although well-validated interviews for diagnosing AUD are available for research use, these require considerable time and training to administer, making them impractical for assessing AUD symptoms in routine health care settings. The current study evaluated the reliability of an Alcohol Symptom Checklist questionnaire for patient completion in routine medical care, including in primary care and mental health specialty settings.

The researchers used electronic health record data from a large integrated health system in Washington State. From 2015, this health system has implemented universal alcohol screening in routine care, followed by use of an Alcohol Symptom Checklist among patients who screen positive for high-risk drinking. Using the checklist, patients report whether they have experienced each of 11 diagnostic criteria for AUD within the past year. The resulting score reflects the number of criteria (0-11) that can help determine if an AUD diagnosis is present (≥2 criteria) and its severity (mild: 2-3 criteria; moderate: 4-5; or severe: 6-11). Previous research has shown that patients who complete the checklist after a positive screen often have AUD symptoms at levels that warrant AUD treatment, and that the checklist can discriminate AUD severity. However, no studies have evaluated the “test-retest” reliability of the checklist when used in routine care, even though this is critical for understanding how the tool performs when administered repeatedly over time. Patients may complete the checklist multiple times as part of clinical monitoring, and test-retest reliability analyses can help providers distinguish whether any reported changes likely reflect an actual change in AUD symptoms rather than an artifact of poor test-retest reliability of the questionnaire. The sample included patients (454 in total) who completed two Alcohol Symptom Checklists 1-21 days apart. Over this time window, past-year AUD symptoms are unlikely to have substantial changes, meaning that any observed changes in checklist scores are likely attributable to test-retest reliability issues, rather than actual changes in patients’ AUD symptoms.

The researchers found that the Alcohol Symptom Checklist when used in routine patient care had good-to-excellent test-retest reliability for measuring AUD symptom counts, particularly when completed in primary care. The checklist may therefore be a valuable tool for supporting AUD-related care and monitoring in routine medical practice. The patient sample was predominantly white and non-Hispanic. Future research will assess test-retest reliability among different racial and ethnic groups and subgroups.

Practical assessment of DSM-5 alcohol use disorder symptoms in routine care: High test-retest reliability of an alcohol symptom checklist. K. A. Hallgren, T. E. Matson, M. Oliver, R. M. Caldeiro, D. Kivlahan, K. A. Bradley (pages xxx)

ACER-21-5092.R1