The AUDIT (Alcohol Use Disorder Identification Test) is Used Worldwide, So How Does It Perform on U.S. College Students?

The AUDIT was developed by the World Health Organization as a simple method of screening for excessive drinking and to assist in brief assessment.

Since then it has been used world-wide in health care settings, but its accuracy on US college students has yet to be investigated since new guidelines for the diagnosis of alcohol use disorder were released in the Diagnostic and Statistical Manual-5.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The accurate identification of alcohol use disorder is the first step in screening, intervention, and third party reimbursement. The clinical criteria used to diagnose an alcohol use disorder has changed since the release of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The Alcohol Use Disorders Identification Test (AUDIT) is one of the most widely used alcohol screening instruments.

Since 2013, the AUDIT has not been validated on the college student population to determine cut-off scores for men and women or assess the accuracy in classifying DSM-5 alcohol use disorder to other drinker classification groups including the previous DSM-IV alcohol abuse or alcohol dependence, or binge drinking.

This study fills a critical gap in the literature by establishing cut-off thresholds based on the new DSM-5 alcohol use disorder diagnostic guidelines. A rigorous empirical validation of the AUDIT will ensure that current alcohol screening procedures are able to accurately identify and properly refer high risk non-treatment seeking college students.

HOW WAS THIS STUDY CONDUCTED?

This study sample consisted of 251 undergraduate students at a southeastern university in the United States who engaged in at least one binge drinking episode in the past 90 days during the year 2013. The participants were diverse with regard to class rank (senior, junior, etc.), gender, and race/ethnicity. The Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM) was used to collect DSM-IV and DSM-5 alcohol use diagnostic information.

The participants were classified as having no alcohol use disorder, DSM-5 alcohol use disorder, DSM-IV alcohol use disorder (either abuse or the more severe form of dependence), and the presence or absence of binge drinking in the previous two weeks (5+ drinks for men and 4 for women in a sitting). Advanced statistical analysis was used to determine optimal cut-off scores for college men and women and the accuracy in classifying DSM-5 alcohol use disorder to other drinker classification groups including the DSM-IV alcohol abuse or alcohol dependence, or binge drinking.

WHAT DID THIS STUDY FIND?

From the 251 students, the percent who did not meet criteria for a DSM-5 alcohol use disorder was 38.2%. The remaining 61.8% who had a DSM-5 alcohol use disorder diagnoses were categorized as follows:

mild 13.5%,
moderate 21.1%
27.1% severe

When classified according to DSM-IV guidelines, the percent of students who met criteria for an alcohol use disorder was 60.2% from which 15.1% met criteria for alcohol abuse and 45% alcohol dependence. DSM-IV alcohol dependence is equivalent to the current DSM-5 guidelines for moderate and severe alcohol use disorder.

Overall, the analysis showed that the AUDIT had reasonably good discrimination across all of the DSM-IV and DSM-5 classifications with the highest level of discrimination occurring for the assessment of binge drinking within the previous two weeks.

To determine the best cut-off scores on the AUDIT that distinguish between students with and without a DSM-5 alcohol use disorder, the researchers identified the score that simultaneously optimized both the sensitivity (ability of the AUDIT to correctly identify students with alcohol use disorder) and specificity (ability of the AUDIT to correctly identify students without alcohol use disorder) which was a score greater than or equal to 8.

When analyzing males separately from females, the results proved to be different.

Among males, the AUDIT was found to have the highest level of discrimination for binge drinking and the lowest discrimination for DSM-IV alcohol abuse or dependence; however, both were still reasonably good at classifying symptomology. The optimal cut-off score to identify college males with an alcohol use disorder was greater than or equal to 9.
The analysis for female college students revealed the optimal cut-off score to identify an alcohol use disorder was greater than or equal to 8, and the AUDIT was most proficient at discriminating binge drinking but still accurate for classifying alcohol use disorder.

WHY IS THIS STUDY IMPORTANT?

This thorough study showed that the AUDIT is valid, helpful & more accurate than chance alone at detecting alcohol use disorder among non-treatment seeking college students.

In addition, the results indicated that gender specific AUDIT cut-off scores should be used to detect alcohol use disorder according to DSM-5 guidelines. This study added to the existing body of literature on the AUDIT which continues to reinforce that different cut-off scores are required to correctly identify DSM-5 alcohol use disorder in females compared to males, which is similar to previous findings on the DSM-IV.

Another important finding was that the AUDIT performed almost equally well in the detection of DSM-IV and DSM-5 diagnostic status. Therefore, any reduction in the diagnostic precision in detecting DSM-IV or DSM-5 classification should be marginal. The result that indicated the AUDIT had more discrimination for the detection of binge drinking was probably due to the items that measure drinking quantity and frequency which can result in increased precision.

LIMITATIONS

It should be noted that the sensitivity and specificities across AUDIT cut-off scores in this sample were low. Therefore, the cutoff scores identified in this study may not be suited for all situations involving college students.
This study included a single sample from one university. Increasing the sensitivity and specificity of the AUDIT will require replication studies on college students recruited from diverse universities.

NEXT STEPS

According to the DSM-5 criteria for alcohol use disorder, there are three classifications of severity: mild (2-3 criteria), moderate (4-5 criteria), and severe (6-7 criteria). More work needs to done to identify AUDIT cut scores that correspond with each of these classifications for college student populations. The identification of severity cut scores would facilitate treatment recommendations and recovery plans.

BOTTOM LINE

For individuals & families seeking recovery: This study of the AUDIT does not lend itself to making specific recommendations for individuals or families seeking treatment or recovery. However, alcohol use disorder can begin to have an impact on people’s lives long before they realize it so obtaining a screening from a health care professional can be helpful in order to gain valuable feedback on alcohol use. In this study it was shown that male versus female college students can have different cutoff scores on this screening device that is used to classify students with an alcohol use disorder. Therefore, it may be important to know that the manifestation of alcohol use disorder may look slightly different in males versus their female counterparts.
For Scientists: This study evaluated the performance of the AUDIT in screening for DSM-5 alcohol use disorder in non-treatment seeking college students. Different cutoff scores were identified for male versus female students (8 and 9 respectively); however, other various demographics were not explored (e.g., high versus low socioeconomic status). Further testing on demographic subtypes may assist in modifying protocols to target populations.
For Policy makers: The accuracy of the AUDIT to detect DSM-5 alcohol use disorders has received little attention in college student populations. Rates of alcohol use disorders peak during the college years. If alcohol use disorders go undiagnosed in college, it may lead to a more severe and chronic form of alcohol use disorder later in life. Consider prioritizing research and funding to determine how other widely used alcohol screening measures perform when compared to the AUDIT. This type of evaluation would assist in screening and brief interventions aimed at sub-groups of high risk college students.
For Treatment professionals and treatment systems: This study adds to a large body of literature that shows that the AUDIT is a valid and reliable screening device for alcohol use disorder. Although this study focused on non-treatment seeking college students, the tool has been well validated in primary care settings as well. The AUDIT consists of only 10 items and has the capability to enhance health services outreach for individuals with alcohol use disorder.

CITATIONS

Hagman, B. T. (2016). Performance of the AUDIT in detecting DSM-5 alcohol use disorders in college students, Substance Use & Misuse, 51:11, 1521-1528. DOI: 10.1080/10826084.2016.1188949