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Validation of alcohol consumption selfreports in the Munich Composite International Diagnostic Interview (M-CIDI) Sren Kuitunen-Paul *, Gerhard Bhringer, Jrgen Rehm, Jakob Manthey, Dirk W. Lachenmeier, Hans-Ulrich Wittchen * Institute of Clinical Psychology and Psychotherapy, TU Dresden, Germany 2nd European Conference on Addictive Behaviours and Dependencies, Lisbon, Portugal, 24.10.2017 Introduction Alcohol consumption Prevalent: Normative recreational behavior, frequently in problematic patterns 1 Hazardous: increased risk of morbidity 2,3 and mortality 3,4 leading to a significant burden for societies and the economics 2,5 Central clinical outcome 6 Usually assesed via subjective reports 7,8, e.g. using the CIDI: diagnostics, epidemiology, basic research 2 3 Gomes de Matos et al. (2016) Roerecke & Rehm (2013) WHO 2014 4 Kuitunen-Paul & 2 7 8 Roerecke (submitted) 5 Trautmann, Rehm & Wittchen (2016) 6 Stockwell et al. (2009) AWMF (2016) 1 Introduction Shortcomings of subjective reports false reports (underreporting) 9,10,11 quality depending on the assessment characteristics of the instrument 9,10 alternative established outcomes limited accordance with objective markers 9,12 therefore

biases might impact sample-/population-based estimations restricted usability of consumption reports as a AUD criterion 13,14 Kip et al. (2008) 12 Kerr & Stockwell (2012) 9 10 13 11 Tourangeau & Yan (2007) Greenfield & Kerr (2008) 14 Rehm (2016) Rehm, Marmet et al. (2013) 3 Research questions 1 (1) Which assesment characteristics & problems are related to quantity and frequency assessment in the M-CIDI? 1,2,3 (2) Are M-CIDI consumption reports valid and relevant in clinical and epidemiological applications? 3,4,5 Kuitunen-Paul, Rehm et al. (2017) 3 2 Kuitunen-Paul, Hfler et al. (in prep.)

Kuitunen & Kuitunen-Paul (in prep.) Results Munich Composite International Diagnostic Interview (M-CIDI) x,1: Gathers information on typical drinking episodes Consumption quantity (drink categories): Consumption frequency (past 12 months, past month, maximum during lifetime): x Lachner et al. (1998) 1 Kuitunen-Paul, Rehm et al. (2017) Results Material: in comparison to alternative instruments using a drink list (AUDIT, TLFB, WHO-CIDI) M-CIDI presents more drink categories 1 1 Kuitunen-Paul, Rehm et al. (2017) Results Material: Descriptive distribution of CIDI drink categories among GP patients and the general population Some categories are irrelevant while others are quite extensive1 1 Kuitunen-Paul, Rehm et al. (2017)

Results (prelim.) Material: AF-CIDI study (n=162), see Maraschino Weizen, Pilsener, Obstler 2 Kuitunen, Scheffel & Kuitunen-Paul (in prep.) Madeira, Ouzo, Malaga Sambuca Sherry, Wermut, Sangria Results Quantity assessment: Comparing % vol-specifications between real beverages and and M-CIDI-conventions in relation to drink category and serving size data from k=22,503 alcoholic beverages sold in Germany in 2010-2016 1 Kuitunen-Paul, Rehm et al. (2017) Results CIDI conventions are inconsistent across categories/sizes1 1 Kuitunen-Paul, Rehm et al. (2017) Assumed number of drinking days per week

Results Frequency assessment 3: Find best-fitting model Predefined M-CIDI answer categories for drinking frequency almost every day 3 to 4 times a week 1 to 2 times a week 1 to 3 times a month less than once a month MINmodel MEDmodel MAXmodel 5 3 1 0.25 0.075* 6 3.5 1.5 0.5 0.125* 7 4 2 0.75 0.25 Number of drinking days past month: CIDI-conversions vs. TLFB (n = 74 AUD inpatients, n = 104 non-AUD males aged 18). Graphs from A.Motzel (2017, Master thesis).

3 Kuitunen-Paul, Hfler Results Relevance of the CIDI QF-Index among n=164 18year old males without alcohol dependence: associated with risky drinking (AUDIT-C classification) 5 among n=1,356 GP patients (APC-Study) who were diagnosed by GP and CIDI: associated with probability for alcohol dependence diagnosis both by GP+CIDI 6 5 Kuitunen-Paul, Pfab et al. (submitted) 6 Kuitunen-Paul, Manthey et al. (2016) Conclusion Consumption self-reports are detailed1 and relevant5,6, but Material can be improved: some drink categories irrelevant1, extensive1, ambiguous2 Quantity-conversion inconsistent1 Frequency-conversion varies, probably according to AUD status3 2 Kuitunen-Paul, Rehm et al. (2017) Kuitunen, Scheffel & Kuitunen-Paul (in 3 prep.) Kuitunen-Paul, Hfler et al. (in prep.) 1 Discussion Strengths: Multicenter studies Multiple methods used (FTIR, self-reports, thirt-person reports) Controlling for several influencing factors

Limitations: Samples from one country (%vol) or two countries (patients) only Unknown acceptance, feasibility, and time demands of the revised supplementary sheet Diagnostic relevance Broader implications: retrospective self reports inferior to EMA or transdermal measurement? 16 Consumption as AUD criterion 13,14,15 13 Rehm (2016) 14 Rehm, Marmet et al. (2013) 15 Saha et al. (2007) 16 Morgenstern et al. (2014) Principal investigators Katja Beesdo-Baum Gerhard Bhringer

Andreas Heinz Dirk W. Lachenmeier Michael A. Rapp Jrgen Rehm Michael N. Smolka Hans-Ulrich Wittchen Ulrich S. Zimmermann Lars Pieper Oana G. Rus Lucie Scholl Miriam Sebold Christian Sommer Jens Strehle Sebastian Trautmann Student assistants Karoline Sauer Lara Seefeld Christoph Scheffel

Gianna Spitta Katrin Staab Anja Tritt Anna-Maria Walter-Daume Jean Wendt Jurij Wiede Monique Zobel Ute Bttner Eva Grunenberg Thesis candidates Lucia Hmmerl Research staff Franziska Bender Firdeus Kadric Anne Beck Erren Hua zlem-Feray Kayali Silke Behrendt Danielle Jackson Julia Kleindienst Julian Birkenstock Robin Jadkowski Elisabeth Kluge Robin Frank Lucia Kuipers

Francie Kriegel Eva Friedel Franziska Koch Paula T. Kuitunen Maria Garbusow Alexandra Motzel Eva Maaen Michael Hfler Theresa Mller Dave Mwisch Anja Krplin Annika Pielenz Elisabeth Mhlfeld Jakob Manthey Anna Rademacher Cornelia Neumann Stephan Nebe Britta Rwer Luise Olbricht Elisabeth Obst

Lena Schulz Sioned Pfab Mirjam Petersen Supported by the German Research Foundation DFG (fundings WI 709/10-1, WI 709/10-2, and others) [email protected] Literature Introduction/Discussion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Gomes de Matos, E., Atzendorf, J., Kraus, L., & Piontek, D. (2016). Substanzkonsum in der Allgemeinbevlkerung in Deutschland: Ergebnisse des Epidemiologischen Suchtsurveys 2015. Sucht, 62, 271-281. Roerecke, M. & Rehm, J. (2013). Alcohol use disorders and mortality: a systematic review and meta-analysis. Addiction, 108, 15621578 WHO World Health Organization (2014 ). Global status report on alcohol and health 2014. Geneva: WHO. Kuitunen-Paul, S., & Roerecke, M. (submitted). Alcohol Use Disorders Identification Test (AUDIT) and mortality risk: A systematic review and meta-analysis. Trautmann, S., Rehm, J., & Wittchen, H.-U. (2016). The economic costs of mental disorders. EMBO reports, 17, 1245-1249. Stockwell, T., Zhao, J., & Thomas, G. (2009). Should alcohol policies aim to reduce total alcohol consumption? New analyses of Canadian drinking patterns. Addiction Research & Theory, 17, 135-151. AWMF Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (2016). S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Strungen. AWMFRegister-Nr. 076-001. Retrieved from Kuitunen-Paul, S., Rehm, J., Lachenmeier, D. W., Kadri, F., Kuitunen, P. T., Wittchen, H.-U., & Manthey, J. (2017). Assessment of alcoholic standard drinks using the Munich composite international diagnostic interview (M-CIDI): An evaluation and subsequent revision. International Journal of Methods in Psychiatric Research, 26, e1563. doi:10.1002/mpr.1563 Kip, M. J., Spies, C. D., Neumann, T., Nachbar, Y., Alling, C., Wurst, F. M. (2008). The Usefulness of Direct Ethanol Metabolites in Assessing Alcohol Intake in Nonintoxicated Male Patients in an Emergency Room Setting. Alcoholism: Clinical and Experimental Research, 32, 1284-1291.

Tourangeau, R. & Yan, T. (2007). Sensitive questions in surveys. Psychological Bulletin, 133, 859-883. Greenfield, T. K., & Kerr, W. C. (2008). Alcohol measurement methodology in epidemiology: Recent advances and opportunities. Addiction, 103, 10821099. Kerr, W. C., & Stockwell, T. (2012). Understanding standard drinks and drinking guidelines. Drug and Alcohol Review, 31, 200205. Rehm, J. (2016). How should prevalence of alcohol use disorders be assessed globally? International Journal of Methods in Psychiatric Research, 25, 79-85. Rehm, J., Marmet, S., Anderson, P., Gual, A., Kraus, L., Nutt, D. J., Samokhvalov, A. V. (2013). Defining Substance Use Disorders: Do we really need more than heavy use? Alcohol and Alcoholism, 48, 633640. Saha, T. D., Stinson, F. S., & Grant, B. F. (2007). The Role of Alcohol Consumption in Future Classifications of Alcohol Use Disorders. Drug and Alcohol Dependence, 89, 82-92. Morgenstern, J., Kuerbis, A., & Muench, F. (2014). Ecological momentary assessment and alcohol use disorder treatment. Alcohol Research: Current Reviews, 36, 101110. Results x Lachner, G., Wittchen, H.

Diagnostic Interview (M-CIDI). Paper presented at the Lisbon Addictions 2017 Congress Lissabon, Portugal. Background: Self-reports of recent alcohol consumption represents a crucial construct in addiction theories and research [1]. Next to biases in reporting behavior [2,3], also measurement characteristics may impact the validity of measures such as questionnaires and interviews [2,4]. Research question: Which properties of the M-CIDI consumption assessment may be related to reporting behavior [1] and how do they translate into population-based consumption estimates [5]? Methods: We compare the M-CIDI to commonly applied self-report measures. Based on epidemiological samples and a non-representative beverage sample, we analyze presented drink types including the type-wise alcohol concentrations, consumption frequency categories, and transformation conventions for the quantity-frequency index. Results: Extra drink-types presented by M-CIDI only may be irrelevant for epidemiological settings. Standard drink conversion factors differ according to drink type and serving amount. Categorical frequency-assessment of the M-CIDI differentially under- or overestimates the number of TLFB drinking days, depending on transformation conventions. Quantity-frequency indices of the M-CIDI are related to alcohol dependence diagnosis both by general practitioners and a standardized diagnostic interview. Key conclusion: We suggest revisions of the M-CIDI drink list concerning classification of drinks [1], conversion of %alc into standard drinks [1], and converting frequencies into the maximum number of days [5], however, possible effects on consumption estimates might be small and equivocal [5]. Analyses were partly supported through grants by the German Research Foundation (WI 709/10-1, WI 709/10-2). Results Outlook Quantity assessment: Understanding of M-CIDI drink categorization by consumers 1 Online survey, finished

05/2017 See identifier NCT03097354 2 Kuitunen & Kuitunen-Paul (in prep.) Outlook Relevance Identification of non-dependent risky drinkers n=164 18year old German males QF-Index associated with AUDIT-C classification, but not with AUDIT classification 5 Relevance Identification of dependence vs. general practicioners n=76 GPs with n=1,356 assessed GP patients (APC-Study) CIDI QF-Index associated with convergent diagnosis both by GP and CIDI 6 5 Kuitunen-Paul, Pfab et al. (submitted) 6 Kuitunen-Paul, Manthey et al. (2016) Abstract Objectives: Quantity and frequency of alcohol consumption are important in risk assessment as well as epidemiological and clinical research. Over the past decades, several large-scale studies have used the Munich Composite International Diagnostic Interview (M-CIDI) to assess drinking amounts. However, the accuracy of this assessment has rarely been evaluated. Methods: We evaluated the relevance of drink categories and pouring sizes, and the factors used to convert actual drinks into standard drinks. We compare the M-CIDI to alternative drink assessment instruments. Drink categories were empirically validated using primary care samples (n=322 from Italy, n=1,189 from Germany), a general population sample (n=3,165 from Germany) and a nonrepresentative set of k=22,503 alcoholic beverages sold in Germany in 2010-2016. Results: The M-CIDI supplement sheet displays more categories than other instruments (AUDIT, TLFB, WHO-CIDI). Beer, wine, and spirits represent the most prevalent categories in population samples. Previous standard drink conversion factors were inconsistent for different pouring sizes of the same drink and, to a smaller extent, across drink categories. Conclusions: For the use in Germany and Italy, we propose to limit M-CIDI drink categories and

pouring sizes, and a revision of the standard drink conversion. We further suggest corresponding examinations and revisions in other cultures. Analyses were partly supported through grants by the German Research Foundation (WI 709/10-1, WI 709/10-2). Ausgangslage Messung von Alkoholkonsum Beispiel: Alcohol Use Disorder Identification Test (AUDIT) 23 Screening-Fragebogen zu Alkoholkonsum und AUD Eingesetzt insbesondere in Forschung, Arztpraxen, Krankenhusern Erfragt typische Trinkmuster im letzten Jahr Frequenz des Konsums: Quantitt des Konsums (landestypisch, in Standarddrinks): Babor et al. (2001) Ausgangslage Messung von Alkoholkonsum Beispiel: Timeline Followback (TLFB)

Strukturiertes Trinktagebuch (Interview und Fragebogen mglich) Eingesetzt insbesondere in Forschung und Therapieverlauf zur Konsumbestimmung Erfragt idiosynkratisch und tagesgenau 24 Frequenz des Konsums (variabel, meist: letzte 45 Tage): Quantitt des Konsums (landestypisch, in Standarddrinks): Sobell & Sobell (1992, 1995) 5. Zusammenhang mit Diagnosestellung Spielt der berichtete Konsum (QF) eine Rolle fr Unterschiede in der AUD-Diagnosestellung zwischen Hausrzten und CIDI? Design: Ergebnisse: Epidemiologische Befragung (APC-Studie) von Ostdeutschen

Hausrzten (n=76) und ihren Patienten (n=1356) Hausrzte und CIDI erkennen hnlich viele Flle (5.6% vs. 6.9%), aber meist unterschiedliche 1 gemeinsam erkannte Flle (1.5%) u.a. mit etwa 4fach hherem Durchschnittskonsum (QF) 1 QF-Indizes sind identisch (MHausrzte=16.4g/Tag [15.1-17.6], MCIDI=16.3 g/Tag [15.2-17.4]) 2 Zusammenfassung: 25 stimmt mit Hausarzteinschtzung zu QF berein und hngt mit grerer Diagnosewahrscheinlichkeit durch CIDI & Hausarzt zusammen 1 Kuitunen-Paul, Manthey et al. (2016). 2 Jackson (2016, Thesis). AF-CIDI Sample Characteristics (N=162) Aim: see 1. Bias is assignment of drinks a) Especially when certain drink name (e.g. "Bierlikr - beer liquor") b) Especially when one is less familiar with drink c) Especially when low use prevalence (sweet liquors and cocktails) d) Especially in drinks that include alcohol mixed with non-alcoholic beverages (e.g. "Radler", a beer-lemonade mix) N Age 161 27 8.2

Female gender 98 60.5 % Martial status: single, divorced 71 46.8 % 91 53.2 % 93 57.4 % married, partnership Students AF-CIDI >90% correct assigned (out of 60) Drink Jules Mumm 1 2 Long Island Ice Tea 3 Maraschino 4 Becks Lemon 5 Veltins V+ Curuba 6 Weizen 7 Caipi 8 Pils 9 Mojito 10 Radler 11 Pina Colada 12 Margarita 13 Cuba Libre

14 Weinschorle 15 Ros Federweier 16 Baileys 17 Gin Prosecco 18 19 Chantr Weinbrand 20 Eierlikr 21 Cognac Rotkppchen Fruchtsecco 22 23 Mirabellenwasser category Sparkling Wine Longdrink Schnapps Beer Beer Beer Longdrink Beer Longdrink Beer Longdrink Longdrink Longdrink Wine Wine Sweet Liqueur Schnapps Sparkling Wine Brandy Sweet Liqueur Brandy

Sparkling Wine Schnapps total (N = 162) students (N = 93) Non-students (N = 69) % % % consumed % correct consumed % correct consumed % correct 0,370 0,586 0,019 0,691 0,309 0,741 0,790 0,809 0,704 0,883 0,691 0,401 0,741 0,722 0,407 0,852 0,698 1,000 1,000 1,000 1,000 1,000 1,000 0,992 0,992 0,991 0,986 0,982 0,970

0,967 0,957 0,955 0,949 0,929 0,376 0,613 0,011 0,774 0,387 0,763 0,817 0,817 0,720 0,882 0,742 0,419 0,828 0,710 0,419 0,839 0,710 1,000 1,000 1,000 1,000 1,000 1,000 0,987 0,987 0,985 0,976 0,986 0,974 0,974 0,955 0,949 0,949 0,939

0,362 0,551 0,029 0,580 0,203 0,710 0,754 0,797 0,681 0,884 0,623 0,406 0,623 0,739 0,391 0,870 0,681 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 0,927 0,964 0,953 0,961 0,963 0,950 0,915 0,784 0,154 0,765 0,296

0,921 0,920 0,919 0,917 0,774 0,129 0,753 0,258 0,917 0,917 0,900 0,917 0,797 0,188 0,783 0,348 0,927 0,923 0,944 0,917 0,346 0,123 0,911 0,900 0,409 0,118 0,947 0,818 0,261 0,130

0,833 1,000 AF-CIDI Bottom ten correct assigned Drink category Madeira Liqueur Malaga Liqueur Sambuca Sweet Liqueur Aperol Spritz Sweet Liqueur Martini Rosso Wine Cachaca Sweet Liqueur German Punsch Sweet Liqueur Wermut Fortified Wine

Ouzo Liqueur Calvados Brandy total (N = 162) % consumed % correct students (N = 93) % consumed % correct Non-students (N = 69) % consumed % correct 0.06 0.00 0.04 0.00 0.07 0.00 0.01 0.00 0.02 0.00

0.00 - 0.43 0.04 0.41 0.00 0.46 0.09 0.69 0.06 0.69 0.08 0.70 0.04 0.25 0.07 0.26 0.08 0.25 0.06 0.35

0.09 0.40 0.08 0.28 0.11 0.70 0.09 0.75 0.00 0.62 0.02 0.16 0.12 0.10 0.00 0.25 0.18 0.80 0.12 0.79

0.16 0.83 0.07 0.15 0.20 0.15 0.14 0.16 0.27

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