Aims: To examine the cultural impact on the diagnosis of alcohol-use disorders using European countries as examples. Design: Narrative review. Results: There are strong cultural norms guiding heavy drinking occasions and loss of control. These norms not only indicate what drinking behaviour is acceptable, but also whether certain behaviours can be reported or not. As modern diagnostic systems are based on lists of mostly behavioural criteria, where alcohol-use disorders are defined by a positive answer on at least one, two or three of these criteria, culture will inevitably co-determine how many people will get a diagnosis. This explains the multifold differences in incidence and prevalence of alcohol-use disorders, even between countries where the average drinking levels are similar. Thus, the incidence and prevalence of alcohol-use disorders as assessed by surveys or rigorous application of standardised instruments must be judged as measuring social norms as well as the intended mental disorder. Conclusions: Current practice to measure alcohol-use disorders based on a list of culture-specific diagnostic criteria results in incomparability in the incidence, prevalence or disease burden between countries. For epidemiological purposes, a more grounded definition of diagnostic criteria seems necessary, which could probably be given by using heavy drinking over time.
Commentary on Agrawal et al. (2011): Assessing the impact of changes to diagnostic criteria on the estimated prevalence of alcohol use disorders in general population surveys
