Heavy drinking and depressive symptoms in college students (Slide1)

Paola Pedrelli, Ph.D.

Massachusetts General Hospital

Boston, MA

AMSP

I. Introduction (Slide 2)

            A.  Alcohol use common age 21-251

                        1. The graph indicates alcohol use across lifetime

                        2. ~70% consume alcohol

                        3. ~43%> 5 drinks within 2 hrs (i.e. heavy episodic drinking [HED])

                        4. ~13% > 5 drinks >5x /mo (i.e. frequent HED)

            B. This lecture reviews college student related: (Slide 3,4)

                        1. Definitions and problems associated with heavy drinking

                        2. Depressive symptoms in college students

                        3. Co-occurring depressive symptoms and heavy episodic drinking (HED)

                        4. Implications: prevention and treatment

II. Definitions and problems associated with heavy drinking (Slide 5)

            A. Standard drink = 10-12 g pure ethanol (beverage alcohol)

1. 12 oz. beer

2. 8 oz. malt liquor

3. 5 oz. wine (~ 5 drinks /750ml bottle of wine)

4. 1.5 oz. ("a shot") 80 proof liquor (spirits/whiskey/vodka/etc)     

            B. Heavy Episodic drinking (HED) (Slide 6)

                        1. BAC: amount of alcohol in blood

                        2. 4/5 drinks ♀/♂ within 2 hr 0.08 BAC

                        3. 4/5 drinks ♀/♂ within 2 hr

            C. HED: common in college students (Slide 7)

                        1. 43% report HED

                        2. 22% college students HED >3 x/mo2

3. 13% > 5 drinks >5x /mo

D.  HED more common in college students3

            1. Prior to age of 18, future 4-yr college students binge less

            2.  Starting at age 18, 4-yr college students binge much more

            E. Myths about heavy drinking (Slide 8)

            1. Everyone drinks heavily in college

            2. Drinking heavily on weekends is OK

            3. Students will grow out of it 

            F. Heavy drinking has societal costs (Slide 9)

                            1. Among <21 age: heavy drinking costs $27 Billion/yr3

                                    a. 61% from lost productivity

                                    b. 25% from premature death (e.g., accidents)

                        2. 40,000 alcohol-related hospitalizations/yr costing $755 million age 15-204

            G. Heavy drinking has personal costs in US universities (Slide 10)

                        1. ~600,000 injuries/yr

                        2. ~700,000 assaulted by a drinking student/yr

                        3. ~97,000 victim sexual assault/yr

                        4. ~1800 deaths/yr5

            H. Illustrative case (Slide 11)

                        1. Jackie: 20-year-old female college student

                                    a. Mild depressive symptoms

                                                1'. ↓Interest in social activities

                                                2'. Behind with schoolwork, missing classes often

                                                3'. ↓Grades

                                                4'. Sleeping 8-10 hrs/day

                                    b. Consumes 8-10 drinks 1x/week

            I. Alcohol use disorder (AUD): 2+ of 11 problems in same 12 mo (slide 12)

                        1. Failed roles

                        2. Hazardous use (e.g., driving/bike riding, etc. after drinking)

                        3. Social problems

                        4. Tolerance (needs to drink more to have same effect)

                        5. Withdrawal (shakes/nausea/anxiety for > 1 day when stop)

                        6. Use longer/more than intended

                        7. Unable to ↓ use

                        8. Lots time using or recovering from effects

                        9. Interferes with activities (e.g. social, hobbies)

                        10. Use despite health or psychological problems

                        11. Craving

            J. Among college students (Slide 13)

                        1. 24% ♂ have AUD

                        2. 13% ♀ have AUD6

            K.  Even without AUD there are alcohol related difficulties among students past yr7 (Slide 14)

                       1. 57% got physically sick from alcohol

                        2. 54% had blackout (forget all or part of evening when drinking)

                        3. 30% had problems with school work

                        4. 31% regretted a sexual activity

                        5. 20% got physically injured

                        6. 13% drank and drove

                        7. 9% accidentally hurt someone

                        8. 7% got into physical fight

            L. Predictors of HED (5+ ♂; 4+ ♀) (Slide 15)

                        1. Men1

                   2. Greek members (fraternity or sorority) 8

                        3. Student athletes

            M. This lecture reviews: Depressive symptoms in college students (Slide 16)

III. Depressive symptoms in college students

            A. Major Depressive Disorder (MDD) definition: (Slide 17)

1.  Must include depressed mood and/or anhedonia and total 5+ from:

                                    a. Depressed mood (~all day/every day)

                                    b. Markedly ↓ interest in anything

                                    c. Weight loss or gain

                                    d. Difficulty sleeping or sleeping too much

                                    e. Agitation (e.g. pacing, gesturing)

                                    f. Fatigue or loss of energy

                                    g. Feel worthless

                                    h. ↓Ability think or concentrate

                                    i. Suicidal ideation

            B. College is associated with onset of depressive symptoms (Slide 18)

                  1. Unique development stage            

                              a. Identity exploration9 (asking “who really am I?”)

            b. From dependence on family to partial-full independence

2. ↓Support from old friends

            C. Depressive symptoms (not necessarily MDD) in college students (Slide 19)

                        1. 10% ♀ 8% ♂ have MDD10,11

                        2. 66% ♀ 51% ♂ are sad 1+ x/yr12

                        3. 50% ♀ 38% ♂ felt hopeless 1+x/yr

                        4. 33% ♀ 27% ♂ so depressed hard to function 1+ x/yr       

                        5. 7% ♀ 6% ♂ seriously considered suicide 1+ x/yr

                        6. 1% ♀ 1% ♂ attempted suicide 1+ x/yr

            D. Depressive symptoms (not necessarily MDD) associated with problems (Slide 20)

            1. Mild dep sx ↑ early school drop out13

            2. Mild dep sx ↑ psychosocial problems14

            3. SI present at sub-threshold MDD15

            E. Back to: Jackie the 20-year-old college student's depressive symptoms (Slide 21)

                        1. Tired all the time

                        2. Is very sad in the morning

                        3. Feels lonely

                        4. Low motivation

                        5. Stops playing piano and exercising

                        6. Sleeps > 10 hours many days

         F. Jackie had depressive symptoms (not full MDD), but still caused problems

                        1. Grades ↓

                        2. Skipped classes

                        3. Isolated, does not spend time with friends

            G. This lecture reviews: Co-occurring depressive symptoms and heavy drinking (Slide 22)

IV. Co-occurring depressive symptoms and heavy drinking

A. Depressive symptoms (dep sx)/MDD + HED together problems (Slide 23)

            1. Dep sx or MDD +HED = alcohol related problems than HED alone 16-18

            2. Dep sx + HED = ↑ risk for suicide20

            3. Among those with unsafe sex

                        a. 14% Dep sx +HED vs

                        b. 10% HED16

            4. Among those who fall behind at school16  

                        a. 29% Dep sx +HED vs

                        b. 24% HED               

B. Social learning theory21 explains co-occurring HED/AUD and depressive symptoms (Slide 24)            1. Alcohol is used to negative emotional states

            2. Alcohol is expected to ↑ mood

            3. Presence of belief there are no alternative ways to cope

            C. Jessie the 20-year-old college student (Slide 25)

                        1. Drinks to feel better

                        2. After HED does not study and falls behind in school

                        3. The week after HED has depr sx and guilt

            D. This lecture reviews: Implications: prevention and treatment (Slide 26)

V. Implications: prevention and treatment

            A. Screenings             (Slide 27)

                        1. Screening can be conducted in a variety of settings22                                                                              a. Throughout the school (email all students)

                                    b. Emergency care23

                                    c. College counseling centers

                                    d. Primary care

                                    e. Fraternities

                                    d. Athletes

                        2. Screening tools for alcohol

                                    a. NIAAA Task Force on Recommended Alcohol questions re last 12 mo:

                                                1’. Frequency of any alcohol use

                                                2’. Typical number of drinks

                                                3’. Frequency of HED

                                    b. Alcohol Use Disorders Identification Test (AUDIT-C)24 (Slide 28)

                                                1’. Questions on:

                                                            a’. Frequency of any alcohol use

                                                            b’. Typical number of drinks

                                                            c’. Frequency of 6+drinks on one occasion

                                                2’. Responses are summed

                                                3’. Score > 3/5 ♀/♂ corresponds to risky drinking (HED) 24-27

                        3. Screening tools for depression

                                    a. Center for Epidemiological Studies depression (CES-D)

                                                1'. CESD: valid measure of MDD 

                                               2’. 20 items ask frequency of sx including:

                                                            a’. I felt that I could not shake off the blues even with help                                                                     from my family or friends.

                                                            b’. I could not get “going”

                                                            c’. I did not feel like eating; my appetite was poor

                                                3'. >16 indicate MDD28,29

                                 b. Patient Health Questionnaire-9 (PHQ-9) (Slide 29)

                                                1'. PHQ-9 is a valid measure of MDD in college students

                                                2’. 9 items ask frequency of sx including:                                                                                                      a’. Little interest or pleasure in doing things

                                                            b’. Feeling down, depressed, or hopeless

                                                            c’. Feeling tired or having little energy

                                                3’. Responses are summed

                                                4'. >10 indicates MDD

                        4. Screening in colleges is not adequate

                                    a. <50% colleges screen for HED or depr sx22

                                    b. 20% colleges that screen use validated tools

            B. HED & dep sx should be treated together (Slide 30)

                        1. Combined HED/depressions treatments better outcome35, 36

                                    a. Combined vs single tx → 90% vs 30% abstinent

                                    b. Combined vs single Rx → 65% improvement depr sx vs 45%

                        2. Tx for HED are not effective31 in college students with dep sx32

                        3. In adults tx for one disorder leads to relapse rates for AUD33, 34

                        4. Examples of Tx for co-occurring disorders (Slide 31)

                                   a. Motivational interviewing (MI)37 + Cognitive behavioral therapy (CBT)38                                                  1’. Both address motivations for drinking37

                                                2’. Integrating MI and CBT is feasible

                                                3’. CBT+MI are effective in treating co-occurring disorders

                                    b. CBT characteristics (Slide 32)

                                                1’. Thoughts cause feelings and behaviors

                                                2'. Brief and time-limited

                                                3'. Structured (goal and agenda setting)

                                                4'. Educational (information on causes and sx of MDD)

                                                5'. Collaborative relationship of clinician and patient

                                                6'. Socratic method (hypothesis testing)

                                                7'. Includes homework (i.e. pt records thoughts)

                                    c. CBT tenets (Slide 33)

                                                1'. Depr sx may relate to negative views of:

                                                            a’. Themselves

                                                            b’. The future

                                                            c’. The world.

                                    d. CBT techniques (Slide 34)

                                                1'. Change unhelpful thoughts by examining their accuracy

                                                            a’. Collect evidence for and against unhelpful thoughts

                                                            b’. Reduce catastrophizing

                                                            c’. Identify mind reading

                                                2'. Increase enjoyable activities (i.e. hobbies, exercise)

                                                            a’. Identify enjoyable activities 

                                                            b’. Problem solve to reduce barriers to enjoyable activities 

                        5. Motivational interviewing (MI) (Slide 35)

                                    a. MI Characteristics                          

                                                1'. Therapeutic relationship like a partnership

                                                2'. Patient-centered (centered on pt thoughts feelings)

                                                3'. Directive method of communication (practitioner guides talk)

                                                4'. Elicit motivation to change unhealthy behaviors

                                                5'. Explores ambivalence about change (explore pros and cons)

                                                6'. Guide pt towards change      

                                    b. MI therapist (Slide 36)

                                                1'. Express empathy of current behavior      

                                                2'. Examine inconsistencies between behaviors and goals

                                                3'. Promote belief that change is possible

                                                4'. Roll with resistance (avoid arguing)

                        7. Example of Tx for HED when co-occurring with MDD with Jackie

                                                a. Personalized feedback from brief MI38 (Slide 37)

                                                1'. Feedback on drinking behaviors, BAC, and problems

                                                2'. Education on

                                                            a'. Peers' normal alcohol use

                                                            b’. Gender specific effects of alcohol

                                    b. CBT for depression (Slide 38)

                                                1'. Changed unhelpful thoughts

                                                            a’. Reframed thoughts that she is flawed

                                                            b’'. Changed thought that her friends do not like her 

                                                2'. Identified pleasant activities alternative to drinking

                                                            a'. Encouraged resuming playing piano

                                                            b'. Encouraged resuming exercising

                        8. Jackie the 20-year-old college student results (Slide 39)

                                    a. Attend classes consistently

                                    b. Exercising and playing piano

                                    c. Is with friends daily

                                    b. Drink < 4 drinks per occasion

                        9. Conclusion/summary (Slide 40)

                                    a. In college students dep sx + HED are common

                                    b. Systematic screening needed

                                    c. Combined Tx more effective

                                    d. CBT+MI example of combined Tx

References

1. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

2. Wechsler H1, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H. Changes in binge drinking and related problems among American college students between 1993 and 1997. Results of the Harvard School of Public Health College Alcohol Study. J Am Coll Health. 1998 Sep;47(2):57-68.

3. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med. 2011 Nov;41(5):516-24. doi: 10.1016/j.amepre.2011.06.045. Erratum in: Am J Prev Med. 2013 Feb;44(2):198.

4. Kim JY, Asrani SK, Shah ND, Kim WR, Schneekloth TD. Hospitalization for underage drinkers in the United States. J Adolesc Health. 2012 Jun;50(6):648-50.

 

5. Hingson RW, Zha W, Weitzmen ER. Magnitude of and trends in alcohol-related mortality and morbidity among U.S. college students ages 18-24, 1998-2005. J Stud Alcohol Drugs Suppl. 2009 Jul;(16):12-20.

 

6. Slutske WS. Alcohol use disorders among US college students and their non-college-attending peers. Arch Gen Psychiatry. 2005 Mar;62(3):321-7.

 

7. Barnett NP, Clerkin EM, Wood M, Monti PM, O'Leary Tevyaw T, Corriveau D, Fingeret A, Kahler CW. Description and predictors of positive and negative alcohol-related consequences in the first year of college. J Stud Alcohol Drugs. 2014 Jan;75(1):103-14.

 

8. Turrisi R, Mallett KA, Mastroleo NR, Larimer ME.Heavy drinking in college students: who is at risk and what is being done about it? J Gen Psychol. 2006 Oct;133(4):401-20.

 

9. Arnett, J.J., Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol, 2000. 55(5): p. 469-80.

10. Blanco, C., Okuda, M., Wright, C., Hasin, C., Grant, BF, Liu, SM., Olfson, M. Mental health of college students and their non-college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry, 2008. 65(12): p. 1429-37.

11. Eisenberg, D., J. Hunt, and N. Speer, Mental health in American colleges and universities: variation across student subgroups and across campuses. J Nerv Ment Dis, 2013. 201(1): p. 60-7.

12. American College Health Association National College Health Association. 2012

13. Arria AM1, Caldeira KM, Vincent KB, Winick ER, Baron RA, O'Grady KE. Discontinuous college enrollment: associations with substance use and mental health. Psychiatr Serv. 2013 Feb 1;64(2):165-72.

 

14. Harrell ZA1, Karim NM. Is gender relevant only for problem alcohol behaviors? An examination of correlates of alcohol use among college students. Addict Behav. 2008 Feb;33(2):359-65.

15. Cukrowicz KC1, Schlegel EF, Smith PN, Jacobs MP, Van Orden KA, Paukert AL, Pettit JW, Joiner TE. Suicide ideation among college students evidencing subclinical depression. J Am Coll Health. 2011;59(7):575-81.

16. Weitzman ER. Poor mental health, depression, and associations with alcohol consumption, harm, and abuse in a national sample of young adults in college. J Nerv Ment Dis. 2004 Apr;192(4):269-77.

17. Harrell ZA1, Karim NM. Is gender relevant only for problem alcohol behaviors? An examination of correlates of alcohol use among college students. Addict Behav. 2008 Feb;33(2):359-65.

18. Dennhardt AA1, Murphy JG. Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychol Addict Behav. 2011 Dec;25(4):595-604.

19. Davis LL, Frazier E, Husain MM, Warden D, Trivedi M, Fava M, Cassano P, McGrath PJ, Balasubramani GK, Wisniewski SR, Rush AJ. Substance use disorder comorbidity in major depressive disorder: a confirmatory analysis of the STAR*D cohort. Am J Addict. 2006 Jul-Aug;15(4):278-85.

20. Dvorak RD1, Lamis DA, Malone PS. Alcohol use, depressive symptoms, and impulsivity as risk factors for suicide proneness among college students. J Affect Disord. 2013 Jul;149(1-3):326-34.

 

21. Marlatt, G.A.; and Gordon, J.R., Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors . New York: Guilford Press, 1985.

22. Winters KC, Toomey T, Nelson TF, Erickson D, Lenk K, Miazga M. Screening for alcohol problems among 4-year colleges and universities. J Am Coll Health. 2011;59(5):350-7.

23.  Yuma-Guerrero PJ1, Lawson KA, Velasquez MM, von Sternberg K, Maxson T, Garcia N. Screening, brief intervention, and referral for alcohol use in adolescents: a systematic review. Pediatrics. 2012 Jul;130(1):115-22.

 

24. Dawson DA1, Grant BF, Stinson FS, Zhou Y.Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res. 2005 May;29(5):844-54.

25. Babor TF, Kranzler HR, Lauerman RJ. Early detection of harmful alcohol consumption: Comparison of clinical, laboratory, and self-report screening procedures. Addict Behav. 1989;14:139–157.

 

26. Berner MM, Kriston L, Bentele M, et al. The alcohol use disorders identification test for detecting at-risk drinking: A systematic review and meta-analysis. J Stud Alcohol Drugs. 2007;68:461–473.

 

27. Kokotailo PK, Egan J, Gangnon R, et al. Validity of the alcohol use disorders identification test in college students. Alcohol Clin Exp Res. 2004;28:914–920.

 

28. Hann, D., Winter, K., & Jacobsen, P. (1999) Measurement of depressive symptoms in cancer patients. Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). Journal of Psychosomatic Research, 46, 437-443.

29. Radloff, L.S. (1977). The CED-D scale: A self-report depression scale for research in the general population.  Applied Psychological Measurement, 1, 385-401.

 

30. Storch EA1, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory-Second Edition in a sample of college students. Depress Anxiety. 2004;19(3):187-9.

 

31. Carey KB1, Scott-Sheldon LA, Carey MP, DeMartini KS. Individual-level interventions to reduce college student drinking: a meta-analytic review. Addict Behav. 2007 Nov;32(11):2469-94.

 

32. Merrill JE, Reid AE, Carey MP, Carey KB. Gender and depression moderate response to brief motivational intervention for alcohol misuse among college students. J Consult Clin Psychol. 2014 Dec;82(6):984-92.

33. Cornelius JR, Maisto SA, Martin CS, Bukstein OG, Salloum IM, Daley DC, Wood DS, Clark DB. Major depression associated with earlier alcohol relapse in treated teens with AUD. Addict Behav. 2004 Jul;29(5):1035-8.

34. Greenfield SF, Weiss RD, Muenz LR, Vagge LM, Kelly JF, Bello LR, Michael J. The effect of depression on return to drinking: a prospective study. Arch Gen Psychiatry. 1998 Mar;55(3):259-65.

35. Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ, Connolly J. Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: short-term outcome. Addiction. 2010 Jan;105(1):87-99.

36. Brown RA, Evans DM, Miller IW, Burgess ES, Mueller TI. Cognitive-behavioral treatment for depression in alcoholism. J Consult Clin Psychol. 1997 Oct;65(5):715-26.

37. Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.

38. Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

37. National Institute on Alcohol and Alcoholism (NIAAA). Alcohol alert No. 58 (2001). Changing the culture of campus drinking.

38. Larimer ME, Cronce JM, Lee CM, Kilmer JR. Brief intervention in college settings. Alcohol Res Health. 2004-2005;28(2):94-104. Review


 

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