Heavy drinking and depressive symptoms in college students (Slide1)

Paola Pedrelli, Ph.D.

Massachusetts General Hospital

Boston, MA


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


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