Alcohol Use Among Depressed Patients: The Need for Assessment and Intervention

Alcohol use recording in adults with depression in English primary care: a cross-sectional study

OBJECTIVES

To investigate alcohol use recording in people with newly diagnosed depression in English primary care and individual characteristics associated with the recording of alcohol use.

DESIGN

A population-based cross-sectional study.

SETTING

Primary care data from English practices contributing to the UK Clinical Practice Research Datalink.

PARTICIPANTS

We included adults (18+ years) diagnosed with depression between 1 January 2011 and 1 January 2017 without previous antidepressant use and at least 1 year of registration before diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

We described the proportion of individuals with alcohol use and level of alcohol use recorded at four time points (the date of depression diagnosis, 3 months before or after depression diagnosis, 12 months before or after depression diagnosis and any point pre or postdepression diagnosis). We used logistic regression to investigate individual characteristics associated with alcohol use recording in the 3 months before or after depression diagnosis.

RESULTS

We identified 36 424 adults with depression. 538 (2%) had alcohol use recorded in the 3 months before or after depression diagnosis using formal validated methods such as the Alcohol Use Disorders Identification Test and its abbreviated versions. At each time point, most individuals with alcohol use recorded were low risk drinkers. Alcohol use recording in the 3 months before or after depression diagnosis was associated with male sex (OR=1.38, 95% CI 1.29 to 1.48) and several other individual-level factors.

CONCLUSIONS

Our study shows low levels of alcohol use recording in the 3 months before or after depression diagnosis. Levels of alcohol use recording varied depending on individual characteristics. Incentivised recording of alcohol use will increase completeness, which could improve clinical management and reduce missed opportunities for care in people with depression.

Association Between Changes in Depressive Symptoms and Hazardous Drinking: Findings From the Korea Welfare Panel Study (2013-2018)

Objective: This study aimed to evaluate the longitudinal association between changes in depressive symptoms and hazardous drinking among South Korean adults. Participants/Methods: This study was conducted using a sample drawn from participants enrolled in the Korea Welfare Panel Study (KoWePS) from 2013 to 2018. Hazardous drinking was defined as a score of 11 points for men and seven points for women on the Korean version of the Alcohol Use Disorders Identification Test. Depressive symptoms were evaluated using an 11-item version of the Center for Epidemiologic Studies Depression Scale. A generalized estimating equation model was used to analyze the association between changes in depressive symptoms and hazardous drinking. Results: Of the 12,878 people registered with KoWePS and without follow-up losses from 2013 to 2018, a total of 2,341 were included in this study, excluding those under the age of 19 and those with missing data. Persistent depressive symptoms (men, odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.48-3.21; women, OR: 2.64, 95% CI: 1.66-4.22) and the changes from non-depressive symptoms to depressive symptoms (men, adjusted OR: 2.18, 95% CI: 1.80-2.64; women, OR: 1.71, 95% CI: 1.27-2.29) increased the likelihood of hazardous drinking. Conclusions: Persistent depressive symptoms and changes from non-depressive to depressive symptoms are associated with increased prevalence of hazardous drinking. This suggests that an evaluation of the underlying mental illness or emotion should be made when counseling for abstaining from alcohol for chronic drinkers or the general public.

Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-Positive Veterans in the Veterans Aging Cohort Study

Background

HIV infection and depression are each associated with increased ischemic stroke risk. Whether depression is a risk factor for stroke within the HIV population is unknown.

Methods and Results

We analyzed data on 106 333 (33 528 HIV‐positive; 72 805 HIV‐negative) people who were free of baseline cardiovascular disease from an observational cohort of HIV‐positive people and matched uninfected veterans in care from April 1, 2003 through December 31, 2014. International Classification of Diseases, Ninth Revision (ICD‐9) codes from medical records were used to determine baseline depression and incident stroke. Depression occurred in 19.5% of HIV‐positive people. After a median of 9.2 years of follow‐up, stroke rates were highest among people with both HIV and depression and lowest among those with neither condition. In Cox proportional hazard models, depression was associated with an increased risk of stroke for HIV‐positive people after adjusting for sociodemographic characteristics and cerebrovascular risk factors (hazard ratio [HR], 1.18; 95% CI: 1.03–1.34; 0.014). The depression‐stroke relationship was attenuated by alcohol use disorders, cocaine use, and baseline antidepressant use, and unaffected by combined antiretroviral therapy use or individual antiretroviral agents. A numerically higher HR of depression on stroke was found among those younger than 60 years.

Conclusions

Depression is associated with an increased risk of stroke among HIV‐positive people after adjusting for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV‐specific factors. Alcohol use disorders, cocaine use, and baseline antidepressant use accounted for some of the observed stroke risk. Depression may be a novel, independent risk factor for ischemic stroke in HIV, particularly among younger people.

Common and differential associations between levels of alcohol drinking, gender-specific neurobehaviors and mental distress in college students

BACKGROUND

Binge drinking is associated with poor academic behaviors and performance. Excessive alcohol drinking induces molecular changes and neurobehaviors that support use of other substances and alter cognitive functions. The purpose of this study was to compare neurobehaviors and academic effort among college students with low alcohol use with those of high alcohol consumption and build conceptual models that represent the integration of the different variables.

METHOD

College students from several U.S colleges were assessed through an anonymous online survey for alcohol use, academic performance, lifestyle factors and mental distress.

RESULTS

Our results depicted common neurobehaviors and differential responses to high alcohol use.

CONCLUSION

The common responses in young men and women with high alcohol use are reflective of a hyperactive limbic system. The different responses involve cognitive aptitudes, typically controlled by cortical regions and affected by levels of brain connectivity known to be dissimilar between men and women.

Testing Mindful Awareness as a Moderator in the Association Between HIV-Related Stress and Drug and Alcohol Use Problems Among People Living with HIV

Objectives

People living with HIV (PLWH) are disproportionately affected by stressful life events. HIV-related stress adds to general life stressors to increase health risks among this population. Stress has not only been associated with HIV progression but it is also linked to HIV transmission risk behavior (e.g., substance use). Older adults living with HIV (OALWH) experience additional age-related stress and are at increased risk for substance use. Mindfulness buffers against stress for PLWH; however, research has yet to examine mindfulness as a buffer between HIV-related stress and substance use for OALWH.

Methods

Participants were 130 OALWH (M _age = 54.65, SD = 4.20) and 74.6% were Black. The majority were male (69.2%), and nearly half identified as heterosexual (48.5%). A hierarchical linear regression examined the main and interactive effects of mindful awareness and two types of HIV-related stress (e.g., stigma and rumination) on alcohol and drug use problems.

Results

In step one of the model, we examined HIV stigma (β = .231, p = .015) and found no significant interaction with mindful awareness. In step two, HIV rumination (β = .288, p = .001) was added. We found a significant interaction (β = .196, p = .020), indicating those with low mindful awareness and high rumination reported the greatest substance use problems. Exploratory analyses revealed an indirect effect of HIV stigma on substance use through HIV rumination as well as a significant effect for second-stage moderated mediation.

Conclusions

These findings support mindful awareness as a buffer against HIV rumination for OALWH. Further, our results have important implications for the utility of mindfulness-based interventions (MBIs) with OALWH and comorbid substance use disorders.

Alcohol consumption predicts incidence of depressive episodes across 10 years among older adults in 19 countries

Alcohol consumption is increasing in many countries, and excessive alcohol consumption is particularly increasing among older adults. Excessive alcohol consumption causes morbidity and mortality, especially among older adults, including an increased risk of depressive episodes. We review the mechanisms through which alcohol consumption may affect depression, and argue that the effects of alcohol consumption on depressive episodes among older adults are understudied. We harmonized data among older adults (≥50 years) on alcohol consumption, depressive episodes, and an array of risk factors across 10 years and 19 countries (N=57,276). Alcohol consumption was categorized as current or long-term abstainer, occasional, moderate and heavy drinking at an average of 2.3 follow-up time points. Depressive episodes were measured through the CES-D or EURO-D. Multi-level Cox proportional frailty models in which the random effect has a multiplicative relationship to hazard were estimated with controls for co-occurring medical conditions, health behaviors, and demographics. Long-term alcohol abstainers had a higher hazard of depressive episodes (HR=1.14, 95% C.I. 1.08-1.21), as did those reporting occasional (HR=1.16, 95% C.I. 1.10-1.21) and heavy drinking (HR=1.22, 95% C.I. 1.13-1.30), compared with moderate drinking. Hazard ratios were attenuated in frailty models; heavy drinking, however, remained robustly associated in a random-effects model with a frailty component (HR=1.16, 95% C.I. 1.11-1.21). Interactions were observed by gender and smoking status: long-term abstainers, women's, and smokers' (HR for interaction, 1.04, 95% C.I. 1.00-1.07) hazards of depressive episodes increased more than what would be expected based on their multiplicative effects, when compared to moderate drinking, non-smoking men. Excessive alcohol consumption among older adults is a concern not only for physical, but also for mental health. Physician efforts to screen older adults for excessive alcohol use is critical for mental health to remain strong in aging populations.

Interventions for Subjects with Depressive Symptoms with or without Unhealthy Alcohol Use: Are There Different Patterns of Change?

Background: It has been suggested that alcohol problems negatively affect therapeutic interventions for depression. This study examines the patterns of change in depressive symptoms following an intervention for depression, in participants with or without comorbid unhealthy alcohol use.

Methods: Depressive symptoms (BDI–II), perceived control of depressive symptoms (UNCONTROL) and unhealthy alcohol use (AUDIT) were assessed in 116 patients before and after attending a cognitive behavioral psychoeducational intervention for depression. At pretest the mean score of AUDIT was 8.1, indicating a, on average, risk of harmful level of alcohol abuse. At pretest the majority of the total sample had a moderate degree of depressive symptoms, with a mean BDI–II score of 25.1 and 36.2% had a risky use of alcohol as measured with AUDIT score at 8 points or above. To assess the relationship between depressive symptoms, perceived uncontrollability of depression and alcohol use across time, a cross-lagged panel model was estimated.

Results: A clinical significant reduction of depressive symptoms, and a parallel and statistically significant increase in the perceived control of depressive symptoms, was identified after attending a cognitive behavioral psychoeducational intervention for depression. At posttest, the mean BDI–II score was 17.8, demonstrating a statistically significant decrease of 7.3 points in depressive symptoms from before starting the course to 6 months later. The effect size (d-value) of 0.83 can be interpreted as a large decrease in depressive symptoms. In this sample alcohol use and depressive symptoms seemed to be unrelated. The cross-lagged correlation panel analysis indicated that a high degree of perceived control of depressive symptoms leads to a reduction in depressive symptoms, and not vice versa.

Conclusion: We found that this intervention for depression were effective in reducing depressive symptoms. The patterns of change seemed to be independent of risky use of alcohol, although leaving the study was systematically associated with higher AUDIT-scores. As participants with or without unhealthy alcohol use show the same patterns of change regarding reduction of depressive symptoms and perceived control of depression, both groups could be offered the same cognitive behavioral psychoeducational interventions for depression.

Do normative perceptions of drinking relate to alcohol use in U.S. Military veterans presenting to primary care?

OBJECTIVE

The current cross sectional study sought to examine whether perceived social normative beliefs are associated with indicators of alcohol use in a sample of alcohol misusing veterans.

METHOD

A sample of 107 U.S. Military Veterans presenting to primary care that screened positive for alcohol misuse on the alcohol use disorders identification test-consumption items (AUDIT-C) was recruited. Assessment measures were used to examine social normative beliefs and alcohol-related concerns as they relate to indicators of alcohol use at baseline.

RESULTS

Our findings indicate mixed support for our two hypotheses in that perceived descriptive norms were associated with alcohol use indicators in the predicted direction; however, this was not the case for alcohol-related concerns. For perceived norms, we found that higher quantity beliefs were significantly related to greater alcohol consumption on a drinking day (p<.01), increased likelihood of dependence (p<.01), and frequency beliefs were significantly related to total number of drinking days (p<.01). Findings for alcohol-related concerns emerged contrary to our hypothesis, with results depicting increased alcohol-related concerns associated with higher alcohol consumption across indicators of use (ps<.01).

SUMMARY

Findings of the current study suggest that social normative beliefs, specifically misperceptions about descriptive norms, are significantly associated with alcohol consumption in a sample of alcohol misusing veterans presenting to primary care.

The role of distress tolerance in the relationship between depressive symptoms and problematic alcohol use

Empirical evidence and theory implicate the role of distress tolerance in the relationship between negative affect and alcohol use. However, limited research has been conducted to explore these relationships. As such, the purpose of this study was to examine whether distress tolerance moderates the relationship between current depressive symptoms and problematic alcohol use in a community sample of adults. Participants included 150 adults, primarily female, recruited from the local community. Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT) total score, which is a composite measure of harmful and hazardous patterns of alcohol use and several current alcohol dependence symptoms. Distress tolerance was measured using a computerized behavioral distress tolerance task, the Computerized Paced Auditory Serial Addition Task (PASAT-C). Tobit regression analyses indicated a significant interaction between distress tolerance and depressive symptoms in predicting alcohol problems, such that depressive symptoms were significantly associated with problematic alcohol use among adults with low, but not high, distress tolerance. Thus, alcohol use interventions with a focus on distress tolerance skills in the context of depressive symptoms may be particularly effective.

Level and change in alcohol consumption, depression and dysfunctional attitudes among females treated for alcohol addiction

Aims: To examine whether individual changes in alcohol consumption among female alcoholics under treatment are predicted by level of and changes in depression and dysfunctional attitudes. Method: A total of 120 women who were treated for alcohol addiction at the Karolinska Hospital in Stockholm (Sweden) were assessed twice over a 2-year period using the Depression scale from the Symptom Checklist-90, the Alcohol Use Inventory and the Dysfunctional Attitude Scale (DAS). Latent growth curve analysis was used. Results: Decrease in alcohol consumption, depression and dysfunctional attitude variables were found at group level. The results also showed significant individual variation in change. Changes in alcohol consumption were predicted by baseline alcohol drinking, as well as by level and changes in depression. Stronger reduction in depression was related to higher level of depression at baseline, and with reduction in dysfunctional attitudes. Different DAS sub-scales resulted in different magnitude of the model relations. Good treatment compliance was related to lower baseline level in depression, but also with higher baseline level in dysfunctional attitudes, and predicted stronger reduction in alcohol consumption. Conclusion: This paper shows the importance of incorporating both individual level and change in depression as predictors of change in alcohol consumption among subjects treated for alcohol addiction. Also, dysfunctional attitudes are both indirectly and directly related to treatment outcome. By incorporating alcohol consumption, depression and dysfunctional attitudes as targets of intervention, treatment compliance and outcome may be enhanced.

Does comorbid substance use disorder impair recovery from major depression with SSRI treatment? An analysis of the STAR*D level one treatment outcomes

Many patients with major depressive disorder (MDD) present with concurrent substance use disorders (SUDs), which has been thought to impair their response to antidepressants. Clinicians often delay antidepressant treatment until sustained sobriety has been established. Unfortunately, these comorbid subjects are typically excluded from depression treatment trials, leaving a gap in understanding the treatment outcomes. In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, 2876 adult outpatients diagnosed with nonpsychotic MDD were prospectively treated with the selective serotonin-reuptake inhibitor (SSRI), citalopram, and returned for at least one post-baseline visit. Participants with SUD (29%) and without SUD (71%) were compared in regard to baseline clinical and sociodemographic features and treatment response. The group with MDD and SUD was further subdivided into those with alcohol only, drug only, and both alcohol and drug use. Despite clear sociodemographic and clinical differences, there were no significant differences between groups in the time to achieve response or rates of response to citalopram; however, those who endorsed both alcohol and drug use had significantly reduced rates of remission and significantly increased times to reach remission compared to the MDD group without SUD. In addition, subjects with MDD and SUD had higher risk of psychiatric serious adverse events (3.3% vs. 1.5%) and hospitalization (2.8% vs. 1.2%). The results indicate that first-line treatment with citalopram in depressed patients with alcohol or drug use respond as well as those without SUD. More intensive treatment is most likely needed for MDD patients with both drug and alcohol use disorders.

Dynamic association between negative affect and alcohol lapses following alcohol treatment

Clinical research has found a strong association between negative affect and returning to alcohol use after a period of abstinence. Yet little is known about the probability of a lapse given a particular level of negative affect or whether there is a reciprocal relationship between negative affect and alcohol use across time. The goal of the current study was to examine the association between negative affect and drinking behavior in the 1st year following alcohol treatment. The authors applied an associative latent transition analysis to the Project MATCH outpatient data (n = 952) and then replicated the model in the Project MATCH aftercare data (n = 774). Changes in drinking following treatment were significantly associated with current and prior changes in negative affect, and changes in negative affect were related to prior changes in drinking (effect size range = 0.13-0.33). The results supported the hypothesis that negative affect and alcohol lapses are dynamically linked and suggest that targeting the relationship between negative affect and alcohol use could greatly decrease the probability of lapses and improve alcohol treatment outcomes.

Alcohol consumption and the use of antidepressants

BACKGROUND

The purpose of the present study is to explore the relation between use of antidepressants and level of alcohol consumption among depressed and nondepressed men and women.

METHODS

Random-digit dialling and computer-assisted telephone interviewing were used to survey a sample of 14,063 Canadian residents, aged 18-76 years. The survey included measures of quantity and frequency of drinking, the World Health Organization's Composite International Diagnostic Interview measure of depression, and a question as to whether respondents had used antidepressants during the past year.

RESULTS

Overall, depressed respondents drank more alcohol than did nondepressed respondents. This was not true, however, for depressed men who used antidepressants; they consumed a mean of 414 drinks during the preceding year, versus 579 drinks for depressed men who did not use antidepressants and 436 for nondepressed men. For women, the positive relation between depression and heavier alcohol consumption held true regardless of their use of antidepressants: 264 drinks during the preceding year for depressed women who used antidepressants; 235, for depressed women who did not use antidepressants; and 179, for nondepressed women.

INTERPRETATION

Results of this cross-sectional study are consistent with a possible beneficial effect of antidepressant use upon drinking by depressed men. Further research is needed, however, to assess whether this finding results from drug effects or some other factor, and to ascertain why the effect was found among men but not women.