This study examined patterns of alcohol use among patients with depression in an outpatient psychiatry clinic, factors associated with heavy episodic drinking and motivation to reduce drinking. In contrast to most prior studies (McDermut et al., 2001
; Sanderson et al., 1990
), we examined patterns of sub-diagnostic use. Results found that heavy episodic drinking and alcohol-related problems were prevalent among both men and women. These findings are especially striking given the practice of the clinic to pre-screen and refer patients with significant alcohol problems to outside services. Heavy episodic drinking in the year prior to intake was associated with demographic characteristics (male gender and younger age) and smoking; and among these patients, motivation to reduce drinking was associated with older age, higher alcohol consumption and more drinking-related problems. These findings have implications for the development of appropriate alcohol interventions, which are integral to the delivery of effective psychiatric services (Weisner and Matzger, 2003
The levels of alcohol use in our results, similar to that found in depressed primary care patient (Roeloffs et al., 2002
) and emergency room samples (Barry et al., 2006
), indicate that a substantial number of depression patients are at risk for poor outcomes. Heavy episodic drinking and alcohol-related problems were even more common in our sample than in these prior studies. While these other studies also examined patients with depression, our sample may not be directly comparable because patients seeking specialty psychiatric services have sociodemographic and clinical differences compared with patients treated in primary care, including higher income, education, and history of suicidality, and better physical health (Gaynes et al., 2008
; Simon et al., 2001
; Xakellis, 2005
). Higher levels of education are associated with treatment seeking for depression after controlling for other factors (Carragher et al., 2010
). Therefore, this sample is likely to be somewhat different in alcohol use prevalence and depression severity from either the general population with depression or those patients with depression treated in primary care.
As in prior studies of non-depressed samples, hazardous drinking was associated with male gender, younger age and smoking (Harrison and McKee, 2008
). It has been suggested that in primary care, smoking status can be used as a likely clinical indicator of alcohol misuse and a cue to screen for heavy drinking (McKee et al., 2007
). Our results suggest that among adults seeking treatment for depression, in which prevalence of these health risk behaviors is correlated, appropriate intervention for both problems may be especially important.
While higher depression severity was not associated with prior-year hazardous drinking, we did find a modest but significant bivariate association between history of alcohol-related problems and depression severity at the time of clinic intake. This pattern of findings is consistent with prior studies suggesting that alcohol problems may precede depression onset (Fergusson et al., 2009
), and contrasts with self-medication theories regarding the association between alcohol consumption and depression. Our finding that moderately depressed participants drank somewhat more frequently than patients with severe depression contrasts with general population studies that found no association between depression severity and drinking frequency (Graham et al., 2007
; Patten and Charney, 1998
). In a treatment-seeking depressed sample, it may be that factors we could not control for, e.g., multiple medications or higher-dose psychotropic medications prescribed to patients with more severe depression (in which case drinking may be strongly contraindicated), could help to explain the observed relationship. Although alcohol problem prevalence has varied by psychiatric disorder, e.g., with higher prevalence among bipolar patients, variation in heavy episodic drinking by diagnosis in our sample (outpatients with mild or greater depression severity) was not significant. To further explore the role of comorbidity, future studies should examine patterns of heavy episodic drinking across diagnostic categories including non-depressed psychiatric patients.
Understanding motivational factors is an important aspect of intervention development, especially in treatment of substance use disorders in which motivational interviewing has emerged as a major intervention approach (Miller and Rollnick, 2002
). Based on the limited prior literature including a study of drunk-driving offenders(Wells-Parker et al., 2006
) and a study of community members with alcohol abuse or dependence and minimal depressive symptoms (Blume et al., 2001
), it was anticipated that greater depression severity might be associated with motivation to reduce drinking. In a psychiatric treatment sample of hazardous drinkers, however, it may be that depression severity lacks motivating force among patients who may or may not have had recent problems related to drinking. Rather, we found that history of alcohol-related problems was the strongest predictor of motivation to reduce drinking, apart from health status or depression symptoms. We also found that older age predicted motivation to reduce drinking. This is consistent with general population studies showing that adults often cut down on alcohol consumption or eliminate drinking as they get older (Moos et al., 2005
; Satre et al., 2007
) and a chemical dependency program study that found that adults age 55 and over were more likely than younger adults to have an abstinence goal at intake (Satre et al., 2003
), and indicates that among depression patients, younger adults may be less ready than older adults to reduce drinking.
Although treatments for alcohol problems are most successful at early stages (Babor et al., 2007
), most people do not seek treatment until their condition is severe. Instead, many individuals with alcohol problems first seek psychiatric treatment (Weisner and Schmidt, 1992
). Yet in psychiatric service settings, providers often fail to recognize warning signs that present opportunities for intervention (Weisner and Matzger, 2003
). When alcohol problems are identified, they are usually those meeting criteria for dependence, while lower levels of use are often not detected or addressed.(Institute of Medicine, 2006
) As a result, potential problems can go unrecognized and untreated even in psychiatric clinics. Our research indicates, somewhat counter-intuitively, that patients reporting higher drinking quantities and alcohol-related problems also express more motivation to reduce drinking, providing intervention opportunities for mental health providers that should not be overlooked. Rather than being discouraged by identifying problem drinking in their patients, clinicians should recognize this as a chance to enhance treatment.
Our results suggest that providers in all psychiatric settings should conduct appropriate screening and treatment when appropriate. For example, brief motivational intervention for heavy episodic drinking could be an effective supplement to depression treatment (Babor and Higgins-Biddle, 2000
; Eberhard et al., 2009
) and could help prevent escalation of alcohol problems. Limited evidence suggests that cognitive behavioral psychotherapy can effectively integrate treatment for depression and sub-diagnostic misuse of alcohol (Hides et al., 2010
). These strategies may be important tools to address co-occurring alcohol problems among patients with depression.
Study Limitations and Strengths
The study has several limitations. Our use of a computerized intake system under-sampled frail and cognitively impaired older adults (Satre et al., 2008
), although these patients are less likely than others to report heavy episodic drinking (Satre et al., 2007
). While computerized measures are valid and very few patients refused to answer, under-reporting of alcohol use by patients would make our prevalence rates conservative. The clinic pre-screened and excluded patients with serious alcohol problems. However, limiting the sample to patients scoring 10+ on the BDI-II in an outpatient setting helps make findings generalizable to treatment-seeking depressed adults.
We note that to increase sensitivity it is preferable to use a lower cutoff for binge drinking for women than for men (3 or 4 drinks per occasion rather than 5), a measure not available in our data. Our use of the higher cutoff could make our estimates of binge drinking among women conservative.
The study also has a number of strengths. Co-occurrence of sub-diagnostic alcohol use, drinking-related problems and depression has received very little study compared to studies of co-occurring substance use disorders (Sullivan et al., 2005
). It is important to study alcohol consumption patterns and risk factors for heavy episodic drinking in this population, in which even moderate alcohol consumption can reduce depression treatment effectiveness (Worthington et al., 1996
). Understanding factors contributing to patient motivation to reduce drinking can help inform clinical services (Blume et al., 2006
; Lau et al., 2010
; Shealy et al., 2007
). We used a treatment-seeking sample who reported recent heavy episodic drinking and elevated depression symptoms in order to investigate motivation. Our results highlight the importance of thoroughly evaluating alcohol consumption among adults with depression.
This study found that heavy episodic drinking was prevalent among men and women seeking outpatient psychiatric treatment for depression. Recent drinking problems were associated with greater depression severity. Importantly, patients with sub-diagnostic heavy episodic drinking may be targeted to prevent substance problem escalation. Patients reporting greater usual alcohol consumption quantity and more alcohol-related problems also express greater motivation to reduce drinking, providing further impetus for mental health clinicians to intervene.