This study examined patterns of alcohol and drug use among depressed older adults in an outpatient psychiatry clinic. Our results indicate that alcohol and drug use in the prior month, especially cannabis use and misuse of sedatives, was prevalent in this sample. These findings are particularly notable given the practice of the clinic to prescreen and refer patients with significant alcohol or drug problems to outside services. The rates of recent alcohol use in our sample were higher than those found in community samples and prior clinical studies. In a primary care study of adults aged 65 years and older, the rate of consuming more than four drinks in the prior year was 5.4% in the general sample but 11.9% among patients with depression.17
In the IMPACT study, 2% of eligible participants (age 60+ years with a diagnosis of major depression) were excluded due to current alcohol problems based on the CAGE screening instrument. Heavy episodic drinking and alcohol-related problems were even more common in our sample than in these prior studies; and this could be due to our selection of a sample drawn from a well-educated, urban population, which tends to have greater alcohol use.26
In addition, patients seeking specialty psychiatric services have sociodemographic and clinical differences compared with patients treated in primary care, including higher income, history of suicidality, and better physical health.32
Older patients treated in an academic medical setting may also differ from typical primary care patients in depression severity33
Therefore, although this sample is likely to be somewhat different in substance use prevalence and depression severity from patients in primary care, it may be similar to samples found in specialty psychiatric settings.
Heavy episodic drinking in the prior year was substantial among both genders. Consumption of 5+ drinks on one or more occasions during the prior year has been used as an indicator of risky drinking in prior studies of older adults26
and validated as a screening measure in healthcare settings for alcohol abuse. Utilizing this criterion, we would estimate that up to 29% of men and 14% of women in our sample could meet criteria for alcohol abuse. Because of the increased sensitivity of older adults to alcohol,7
5+ drinks is likely a conservative measure of drinking problems in this population. On the SMAST measure of lifetime alcohol problems, 13% of both men and women had elevated scores. This level of drinking and related problems is clinically significant, especially given the elevated suicide risk posed by heavy episodic drinking9
and potential problems with antidepressant response and compliance.
Patients reporting any cannabis use were typically frequent users, with an average prior-month frequency of 13 days for men and 16 days for women. We found a significant association between depression severity and cannabis use even after controlling for age, gender and health status. Studies of younger adults have also found that depression severity is higher among cannabis users than nonusers.5
Although the study did not explore temporal relationships, some patients may use cannabis to help manage depression, cannabis may exacerbate depression symptoms, or the association could be explained by other symptoms such as anxiety. Limited evidence suggests that past cannabis use does not significantly predict onset of depression among adults,35
although this has not been studied in adults older than 60 years. Future studies should investigate these relationships, especially because the number of older adults using cannabis is expected to increase.12,36
Medical use of cannabis, which the study did not differentiate, is an important factor among educated, urban populations in which its use may be legal and socially accepted. Future studies should measure the extent of medical cannabis use among older adults and possible use of cannabis to manage depression, anxiety, and chronic pain.
Self-reported misuse of sedatives was also common in our sample and has important clinical implications. In a similar investigation, a primary care sample of adults older than 60 years in Sweden found that sedative use was higher among patients with depression than others, although the study did not report whether sedatives were used properly.37
Sleep data on our sample were not available. However, older adults are more likely than younger adults to have sleep problems, and insomnia is prevalent among older adults with depression.15
Clinicians should be aware that depression patients may not use sedatives as prescribed and consider strategies for improving adherence.
In contrast to prior studies, we did not find younger age or female gender predictive of prescription drug misuse.20
The finding that being married or partnered was associated with sedative use “other than as prescribed” is not easily explained. It may be that participants in our sample accessed their partner’s sedatives or that having a partner intolerant of sleep disturbance could motivate participants to use a higher dose than prescribed. Factors associated with prescription drug misuse may also differ by gender,14
which our sample was not powered to test. These issues should be explored in future studies to identify modifiable risk factors.
Clinicians may be less likely to screen older adults than younger adults for drug and alcohol problems due to physical comorbidities that may be more salient during the clinical interview, discomfort, or lack of awareness around substance use.18
Our results suggest that despite these obstacles, evaluating alcohol and drug use is an important part of assessing older patients. In addition to quantity, frequency, and problem-based measures, assessment should include the social context and circumstances of alcohol and drug use, as well as use of alcohol or drugs to cope with low moods, loneliness, grief, physical pain, or sleep problems.18
Older patients should be asked about prior experiences in alcohol and drug treatment and whether they would consider returning if needed. Understanding these aspects of alcohol and drug use is critical in developing effective interventions.
Psychiatric clinics are important settings for screening and intervention.38
Many people with drug or alcohol problems first seek mental health treatment, although screening rates generally have been poor.6
Brief interventions could supplement psychiatric services and prevent escalation of alcohol and drug problems and have been used effectively in studies of hazardous drinking among older adults.39
Older patients seeking treatment for depression thus provide clinicians with an opportunity to integrate care and to facilitate referral to more intensive services if needed.
Study Limitations and Strengths
The study has several limitations. Our use of a computerized intake system is likely to undersample frail or cognitively impaired older adults, although these patients are less likely than others to report drug or alcohol use.16
Although computerized measures are valid and very few patients refused to answer, underreporting of alcohol and drug use by patients would make our prevalence rates conservative. The clinic prescreened and excluded patients with serious alcohol and drug problems. However, limiting the sample to patients aged 60 years and older (with a mean age of 67.5 years) with symptoms consistent with major depression (10+ on the BDI-II) in an outpatient setting helps make findings generalizable to treatment-seeking depressed older adults.
Although the BDI-II has been validated among older adults, its inclusion of somatic symptoms more commonly experienced by older adults could result in the confounding of physical symptoms of depression with those of age-related illness. Thus, the BDI could overstate depression severity. We note that to increase sensitivity, it is preferable to use a lower cutoff for binge drinking for women than for men (three or four drinks per occasion rather than five), a measure not available in our data. Our use of the higher cutoff could make our estimates of binge drinking among older women conservative. Future studies should explore the relationship of depression to alcohol consumption among older adults using more sensitive drinking measures, because prior studies have found significant associations between alcohol problems and onset of major depression.19
Multiple testing increases the possibility of Type 1 errors in the analyses (e.g., gender differences in ), although adjustment was not considered necessary.40
The small total numbers of patients reporting heavy episodic drinking, cannabis use, and misuse of sedatives limited statistical power for these analyses. However, results regarding greater depression severity and cannabis use were significant after controlling for other factors, suggesting that these relationships were strong.
The study also has a number of strengths. Cooccurrence of substance use, substance-related problems, and depression among older adults has received very little study compared with research based on younger populations.9,10
To our knowledge, this is the first study to examine predictors of cannabis use and sedative misuse in an older adult psychiatric sample, including potential associations with depression symptoms after controlling for health and other factors. As a next step, future studies should examine medical cannabis use, especially because attitudes toward its use are more tolerant among older adults of the “Baby Boom” cohort than prior older adult cohorts.13
Our results highlight the importance of thoroughly evaluating patterns of alcohol and drug use among older adults seeking treatment for depression.