Addictive behaviors and depression among african americans residing in a public housing community

Addictive Behaviors, Vol. 25, No. 1, pp. 45–56, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0306-4603/00/$–see front matter

Pergamon

PII S0306-4603(99)00035-0

ADDICTIVE BEHAVIORS AND DEPRESSION AMONG AFRICAN AMERICANS RESIDING IN A PUBLIC HOUSING COMMUNITY CARLA D. WILLIAMS*† and LUCILE L. ADAMS-CAMPBELL* *Howard University Cancer Center; and †Howard University Graduate School of Arts and Sciences

Abstract — Numerous studies have indicated that there is an association between cigarette smoking, alcohol use, and depression. However, little attention has been devoted to understanding how demographic factors, such as socioeconomic status and ethnicity, influence these relationships. To address this gap in the literature, cigarette and alcohol use were examined in a sample of African Americans from an urban area. A single public-housing community in Washington, DC was selected for complete ascertainment of the adult population. A total of 126 African American subjects were recruited. Semi-structured interviews were conducted to assess depressive symptoms and to characterize cigarette and alcohol use patterns. Cigarette smoking was not related to the severity of depressive symptoms. By contrast, increased symptoms of depression were related to alcohol use patterns. Light drinkers had a mean score of 5.77 on the Centers for Epidemiologic Studies Depression Scale, compared to a mean of 8.30 for abstainers and 10.07 for heavy drinkers (F 5 4.968, p , .003). An analysis of patterns of substance use revealed that subjects were more likely to either abstain from both substances (30.2%) or to use both substances (32.5%) (x2 5 8.516, df 5 1, p , .004). It is unclear which specific processes work to link alcohol use and depressive symptoms in this group of urban African Americans from a low-income community. What is clear is that alcohol use is clearly related to depressive symptoms in the sample. It is hypothesized that both self-medicating processes and substance-induced depressive symptoms may be responsible for these findings. Important factors to consider in developing effective intervention programs that target this specific population are discussed. © 2000 Elsevier Science Ltd Key Words. Depression, Alcohol, Smoking, African Americans. I N T R O D U C T I O N

Cigarette smoking and alcohol misuse are common maladaptive behaviors in the United States (Centers for Disease Control, 1993; Pierce, Giovino, Hatziandreu, & Shopland, 1989; Slade, 1989; U.S. Bureau of the Census, 1997). Historically, the ill health effects resulting from these behaviors have disproportionately affected African Americans (Centers for Disease Control, 1993; Feigelman & Gorman, 1989). Cigarette and alcohol addiction have been linked to substantial rates of morbidity and mortality, which carry significant monetary and human costs (Nelson & Stussman, 1994; Schwartz & Swanson, 1997; Slade, 1989; Willems, Hunt, & Schorling, 1997). Targeted advertising practices and limited awareness of cancer-causing behaviors have been noted as influential determinants of continued use of these substances (Crews, 1994; Shervington, 1994). In addition to these structural factors, there are a number of important psychosocial factors that influence choices about cigarette and alcohol consumption. Mood regulation is one variable that has been consistently linked to these behaviors. Smokers, particularly nicotine-dependent smokers, have consistently been shown to be more likely This work was supported by National Institutes of Health grants CA-66867 and T32HL07804 awarded to Dr. Adams-Campbell. Requests for reprints should be sent to Lucile L. Adams-Campbell, Howard University Cancer Center, Division of Epidemiology and Biostatistics, 2041 Georgia Avenue, NW, Washington, DC 20060. 45

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to suffer from a depressive disorder (Anda et al., 1990; Breslau, Kilbey, & Andreski, 1993; Glassman et al., 1988; Lerman et al., 1996). Similarly, alcohol use disorders have also been associated with depression (Grant & Hartford, 1995; Lipton, 1994; Schoenborn & Horm, 1993). The self-medication hypothesis (Khantzian, 1985) is a theoretical explanation of the link between substance use disorders and psychiatric illness. This theory is rooted in psychodynamic theory and supported by evidence from neurobiological changes associated with drug use (Markou, Kosten, & Kook, 1998). The self-medication hypothesis contends that substance use can be understood as an attempt to alter undesirable mood states (Khantzian, 1985; Weiss, Griffin, & Mirin, 1992). An exacting interpretation of the self-medication process presumes the existence of an independent depressive disorder that logically relates to the substance use disorder in terms of temporal development and function. In other words, verification of a true self-medicating process demands that the emergence of maladaptive substance use patterns and consequent substance use disorders stem from self-administration of addictive substances to alleviate symptoms of a preexisting, independent mental or physical disorder (Raimo & Schuckit, 1998). Indeed, well-executed empirical research has not supported the notion of increased risk of independent major depression among substance abusers (Merikangas et al., 1998; Raimo & Schuckit, 1998). Furthermore, the comorbidity between depressive disorders and cigarette smoking has been more aptly explained by common or correlated risk factors (Fergusson, Lynskey, & Horwood, 1996; Kendler et al., 1993). Although the influence of self-medicating motives on initiation of substance use remains muddled, the mood-altering effects associated with substances of abuse are quite clear (Markou et al., 1998). Thus, it is important to adequately explore all avenues toward explaining the link between substance use disorders and depressive illness. In empirical evaluations of the self-medication hypothesis, the literature suggests that people frequently report using addictive substances in response to depressive symptoms (Weiss et al., 1992). However, this method of managing depressive symptoms has been shown to have little or no positive effect on symptoms (Hendrie, Sairally, & Starkey, 1998). In fact, the changes in neurotransmitter functioning resulting from repeated administration of and withdrawal from many drugs of abuse creates the potential for developing and/or exacerbating depressive symptoms (Markou et al., 1998). It has been suggested that any self-medicating processes associated with substance abuse may actually reflect attempts to counterbalance changes in neurotransmitter function produced by prolonged drug administration and to alleviate withdrawal symptoms (Markou et al., 1998). The impact of substance-induced depression on the epidemiologic evidence linking drug use to depression cannot be overlooked. Schuckit et al. (1997) sampled 2,845 alcoholics and gathered retrospective data regarding the temporal relationship between onset of mood disorders and the emergence of a substance use disorder as classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987). Their results revealed that 15.2% of subjects had independent depressive disorders, compared to 26.4% who had at least one substance-induced depressive episode. A 5-year prospective study investigating the role of depression in stages of smoking was carried out in a sample of 1,007 young adults aged 21–30 years (Breslau, Peterson, Schultz, Chilcoat, & Andreski, 1998). The results revealed that not only was a history of major depression associated with an increase in risk of becoming a regular smoker, but daily smoking increased the risk for developing a later depres-

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47

sive disorder. Data from studies such as these lend strong credence to the position that substance-induced depression may account for a large part of the comorbidity between nicotine and alcohol dependence and depression. However, as Schuckit et al. (1997) point out, properly conducted prospective studies are needed to evaluate whether a substance actually induces depression. Until such data become available, the term substance-coincident depression may be a more appropriate way to characterize the apparent relationship between cigarette and alcohol use and depression (Schuckit et al., 1997). When individuals attempt to modify these behaviors, the onset or exacerbation of depressive symptoms commonly bear on the outcome of the attempt. A major depressive episode frequently develops during smoking cessation attempts, especially when the smoker has a history of depressive illness (Borrelli, Bock, & King, 1996; Borrelli, Niaura, et al., 1996; Covey, Glassman, & Stetner, 1997). Further, people who have a history of depression are more likely to relapse into smoking, compared to those with no such history (Glassman et al., 1988; Valois, Adams, & Kammermann, 1996). Drinking relapse is also more likely to occur in those who suffer from depressive disorders (Mason, Kocsis, Ritvo, & Cutler, 1996). Although the mechanisms linking substance use disorders with mood disturbance require further study, the health effects of maladaptive substance use are well-documented (McGinnis & Foege, 1993; U.S. Department of Health and Human Services, 1990). The detrimental effects of cigarette and alcohol use are often compounded by concurrent use of both substances. Smoking and heavy drinking have consistently been shown to be associated behaviors. People who smoke are more likely to use alcohol heavily and heavy drinkers are more likely to smoke cigarettes (Bien & Burge, 1990; DiFranza & Guerrera, 1990; Madden, Heath, Starmer, Whitfield, & Martin, 1995). Data from the cohort surveys of the Minnesota Heart Health Study (MHHS) (Nothwehr, Lando, & Bobo, 1995) indicate that 21.8% of the study sample used both cigarettes and alcohol, while 29.3% of subjects used neither substance. The fact that majority of MHHS subjects (39.9%) used alcohol only, while 8.9% used cigarettes only, may reflect important social and cultural differences in health behavior trends. In an examination of the social correlates of cardiovascular disease risk factors in a highly urbanized, predominantly African American community, the prevalence of cigarette smoking was substantially greater (Diez-Roux, Northridge, Morabia, Bassett, & Shea, 1999). Of 287 males surveyed, 47.5% were current smokers. Among the 408 women in the study, 41.2% currently smoked. Thus, culturally related factors such as normative behaviors and access to relevant information and interventions may strongly influence health behaviors and health outcomes. There is strong evidence to suggest that the risk factors for smoking, drinking, and depression vary by ethnicity. Many studies have attempted to understand this phenomena by making inter-ethnic comparisons (Feigelman & Gorman, 1989; Royce, Hymowitz, Corbet, Hartwell, & Orlandi, 1993; Son, Markovitz, Winders, & Smith, 1997; Vega, Zimmerman, Warheit, Apospori, & Andres, 1993). These studies have illuminated important behavioral patterns. However, in order to more fully understand how the relationships between these variables are expressed in different ethnic groups, intra-ethnic comparisons are also necessary. This investigation addressed the special issues related to cigarette and alcohol use among African Americans residing in an urban public-housing community. This distinct group of African Americans face sizable barriers to maintaining optimal health. Public-housing residents in the District of Columbia have a median annual

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income of $6,048. Low-income families occupy 50% of the public housing units. The remaining half are occupied by the elderly and people with disabilities. Forty-six percent of all residents receive some type of public income assistance (District of Columbia Housing Authority, 1997). The potential limits placed on access to health care and health promotion resources combined with significant socioeconomic stressors puts public-housing residents at considerable risk for experiencing unfavorable mental and physical health states (Franklin, 1989; Jones & Clifford, 1990). Thus, it is particularly important to study the correlates of modifiable health behaviors in this population. The goal of the study was to determine whether a relationship exists between cigarette smoking, alcohol consumption, and depressive illness among African American residents of a public-housing community in Washington, DC. M E T H O D S

Subjects were recruited from a single public-housing community in Washington, DC. The recruitment procedure was designed to obtain complete ascertainment of all residents aged 18 and older at the selected site. This site was selected to allow access to a predominately African American population who were relatively homogenous in terms of socioeconomic status. After obtaining informed consent, trained interviewers conducted individual, face-to-face, semi-structured interviews. The interview evaluated physical activity and history of chronic disease (heart disease, hypertension, stroke, and diabetes) in the subject and his/her first and second-degree relatives. Face valid questions assessing lifetime history of cigarette use, past year history of alcohol use, and current cigarette and alcohol use patterns were also administered during the interview. A modified version of the Centers for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) presented in pencil-paper format was used to assess depressive symptoms. This 13-item questionnaire consisted of 11 items from the original scale assessing somatic symptoms (4 items), interpersonal symptoms (3 items), depressed mood (2 items), and positive affect (2 items). Two items assessing additional problems in the interpersonal domain were included. Subjects were asked to indicate how often they had experienced each symptom during the week preceding the interview (hardly ever, some of the time, or most of the time). Parameters standardizing symptom frequency were not provided, thus responses were subjectively defined by each subject. One point was scored if the symptom was reported some of the time and 2 points were scored when subjects reported the symptom occurring most of the time, thus a maximum score of 26 was possible. Research has suggested that African Americans may express depressive symptoms differently than other ethnic groups. African Americans tend to present with more severe somatic complaints (Brown, Schulberg, & Madonia, 1996) and problems in the interpersonal domain have been shown to predict treatment seeking for depression among African Americans (Sussman, Robins, & Earls, 1987). Further, while Roberts (1980) indicated no differences in the CES-D factor structure for Whites, Blacks, and Mexican Americans, Callahan and Wolinsky (1994) have suggested that differential CES-D response patterns exist among different ethnic groups. Thus, the CES-D was modified to more accurately capture the presentation of depression among the study population. Items from the original scale, such as, “I felt hopeful about the future,” may have elicited responses that reflected artifacts of living in a socially and economically oppressive environment. Similarly, items like, “I felt fearful” may have been en-

Smoking, alcohol, and depression

49

dorsed due to actual threats associated with residing in a densely populated urban area. The modified instrument maintained acceptable internal consistency (Cronbach’s alpha 5 .775). D A T A

A N A L Y S I S

To explore how depressive symptoms might impact substance use patterns, a oneway analysis of variance (ANOVA) was use to examine the relationship between depression scores and patterns of cigarette and alcohol consumption. To control for the ways in which age, gender, and body mass index (BMI) (calculated as [weight (kg)/ height (m)2] 3 705) might impact consumption patterns, a factorial ANOVA was used further test significant univariate findings. A graphic display of the data indicated that CES-D scores peaked for subjects who consumed between five and nine drinks per day and declined again for subjects reporting higher rates of alcohol consumption. Due to the small sample size in this study, the score for a few outliers would have artificially increased the effect size demonstrated for heavy drinkers. We chose to minimize this effect by analyzing our data categorically, thus absorbing the outliers into the group mean. Thus, the analysis provides a conservative estimation of the relationship between our dependent and independent variables. Cigarette consumption was divided into three categories (light, moderate, and heavy). Subjects were considered light smokers if they reported smoking five or fewer cigarettes per day. Moderate smokers were those who consumed 6 to 10 cigarettes per day, and heavy smokers smoked 11 or more cigarettes each day. These demarcations differ substantially from those generally used to classify levels of nicotine dependence. Cigarettes per day is a component of the 6-item Fagerstrom Test of Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). The FTND scores no points less than 10 cigarettes per day. A maximum of 3 points is possible based on three increasing levels of consumption (11–20, 21–30, and 31 or more cigarettes per day). However, African Americans tend to smoke fewer cigarettes per day (Centers for Disease Control, 1993; Kabat, Morabia, & Wynder, 1991). In this sample, 96.3% of subjects reported smoking 20 or fewer cigarettes per day. Thus, the cigarette consumption categories were established to reflect differences in smoking patterns. Alcohol consumption was categorized based on the typical number of alcoholic drinks consumed per day on the days when subjects drank alcohol. Alcoholic beverages were defined to subjects as, “beer, ale, wine, wine coolers, liquor, cocktails, and mixed drinks containing liquor,” however, uniform serving sizes were not defined. Two subjects who reported use of alcohol in the past year were excluded from this analysis because they reported having less than one drinking occasion per month. Light consumption was considered to be two drinks or less per day. Three to four drinks per day was considered moderate and five or more drinks per day was classified as heavy drinking. These categorizations are similar to those used in epidemiologic data gathering on drinking behaviors (National Center for Chronic Disease Prevention and Health Promotion, Division of Adult Health, 1996). R E S U L T S

Sample characteristics A total of 126 subjects were recruited into the study; representing a 65% response rate for the adult population of the community. Subjects included 83 women and 43

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C. D. WILLIAMS and L. L. ADAMS-CAMPBELL

men who ranged in age from 20 to 69 years. Men and women did not differ in terms of prevalence of substance use. Similarly, there were no gender differences in mean depression scores, which ranged from 0 to 18. Because substance use and depression scores did not differ by gender, analyses were only performed for the sample as a whole to maximize statistical power to detect between groups differences. Table 1 presents the prevalence of current substance use and CES-D scores for the sample. It was hypothesized that cigarette smoking and alcohol use would be associated behaviors. As illustrated in Table 1, subjects who used one substance were more likely to use the other as well. Similarly, subjects who abstained from one substance were more likely to abstain from the other (x2 5 8.516, df 5 1, p , .004). Substance use and depression Depression scores for current cigarette users and current alcohol users were compared to those of abstainers. Smokers and nonsmokers had comparable mean CES-D scores (7.95 and 6.87, respectively, t 5 1.126, p . .05). Similarly, depression scores for current drinkers were not significantly different from abstainers (7.04 and 8.30, respectively, t 5 21.674, p . .05). To test the combined effects of cigarette and alcohol use, subjects who used both substances were compared to those who used only one substance and to subjects who abstained from both substances. Table 2 shows that there were no differences between these groups in terms of mean CES-D scores. These findings indicate that depressive symptoms were not related to whether or not subjects from this population use cigarettes or alcohol. Pattern of substance use and depression While depressive symptoms were unrelated to the prevalence of substance use in this sample, it was hypothesized that, among substance users, heavier cigarette and alTable 1. Characteristics of African American residents of public housing Variable Mean age (SD) Mean CES-D score (SD) %Male Substance use None Cigarettes only Alcohol only Cigarettes and alcohol Current cigarette use No Yes 1–5 cigarettes/day 6–10 cigarettes/day 101 cigarettes/day Current alcohol use No Yes 1–2 drinks/day 3–4 drinks/day 51 drinks/day

n

X or %

126 126 43

35.0 (9.4) 7.6 (4.2) 34.1

38 19 28 41

30.2a 15.1a 22.2 32.5

66 60 26 20 14

52.4 47.6 43.3 33.3 23.3

57 69 35 19 15

45.2a 54.8 50.7 27.5 21.7

CES-D 5 Centers for Epidemiologic Studies Depression Scale. a Percentages are unequal due to rounding error.

Smoking, alcohol, and depression

51

cohol use would be associated with more reported symptoms of depression. This hypothesis was partially supported. Table 2 reveals that there were no significant differences in depression scores based on cigarette consumption. By contrast, CES-D scores differed significantly according to level of alcohol consumption. Subjects who typically drank five or more drinks per occasion had higher mean CES-D scores than light drinkers. Interestingly, light drinkers had significantly lower CES-D scores than abstainers. There were no independent effects of age, gender, or BMI. However, as illustrated in Table 3, the main effects for level of alcohol consumption remained significant. Furthermore, the variation among CES-D scores was not related to any interaction effect between cigarette and alcohol consumption.

D I S C U S S I O N

The majority (nearly 70%) of subjects in this sample of African American residents from an urban public-housing community reported regular consumption of cigarettes and/or alcohol. The overall prevalence of cigarette and alcohol use in this sample is similar to that found in a large epidemiologic cohort (Nothwehr et al., 1995). However, the distribution of substance use patterns differed somewhat from the Minnesota Heart Health sample, with more subjects in our sample reporting use of both substances (32.5% vs. 21.8%). The findings in this study also differed from previous studies in that cigarette smoking was not associated with the presence or severity of depressive symptoms. Previous studies have indicated a consistent association between smoking and depression (Breslau, 1995; Breslau et al., 1998; Lerman et al., 1996). However, these studies have used predominantly White subject samples. The lack of support for the relationship between cigarette smoking and depressive symptoms in this sample suggests that the linkages between substance use and mood symptoms may vary between populations. The existence of such differences may have important implications for the development of substance abuse intervention and treatment programs.

Table 2. Substance use patterns and CES-D scores Substance use Concurrent substance use None Cigarettes only Alcohol only Cigarettes and alcohol Typical cigarette consumption None Light (1–5/day) Moderate (6–10/day) Heavy (10 or more/day) Typical alcohol consumption None Light (2 or less) Moderate (3–5) Heavy (6 or more)

n

CES-D M

SD

38 19 28 41

8.16 8.58 6.14 7.66

4.38 3.82 3.24 4.70

44 33 28 21

7.09 8.09 6.79 8.29

4.21 4.70 4.05 3.55

57 35 17 15

8.30a,b 5.77a 6.94 10.07b

4.17 3.87 4.05 3.92

CES-D 5 Center for Epidemiological Studies Depression Scale. are significantly different at p , .05, adjusted for multiple comparisons. b Means are significantly different at p , .05, adjusted for multiple comparisons. a Means

F

p

1.704

0.170

0.693

0.558

4.968

0.003

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C. D. WILLIAMS and L. L. ADAMS-CAMPBELL

Table 3. Factorial analysis of variance of CES-D scoresa Variable Age Gender BMI Alcohol consumption pattern Cigarette consumption pattern Alcohol consumption 3 cigarette consumption Overall model Residual Total

Sum of squares

Mean square

F

p

32.90 2.63 12.37 263.32 25.78 87.69 460.75 1722.91 2183.66

32.90 2.63 12.37 87.77 8.60 9.74 25.60 16.57 17.9

1.986 0.159 0.747 5.3 0.52 0.59 1.55

0.162 0.691 0.39 0.002 0.67 0.084 0.089

CES-D 5 Center for Epidemiologic Studies Depression Scale; BMI 5 body mass index. effects entered simultaneously.

a All

By contrast, patterns of alcohol use were related to CES-D depression scores. Even when age, gender, and BMI were controlled, subjects who consumed one to two drinks per day had lower mean depression scores than abstainers and subjects who consumed five or more drinks per day. The results of this study support outcomes of previous studies, which have found consistent relationships between use of alcohol and depressive disorders (Grant & Hartford, 1995; Lipton, 1994; Schoenborn & Horm, 1993; Son et al., 1997). For the population examined in this study, alcohol use was clearly associated with the presence of depressive symptoms. Compared to abstainers, subjects who consumed relatively light quantities of alcohol had significantly lower CES-D scores. By contrast, subjects who reported heavy alcohol usage evidenced significantly more depressive symptoms than abstainers or light drinkers. The literature purports two leading hypotheses regarding previously documented associations between substance use and mood symptoms. The self-medication hypothesis (Khantzian, 1985) suggests that people use drugs to relieve the discomfort of negative mood symptoms. Alternatively, the apparent link between substance use and depressive symptoms may be an artifact of the capacity for various substances of abuse, including alcohol and potentially nicotine, to actually induce a mood disorder in some individuals. Both processes have been documented in a carefully executed study (Schuckit et al., 1997). These two explanations for the relationship between alcohol use and depression are not necessarily competing hypotheses. It is possible that the lower CES-D scores for light drinkers compared to abstainers in this study are indicative of a self-medicating process by which limited alcohol use provides modest amelioration of negative mood symptoms. It may also be possible that the higher levels of depressive symptoms among the heaviest drinkers in this sample represent substance-induced depressive symptoms. It is reasonable to postulate that both processes may be responsible for the findings in this study. However, without more adequate history regarding the onset of depressive symptoms in relation to alcohol use, we cannot ascertain the exact reasons for the association between depression and drinking. In order to fully evaluate these hypotheses, longitudinal data documenting the sequence of the onset of drinking in relation to the development of the depressive symptoms are needed. Furthermore, in this study, data on length of abstinence was assessed in terms of years rather than weeks or months. Therefore, we do not know whether the depression scores for abstainers represent an actual baseline level of depressive symptoms that are not influenced by alcohol use, or whether mean CES-D scores were artificially inflated by some individuals who may have been experiencing depressive symptoms due to recent alcohol withdrawal.

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Despite the limitations of these data to distinguish substance-induced depression from self-medicating substance use patterns, this study has identified a clear need to focus more attention on the patterns of substance use in this often marginalized segment of the population. Among the 126 study participants, 55 (48.7%) reported that they believed that they had a drinking problem at some point in their lives. It is clear that individuals in this population could benefit from effective substance abuse treatments. In order to develop such interventions, it is necessary to understand the unique patterns of behavior exhibited in this population. Many public-housing residents face substantial environmental stressors, including poverty, joblessness, and community violence. Factors such as these may increase the likelihood that these individuals may frequently experience symptoms of depression (Pierce, Frone, Russell, & Cooper, 1994). Alcohol use may be a learned response to the experience of stress because it provides a temporary reduction in felt stress by keeping the drinker from thinking clearly about his/her problem(s). However, because alcohol is a central nervous system depressant, heavy and prolonged use can serve to exacerbate depressive symptoms. Moreover, the problems typically associated with alcohol abuse can create additional sources of stress that fuel negative mood states. For example, impaired occupational functioning due to alcohol abuse may result in notable economic impacts on people who have few economic resources. Also, the overuse of these drugs may result in social disapproval and/or pressure to alter the behavior. The deleterious effects of heavy use combined with drug tolerance render void any mood-enhancing properties alcohol use may have. The findings from this investigation have important implications for development of interventions for smoking and maladaptive alcohol consumption. The unique social and environmental factors that affect this population must be taken into account when planning interventions. If the depressive symptoms are fueled by environmental hardships such as those described above, any intervention program must not only address the substance abuse, but must also attend to the sociocultural reality of the population. This population is often politically and economically disenfranchised. As a result, they may perceive themselves as being powerless to effect changes in their environments. An intervention designed to remove alcohol as a means of coping with or escaping from environmental stressors must provide very real ways for these individuals to become empowered to change their circumstances. Also, if it is true that drinking allows people to become detached from the experience of overwhelming negative emotions, treatment programs must be designed to help these individuals learn to tolerate the full range of emotions, including those emotions that are aversive and difficult to manage. Helping substance abusers to set attainable life goals will be an important step in the process of change. Further, an intervention program should make effective use of the social bonds that exist within communities such as these. Drinking is often a social behavior during which the substance users create an atmosphere of support and universality. In other words, they feel they are not alone in the problems they face. Because the heavy drinker may feel estranged from nondrinking family and friends, the social network of drinkers takes on added importance. A substance abuse intervention designed for this population should also focus on rebuilding interpersonal bonds with nondrinking members of the user’s social network. Reestablishing adaptive social relationships may also help to alleviate interpersonal symptoms of depression such as feelings of loneliness and isolation. Although cigarette smoking was not related to depression in this study, an association between smoking and depression was noted. The two behaviors co-occurred more

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often than would have been expected by chance. Smoking cessation should also be a part of any substance abuse intervention program. Substance users should come to see themselves giving up maladaptive coping strategies and replacing them with behaviors that are adaptive, promote physical and emotional health, and provide the user with a sense of self-efficacy. The sense of accomplishment people attain when they successfully enter recovery can be an effective motivator to maintain a drug-free lifestyle. It is important to gather longitudinal data that will sufficiently assess the prevalence of substance-induced depression and self-medicating behaviors. However, it would be remiss to not build prevention and intervention components into the design of future studies. Goals for future research should be to test culturally sensitive interventions that incorporate the key components described above. Randomized trials should be used to evaluate the efficacy of such intervention programs. It is of paramount importance that the interventions be specialized to fit the population with which they will be used. S T U D Y

L I M I T A T I O N S

The data used to study the relationship between substance use and depression were derived from a study intended to assess participants’ health status, their awareness of breast cancer education, and attitudes and behaviors related to breast cancer prevention. Many important correlates of depression and substance use were not measured. We did not assess perceived environmental stressors, which may have impacted both depressive symptoms and substance use. Familial factors, including history of depression and substance dependence were not measured. Furthermore, although the income restrictions required for acceptance into a public-housing project creates a generally economically homogenous group, we did not obtain sufficient background data regarding educational attainment, annual income, and employment status. Factors such as educational attainment have been shown to attenuate the relationship between nicotine dependence and depression for some groups (Son et al., 1997). The generalizability of this study is limited to similar populations of African Americans. The unique issues related to living in urban public-housing communities cannot be broadly generalized to larger, more diverse populations. Larger samples from various segments of the African American community are needed to better understand how mood symptoms are related to the process of substance abuse. Additionally, comprehensive assessments of depression and substance use history were not carried out. To fully answer the question about how depression relates to substance use, clinically derived data on the presence, severity, and history of depression are needed. Similarly, a more detailed history of substance use is also required to provide a complete picture of how depression and substance abuse are related. Also, data on the use of other illicit drugs may prove beneficial. Longitudinal data indicating the pattern of progression of substance abuse in relation to the development of depressive symptoms would provide important information about causal relationships. Further research addressing the special needs of this population is warranted. R E F E R E N C E S American Psychiatric Association. (1987). Diagnostic and statistical manual of mental d5454isorders (3rd. ed., rev.). Washington, DC: Author. Anda, R. F., Williamson, D. F., Escobedo, L. G., Mast, E. E., Giovino, G. A., & Remington, P. L. (1990). Depression and the dynamics of smoking: A national perspective. Journal of the American Medical Association, 265, 1541–1545.

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