- Email: [email protected]
The association of depression and problem drinking
Addictive Behaviors 26 (2001) 765 – 773
Brief report
The association of depression and problem drinking: Analyses from the Baltimore ECA follow-up study Rosa M. Cruma,b,c,*, Clayton Brownd, Kung-Yee Liangd, William W. Eatonc a
Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA b Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA c Department of Mental Hygiene, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA d Department of Biostatistics, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA
Abstract In this study, we hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women. As part of the Epidemiologic Catchment Area (ECA) program, probability samples of area residents were selected and the baseline interview for the Baltimore site was completed in 1981. Between 1993 and 1996, 73% of the survivors (n = 2633) were reinterviewed. For the 334 problem drinkers identified, the occurrence of a depressive episode and level of alcohol consumption for each intervening year between the baseline and followup interviews were assessed. Generalized estimating equations (GEE) were used for logistic regression analyses to examine the association between the occurrence of depression in the prior year with transition to higher-level drinking in the subsequent year. The problem drinkers tended to have a bimodal association of transitioning to higher-level drinking; although the strength of the association was greater for men. Future research will need to assess the potential influences on this relationship of other sociodemographic and psychopathologic characteristics, including the effect of treatment for depression or substance use. D 2001 Elsevier Science Ltd. All rights reserved. Keywords: Alcohol; Comorbidity; Depression; Problem drinking; Risk
* Corresponding author. Johns Hopkins Health Institutions, Welch Center for Prevention, Epidemiology, and Clinical Research, Suite 2-500, 2024 East Monument Street, Baltimore, MD 21205, USA. Tel.: +1-410-614-2411; fax: +1-410-614-0588. E-mail address: [email protected] (R.M. Crum). 0306-4603/01/$ – see front matter D 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 0 ) 0 0 1 6 3 - 5
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R.M. Crum et al. / Addictive Behaviors 26 (2001) 765–773
1. Introduction The cooccurrence of alcohol abuse and dependence with depressive disorders has been well recognized in clinical samples (e.g., Brown et al., 1998; Davidson, 1995). In addition, data from population-based studies have showed that the odds of alcohol abuse or dependence among those with depression relative to those without depression is significantly elevated (e.g., Grant & Harford, 1995), and that this relationship may differ by sex (Kessler et al., 1997). Furthermore, the timing of the assessments is a consideration in the interpretation of findings from several prospective studies (e.g., Hartka et al., 1991; Moscato et al., 1997). Theories to account for the comorbid relationship between depression and alcoholism often focus on the use of alcohol for self-medication of mood symptoms. There may be common underlying factors that predispose to an increased risk for both alcohol and depressive disorders, such as genetic factors or social and environmental characteristics (Dohrenwend et al., 1992; Kendler, Health, Neale, Kessler, & Eaves, 1993). The tensionreduction theory posits that consumption is related to the reduction of tension (e.g., MacAndrew, 1982). One component of the stress-coping model of drinking behavior may be the expectations for regulating negative mood (Kassel, Jackson, & Unrod, 2000). Cloninger’s theory of personality dimensions (novelty seeking, harm avoidance, reward dependance) may explain some patterns of comorbid conditions (Mulder, Joyce, & Cloninger, 1994). Furthermore, the relationship of other characteristics (e.g., social contact) may be important integrating factors with both depression and problem drinking (Peirce, Frone, Russell, Cooper, & Mudar, 2000). In this study, we aimed to assess the relationship between depression and problem drinking for specific levels of alcohol use among problem drinkers. We hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women, based on findings from prior studies showing a stronger comorbid relationship among females (e.g., Kessler et al., 1997). Prior prospective research has not assessed these relationships among problem drinkers identified from community-based samples, which potentially reduce selection biases evident in some treatment studies.
2. Methods From 1980 to 1984, collaborators in the Epidemiologic Catchment Area (ECA) program recruited adult participants, 18 years of age and older, in probability samples of residents in five metropolitan areas, including Baltimore, MD (n = 3481). Study data on psychopathology were gathered with the Diagnostic Interview Schedule, for which reliability and validity estimates have been published (e.g., Anthony et al., 1985; Robins, Helzer, Croughan, & Ratcliff, 1981). Between 1993 and 1996, the 1981 Baltimore site cohort was traced, and 73% (n = 1920) of the 2633 survivors were reinterviewed; 848 (24%) respondents had died, 415 could not be located, and 298 refused to participate. The median length of follow-up was 12.6 years. Attrition was associated with the occurrence of some psychiatric conditions (e.g., cocaine use, antisocial personality disorder), but was not associated with depression or
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alcohol abuse or dependence (Badawi, Eaton, Myllyluoma, Weimer, & Gallo, 1999). A total of 334 individuals were identified who reported at least one alcohol-related problem occurring in their lifetime, and comprised the study sample for these analyses. Data on the occurrence of a depressive episode and alcohol consumption among problem drinkers was assessed using the Life Chart Interview (Lyketsos, Nestadt, Cwi, Heithoff, & Eaton, 1994), a retrospective assessment of the course of psychopathology as it occurs in each year of the observational interval from the baseline to the follow-up interview using age- and calendarlinked personal landmarks, as well as life events as memory cues. A depressive episode, as used in this study and other analyses of the ECA (e.g., Anthony & Petronis, 1991), was defined as dysphoria or anhedonia with a clustering of other depressive symptoms during a period of 2 weeks or more, based on DSM-III-R major depression symptom criteria (American Psychiatric Association, 1987). Alcohol-related problems were identified if a study participant responded positively to one of the 19 questions concerning problems related to alcohol use. Alcohol consumption was assessed for each year from the time of onset of the alcohol-related problem to the time of the most recent drink, using an ordinal scale of 10 levels ranging from no consumption in that year, to everyday but more than once each day. For each year in the period 1981–1996, the Life Chart Interview contained incidence, recency, and duration of depression and alcohol use, and therefore was treated as longitudinal data (repeated measures). The data was pooled to create dyad years of observation, resulting in 3780 person-year observations. Generalized estimating equations (GEE) (Liang & Zeger, 1986), a method for fitting regression models with correlated longitudinal response, were used to account for the fact that the subjects’ drinking levels were correlated over observational years. To test our hypotheses, we completed exploratory analyses and fit logistic regression models with drinking level (dichotomized) as the response variable and the dichotomous depressive episode variable (Yes/No) from the prior year as the explanatory covariate. The initial cut point for drinking in the following year was divided between ‘‘high’’ consumption (drinking at least daily) relative to ‘‘low’’ consumption (less than daily drinking), controlling for the prior year level of drinking (also dichotomized), depression in the prior year (Yes/No), and the continuous covariates calendar year and age. The final logistic regression model included the main effect covariates, as well as terms to assess the interaction between depression and sex, alcohol use in the prior year and sex, and alcohol use in the prior year with depression.
3. Results Of the 334 problem drinkers, 216 (65%) were men, and almost half (49%) were between the ages of 18 and 29 years at the time of the baseline interview (Table 1). Approximately 60% of the problem drinkers indicated that their highest level of education was high school. The majority of the sample described themselves as African–American (66%), with the remaining sample being predominately White (31%). At the time of the follow-up interview, a total of 128 (38%) were married, and an equal proportion were never married. We initially dichotomized the drinking outcome variable to distinguish two categories: ‘‘high’’ alcohol consumption, those who drank at least daily referenced to ‘‘low’’ alcohol
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Table 1 Frequency distribution of problem drinkers (N = 334) Number
Percentage (%)
Sex Men Women
216 118
64.7 35.3
Age (years)a 18 – 29 30 – 39 40 – 49 50 – 59 60 – 69 70 – 79
165 81 46 25 16 1
49.0 24.0 14.0 8.0 5.0 0.3
Race – ethnicityb African – American White Other
222 104 2
66.5 31.1 0.6
Years of schooling 0–8 9 – 12 > 12
36 203 95
10.8 60.8 28.4
Marital status Married Widowed Separated Divorced Never married
128 13 35 31 127
38.3 3.9 10.5 9.3 38.0
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. a Age at the time of the baseline interview. b A total of six individuals (1.8%) did not provide information on race – ethnicity.
consumption, those who reported drinking less than once a day. This was done to model our initial logistic regression analyses to assess the association of depression with transition to daily drinking. Analysis of the GEE parameter estimates showed that the strongest predictor of higher-level drinking was the level of consumption in the prior year (parameter estimate = 6.79; 95% CI, 6.32–7.25; P .001) (Table 2, model A). Interaction terms were then included in the model (Table 2, model B). Among those who were not drinking daily in the prior year, there was a threefold increased odds of transition to daily drinking for depressed male problem drinkers relative to those without depression (OR = 3.15; 95% CI, 0.73–13.52, P = .12), and a twofold increased odds of daily drinking among depressed female problem drinkers relative to those without depression (OR = 2.00; 95% CI, 0.43–9.24, P = .37). In order to explore these relationships further, we assessed the association of depression in the prior year with transition to higher-level drinking for each level of alcohol consumption, calculating an odds ratio for each cut point of the 10-level ordinal alcohol
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Table 2 GEEa parameter estimates for odds of transition to daily drinking in the subsequent year among problem drinkers based on logistic regression analyses Variable Model A parameter Model B parameter estimate (95% CIb) estimate (95% CIb) Calendar year Age Prior year alcohol consumption Depression in the prior year Sex
0.07 0.01 6.79 0.04 0.24
( 0.12, 0.02)* (0.001, 0.02)* (6.32, 7.25)*** ( 1.24, 1.17) ( 0.61, 0.12)
Interaction terms Depressionc Sex Alcohold Sex Alcohold Depressionc
0.07 0.01 7.00 1.14 0.07
( 0.12, 0.01)* (0.001, 0.03)* (6.43, 7.58)*** ( 0.31, 2.60) ( 0.69, 0.84)
0.45 ( 0.41 ( 1.44 (
2.03, 1.13) 1.39, 0.57) 3.28, 0.39)
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. * P < 0.05; *** P < 0.001 a GEE, generalized estimating equations. b CI, confidence interval. c Depression in the prior year. d Alcohol consumption in the prior year.
consumption scale for men and women (Fig. 1; Table 3). The odds for transition to higherlevel drinking among depressed men relative to those without prior year depression was
Fig. 1. Odds ratios for transition to higher level drinking for depressed problem drinkers relative to those without depression, for each cut point in the 10-point ordinal scale of alcohol consumption, by sex. Data are from Baltimore ECA Follow-up study, 1981 – 1996. Alcohol consumption was measured using an ordinal scale of 10 levels ranging from no consumption in that year (variable value = 00), to use once a year (01), several times a year (02), once a month (03), two to three times a month (04), once a week (05), two to three times a week (06), four to six times a week (07), everyday once a day (08), and everyday but more than once each day (09).
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Table 3 GEEa estimates for odds of transition to higher-level drinking in the subsequent year among problem drinkers based on logistic regression analyses for each cut point in the 10-point ordinal scale of alcohol consumption, by sex Alcohol level cut pointb
Odds Ratio (95% CIc), P-value for Women
Odds Ratio (95% CIc), P-value for Men
00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09
0.99 1.68 0.30 0.34 0.95 0.55 0.61 2.00 1.14
3.45 8.12 5.52 2.19 2.08 0.63 1.51 3.15 1.03
(0.15 – 6.70), (0.28 – 9.93), (0.02 – 3.83), (0.04 – 3.12), (0.19 – 4.80), (0.06 – 4.63), (0.06 – 6.15), (0.43 – 9.24), (0.16 – 8.33),
0.99 0.57 0.36 0.34 0.95 0.58 0.68 0.37 0.89
(0.41 – 28.84), 0.25 (0.85 – 77.17), 0.07 (1.13 – 26.99), 0.03 (0.21 – 22.61), 0.51 (0.32 – 13.41), 0.44 (0.05 – 7.22), 0.71 (0.19 – 11.94), 0.69 (0.73 – 13.52), 0.12 (0.09 – 12.04), 0.98
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. a GEE, generalized estimating equations. b Alcohol consumption was measured using an ordinal scale of 10 levels ranging from no consumption in that year (variable value = 00), to use once a year (01), several times a year (02), once a month (03), two to three times a month (04), once a week (05), two to three times a week (06), four to six times a week (07), everyday once a day (08), and everyday but more than once each day (09). c 95% CI, confidence interval.
generally greater than one, and indicated a bimodal association. Among women, a similar pattern was found, but the strength of the associations were reduced. In addition, the odds ratios were less than one for most cut points, signifying that relative to nondepressed women, prior year depression was associated with a decreased odds of transition to higher-level drinking. These findings did not meet criteria for statistical significance at the .05 level, but did imply that contrary to our initial hypotheses, male problem drinkers with prior year depression relative to nondepressed men had the higher odds of transitioning to higher-level drinking when contrasted to the findings for women.
4. Discussion Our findings for this study were not consistent with our initial hypotheses but indicated several associations between the occurrence of depression with transition in drinking among problem drinkers. We found that the odds of transition to daily drinking tended to be higher among depressed men relative to men who were not depressed, than it was for depressed women relative to nondepressed women. Furthermore, we found that depressed problem drinkers tended to have a bimodal association of transitioning to higher-level drinking relative to those without depression in the prior year, with the strength of the associations being greater among men. Among depressed women, there was a general decreased likelihood of transitioning to higher-level drinking across most cut points of the alcohol consumption scale relative to women without depression in the prior year. Because these findings did not meet
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criteria for statistical significance, we cannot make firm conclusions about these associations, but the results indicate trends that may be explored further in future investigations. The tendency for a bimodal association of transitioning to higher-level drinking after the occurrence of depression may indicate more than one etiologic pathway operating in this population. Those individuals transitioning from a baseline low drinking level may have been drinking to reduce tension or to alleviate negative mood, and may have attempted to implement the mood elevating effects of alcohol. Yet, those whose baseline drinking was already at a relatively high level were more likely to have had chronic drinking patterns that may actually have contributed to the onset of the depressive episode, rather than the reverse. Furthermore, there are several plausible explanations for the finding that depression among some problem drinkers was associated with a tendency for reduction in alcohol consumption. The occurrence of depression may have signaled to these drinkers the need to reduce alcohol use. This is consistent with some reports of treatment samples in which the occurrence of depressive symptoms was associated with improvement in substance use or drinking outcomes (e.g., Kranzler, Del Boca, & Rounsaville, 1996; Salloum et al., 1998). In addition, depressive symptoms may have forced some individuals to enter treatment, with subsequent recommendations for reductions in alcohol made by treating clinicians. Treatment for depression also may have decreased the potential need to self-medicate affective symptoms with alcohol. There are several limitations in the current report. For one, this study only included problem drinkers and the findings may not be generalizable to other drinking populations. Second, the assessment of alcohol consumption did not include a quantity measure. Third, depression was assessed only for the prior year, and did not incorporate symptom duration. Fourth, we were unable to assess whether any treatment was received during the intervening years between the baseline and follow-up interviews. Notwithstanding these limitations, the current report has several strengths including the use of a community-based sample rather than a treatment population, reducing potential selection biases. Findings from these and similar studies may improve our understanding of patterns of comorbid psychopathology, and highlight the need to further examine the relationship of depression with drinking patterns.
Acknowledgments This work was supported by a Scientist Development Award for Clinicians from the National Institute on Alcohol Abuse and Alcoholism (AA00168) (Dr. Crum). Data gathering for the Baltimore ECA Follow-up survey was supported by a grant from the National Institute of Mental Health (MH47447). Data gathering for the original surveys was supported by the ECA Program of the National Institute of Mental Health Division of Biometry and Epidemiology. The Principal Investigators, Co-Investigators, and grant award numbers during data gathering were Jerome K. Myers, Myrna M. Weissman, and Gary L. Tischler at Yale University (MH34224); Morton Kramer, Ernest Gruenberg, and Sam Shapiro at the Johns Hopkins University (MH33870); Lee N. Robins and John E. Helzer at Washington University (MH33883); Dan Blazer and Linda George at Duke University (MH35386); and Marvin
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Karno, Richard L. Hough, Javier I. Escobar, M. Audrey Burnam, and Dianne Timbers at the University of California, Los Angeles (MH35865). At the NIMH, principal collaborators during data gathering were Darrel A. Regier, Ben Z. Locke, William W. Eaton, Carl A. Taube, and Jack D. Burke, Jr. References American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders — third revised edition. Washington, DC: American Psychiatric Association. Anthony, J. C., Folstein, M., Romanoski, A. J., Von Korff, M. R., Nestadt, G. R., Chahal, R., Merchant, A., Brown, C. H., Shapiro, S., Kramer, M., & Gruenberg, E. M. (1985). Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis: experience in eastern Baltimore. Archives of General Psychiatry, 42, 667 – 675. Anthony, J. C., & Petronis, K. R. (1991). Suspected risk factors for depression among adults 18 – 44 years old. Epidemiology, 2, 123 – 132. Badawi, M. A., Eaton, W. W., Myllyluoma, J., Weimer, L. G., & Gallo, J. (1999). Psychopathology and attrition in the Baltimore ECA follow-up 1981 – 1996. Social Psychiatry and Psychiatric Epidemiology, 34, 91 – 98. Brown, R. A., Monti, P. M., Myers, M. G., Martin, R. A., Rivinus, T., Dubreuil, M. E., & Rohsenow, D. J. (1998). Depression among cocaine abusers in treatment: relation to cocaine and alcohol use and treatment outcome. American Journal of Psychiatry, 155, 220 – 225. Davidson, K. M. (1995). Diagnosis of depression in alcohol dependence: changes in prevalence with drinking status. British Journal of Psychiatry, 166, 199 – 204. Dohrenwend, B. P., Levav, I., Shrout, P. E., Schwartz, S., Naveh, G., Link, B. G., Skodol, A. E., & Stueve, A. (1992). Socioeconomic status and psychiatric disorders: the causation-selection issue. Science, 255, 946 – 952. Grant, B. F., & Harford, T. C. (1995). Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey. Drug and Alcohol Dependence, 39, 197 – 206. Hartka, E., Johnstone, B., Leino, E. V., Motoyoshi, M., Temple, M.T.;, & Fillmore, K. M. (1991). The collaborative alcohol-related longitudinal project. A meta-analysis of depressive symptomatology and alcohol consumption over time. British Journal of Addiction, 86, 1283 – 1298. Kassel, J. D., Jackson, S. I., & Unrod, M. (2000). Generalized expectancies for negative mood regulation and problem drinking among college students. Journal of Studies on Alcohol, 61, 332 – 340. Kendler, K. S., Health, A. C., Neale, M. C., Kessler, R. C., & Eaves, L. J. (1993). Alcoholism and major depression in women. A twin study of the causes of comorbidity. Archives of General Psychiatry, 50, 690 – 698. Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J. C. (1997). Lifetime cooccurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry, 54, 313 – 321. Kranzler, H. B., Del Boca, F. K., & Rounsaville, B. J. (1996). Comorbid psychiatric diagnosis predicts threeyear outcomes in alcoholics: a post-treatment natural history study. Journal of Studies on Alcohol, 57, 619 – 626. Liang, K. Y., & Zeger, S. L. (1986). Longitudinal data analysis using Generalized Linear Models. Biometrika, 73, 13 – 22. Lyketsos, C. G., Nestadt, G., Cwi, J., Heithoff, K., & Eaton, W. W. (1994). The Life Chart Interview: a standardized method to describe the course of psychopathology. International Journal of Methods in Psychiatric Research, 4, 143 – 155. MacAndrew, C. (1982). An examination of the relevance of the individual differences (A-trait) formulation of the tension-reduction theory to the etiology of alcohol abuse in young males. Addictive Behaviors, 7, 39 – 45. Moscato, B. S., Russell, M., Zielezny, M., Bromet, E., Egri, G., Mudar, P., & Marshall, J. R. (1997). Gender differences in the relation between depressive symptoms and alcohol problems: a longitudinal perspective. American Journal of Epidemiology, 146, 966 – 974.
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Mulder, R. T., Joyce, P. R., & Cloninger, C. R. (1994). Temperament and early environment influence comorbidity and personality disorders in major depression. Comprehensive Psychiatry, 35, 225 – 233. Peirce, R. S., Frone, M. R., Russell, M., Cooper, M. L., & Mudar, P. (2000). A longitudinal model of social contact, social support, depression, and alcohol use. Health Psychology, 19, 28 – 38. Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). National Institute of Mental Health Diagnostic Interview Schedule. Its history, characteristics, and validity. Archives of General Psychiatry, 38, 381 – 389. Salloum, I. M., Moss, H. B., Daley, D. C., Cornelius, J. R., Kirisci, L., & Al-Maalouf, M. (1998). Drug use problem awareness and treatment readiness in dual-diagnosis patients. American Journal of Addictions, 7, 35 – 42.
Brief report
The association of depression and problem drinking: Analyses from the Baltimore ECA follow-up study Rosa M. Cruma,b,c,*, Clayton Brownd, Kung-Yee Liangd, William W. Eatonc a
Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA b Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA c Department of Mental Hygiene, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA d Department of Biostatistics, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA
Abstract In this study, we hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women. As part of the Epidemiologic Catchment Area (ECA) program, probability samples of area residents were selected and the baseline interview for the Baltimore site was completed in 1981. Between 1993 and 1996, 73% of the survivors (n = 2633) were reinterviewed. For the 334 problem drinkers identified, the occurrence of a depressive episode and level of alcohol consumption for each intervening year between the baseline and followup interviews were assessed. Generalized estimating equations (GEE) were used for logistic regression analyses to examine the association between the occurrence of depression in the prior year with transition to higher-level drinking in the subsequent year. The problem drinkers tended to have a bimodal association of transitioning to higher-level drinking; although the strength of the association was greater for men. Future research will need to assess the potential influences on this relationship of other sociodemographic and psychopathologic characteristics, including the effect of treatment for depression or substance use. D 2001 Elsevier Science Ltd. All rights reserved. Keywords: Alcohol; Comorbidity; Depression; Problem drinking; Risk
* Corresponding author. Johns Hopkins Health Institutions, Welch Center for Prevention, Epidemiology, and Clinical Research, Suite 2-500, 2024 East Monument Street, Baltimore, MD 21205, USA. Tel.: +1-410-614-2411; fax: +1-410-614-0588. E-mail address: [email protected] (R.M. Crum). 0306-4603/01/$ – see front matter D 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 0 ) 0 0 1 6 3 - 5
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R.M. Crum et al. / Addictive Behaviors 26 (2001) 765–773
1. Introduction The cooccurrence of alcohol abuse and dependence with depressive disorders has been well recognized in clinical samples (e.g., Brown et al., 1998; Davidson, 1995). In addition, data from population-based studies have showed that the odds of alcohol abuse or dependence among those with depression relative to those without depression is significantly elevated (e.g., Grant & Harford, 1995), and that this relationship may differ by sex (Kessler et al., 1997). Furthermore, the timing of the assessments is a consideration in the interpretation of findings from several prospective studies (e.g., Hartka et al., 1991; Moscato et al., 1997). Theories to account for the comorbid relationship between depression and alcoholism often focus on the use of alcohol for self-medication of mood symptoms. There may be common underlying factors that predispose to an increased risk for both alcohol and depressive disorders, such as genetic factors or social and environmental characteristics (Dohrenwend et al., 1992; Kendler, Health, Neale, Kessler, & Eaves, 1993). The tensionreduction theory posits that consumption is related to the reduction of tension (e.g., MacAndrew, 1982). One component of the stress-coping model of drinking behavior may be the expectations for regulating negative mood (Kassel, Jackson, & Unrod, 2000). Cloninger’s theory of personality dimensions (novelty seeking, harm avoidance, reward dependance) may explain some patterns of comorbid conditions (Mulder, Joyce, & Cloninger, 1994). Furthermore, the relationship of other characteristics (e.g., social contact) may be important integrating factors with both depression and problem drinking (Peirce, Frone, Russell, Cooper, & Mudar, 2000). In this study, we aimed to assess the relationship between depression and problem drinking for specific levels of alcohol use among problem drinkers. We hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women, based on findings from prior studies showing a stronger comorbid relationship among females (e.g., Kessler et al., 1997). Prior prospective research has not assessed these relationships among problem drinkers identified from community-based samples, which potentially reduce selection biases evident in some treatment studies.
2. Methods From 1980 to 1984, collaborators in the Epidemiologic Catchment Area (ECA) program recruited adult participants, 18 years of age and older, in probability samples of residents in five metropolitan areas, including Baltimore, MD (n = 3481). Study data on psychopathology were gathered with the Diagnostic Interview Schedule, for which reliability and validity estimates have been published (e.g., Anthony et al., 1985; Robins, Helzer, Croughan, & Ratcliff, 1981). Between 1993 and 1996, the 1981 Baltimore site cohort was traced, and 73% (n = 1920) of the 2633 survivors were reinterviewed; 848 (24%) respondents had died, 415 could not be located, and 298 refused to participate. The median length of follow-up was 12.6 years. Attrition was associated with the occurrence of some psychiatric conditions (e.g., cocaine use, antisocial personality disorder), but was not associated with depression or
R.M. Crum et al. / Addictive Behaviors 26 (2001) 765–773
767
alcohol abuse or dependence (Badawi, Eaton, Myllyluoma, Weimer, & Gallo, 1999). A total of 334 individuals were identified who reported at least one alcohol-related problem occurring in their lifetime, and comprised the study sample for these analyses. Data on the occurrence of a depressive episode and alcohol consumption among problem drinkers was assessed using the Life Chart Interview (Lyketsos, Nestadt, Cwi, Heithoff, & Eaton, 1994), a retrospective assessment of the course of psychopathology as it occurs in each year of the observational interval from the baseline to the follow-up interview using age- and calendarlinked personal landmarks, as well as life events as memory cues. A depressive episode, as used in this study and other analyses of the ECA (e.g., Anthony & Petronis, 1991), was defined as dysphoria or anhedonia with a clustering of other depressive symptoms during a period of 2 weeks or more, based on DSM-III-R major depression symptom criteria (American Psychiatric Association, 1987). Alcohol-related problems were identified if a study participant responded positively to one of the 19 questions concerning problems related to alcohol use. Alcohol consumption was assessed for each year from the time of onset of the alcohol-related problem to the time of the most recent drink, using an ordinal scale of 10 levels ranging from no consumption in that year, to everyday but more than once each day. For each year in the period 1981–1996, the Life Chart Interview contained incidence, recency, and duration of depression and alcohol use, and therefore was treated as longitudinal data (repeated measures). The data was pooled to create dyad years of observation, resulting in 3780 person-year observations. Generalized estimating equations (GEE) (Liang & Zeger, 1986), a method for fitting regression models with correlated longitudinal response, were used to account for the fact that the subjects’ drinking levels were correlated over observational years. To test our hypotheses, we completed exploratory analyses and fit logistic regression models with drinking level (dichotomized) as the response variable and the dichotomous depressive episode variable (Yes/No) from the prior year as the explanatory covariate. The initial cut point for drinking in the following year was divided between ‘‘high’’ consumption (drinking at least daily) relative to ‘‘low’’ consumption (less than daily drinking), controlling for the prior year level of drinking (also dichotomized), depression in the prior year (Yes/No), and the continuous covariates calendar year and age. The final logistic regression model included the main effect covariates, as well as terms to assess the interaction between depression and sex, alcohol use in the prior year and sex, and alcohol use in the prior year with depression.
3. Results Of the 334 problem drinkers, 216 (65%) were men, and almost half (49%) were between the ages of 18 and 29 years at the time of the baseline interview (Table 1). Approximately 60% of the problem drinkers indicated that their highest level of education was high school. The majority of the sample described themselves as African–American (66%), with the remaining sample being predominately White (31%). At the time of the follow-up interview, a total of 128 (38%) were married, and an equal proportion were never married. We initially dichotomized the drinking outcome variable to distinguish two categories: ‘‘high’’ alcohol consumption, those who drank at least daily referenced to ‘‘low’’ alcohol
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Table 1 Frequency distribution of problem drinkers (N = 334) Number
Percentage (%)
Sex Men Women
216 118
64.7 35.3
Age (years)a 18 – 29 30 – 39 40 – 49 50 – 59 60 – 69 70 – 79
165 81 46 25 16 1
49.0 24.0 14.0 8.0 5.0 0.3
Race – ethnicityb African – American White Other
222 104 2
66.5 31.1 0.6
Years of schooling 0–8 9 – 12 > 12
36 203 95
10.8 60.8 28.4
Marital status Married Widowed Separated Divorced Never married
128 13 35 31 127
38.3 3.9 10.5 9.3 38.0
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. a Age at the time of the baseline interview. b A total of six individuals (1.8%) did not provide information on race – ethnicity.
consumption, those who reported drinking less than once a day. This was done to model our initial logistic regression analyses to assess the association of depression with transition to daily drinking. Analysis of the GEE parameter estimates showed that the strongest predictor of higher-level drinking was the level of consumption in the prior year (parameter estimate = 6.79; 95% CI, 6.32–7.25; P .001) (Table 2, model A). Interaction terms were then included in the model (Table 2, model B). Among those who were not drinking daily in the prior year, there was a threefold increased odds of transition to daily drinking for depressed male problem drinkers relative to those without depression (OR = 3.15; 95% CI, 0.73–13.52, P = .12), and a twofold increased odds of daily drinking among depressed female problem drinkers relative to those without depression (OR = 2.00; 95% CI, 0.43–9.24, P = .37). In order to explore these relationships further, we assessed the association of depression in the prior year with transition to higher-level drinking for each level of alcohol consumption, calculating an odds ratio for each cut point of the 10-level ordinal alcohol
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Table 2 GEEa parameter estimates for odds of transition to daily drinking in the subsequent year among problem drinkers based on logistic regression analyses Variable Model A parameter Model B parameter estimate (95% CIb) estimate (95% CIb) Calendar year Age Prior year alcohol consumption Depression in the prior year Sex
0.07 0.01 6.79 0.04 0.24
( 0.12, 0.02)* (0.001, 0.02)* (6.32, 7.25)*** ( 1.24, 1.17) ( 0.61, 0.12)
Interaction terms Depressionc Sex Alcohold Sex Alcohold Depressionc
0.07 0.01 7.00 1.14 0.07
( 0.12, 0.01)* (0.001, 0.03)* (6.43, 7.58)*** ( 0.31, 2.60) ( 0.69, 0.84)
0.45 ( 0.41 ( 1.44 (
2.03, 1.13) 1.39, 0.57) 3.28, 0.39)
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. * P < 0.05; *** P < 0.001 a GEE, generalized estimating equations. b CI, confidence interval. c Depression in the prior year. d Alcohol consumption in the prior year.
consumption scale for men and women (Fig. 1; Table 3). The odds for transition to higherlevel drinking among depressed men relative to those without prior year depression was
Fig. 1. Odds ratios for transition to higher level drinking for depressed problem drinkers relative to those without depression, for each cut point in the 10-point ordinal scale of alcohol consumption, by sex. Data are from Baltimore ECA Follow-up study, 1981 – 1996. Alcohol consumption was measured using an ordinal scale of 10 levels ranging from no consumption in that year (variable value = 00), to use once a year (01), several times a year (02), once a month (03), two to three times a month (04), once a week (05), two to three times a week (06), four to six times a week (07), everyday once a day (08), and everyday but more than once each day (09).
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Table 3 GEEa estimates for odds of transition to higher-level drinking in the subsequent year among problem drinkers based on logistic regression analyses for each cut point in the 10-point ordinal scale of alcohol consumption, by sex Alcohol level cut pointb
Odds Ratio (95% CIc), P-value for Women
Odds Ratio (95% CIc), P-value for Men
00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09
0.99 1.68 0.30 0.34 0.95 0.55 0.61 2.00 1.14
3.45 8.12 5.52 2.19 2.08 0.63 1.51 3.15 1.03
(0.15 – 6.70), (0.28 – 9.93), (0.02 – 3.83), (0.04 – 3.12), (0.19 – 4.80), (0.06 – 4.63), (0.06 – 6.15), (0.43 – 9.24), (0.16 – 8.33),
0.99 0.57 0.36 0.34 0.95 0.58 0.68 0.37 0.89
(0.41 – 28.84), 0.25 (0.85 – 77.17), 0.07 (1.13 – 26.99), 0.03 (0.21 – 22.61), 0.51 (0.32 – 13.41), 0.44 (0.05 – 7.22), 0.71 (0.19 – 11.94), 0.69 (0.73 – 13.52), 0.12 (0.09 – 12.04), 0.98
Data are from the Baltimore ECA Follow-up study, 1981 – 1996. a GEE, generalized estimating equations. b Alcohol consumption was measured using an ordinal scale of 10 levels ranging from no consumption in that year (variable value = 00), to use once a year (01), several times a year (02), once a month (03), two to three times a month (04), once a week (05), two to three times a week (06), four to six times a week (07), everyday once a day (08), and everyday but more than once each day (09). c 95% CI, confidence interval.
generally greater than one, and indicated a bimodal association. Among women, a similar pattern was found, but the strength of the associations were reduced. In addition, the odds ratios were less than one for most cut points, signifying that relative to nondepressed women, prior year depression was associated with a decreased odds of transition to higher-level drinking. These findings did not meet criteria for statistical significance at the .05 level, but did imply that contrary to our initial hypotheses, male problem drinkers with prior year depression relative to nondepressed men had the higher odds of transitioning to higher-level drinking when contrasted to the findings for women.
4. Discussion Our findings for this study were not consistent with our initial hypotheses but indicated several associations between the occurrence of depression with transition in drinking among problem drinkers. We found that the odds of transition to daily drinking tended to be higher among depressed men relative to men who were not depressed, than it was for depressed women relative to nondepressed women. Furthermore, we found that depressed problem drinkers tended to have a bimodal association of transitioning to higher-level drinking relative to those without depression in the prior year, with the strength of the associations being greater among men. Among depressed women, there was a general decreased likelihood of transitioning to higher-level drinking across most cut points of the alcohol consumption scale relative to women without depression in the prior year. Because these findings did not meet
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criteria for statistical significance, we cannot make firm conclusions about these associations, but the results indicate trends that may be explored further in future investigations. The tendency for a bimodal association of transitioning to higher-level drinking after the occurrence of depression may indicate more than one etiologic pathway operating in this population. Those individuals transitioning from a baseline low drinking level may have been drinking to reduce tension or to alleviate negative mood, and may have attempted to implement the mood elevating effects of alcohol. Yet, those whose baseline drinking was already at a relatively high level were more likely to have had chronic drinking patterns that may actually have contributed to the onset of the depressive episode, rather than the reverse. Furthermore, there are several plausible explanations for the finding that depression among some problem drinkers was associated with a tendency for reduction in alcohol consumption. The occurrence of depression may have signaled to these drinkers the need to reduce alcohol use. This is consistent with some reports of treatment samples in which the occurrence of depressive symptoms was associated with improvement in substance use or drinking outcomes (e.g., Kranzler, Del Boca, & Rounsaville, 1996; Salloum et al., 1998). In addition, depressive symptoms may have forced some individuals to enter treatment, with subsequent recommendations for reductions in alcohol made by treating clinicians. Treatment for depression also may have decreased the potential need to self-medicate affective symptoms with alcohol. There are several limitations in the current report. For one, this study only included problem drinkers and the findings may not be generalizable to other drinking populations. Second, the assessment of alcohol consumption did not include a quantity measure. Third, depression was assessed only for the prior year, and did not incorporate symptom duration. Fourth, we were unable to assess whether any treatment was received during the intervening years between the baseline and follow-up interviews. Notwithstanding these limitations, the current report has several strengths including the use of a community-based sample rather than a treatment population, reducing potential selection biases. Findings from these and similar studies may improve our understanding of patterns of comorbid psychopathology, and highlight the need to further examine the relationship of depression with drinking patterns.
Acknowledgments This work was supported by a Scientist Development Award for Clinicians from the National Institute on Alcohol Abuse and Alcoholism (AA00168) (Dr. Crum). Data gathering for the Baltimore ECA Follow-up survey was supported by a grant from the National Institute of Mental Health (MH47447). Data gathering for the original surveys was supported by the ECA Program of the National Institute of Mental Health Division of Biometry and Epidemiology. The Principal Investigators, Co-Investigators, and grant award numbers during data gathering were Jerome K. Myers, Myrna M. Weissman, and Gary L. Tischler at Yale University (MH34224); Morton Kramer, Ernest Gruenberg, and Sam Shapiro at the Johns Hopkins University (MH33870); Lee N. Robins and John E. Helzer at Washington University (MH33883); Dan Blazer and Linda George at Duke University (MH35386); and Marvin
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