Paola Pedrelli, Ph.D. Massachusetts General Hospital Boston, MA Heavy Drinking And Depressive Symptoms In College Students 1© AMSP 2015

Alcohol in Young Adults Alcohol increases at a young age Alcohol common age % consume alcohol 2© AMSP 2015 HED Current Frequent HED

3© AMSP 2015 This Lecture Reviews: Definitions & alcohol on campus Depressive symptoms on campus Depressive symptoms & HED Implications

4© AMSP 2015 This Lecture Reviews: Definitions & alcohol on campus Depressive symptoms on campus Depressive symptoms & HED Implications

Definition Standard drink = g pure ethanol

Heavy Episodic Drinking BAC: Amount of alcohol in blood HED ~ 0.08 BAC HED: ♀/♂ > 4/5 drinks/occasion 2h 6© AMSP 2015

HED Common in College Students Past month prevalence of HED 7© AMSP 2015

Everyone drinks heavily in college Drinking heavily on weekends is OK Students will grow out of it Myths About HED 8© AMSP 2015

Among <21 age: costs $27 Billion/yr - 61% from lost productivity - 25% from premature death 40,000 hospitalizations/yr due to alcohol HED Societal Costs 9© AMSP 2015

Each yr in college students ~600,000 injuries ~700,000 assault ~97,000 victim sexual assault ~1800 deaths HED Personal Costs 10© AMSP 2015

Jackie: 20-year-old female student Mild depressive symptoms ↓Interest in social activities Behind with schoolwork ↓Grades Sleeping 8-10 hrs/day Consume 8-10 drinks 1x/week Illustrative Case 11© AMSP 2015

Role failure Risk of harm Social problems Tolerance Craving DSM-V Alcohol Use Disorders 12© AMSP 2015 Withdrawal Larger/longer Unable to ↓ down ↓ Time elsewhere Use despite problems >2 past 12 mos

13© AMSP 2015 AUD in College Students 24% ♂ have AUD 13% ♀ have AUD

Alcohol Problems in Students 57% physically sick & blackout 30% school problems 31% regretted a sexual activity 20% physically injured 13% drank and drove 7% got into physical fight © AMSP

16 © AMSP 2015 Predictors of HED

16© AMSP 2015 This Lecture Reviews: Definitions & alcohol on campus Depressive symptoms on campus Depressive symptoms & HED Implications

Depressed Mood Markedly ↓ interest Weight loss/gain Diff sleeping Agitation Major Depressive Disorders 17© AMSP 2015 Fatigue Feel worthless ↓ Ability think Suicidal ideation >5 past 12 mo

Unique development stage -Identity exploration -From dependence to independence ↓Support from old friends College is Difficult 18© AMSP 2015

Depressive Symptoms SymptomsWomenMen Have MDD10%8% Are sad66%51% Felt hopeless50%38% Hard to function33%27% Seriously considered suicide 7% 6% Attempted suicide 1%

Problems with Dep Sx Mild dep sx ↑ early school drop out Mild dep sx ↑ psychosocial problems SI present at sub-threshold MDD © AMSP

Tired all the time Feels lonely ↓ Motivation ↓ Piano playing & exercise Sleeps > 10 hr many days Grades ↓& skipping classes Isolates Jackie 21© AMSP 2015

22© AMSP 2015 This Lecture Reviews: Definitions & alcohol on campus Depressive symptoms on campus Depressive symptoms & HED Implications

Depressive Sx + HED =↑ Problems Dep sx + HED = ↑ risk for alcohol problems Dep sx + HED = ↑ risk for suicide Unsafe sex - 14% Dep sx +HED - 10% HED alone Behind at school - 29% Dep sx +HED - 24% HED alone © AMSP

Social Learning Theory © AMSP Alcohol is used: To ↓ negative emotional states With expectation ↑ mood Belief no alternative ways to cope

Jackie Drinks to feel better Behind in school due to HED Regrets actions during HED © AMSP

26© AMSP 2015 This Lecture Reviews: Definitions & alcohol on campus Depressive symptoms on campus Depressive symptoms & HED Implications

Settings for Screenings Throughout school College counseling centers Primary care Emergency care © AMSP

Screening Tool for Alcohol Alcohol Use Disorders Identification Test (AUDIT-C) Items on: - Frequency of any alcohol use - Typical number of drinks - Frequency of 6+ drinks Responses are summed Score > 3/5 ♀/♂ indicates at-risk drinking © AMSP

Screening Tool for Depression Patient health questionnaire (PHQ-9) - 9 items ask frequency of sx - Responses are summed - Score >10 indicates MDD © AMSP

Recommended Treatment Combined vs single Tx - 90% vs 30% abstinent - 65% vs 45% improvement dep sx HED & dep sx should be treated together - Tx for HED not effective in dep students - Tx for 1 disorder leads to ↑ relapse rates - Combined HED/dep TX → better outcome AMSP

Tx For Co-occurring Sx Motivational interviewing (MI) + Cognitive Behavioral Therapy (CBT) - Both address motivations for drinking - Integrating MI and CBT is feasible - CBT+MI effective for co-occurring sx © AMSP

CBT Thoughts  feelings  behaviors Brief and time-limited Structured Educational Collaborative relationship Socratic method Includes homework © AMSP

CBT Tenets Dep sx relate to negative views of: -Themselves -The future -The world © AMSP

CBT Techniques Change unhelpful thoughts - Evidence for and against thoughts - Reduce catastrophizing - Identify mind reading ↑ Enjoyable activities © AMSP

MI Therapy ~ partnership Patient-centered Directive method communication Elicit own motivation to change Explores ambivalence re change Guide pt towards change © AMSP

MI Therapist Express empathy of current behavior Examine inconsistencies Promote belief that change is possible Roll with resistance © AMSP

Combined Tx For Jackie Feedback from brief MI - On drinking behaviors - Blood Alcohol Concentration - Drinking problems Education on - Peers' normal alcohol use - Gender specific effects of alcohol © AMSP

CBT For Jackie Changed thoughts: - “I am flawed” - “My friends do not like me” Increased pleasant activities: - Encouraged resuming piano - Encouraged resuming exercising © AMSP

Jackie: Results Attending classes consistently ↑ Exercising and playing piano Seeing friends daily Drink < 4 drinks per occasion © AMSP

Conclusion/Summary In college students: Depressive symptoms + HED are common Screening important Combined Tx more effective CBT+MI example of combined Tx © AMSP