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Major Depression in 6050 Former Drinkers
Association With Past Alcohol Dependence
Deborah S. Hasin, PhD;
Bridget F. Grant, PhD
Arch Gen Psychiatry. 2002;59:794-800.
ABSTRACT
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Background The association between alcoholism and major depression in the general
population has been explained as misdiagnosed alcohol intoxication and withdrawal
effects mistaken for depressive syndromes. To investigate whether this could
account for the entire relationship, the association of past alcohol dependence
with current major depression (ie, nonoverlapping time frames) was investigated
in individuals who no longer drink or who drink very little. We conducted
the study using data from the National Longitudinal Alcohol Epidemiologic
Survey, a representative sample.
Methods Former drinkers who did not use drugs or smoke in the past year (n =
6050) were divided into those with and without past DSM-IV alcohol dependence. These 2 groups were compared for the presence
of current (last 12 months) DSM-IV major depression.
The association between prior alcohol dependence and current major depression
was tested with linear logistic regression, controlling for other variables.
Results Prior alcohol dependence increased the risk of current major depressive
disorder more than 4-fold. This relationship was not attenuated by control
variables. The majority of subjects with major depression last used substances
2 or more years prior to the interview, which eliminates acute intoxication
or withdrawal effects as an explanation of their depressions.
Conclusions The strong, specific association between prior alcohol dependence and
current or recent major depression in a nationally representative sample of
former drinkers indicates that the association is not entirely an artifact
of misdiagnosed intoxication and withdrawal effects. A better understanding
of the nature of the relationship between the 2 disorders should be sought
and will have important public health significance.
INTRODUCTION
NATIONAL AND international epidemiologic surveys1-6
and reviews of the many studies of treated alcoholic subjects7-8
consistently indicate a strong association between alcohol dependence or alcoholism
and depression. However, although the association itself is well established,
the reasons for it have been the subject of some debate. Given the high prevalence
of each of the 2 disorders and their common co-occurrence, understanding the
reasons for the association is important. It has been proposed that the association
is either causal, due to shared etiology, or artifactual.7
A directly causal relationship might arise if heavy alcohol intake pharmacologically
induces major depression and its symptoms. An indirectly causal relationship
between alcohol dependence and depression could arise if alcoholism causes
risk factors for depression, such as job loss. A high level of association
due to shared etiologic factors could arise from common underlying genetic
and environmental factors, such as a disruptive family environment.
Family and adoption studies on the shared etiology hypothesis have been
inconsistent.9-10 Longitudinal
studies of the effects of a lifetime diagnosis of depression on the outcome
of alcoholism were also inconsistent,11-13
possibly due to the nonspecific lifetime time frame. In contrast, with only
1 exception,14 longitudinal studies using more
clearly defined time frames showed that major depression measured at a specific
point in time predicted subsequent poor outcome of alcoholism15-16
or dependence on multiple substances including alcohol.17
Further, changes in the status of alcoholism measured similarly predicted
subsequent changes in the status of depression.18
Numerous randomized clinical trials have investigated this issue as well through
testing whether treating depression in alcoholic subjects can improve the
course of alcoholism. Studies of antidepressant medication treatment during
treatment for alcoholism19-22
generally show that depression improves and substance abuse is modestly improved
when such treatment is given. However, from an epidemiologic point of view,
these studies are problematic because they rely on treated samples and thus
may not fully represent the underlying population of individuals with comorbid
alcohol dependence and major depression.
One factor that has persistently complicated investigation of the relationship
between alcohol dependence and major depression is diagnosis. The diagnosis
of major depression among actively drinking alcoholics is complicated by the
fact that intoxication and withdrawal from alcohol and other substances can
induce transient symptoms that mimic an independent depressive disorder.23-24 Thus, it has been proposed that the
directly causal relationship is instead artifactual, arising from diagnostic
confusion.23 To avoid such confusion between
these transient symptoms and an actual diagnosis of major depressive disorder,
numerous attempts have been made to define an independent depressive disorder
in individuals with a history of alcohol dependence. Most of these definitions
were based, in whole or in part, on the lifetime order of onset of major depression
and alcoholism or alcohol dependence.25-27
In these definitions, lifetime initial onset of major depression before the onset of alcohol dependence was termed "primary" major depression,
and lifetime initial onset of major depression after
the initial onset of alcohol dependence was termed "secondary." Assessing
subjects retrospectively on a lifetime basis (the usual method) can present
problems in recalling the order of onset for events that often occurred many
years in the past. Further, the primary/secondary distinction was based on
the initial occurrence of diagnosed alcoholism, but heavy drinking leading
to transient depressive symptoms could precede the onset of alcohol dependence
or could even occur in the absence of an alcoholism diagnosis.
The treatment of this issue in DSM-IV represented
a substantial improvement. The DSM-IV differentiation
between primary and substance-induced depressive disorder allows individuals
with alcoholism to receive a diagnosis of primary major depressive disorder
2 ways. In the first, the syndrome is established prior to substance use leading
to intoxication and/or withdrawal. In the second, the syndrome persists more
than 4 weeks after the cessation of acute intoxication or withdrawal. The
use of these specific time frames, especially the latter, provides a clearly
defined situation for studying the association of alcoholism and later major
depression that eliminates the potential diagnostic complications of acute
alcohol intoxication and withdrawal.
To date, no general population study has made use of these new definitions
to investigate the nature of the association between alcohol dependence and
major depression. As described above, an important question in this debate
concerns whether the association is entirely an artifact of intoxication or
withdrawal symptoms mimicking major depression. An informative group on this
question would be former drinkers who currently abstain completely or whose
current drinking is so light that it could not possibly have caused intoxication
or withdrawal symptoms sufficient to mimic a full depressive disorder. In
such a group of former drinkers, the prevalence of current major depression
could be compared between those with a history of prior alcohol dependence
and those without such a history. In studying a large representative group
of former drinkers, a substantial step could be taken toward clarifying whether
the relationship between alcohol dependence and major depression represents
more than an artifact of misdiagnosis. Such an approach would be a fresh look
at a question that has long been debated. We present such an investigation.
SUBJECTS AND METHODS
SAMPLE
Data were derived from the 1992 National Longitudinal Alcohol Epidemiologic
Survey (NLAES), a nationally representative sample of the US adult population,
18 years and older (n = 42 862).28-29
The household response rate was 91.9%, and the sample person response rate
was 97.4%. The NLAES featured a complex multistage design. Primary sampling
units were stratified according to sociodemographic criteria and were selected
with probability proportional to size. From a sampling frame of approximately
200 primary sampling units, 198 were selected for inclusion in the 1992 NLAES
sample, including 52 that were self-representing, ie, selected with certainty.
Within primary sampling units, geographically defined secondary sampling units,
referred to as segments, were selected systematically for the sample. Oversampling
of the African American population was accomplished at this stage of sample
selection to secure adequate numbers for analytic purposes. Segments then
were divided into clusters of approximately 4 to 8 housing units, and all
occupied housing units were included in the NLAES. Within each household,
one randomly selected respondent, 18 years or older, was selected to participate
in the survey. Oversampling of adults aged 18 to 29 years was done at this
stage of the sample selection to include a greater representation of this
heavy-drinking population subgroup. This subgroup of young adults was randomly
sampled at a ratio of 2.25:1.00.
In the NLAES, former drinkers were defined as those who were past but
not current drinkers. More specifically, these subjects had had 1 or more
years in the past during which they drank at least 12 drinks of any type of
alcoholic beverage, but they did not drink at least 12 drinks during the 12
months prior to the interview. Although this cutoff can be considered conservative
in identifying persons not at risk for withdrawal, we wished to use a cutoff
that would not leave the issue of withdrawal in question. Of the total sample,
9264 respondents (21.6%) were classified as former drinkers. To further ensure
that any current major depressions could not be attributed to the effects
of drugs or smoking, all subjects who used drugs or smoked cigarettes in the
12 months prior to the interview were also excluded. The 6050 subjects remaining
constituted the sample investigated in this report. This definition of former
drinker was not as rigid as a requirement that no alcohol whatsoever was consumed
in the 12 months prior to the interview, which might itself have produced
an idiosyncratic sample. However, it eliminated the possibility that acute
intoxication and/or withdrawal effects could have occurred on a persistent
basis throughout the 12 months prior to the interview. Note that lifetime
abstainers were not included in the analysis because they were not at risk
of developing alcohol dependence.
DIAGNOSTIC ASSESSMENT
Diagnoses of DSM-IV alcohol use disorders and
major depression were derived from the Alcohol Use Disorder and Associated
Disabilities Interview Schedule (AUDADIS), a fully structured diagnostic interview
designed to be administered by trained interviewers who were not clinicians.29-31 The AUDADIS included
an extensive list of symptom questions that operationalized the DSM-IV criteria for alcohol use disorders and major depression. These
questions have been described in detail elsewhere.31-32
In the AUDADIS, current disorders are defined as occurring within the 12 months
prior to the interview. Past disorders are those occurring prior to the last
12 months. In an independent test-retest study conducted in the general population,
AUDADIS diagnoses of alcohol use disorders and major depression were shown
to be highly reliable, with  between 0.73 and 0.76 for alcohol use
disorders and 0.60 and 0.65 for major depression for the 2 time frames.32 Several US and international studies have supported
the reliability and validity of DSM-IV diagnoses
made by the AUDADIS in various types of samples.33-37
These diagnoses have formed the basis of an extensive series of studies of
alcohol use disorders and related conditions in the general population.29, 38-41
Consistent with the DSM-IV, an AUDADIS diagnosis
of alcohol dependence requires that a person exhibit a maladaptive pattern
of alcohol use leading to clinically significant impairment or distress, as
demonstrated by at least 3 of 7 criteria of dependence in any 1-year period.
The symptoms include (1) tolerance, (2) withdrawal or relief or avoidance
of withdrawal, (3) persistent desire or unsuccessful attempts to cut down
or stop drinking, (4) spending much time drinking or recovering from its effects,
(5) giving up or reducing occupational, social, or recreational activities
in favor of drinking, (6) impaired control over drinking, and (7) continuing
to drink despite a physical or psychological problem caused or exacerbated
by drinking. The AUDADIS is structured to confirm that symptoms cluster within
a 1-year period, both for current and past dependence. An AUDADIS DSM-IV diagnosis of abuse requires at least 1 of the following in any
1 year: (1) continuing to drink despite a social or interpersonal problem
caused or exacerbated by the effects of drinking, (2) recurrent drinking in
situations in which alcohol use is physically hazardous, (3) recurrent drinking
resulting in a failure to fulfill major role obligations, or (4) recurrent
alcohol-related legal problems. The diagnosis of abuse is precluded by a diagnosis
of dependence, as required by DSM-IV.
Episodes of DSM-IV major depressive disorder
were also constructed within the past year and prior to the past year time
frames. Consistent with the DSM-IV, AUDADIS diagnoses
of major depression required the presence of at least 5 depressive symptoms
(1 of which must have been depressed mood or anhedonia) nearly every day for
most of the day for at least a 2-week period. Social and/or occupational dysfunction
must also have been present during the disturbance. Episodes of DSM-IV major depression due to bereavement or physical illness were
ruled out. The AUDADIS diagnosis of major depression and its distribution
in the entire NLAES sample has been reported in detail elsewhere.42
STATISTICAL ANALYSIS
A linear logistic regression analysis was used to assess the risk of
past-year major depression among former drinkers. The analytic models were
not conditioned on a prior history of past depression because this was not
relevant to our specific research question, which focused on the occurrence
of current depression in the absence of intoxication or withdrawal effects.
The logistic regression analysis was conducted on weighted data using SUDAAN,43 a software package that uses Taylor series linearization
to adjust for the complex sampling design of the NLAES. The main predictor
variable in the model was a past (ie, prior to the past year) diagnosis of DSM-IV alcohol dependence. A past diagnosis of alcohol
abuse was included as well. Control variables included sex, race, age, current
marital status, and education.
RESULTS
Among the sample of 6050 former drinkers who also used no drugs and
did not smoke in the 12 months prior to the interview, 13.8% were classified
as having a diagnosis of DSM-IV alcohol dependence
at some point prior to the previous 12 months. The demographic characteristics
of the subjects with and without a past diagnosis of DSM-IV alcohol dependence are shown in Table 1. As expected, slightly less than half the subjects without
a past diagnosis of alcohol dependence were men, and a higher proportion of
men had a past diagnosis of alcohol dependence. Fewer subjects with a past
diagnosis of alcohol dependence were in the oldest age category. Race, education,
and marital status did not differ markedly between the groups with or without
a past diagnosis of alcohol dependence.
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Table 1. Demographic Characteristics of the Sample by History of Past
Alcohol Dependence
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Of the subjects with past diagnoses of DSM-IV
alcohol dependence, 7.6% had a past-year diagnosis of major depression. Among
subjects with no diagnosis of past DSM-IV alcohol
dependence, 2.0% had past-year diagnoses of major depression. Among the group
with no past diagnosis of alcohol dependence, 5.1% received a diagnosis of
alcohol abuse.
The results of the logistic regression analysis of past-year major depressive
disorder are shown in Table 2.
As shown, the risk of major depression during the past year was 4.2 times
greater among respondents with a history of alcohol dependence than among
those with no history of alcohol dependence. This result was obtained controlling
for the effects of sociodemographic characteristics. Note that the diagnosis
of past DSM-IV alcohol abuse was not significantly
related to major depression. Removing the abuse term from the model did not
change the association of past alcohol dependence with current major depression
among this sample of former drinkers (adjusted odds ratio, 4.12; 95% confidence
interval, 2.77-6.14). Further, past alcohol abuse was not significantly related
to current major depression in a model with the same covariates that did not
include a term for past DSM-IV alcohol dependence
(adjusted odds ratio, 0.94; 95% confidence interval, 0.46-1.91). These results
indicate that the association with current major depression and a past alcohol
use disorder was specific to alcohol dependence.
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Table 2. Relationship of Past Alcohol Dependence to Current (Last 12
Months) Major Depression: Results of Logistic Regression Analysis*
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Considerable care was taken in the analyses to exclude subjects whose
current use of alcohol, drugs, or cigarettes could have caused diagnostic
confusion regarding intoxication or withdrawal effects. However, a concern
could still be raised that the depressions were lingering intoxication or
withdrawal effects among subjects who used any of these substances shortly
before the beginning of the current 12-month period. To address this concern
regarding drugs or cigarettes, the recency of drug and cigarette use was examined
in the subjects with major depression during the current 12-month period.
Among subjects with major depression in the 12 months prior to the interview
who had ever used drugs, 5.1% last used drugs 13 to 23 months prior to the
interview, 6.1% last used drugs 24 to 35 months prior to the interview, 6.3%
last used drugs 36 to 47 months prior to the interview, and 82.5% last used
drugs 48 or more months prior to the interview. The fact that the last use
of drugs was more than 2 years prior to the interview in such a high proportion
of the subjects with depression indicated that lingering intoxication or withdrawal
effects were quite unlikely to have caused the current major depressive episodes.
Similar results were found for recency of smoking. Among the subjects with
major depression who ever smoked, 5.1% last smoked 13 to 23 months prior to
the interview, 5.5% last smoked 24 to 35 months prior to the interview, 6.5%
last smoked 36 to 47 months prior to the interview, and 82.9% last smoked
48 or more months prior to the interview. Thus, the episodes of major depression
cannot be attributed to intoxication or withdrawal effects occurring among
subjects who stopped smoking or using drugs shortly before the current 12-month
time frame. This is because the chance that lingering withdrawal effects caused
the depressions is minimal due to the extended gap between last use and the
recently reported depressions in the large majority of the cases.
As described previously, we included subjects who consumed 1 to 11 drinks
in the year prior to the interview in the sample because this drinking could
not have been sufficient to cause ongoing intoxication or withdrawal effects.
However, to address concerns about lingering alcohol intoxication or withdrawal
effects, we removed all subjects who had any alcohol in the 12 months prior
to the interview from the sample (n = 3496) and re-ran the analysis. Despite
removing such a large number of subjects, the association between past DSM-IV alcohol dependence and current major depression
remained strong and significant, with an odds ratio of 3.85 (95% confidence
interval, 2.05-6.83). To eliminate concerns that the depressions in subjects
who abstained were due to lingering intoxication or withdrawal effects among
subjects who drank shortly before the beginning of the current 12-month period,
we examined recency of drinking among the abstainers. The data indicated that
9.2% of the total subjects who abstained with major depression last drank
13 to 23 months prior to the interview, 16.0% last drank 24 to 35 months prior
to the interview, 11.3% last drank 36 to 47 months prior to the interview,
and the rest, 63.5%, last drank 48 or more months prior to the interview.
These results confirm that lingering alcohol intoxication or withdrawal effects
did not cause a syndrome mimicking major depressive disorder in these subjects
because all subjects who abstained last drank alcohol 13 or more months prior
to the interview and more than 90% of them last drank alcohol 2 or more years
prior to the interview.
COMMENT
These data from a large national epidemiological survey indicate that
among former drinkers, a past diagnosis of alcohol dependence was associated
with more than a 4-fold increase in risk of current or recent (last 12 months)
major depressive disorder. The individuals in this study either did not drink
at all or did not drink enough in the previous 12 months to experience intoxication
or withdrawal effects that could mimic the 2 or more required weeks of mood
and symptoms characterizing a major depressive disorder. Further, these results
were found among individuals who had neither used drugs nor smoked cigarettes
in the 12 months prior to the interview. Most of these subjects last drank
more than 2 years prior to the interview, and, if they ever smoked or used
drugs, their use of these substances was equally distal from the time of the
interview. Thus, the potential confounding effects of numerous other substances
were eliminated as possible explanations of the results.
Many methodological problems that characterized earlier studies examining
the relationship of major depression to alcoholism were overcome in this study.
First, a large group of former drinkers was identified whose current drinking
levels were so low that they could not have produced the intoxication and/or
withdrawal effects that mimic the mood and symptoms of major depressive disorder.
These subjects were at lifetime risk for alcohol use disorders due to their
past drinking, but their recent past could be examined for depression without
diagnostic confusion.
Second, this study is based on a large epidemiological survey that used
state-of-the-art scientific procedures to select a nationally representative
sample. This eliminated the many potential biases that can arise when samples
are composed of alcoholic subjects selected from treatment settings.44 Similarly, samples composed of relatives of patients
may also be biased by selection factors, even if the relatives have never
been treated themselves. This is because their method of selection, membership
in families of treated alcoholic patients, is not designed to produce samples
representing the general population. Research on comorbidity in samples of
alcoholic patients and their relatives can obviously offer many important
findings, but the findings should be confirmed in representative samples whenever
possible before being accepted as definitive.
A third strength of this study is the use of 2 clearly defined and nonoverlapping
time frames in measuring the episodes of alcohol dependence and major depression:
past year and prior to the past year. This approach differs from the approach
of the Epidemiological Catchment Area study, the National Comorbidity Survey,
and other studies based on lifetime and current diagnoses. For our particular
research question, reliance on lifetime or current diagnoses would not have
been suitable because simultaneous occurrence of the conditions cannot be
ruled in or out within these time frames. The possibility of simultaneous
occurrence would not have allowed us to investigate the specific question
of misdiagnosis of alcohol intoxication or withdrawal symptoms as an explanation
of the depressive syndromes. Only by using sequential, nonoverlapping time frames could we rule out alcohol intoxication and
withdrawal as constituting the entire cause of the syndromes of depression.
This approach also offered other advantages in answering our research
question. It eliminated the need to determine the order of initial onset of
alcohol dependence and major depression based on semistructured retrospective
timelines of events, often occurring many years in the past. The approach
also required the recall of depressions only during a recent period, the last
12 months, increasing the likelihood of accurate recall and reporting. Methodological
research45 suggests that recall for past psychopathological
behaviors involving externalizing behavior such as substance use is better
than recall for past depression. Therefore, the fact that our research design
required recall of recent but not past depressions was an advantage, whereas
the reports of past alcohol dependence were less likely to be problematic.
As noted, DSM-IV alcohol abuse did not have
the same relationship to major depression as DSM-IV
alcohol dependence. Numerous questions have been raised about the relationship
of abuse to dependence, including the concern that abuse is simply a prodromal
state to dependence and therefore should be subsumed under the dependence
diagnosis. The results of this analysis suggest that such a course would be
unwise because this would increase the heterogeneity of the dependence category
and weaken or obscure the relationships found.
Neither intoxication nor withdrawal is required for DSM-III-R, DSM-IV, or other present-day diagnoses
of substance use disorders. Some independent or primary depressions defined
in earlier studies as occurring prior to the onset of dependence may actually
have been substance-induced due to high levels of drinking or drug use that
predated the onset of dependence and produced intoxication and/or withdrawal.
Also, independent disorders occurring either before or after the onset of
dependence but during a period of abstinence do not rule out the occurrence
of a substance-induced major depression or transient self-induced depression
occurring prior to the onset of dependence. The occurrence of primary disorders
may actually increase the chances that a substance-induced depression or transient
depressive state will occur. Regardless of etiology, when such depressive
states occur in treated patients, they need to be recognized and addressed
clinically to deal with the immediate impact of the symptoms.46
Our results differ from those of Schuckit et al,46
who studied major depression in a large sample of treated alcoholic subjects
(n = 954), their alcoholic relatives who received a lifetime diagnosis of
alcoholism (n = 1759), and controls (n = 919), recruited from medical and
dental centers, advertisements, driver's license records, and questionnaires
mailed to random subjects at a university. The lifetime rate of independent
major depression was actually lower among subjects diagnosed with lifetime
alcoholism than among controls, although lifetime rates including both independent
and "concurrent" major depression were higher among the alcoholic subjects.
The lack of an association between lifetime diagnoses of alcoholism and independent
major depression in the Schuckit et al study may be due to several factors,
including various selection and other biases among the different groups. However,
a more salient difference may pertain to the assessment method. Among probands
and their relatives, a lifetime "independent" major depression could only
be diagnosed if it predated the initial onset of alcoholism or occurred during
a period of complete abstinence. This method assumes that any drinking after
the initial diagnosis of alcoholism must have been accompanied by sufficient
intoxication or withdrawal effects to cause full major depressive syndromes.
Although this is likely to be true for the patients, it is not as likely for
the relatives, who constituted about 65% of the cases. Because most of these
relatives were never treated for alcoholism, it is possible that a number
of them had an early episode of developmentally limited alcoholism that remitted
spontaneously without treatment,47-48
followed by years of normal drinking. (This reasoning is consistent with known
differences between treated and untreated drinkers.49-50)
Among the relatives with this type of history, major depression could not
be diagnosed during periods of normal drinking despite the absence of chronic
intoxication and withdrawal effects. If there were many cases of this type,
then the rates of depression among the relatives would have been underestimated,
leading to an impression that their rates were lower than they actually were.
This would reduce the overall rate of independent major depression in the
case group compared with controls, producing a result different from the results
obtained in the present study.
Of course, having a current depressive disorder does not preclude a
history of past depressions. The onset of major depression can follow the
onset of alcoholism, especially in men, resulting in a diagnosis of major
depression that is chronologically secondary to another disorder, such as
alcoholism. We did not examine the timing of the onset of the disorders nor
condition the analyses on having a prior history of depression because these
steps were not relevant to the specific research question we asked, ie, whether
alcohol dependence and major depression were associated even when acute intoxication
or withdrawal effects were ruled out as an explanation. The fact that the
association was found under these circumstances, and that it was as strong
as it was, indicates that the association is not merely an artifact of misdiagnosis
and suggests that the association is important to investigate further.
This study does not resolve the question of whether the relationship
between DSM-IV alcohol dependence and major depressive
disorder is indirectly causal (as defined by Swendsen and Merikangas7) or arises from shared etiologic factors. The findings
are consistent with an indirectly causal explanation if the diagnosis of DSM-IV alcohol dependence caused life problems that were
either ongoing themselves or that caused an ongoing successive series of difficulties
eventually leading to major depression. Shared etiology also cannot be ruled
out from these results because the same etiological factors may affect onset
but different factors may affect the remission of each disorder, leading to
cessation of one but not the other.
The results of the study should be interpreted in light of the methods
used. One limitation is the cross-sectional nature of the data. Long-term
prospective investigations of very large samples would be more suitable, as
they are in studies of any health conditions. However, such studies are very
costly and difficult. In the absence of large-scale prospective studies of
representative samples, the current investigation offers information that
has not been available previously. Another issue is that the information on
drinking was based on self-report. Although some subjects may have minimized
their levels of current drinking, numerous methodological studies of this
issue51-54
have shown that collateral reports do not necessarily indicate higher drinking
levels when compared with self-report. Thus, we do not believe that the present
results have been substantially altered by this factor.
Alcohol dependence and major depression are among the most prevalent
mental disorders in the general population and have increased in more recent
birth cohorts.2, 29, 55
If the lifetime co-occurrence of these 2 disorders is not an artifact of misdiagnosis,
as suggested by this study, then a better understanding of the reasons for
the comorbidity may lead to better prevention and intervention efforts for
each disorder. Further, these findings, in conjunction with other findings
that depression during abstinence is a risk factor for relapse,15-17
suggest that treatment for depression should not be withheld from alcoholics
in stable remission on the assumption that any depressions in such individuals
are due to protracted intoxication or withdrawal effects. Further clinical
research is needed to help define the parameters of clinical decision-making
in such cases so that the optimal treatments may be offered.
AUTHOR INFORMATION
Submitted for publication April 20, 2001; accepted October 4, 2001.
This study was supported by grant K02AA00161 (Dr Hasin) from the National
Institute on Alcohol Abuse and Alcoholism, Bethesda, Md, and contributions
from the New York State Psychiatric Institute, New York.
Corresponding author and reprints: Deborah S. Hasin, PhD, Columbia
University, New York State Psychiatric Institute, 1051 Riverside Dr, Box 123,
New York, NY 10032 (e-mail: dsh2{at}columbia.edu).
From the Department of Epidemiology, Mailman School of Public Health,
Columbia University, and New York State Psychiatric Institute, New York (Dr
Hasin); and the Division of Biometry and Epidemiology, National Institute
on Alcohol Abuse and Alcoholism, Bethesda, Md (Dr Grant).
REFERENCES
| |
1. Regier D, Farmer M, Rae D, Locke B, Keith S, Judd L, Goodwin F. Comorbidity of mental disorders with alcohol and other drug abuse:
results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;264:2511-2518.
FREE FULL TEXT
2. Kessler RC, McGonagle KA, Zhao S, Nelson C, Hughes M, Eshleman S, Kendler K. Lifetime and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States: results from the National Comorbidity
Survey. Arch Gen Psychiatry. 1994;51:8-19.
FREE FULL TEXT
3. Merikangas KR, Mehta RL, Molnar BE, Walters EE, Swendsen JD, Aguilar-Gaziola S, Bijl R, Borges G, Caraveo-Anduaga JJ, DeWit DJ, Kolody B, Vega WA, Wittchen HU, Kessler RC. Comorbidity of substance use disorders with mood and anxiety disorders:
results of the International Consortium in Psychiatric Epidemiology. Addict Behav. 1998;23:893-907.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
4. Swendsen JD, Merikangas KR, Canino GJ, Kessler RC, Rubio-Stipec M, Angst J. The comorbidity of alcoholism with anxiety and depressive disorders
in 4 geographic communities. Compr Psychiatry. 1998;39:176-184.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
5. Grant BF. Comorbidity between DSM-IV alcohol use disorders
and major depression: results of a national survey of adults. J Subst Abuse. 1995;7:481-497.
FULL TEXT
| PUBMED
6. Hasin D, Glick H. Depressive symptoms and DSM-III-R alcohol
dependence: general population results. Addiction. 1993;88:1431-1436.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
7. Swendsen JD, Merikangas KR. The comorbidity of depression and substance use disorders. Clin Psychol Rev. 2000;20:173-189.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
8. Hasin D, Nunes E. Comorbidity of alcohol, drug, and psychiatric disorders: epidemiology. In: Kranzler HR, Rounsaville BJ, eds. Dual Diagnosis
and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York, NY: Marcel Dekker Inc; 1997:1-31.
9. Maier W, Merikangas KR. Co-occurrence and cotransmission of affective disorders and alcoholism
in families. Br J Psychiatry Suppl. 1996;30:93-100.
10. Cadoret RJ, Winokur G, Langbehn D, Troughton E, Yates WR, Stewart MA. Depression spectrum disease, I: the role of gene-environment interaction. Am J Psychiatry. 1996;153:892-899.
FREE FULL TEXT
11. Rounsaville B, Dolinsky Z, Babor T, Meyer R. Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry. 1987;44:505-513.
FREE FULL TEXT
12. O'Sullivan K, Rynne C, Miller J, O'Sullivan S, Fitzpatrich V, Hux M, Cooney J, Clare A. A follow-up study on alcoholics with and without coexisting affective
disorder. Br J Psychiatry. 1988;152:813-819.
FREE FULL TEXT
13. Kranzler HR, Del Boca FK, Rounsaville BJ. Comorbid psychiatric diagnosis predicts 3-year outcomes in alcoholics:
a posttreatment natural history study. J Stud Alcohol. 1996;57:619-626.
WEB OF SCIENCE
| PUBMED
14. Hodgins D, el-Guebaly N, Armstrong S, Dufour M. Implications of depression on outcome from alcohol dependence: a 3-year
prospective follow-up. Alcohol Clin Exp Res. 1999;23:151-157.
WEB OF SCIENCE
| PUBMED
15. Greenfield S, Weiss R, Nuenz L, Vagge L, Kelly J, Bellow L, Michael J. The effect of depression on return to drinking: a prospective study. Arch Gen Psychiatry. 1998;55:259-265.
FREE FULL TEXT
16. Hasin D, Tsai W-Y, Endicott J, Mueller TI, Coryell W, Keller MB. The effects of major depression on alcoholism: 5-year course. Am J Addict. 1996;5:144-155.
17. Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry. 2002;59:375-380.
FREE FULL TEXT
18. Hasin DS, Tsai W-Y, Endicott J, Mueller TI, Coryell W, Keller MB. Five-year course of major depression: effects of comorbid alcoholism. J Affect Disord. 1996;41:63-70.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
19. Nunes E, McGrath P, Quitkin F, Stewart J, Harrison W, Tricamo E, Ocepek-Welikson K. Imipramine treatment of alcoholism with comorbid depression. Am J Psychiatry. 1993;150:963-965.
FREE FULL TEXT
20. McGrath P, Nunes E, Stewart J, Goldman D, Agosti V, Ocepek-Welikson K, Quitkin F. Imipramine treatment of alcoholics with primary depression: a placebo
controlled trial. Arch Gen Psychiatry. 1996;53:232-240.
FREE FULL TEXT
21. Mason B, Kocis J, Ritvo E, Cutler R. A double-blind, placebo-controlled trial of desipramine for primary
alcohol dependence stratified on the presence or absence of major depression. JAMA. 1996;275:761-767.
FREE FULL TEXT
22. Cornelius J, Salloun I, Ehler J, Jarrett P, Cornelius M, Perel J, Thase M, Black A. Fluoxetine treatment in depressed alcoholics: a double-blind, placebo-controlled
study. Arch Gen Psychiatry. 1997;54:700-705.
FREE FULL TEXT
23. Schuckit MA. The clinical implications of primary diagnostic groups among alcoholics. Arch Gen Psychiatry. 1985;42:1043-1049.
FREE FULL TEXT
24. Schuckit MA. Genetic and clinical implications of alcoholism and affective disorder. Am J Psychiatry. 1986;143:140-147.
FREE FULL TEXT
25. Cook BL, Winokur G, Fowler RC, Liskow BI. Classification of alcoholism with reference to comorbidity. Compr Psychiatry. 1994;35:165-170.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
26. Guze SB. Secondary depression: observations in alcoholism, Briquet's syndrome,
anxiety disorder, schizophrenia, and antisocial personality. Psychiatr Clin North Am. 1990;13:651-659.
WEB OF SCIENCE
| PUBMED
27. Schuckit MA, Tipp JE, Bergman M, Reich W, Hesselbrock VM, Smith TL. Comparison of induced and independent major depressive disorders in
2945 alcoholics. Am J Psychiatry. 1997;154:948-957.
ABSTRACT
28. Grant BF, Peterson A, Dawson DA, Chou PS. Source and Accuracy Statement for the National Longitudinal
Alcohol Epidemiologic Survey. Rockville, Md: National Institute on Alcohol Abuse and Alcoholism;
1994.
29. Grant B. Prevalence and correlates of alcohol use and DSM-IV alcohol dependence in the United States: results of the National Longitudinal
Alcohol Epidemiological Survey. J Stud Alcohol. 1997;5:464-473.
30. Grant BF, Hasin DS. The Alcohol Use Disorder and Associated Disabilities
Interview Schedule (AUDADIS). Rockville, Md: National Institute on Alcohol Abuse and Alcoholism;
1992.
31. Grant BF, Harford TC, Dawson DA, Chou SP, Dufour MC, Pickering RP. Prevalence of DSM-IV alcohol abuse and dependence,
United States, 1992. Alcohol Health Res World. 1994;18:243-248.
32. Grant BF, Harford TC, Dawson D, Chou P, Pickering R. The Alcohol Use Disorder and Associated Disabilities Schedule (AUDADIS):
reliability of alcohol and drug modules in a general population sample. Drug Alcohol Depend. 1995;39:37-44.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
33. Hasin D, Carpenter KM, McCloud S, Smith M, Grant B. The Alcohol Use Disorder and Associated Disabilities Interview Schedule
(AUDADIS): reliability of alcohol and drug modules in a clinical sample. Drug Alcohol Depend. 1997;44:133-141.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
34. Hasin D, McCloud S, Li Q, Endicott J. Cross-system agreement among demographic subgroups: DSM-III, DSM-III-R, DSM-IV, and ICD-10 diagnoses
of alcohol use disorders. Drug Alcohol Depend. 1996;41:127-135.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
35. Hasin D, Van Rossem R, McCloud S, Endicott J. Differentiating DSM-IV alcohol dependence
and abuse by course: community heavy drinkers. J Subst Abuse. 1997;9:127-135.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
36. Hasin D, Van Rossem R, McCloud S, Endicott J. Alcohol dependence and abuse diagnoses: validity in community sample
heavy drinkers. Alcohol Clin Exp Res. 1997;21:213-219.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
37. Hasin D, Grant B, Cottler L, Blaine J, Towle L, Üstün B, Sartorius N. Nosological comparisons of alcohol and drug diagnoses: a multisite,
multi-instrument international study. Drug Alcohol Depend. 1997;47:217-226.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
38. Grant BF. Toward an alcohol treatment model: a comparison of treated and untreated
respondents with DSM-IV alcohol use disorders in
the general population. Alcohol Clin Exp Res. 1996;20:372-378.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
39. Dawson DA, Grant BF, Chou SP, Pickering RP. Subgroup variation in US drinking patterns: results of the 1992 National
Longitudinal Alcohol Epidemiologic Study. J Subst Abuse. 1995;7:331-344.
FULL TEXT
| PUBMED
40. Dawson DA. Drinking patterns among individuals with and without DSM-IV alcohol use disorders. J Stud Alcohol. 2000;61:111-120.
WEB OF SCIENCE
| PUBMED
41. Hasin D, Paykin A, Endicott J, Grant B. The validity of DSM-IV alcohol abuse: drunk
drivers vs all others. J Stud Alcohol. 1999;60:746-755.
WEB OF SCIENCE
| PUBMED
42. Grant BF, Hasin DS, Dawson DA. The relationship between DSM-IV alcohol use
disorders and DSM-IV major depression: examination
of the primary-secondary distinction in a general population sample. J Affect Disord. 1996;38:113-128.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
43. Software for Survey Data Analysis (SUDAAN). Version 7.5. Research Triangle Park, NC: Research Triangle Institute;
2000.
44. Cohen J, Cohen P. The clinician's illusion. Arch Gen Psychiatry. 1984;41:1178-1182.
FREE FULL TEXT
45. Fendrich M, Weissman MM, Warner V, Mufson L. Two-year recall of lifetime diagnoses in offspring at high and low
risk for major depression: the stability of offspring reports. Arch Gen Psychiatry. 1990;47:1121-1127.
FREE FULL TEXT
46. Schuckit MA, Tipp JE, Bucholz KK, Nurnberger JI, Hesselbrock CM, Crowe RR, Kramer J. The lifetime rates of 3 major mood disorders and 4 major anxiety disorders
in alcoholics and controls. Addiction. 1997;92:1289-1304.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
47. Zucker RA. The 4 alcoholisms: a developmental account of the etiologic process. In: Rivers PC, ed. Alcohol and Addictive Behavior. Lincoln: University of Nebraska Press; 1987:27-83.
48. Dawson DA. The link between family history and early onset alcoholism: earlier
initiation of drinking or more rapid development of dependence? J Stud Alcohol. 2000;61:637-646.
WEB OF SCIENCE
| PUBMED
49. Helzer JE, Robins LN, Taylor JR, Carey K, Miller RH, Combs-Orme T, Farmer A. The extent of long-term moderate drinking among alcoholics discharged
from medical and psychiatric treatment facilities. N Engl J Med. 1985;312:1678-1682.
ABSTRACT
50. Taylor JR, Helzer JE, Robins LN. Moderate drinking in ex-alcoholics: recent studies. J Stud Alcohol. 1986;47:115-121.
WEB OF SCIENCE
| PUBMED
51. Polich JM. The validity of self-reports in alcoholism research. Addict Behav. 1982;7:123-132.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
52. Leonard K, Dunn NJ, Jacob T. Drinking problems of alcoholics: correspondence between self and spouse
reports. Addict Behav. 1983;8:369-373.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
53. Sobell LC, Agrawal S, Sobell MB. Factors affecting agreement between alcohol abusers' and their collaterals'
reports. J Stud Alcohol. 1997;58:405-413.
WEB OF SCIENCE
| PUBMED
54. Chermack ST, Singer K, Beresford TP. Screening for alcoholism among medical inpatients: how important is
corroboration of patient self-report? Alcohol Clin Exp Res. 1998;22:1393-1398.
FULL TEXT
|
WEB OF SCIENCE
| PUBMED
55. Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol
abuse and dependence with other psychiatric disorders in the National Comorbidity
Survey. Arch Gen Psychiatry. 1997;54:313-321.
FREE FULL TEXT
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