Adolescent Depression, Alcohol and Drug Abuse

Adolescent Depression, Alcohol and Drug Abuse EVA Y. DEYKIN, DRPH, JANICE C. LEVY, MD, AND VICTORIA WELLS, MD, DRPH Abstract: The Diagnostic Interview Schedule was employed to ascertain the prevalence of major depressive disorder (MDD), alcohol and substance abuse in a sample of 424 college students aged 16 to 19 years. Applying DSM III criteria, the prevalence of MDD was 6.8 per cent; of alcohol abuse, 8.2 per cent; and of substance abuse 9.4 per cent. Alcohol abuse was associated with MDD, but not Introduction The clinically observed association of alcohol or drug abuse and depression',2 is well known, but its temporal sequence is difficult to determine. Alcohol as well as many illicit drugs are depressogens, the repeated use of which produces both the subjective feelings of depression and the neurovegetative signs such as sleep and appetite disturbance, cognitive impairment, and decreased energy characteristic of the depressed syndrome. The differentiation of the antecedents of alcohol and drug abuse from their sequelae is an important issue in adolescence when substance abuse usually begins. Several longitudinal studies3-5 have investigated the demographic and pyschosocial correlates of drug abuse, but the findings have been somewhat conflicting. Kaplan reported that among adolescents, lowered self-esteem initiated drug use which then produced an improvement in self-esteem.5 This would suggest that depressive symptomatology preceded drug use. Conversely, Kandel found that depressive mood was only a weak predictor of marijuana initiation among non-drug users, but an important factor in the first use of other illicit drugs among adolescents who were already marijuana users.4 The distinction between depression as a primary disorder and as a consequence of substance abuse may become blurred after many years of alcohol and/or drug abuse, resulting in a state of chronic disability in which it is impossible to unravel the sequence of symptom evolution, state of psychologic functioning, or pattern of substance abuse.6 The nature of this complex association may be more readily determined in adolescence, before the onset of personality disorder or depressive states secondary to chronic substance abuse. Furthermore, adolescents' recall, as assessed in cross-sectional prevalence studies of drug use, has proved quite reliable, confirming reports of longitudinal studies.7 The recent availability of the Diagnostic Interview Schedule, a research assessment interview based on accepted diagnostic criteria, facilitates the ascertainment of the occurrence of depressive disorder, alcohol and substance abuse in the adolescent age group, allows for the quantification of the association and temporal sequence of these conditions among teenagers. Address repnrnt requests to Eva Y. Deykin, DrPH, Associate Professor, Department of Maternal and Child Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. Dr. Levy is with the Department of Psychiatry, Massachusetts General Hospital, Boston; Dr. Wells is with the Department of Epidemiology, Harvard School of Public Health. This paper, submitted to the Journal March 10, 1986, was revised and accepted for publication June 18, 1986. 1987 American Journal of Public Health 0090-0036/87$1.50 178 with other psychiatric diagnoses. Substance abuse was associated both with MDD and with other psychiatric diagnoses as well. The onset of MDD almost always preceded alcohol or substance abuse suggesting the possibility of self-medication as a factor in the development of alcohol or substance abuse.am J Public Health 1986; 76:178-182.) Methods Study Sample The present investigation was part of a cross sectional study designed to identify the manifestations and correlates of major depressive disorder (MDD) in adolescence. The sample for this investigation consists of 424 (271 females and 153 males) college students aged 16 to 19 attending two Boston area colleges, and represents 42 per cent of students invited to participate. An additional 10 per cent refused participation, and the remainder did not respond. A subsequent mailing to non-responders revealed that loss of the original letter and conflict with study time were two most common reasons for non-response. We have few data on which to compare the negative and positive responders. The preponderance of females in the sample is due to the inclusion of an all female school. Although a few subjects were younger, nearly all (94 per cent) were 18 to 19 years old. As might be expected in a college sample, 72 per cent of the subjects came from the two highest social classes as defined by the Hollingshead classification of paternal occupation.8 Racially, were non-caucasian. All students aged 16 to 19 years were sent a letter describing the purpose of the study and inviting their participation. Students who responded negatively on an enclosed self-addressed postcard were not contacted further; others were telephoned and an interview time arranged. The interview lasted about an hour: subjects were remunerated five dollars for their time. The study protocol was reviewed and approved by the institutional review boards of the Harvard School of Public Health, and by the appropriate authorities at the two participating colleges. Data Collection Data for the study were obtained by means of the Diagnostic Interview Schedule (DIS), a structured, standardized interview developed for epidemiologic purposes,9 and previously used in the Epidemiologic Catchment Area Project involving 20,000 subjects.'0 The reliability of the DIS, measured by diagnostic agreement between psychiatrists and by lay interviews both using the DIS, was high with the overall Kappa statistic of.69.9 The accuracy of the DIS was measured by the degree of concordance between DISgenerated diagnoses and those resulting from psychiatric interview. Concordance rates ranging between 79 and 96 per cent, depending on specific diagnoses, indicated the diagnostic validity of the DIS." The DIS can provide diagnoses based on Research Diagnostic Criteria, on Feighner criteria, and on DSM-III criteria. This study uses the DSM III criteria, the official classification system of the American Psychiatric Association. Only subjects who met definite criteria were considered positive for psychiatric illness. Major depressive the sample was predominantly White; 6 per cent A1JPH February 1987, Vol. 77, No. 2

ADOLESCENT DEPRESSION, ALCOHOL AND DRUG ABUSE TABLE 1-Alcohol Abuse and Major Depressive Disorder (MDD) MDD Alcohol Abuse Yes No Total Total Sample Yes 8 27 35 No 27 362 389 Total 35 389 424 Odds ratio: 3.6 95% C.l.: 1.7-5.4 Males Yes 2 17 19 No 5 129 134 Total 7 146 153 Odds ratio: 3.0 95% C.1.: 0.5-15.6 Females Yes 6 10 16 No 22 223 255 Total 28 243 271 Odds ratio: 6.4 95% C.1.: 2.4-17.1 disorder (MDD) was determined by the presence of dysphoria lasting two weeks or longer and by at least four of a possible eight vegetative symptoms. Alcohol abuse was determined by either a pattern of pathologic alcohol use or by impairment in social/occupational functioning due to alcohol use. A diagnosis of drug abuse was based on a pattern of pathologic use, and impairment of social and occupational functioning lasting at least one month. Age of onset for any DSM III psychiatric classification was obtained by the DIS interview for those subjects whose responses for relevant symptoms were positive. Data collected by the Diagnostic Interview Schedule were entered directly into the computer and the specially designed SAS program was applied to determine the presence or absence of psychiatric disorders. Data Analyses Associations of alcohol or drug abuse with other psychiatric diagnoses were estimated by computing the odds ratios and their accompanying 95 per cent confidence intervals. To establish whether alcohol or drug abuse preceded or followed other diagnoses, the age of onset for alcohol or drug abuse was compared to the age of onset of other diagnoses among subjects in which both alcohol or drug abuse and another psychiatric disturbance were present. Results Alcohol Abuse and Major Depressive Disorder The lifetime prevalence of alcohol abuse/dependence was 8.2 per cent and of substance abuse/dependence, 9.4 per cent. The lifetime prevalence of major depressive disorder was 6.8 per cent. Since stringent DSM III criteria were applied to establish diagnoses, the prevalence reported here represent conservative estimates of occurrence. For example, the prevalence of MDD would have been doubled had the DSM III criteria specified only three rather than four symptoms in addition to dysphoria. In our adolescent sample, subjects who report a history of alcohol abuse are almost four times as likely to have a history of MDD as the subjects who have not abused alcohol (Table 1). The association between these two diagnostic classifications is particularly striking among females who are AJPH February 1987, Vol. 77, No. 2 TABLE 2-Substance Abuse and Major Depresive Disorder (MDD) MDD Substance Abuse Yes No Total Total Sample Yes 8 32 40 No 27 357 384 Total 35 389 424 Odds ratio: 3.3 95% C.1.: 1.4-7.5 Males Yes 3 16 19 No 4 130 134 Total 7 146 153 Odds ratio: 6.1 95% C.1.: 1.5-25.0 Females Yes 5 16 21 No 23 227 250 Total 28 243 271 Odds ratio: 3.1 95% C.1.: 1.1-8.9 TABLE 3-Alcohol Abuse among Adolescents with MDD, Other Diagnose, and No Diagnoses Alcohol Abuse MDD Other Dx No Dx Total Yes 8 8 19 35 No 27 73 289 389 Total 35 81 309 424 MDD vs No Dx Other Dx vs No Dx Odds ratio 4.5 1.6 95% C.1. 1.8-10.0 0.7-3.7 more than six times as likely to have experienced MDD if they are alcohol abusers than if they are not. Drug Abuse and Major Depressive Disorder Subjects who met DSM III criteria for abuse of any prescription drug were classified as drug abusers, irrespective of what drug they used. Marijuana was the drug most frequently abused. Report of heroin and cocaine abuse was rare and tended to be part of poly drug abuse. Like alcohol, drug abuse is strongly associated with a lifetime prevalence of MDD (Table 2). Overall, subjects who qualified as drug abusers were 3.3 times as likely as nonabusers to have history of MDD. Alcohol, Drug Abuse, MDD, and other Psychiatric Disorders To assess whether alcohol or drug abuse were uniquely associated with MDD or whether they were also correlates of other psychiatric illnesses, we tested the association of alcohol and drug abuse, each separately, with other DSM III diagnoses (exclusive of MDD). Whereas alcohol abuse has no strong association with psychiatric diagnoses other than MDD (Table 3), drug abuse is markedly associated with other psychiatric classifications as well (Table 4). A total of eight subjects met DSM III criteria both for alcohol and drug abuse. Five of these eight subjects also had another psychiatric diagnosis (MDD in three; obsessive compulsive and phobic disorder in the other two). Four of the eight had two or more other psychiatric diagnoses indicating an extraordinary high load of psychopathology in this small subgroup of poly drug abusers. 179

DEYKIN, ET AL. TABLE 4-Substance Abuse among Adolescents with MDD, Other Dagnoses, and No Diagnoses Substance Abuse MDD Other Dx No Dx Total Yes 8 13 19 40 No 27 68 289 384 Total 35 81 308 424 MDD vs No Dx Other Dx vs No Dx Odds ratio 4.5 2.9 95% C.1. 1.7-11.6 1.4-6.0 Sequence of Alcohol or Substance Abuse and Other Psychiatric Disorders The data in Table 5 indicate that the initiation of alcohol abuse tends to follow, rather than precede the onset of other psychiatric disturbances. Among the eight subjects who had MDD, six had a history of MDD that began an average of 4.5 years prior to onset of alcohol abuse. For four of the eight, the diagnosis of MDD preceded even the first exposure to alcohol. Similarly, among the six subjects who had a psychiatric diagnoses exclusive of MDD, five experienced their first psychiatric disturbance either prior to or concurrently with alcohol abuse. Similar data (Table 6) were evident when the age of onset of drug abuse was compared to age at the beginning of other psychiatric disturbances. Of the 19 subjects who had both drug abuse and another psychiatric disturbance, eight also had MDD. Among these eight subjects, MDD had preceded or occurred concurrently with drug abuse in six subjects, with an average interval between the two disorders of 1.7 years. In half of the subjects with both MDD and drug abuse, depressive illness had occurred prior even to the first instance of illicit drug use. Among the remaining 11 subjects who had drug abuse and another psychiatric diagnosis exclusive of MDD, the psychiatric illness preceded or occurred concurrently with the drug abuse in nine cases. The average interval between psychiatric illness and subsequent drug abuse was 6.2 years, and in most cases the psychiatric diagnosis preceded the first instance of illicit drug use. Early Alcohol Use The prevalence of early problem drinking (defined as being drunk more than twice before age 15) for the entire sample was 17.5 per cent. However, for subjects with MDD, the occurrence of early problem drinking was 1.7 times as great as for subjects without MDD (28.7 vs 16.5 per cent) suggesting that repeated drunkenness at a young age might be an early marker of MDD. Not surprisingly, early problem drinking was strongly associated both with a diagnosis of alcohol abuse and drug abuse. Subjects who met criteria for a diagnosis of alcohol abuse were four times as likely to have had early problem drinking as subjects without such a diagnosis. The association was even more marked for drug abusers who were 5.5 times as likely to have experienced early problem drinking. Discussion The life-time prevalence of major affective disorder (6.8 per cent), alcohol abuse (8.2 per cent), and drug abuse (9.4 per cent) in our sample are very similar to those reported (6.0 per cent, 1 1.6 per cent, and 5.8 per cent) by the Epidemiologic Catchment Area (ECA) study based on 1,550 college graduates aged 18 and over.'0 The higher life-time prevalence of drug abuse in our sample relative to the ECA study may reflect time changes in the use of illicit drugs. The ECA study assessed the prevalence of drug abuse in college graduates aged 18 and over while our study sample consisted of individuals currently aged 16 to 19. The higher occurrence of alcohol abuse in the ECA study may indicate that the period of risk for this disorder extends beyond age 19. Data obtained from 424 apparently healthy, well-functioning young college students suggest that alcohol is a potent marker of major depressive disorder among females. The association of depression and alcohol abuse in our subsample of college coeds is not due to a concomitant higher prevalence of these disorders among women. The data from the ECA study clearly indicate that while depression is more common among females, alcohol abuse is typically a male disorder. 10 Thus, the observed association is not confounded by gender, nor is alcohol abuse associated with other psychiatric diagnoses. Because of the small number of males in the sample, the magnitude of the association among males requires further verification. In contrast, drug abuse in both sexes is highly associated both with MDD and other psychiatric diagnoses. College students who meet criteria for MDD and for alcohol or drug abuse are almost always subject to depressive illness first and alcohol/substance abuse subsequently. This temporal sequence applies to other diagnostic classfiications TABLE 5-Subjects with Alcohol Abuse and Other PsychIaric Diagnoses* Age of Onset of Age of Age of Age/Sex Other Psychiatric Dx Psychiatric Dx Alcohol Abuse 1st drink 18/F MDD 9 16 12 19/F MDD 13 15 11 18/F MDD 8 18 16 18/F MDD 16 18 18 18/F MDD 17 16 16 18/F MDD 9 16 unknown 18/F MDD 18 16 15 19/M MDD 14 14 13 18/F Phobic disorder 5 15 15 18/F Phobic disorder 9 16 16 18/F Phobic disorder 17 16 14 19/M Phobic disorder 8 17 17 19/M Phobic disorder 7 18 16 19/M Obsessive/compulsive disorder 18 18 18 *Two subjects with alcohol abuse had substance abuse as their only other psychiatric diagnosis and are eliminated from this table. 180 AJPH February 1987, Vol. 77, No. 2

TABLE S-Subjects wth Subsbtnce Abuse and Other Psychiatric Dlagneses* ADOLESCENT DEPRESSION, ALCOHOL AND DRUG ABUSE Age of Onset of Age of Onset Age of First Age/Sex Other Psychiatric Dx Psychiatric Dx Substance Abuse Use of Drugs 18/F MDD 9 15 15 19/F MDD 13 14 12 18/F MDD 14 15 15 18/F MDD, Bipolar II 15 unknown 13 19/F MDD, Phobic 16 18 14 19/F MDD 17 17 16 19/M MDD 17 13 13 19/M MDD 14 14 14 18/F Dysthymia 12 18 16 18/F Panic disorder 14 18 12 18/F Phobic disorder 5 18 16 19/F Phobic disorder 14 18 12 18/F Phobic disorder 16 16 14 19/M Phobic disorder 17 19 18 19/M Phobic disorder 2 17 14 19/F Obsessive/compulsive disorder 18 16 16 19/M Obsessive/compulsive disorder 18 19 14 19/M Obsessive/compulsive disorder 18 15 15 18/M Schizophrenia 18 18 16 *Two subjects with substance abuse had alcohol abuse as their only other psychiatric diagnosis and are eliminated from this table. as well as to MDD. Lastly, the data indicate that early drunkenness constitutes an important risk factor both for substance abuse and for major depressive disorder. The distinction between primary and secondary depression'2"3 offers a means of clarifying the nature of the relationship between alcohol/drug abuse and depression in adolescents. According to this distinction, primary depression is defined as depression occurring in a patient whose previous psychiatric history is negative, or positive only for pre-existing mania or depression. Secondary depression is defined as a depressive episode in a patient who has a pre-existing, diagnosable psychiatric disorder (for example, alcoholism and/or drug abuse in this study). The key to the classification is the chronology of the onset of the disorders. In our sample, 79 per cent of both alcohol and drug abusers had another primary psychiatric disorder anteceding the alcohol or drug abuse. While others4 have identified specific psychosocial or personality attributes antecedent to drug abuse among adolecents, we believe this study is the first to document the association and sequence of psychiatric disorders, alcohol and drug abuse, rigorously defined and ascertained in a normal adolescent population. Our data are consistent with the "self-medication" hypothesis first elaborated by psychoanalysts'4 and more recently summarized by Khantzian.'5 The use of drugs as a coping strategy to regulate painful affects, most often that of moderate to severe depression, may explain the observation that the "amotivational syndrome" with resultant lethargy, social, and personal deterioration'6 initially thought to be a consequence of marijuana use, instead appears to precede it.4 Evidence ofgender differences in the strength and nature of the association between alcoholism and depression has been noted before.2"7'9 The association between early and repeated drunkenness ("problem drinking") and other drug abuse is consistent with Hamburg's notion of a hierarchy of substance use,20 with problem drinking high on the ladder, and with other findings that early use of any illicit drug is associated with greater use of all drugs. This particular high-risk group should be the focus of early clinical attention, in view of the high occurrence of associated multi-problem behaviors. Some evidence suggests that drug abusing adolescents continue to exhibit deviant behavior patterns as young adults2' and data from the present study highlight the need for comprehensive, sophisticated psychiatric evaluation. ACKNOWLEDGMENTS This investigation was supported by the Charles A. King Trust and by a Biomedical Scientific Research Grant. REFERENCES 1. Keller MH, Taylor IC, Miller WC: Are all recently detoxified alcoholics depressed? Am J Psychiatry 1980; 136:586-588. 2. Weissman MM, Myers JK: Clinical depression in alcoholism. Am J Psychiatry 1980; 137:372-373. 3. Jessor R, Jessor SL: Adolescent development and the onset of drinking: A longitudinal study. J Stud Alcohol 1975; 36:27-51. 4. Kandel DB: Epidemiologic and psychosocial perspectives on adolescent drug use. J Am Acad Child Psychiatry 1982; 21:328-347. 5. Kaplan HB: Increase in self-rejection and continuing/discontinuing deviant response. J Youth Adolesc 1977; 6:77-87. 6. O'Sullivan K, Whillans P, Daly M, Clare A, Cooney J: A comparison of alcoholics with and without coexisting affective disorder. Br J Psychiatry 1983; 143:133-138. 7. Robins LN: Natural history of adolescent drug use. Am J Public Health 1984; 74:656-657. 8. Hollingshead AB, Redlich FC: Social Class and Mental Illness: A Community Study. New York: John Wiley, 1958. 9. Robins LN, Helzer JE, Crougham J, Ratcliff KS: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics and validity. Arch Gen Psychiatry 1981; 38:381-389. 10. Robins LN, HelzerJE, Weissman MM, Orvaschel H, Gruenberg E, Burke JD, Regier DA: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984; 41:949-958. 11. Helzer JE, Robins LN, McEvoy LT, Spitznagel EL, Stoltzman RK, Farmer A, Brockington IF: A comparison of clinical and diagnostic interview schedule diagnoses. Arch Gen Psychiatry 1985; 42:657-666. 12. Robins E, Guze A: Classification of affective disorders: The primary, secondary, the endogenous and the neurotic-psychotic concepts. In: Recent Advances in the Psychobiology of the Depressive Illness. Pub. No. #HSM 70-9053, US Department of Health, Education, and Welfare. Washington, DC: Govt Printing Office, 1972. 13. Robins E, Munoz RA, Marten S, Gentry KA: Primary and secondary affective disorders. In: Zubin J, Freyman FA (eds): Disorders of Mood. Baltimore: Johns Hopkins University Press, 1972. 14. Rado S: The psychoanalysis of pharmacothymia. Psychoanal Q 1933; 2:2-23. 15. Khantzian EJ: The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine. Am J Psychiatry 1985; 142:1259-1264. AJPH February 1987, Vol. 77, No. 2 181

DEYKIN, ET AL. 16. National Commission on Marijuana and Drug Abuse: Marijuana: A Signal of Misunderstanding, Appendix Vols. I and II. Washington, DC: Govt Printing Office, 1972. 17. Schucket M, Pitts FN, Reich T, King LJ, Winokur G: Alcoholism: I. Two types of alcoholism in women. Arch Gen Psychiatry 1969; 20:301-306. 18. Goodwin DW, Schulsenger F, Guze SB, Winokur G: Alcohol problems in adoptees raised apart from alcoholic biologic parents. Arch Gen Psychiatry 1973; 28:238-243. 19. Goodwin DW, Schulsenger F, Knopp J, Mednick S, Guze SB: Alcoholism and depression in adopted-out daughters of alcoholics. Arch Gen Psychiatry 1977; 34:751-755. 20. Hamburg BA, Kraemer HC, Jahnhe W: A hierarchy of drug use in adolescence: Behavioral and attitudinal correlates of substantial drug use. Am J Psychiatry 1975; 132:11. 21. Kandel DB: Marijuana users in young adulthood. Arch Gen Psychiatry 1984; 41:200-209. Nine Cities Selected for New Initiative in Mental Health Services The Robert Wood Johnson Foundation and the US Department of Housing and Urban Development recently announced that nine cities have been selected to participate in a new initiative to improve the delivery of services to the chronically mentally ill. Contributions will total more than $10 million per city under this national program. The Progran for the Chronically Mentally Ill is a unique public/private partnership sponsored in cooperation with the US Conference of Mayors, the National Governor's Association, the National Association of Counties, and the National Conference of State Legislatures. The nation's 60 largest cities were eligible to apply for the Program. The nine cities selected for the Progran for the Chronically Mentally Ill are: Austin, Texas Cincinnati, Ohio Honolulu, Hawaii Baltimore, Maryland Columbus, Ohio Philadelphia, Pennsylvania Charlotte, North Carolina Denver, Colorado Toledo, Ohio The Foundation will provide approximately $29 million in grants and loans over five years to support the development of city-wide mental health authorities that offer a range of community services and supervised housing. The cities will also be eligible for federal rent subsidies valued at approximately $85 million over a 15-year period. The National Institute of Mental Health and the Foundation will share in the cost of an extensive scientific evaluation of the Program's effectiveness. Spokespersons for the sponsoring groups emphasize the focus of the program is to: * improve access by the chronically mentally ill to appropriate medical care, housing, and rehabilitation services; * spur collaboration between public and private agencies at the local and state levels; * help improve community programs throughout the country through the knowledge gained from this program. The nine cities selected for funding under the Program share the following elements: a tight and clearly defined organizational structure; assignment of continuing responsibility for each chronically mentally ill person in the community; a comprehensive set of services that provides realistic alternatives to institutional care; and budgetary control over the broad range of relevant services and settings, with fiscal incentives for providing appropriate and cost-effective care. Examples of services that might be initiated or expanded uner this program include: new residential facilities with varying levels of treatment and supervision, innovative case management and treatment teams, model vocational and employment programs, new public corporations to finance and manage care for the chronically mentally ill, and outreach for locating and assisting the homeless mentally ill. Technical assistance and direction for the Program for the Chronically Mentally Ill is being provided by Miles F. Shore, MD, Bullard Professor of Psychiatry at the Harvard Medical School, area director and superintendent of the Massachusetts Mental Health Center of the Massachusetts Department of Mental Health, and a senior program consultant to the Johnson Foundation. 182 AJPH February 1987, Vol. 77, No. 2