1. Addressing Co-Occurring Mood and Alcohol Use Disorders in College Populations The Healthy Minds Network Webinar Series Session #6, February 2014

2. Todays Webinar Welcome and About The Healthy Minds Network Daniel Eisenberg, PhD, Director, HMN Definition and scope of the problem Justin Heinze, PhD, University of Michigan School of Public Health Treating co-occurring depression and hazardous alcohol use Paola Pedrelli, PhD, Harvard University/MGH Discussion Please submit questions at any point throughout the webinar!

3. 3 I. Welcome and About The Healthy Minds Network II. Definition and scope of the problem III. Treating co-occurring depression and hazardous alcohol use IV. Discussion

4. Welcome and About The Healthy Minds Network The Healthy Minds Network Research-to-practice network based at University of Michigan Public health approach to mental health among young people HMN Research-to-Practice Objectives: (1) produce knowledge (research) (2) distribute knowledge (dissemination) (3) use knowledge (practice) 4

5. Significance of Population Adolescents and young adults in the U.S., mental disorders account for the largest burden of disease (Michaud et al., 2006) 75% of lifetime mental disorders have first onset by age 24 (Kessler et al., 2005) Periods of intensive investment in human capital Campuses offer a unique opportunity for public health approaches with high impact Access to millions of adolescents and young adults 22 million in U.S. postsecondary education (Department of Education, 2012) 5

6. 6 I. Welcome and About The Healthy Minds Network II. Definition and scope of the problem III. Treating co-occurring depression and hazardous alcohol use IV. Discussion

7. Justin Heinze, PhD Research Investigator, University of Michigan School of Public Health, Department of Health Behavior and Health Education Research interests/expertise Transition to adulthood Identity development/Social belonging First Year Experience

8. Definition of Binge Drinking Alcohol consumption leading to blood alcohol concentration (BAC) of 0.08 g/DL within 2 hours Women: 4 standard drinks Men: 5 standard drinks

9. Standard Drink

10. College Student Standard Drink

11. Prevalence of Binge Drinking

12. Binge Drinking in Adults Aged 18 to 22

13. Consequences of High-Risk College Drinking

14. Co-occurring Drug Use and Binge Drinking

15. Many College Students Have a Difficult Time College students are in an unique development stage Identity formation Transition from dependence to semi-full independence Far from home and peer support

16. Prevalence of Mental Health Problems (Depression: ~17%)

17. Co-Occurrence of MDD and HED: The Healthy Minds Study High prevalence of MDD and HED among college students 10% vs. 6.7% ~50% vs. 15.4-23.3% HED among MDD vs. non-depressed students MDD associated with number of drinks per HED episode

18. 18 I. Welcome and About The Healthy Minds Network II. Definition and scope of the problem III. Treating co-occurring depression and hazardous alcohol use IV. Discussion

19. Paola Pedrelli, PhD Director of Dual Diagnoses Studies, Department of Psychiatry, Massachusetts General Hospital Topics Arguments for a combined treatment Example of a combined treatment Considerations related to treating young adults

20. Alcohol Use Associated with Worse Symptoms Greater alcohol use is associated with Worse depressive symptoms (Pedrelli et al., 2011) Greater psychological distress (Geisner et al., 2004) Poor overall mental health/depressive symptoms is associated with consuming any alcohol (Weitzman, 2004)

21. Psychological Distress and Alcohol Related Problems

22. Depression and Binge Drinking Risks BD + depression have a higher alcohol-related problems: Overdose Unsafe sex Fall behind at school Increased risk for: Alcohol dependence Alcohol abuse Suicidal behaviors

23. Critical Components of Tx Screening Combined treatment (CBT+MI) Tailored aspects

25. Alcohol Use Screening Frequency: On average, how many days per week do you drink alcohol? Quantity: On a typical day when you drink, how many drinks do you have? Binge drinking: How many times did you have more than four/five drinks on a single occasion in the last 30 days?

26. AUDIT

27. AUDs and Depression Should be Treated Together Depressive symptoms increase the risk of relapse and is associated with worse outcome Alcohol use may prevent depression improvement

28. Why MI+CBT? NIAAA recommends Combining CBT and MI CBT is effective in treating depressive symptoms MI matches patients readiness to change MI reduces alcohol use and increases engagement Integrating MI and CBT is feasible MI+CBT addresses motivations for drinking

29. MI Is client-centered Enhances intrinsic motivation to change unhealthy behaviors Explores and resolves ambivalence about change Facilitate clients movement along the continuum of readiness toward behavior change

30. Core Skills Open-ended questions Tell me a little bit about your drinking? Affirm You are really trying hard to quit it is important to you Reflective Listening You are feeling that you are drinking as much as your friends.. Summarize So what you decided today it is to avoid drinking games

31. MI Principles to Facilitate Change Express empathy and acceptance of current behavior Develop discrepancy between current behaviors and personal goals Avoid direct confrontation to avoid resistance (non- judgmental stance) Deflect resistance by using reflective statements and by reframing individuals statement towards increase discrepancy (roll with resistance)

32. Decisional Balance

33. MI Techniques

34. BASICS Personalized feedback Normative feedback Estimate BAC Gender specific effect of alcohol Personalized feedback on alcohol- related problems

35. Personalized Feedback Drinking Pattern: According to the information you provided at baseline, in the past month, during a typical week the number of occasions you drank was 5 times a week. The average amount you drank on each occasion was 4.1 drinks and during a typical week, you reported that you consumed a total of 20.5 drinks per week. During the heaviest drinking week, in the past month, the number of occasions you drank was 6 times a week. The average amount you drank on each occasion was 6.6 drinks and during the heaviest drinking week, you reported that you consumed a total of 33 drinks.

36. Personalized Feedback Comparison to National Average: Comparing your amount of drinks on the typical week to other college students across the country, your percentile rank was >98.4. This percentile represents the percentage of students of your gender who drink as much or less than you do; in your case, 98.4% of the students across the country drink as much or less than you do, and it also means that 1.6 % drink more than you do. Comparing your amount of drinks on the heaviest drinking week to other college students across the country, your percentile rank was >96.4%. This percentile represents the percentage of students of your gender who drink as much or less than you do; in your case, 99.6% of the students across the country drink as much or less than you do, and it also means that 0.4 % drink more than you do.

37. Personalized Feedback Heavy Drinking Episodes: Heavy drinking episodes are defined as having 4 or more drinks on one occasion for women. At baseline, you reported on a typical week, last month 3 heavy drinking episodes and during your heaviest drinking week 4 heavy drinking episodes. Blood Alcohol Concentration: At baseline, on a typical occasion when you drank your Blood Alcohol Concentration (BAC) was 0.058 to 0.121. In the past month, on the heaviest drinking occasion, your peak BAC was between 0.232. For sake of comparison, the legal limit for driving in Massachusetts is 0.08.

38. PFF Consequences of Drinking I had a hangover after drinking. I have taken foolish risks when I have been drinking. I have not been able to remember large stretches of time while drinking heavily. My drinking has gotten me into sexual situations I regretted. While drinking, I have said or done embarrassing things. I have felt very sick to my stomach or thrown up after drinking. When drinking, I have done impulsive things I later regretted. I have felt badly about myself because of my drinking. My drinking has created problems between myself and my boyfriend/girlfriend/spouse, parents, or other near relatives. I have become very rude, obnoxious, or insulting after drinking.

39. CBT CBT: thoughts cause our feelings and behaviors CBT is Briefer and Time-Limited CBT is based on a collaborative effort between the therapist and the client CBT uses the Socratic Method CBT is structured and directive CBT is based on an educational model Homework is a central feature of CBT

40. Cognitive Triad

41. CBT Techniques

42. Thought Record

44. TAY Problem List

45. How to Hook Them In MI (pros and cons of tx) Evoke discrepancy between actual self and ideal self How life will change Family involvement?

46. Special Considerations Negative consequences may not be severe yet Less committed to therapy College myths Family involvement Confidentiality M-therapy

47. Summary Binge drinking and mood problems are common on college campuses Effective interventions exist to help individuals, communities, and colleges decrease the prevalence of binge drinking Treatment programs for young adults needs to be tailored

48. Web Resources Healthy Minds (American Psychiatric Association) Ulifeline (Duke University Medical Center) Half of Us The JED Foundation Campus Calm

49. 49 I. Welcome and About The Healthy Minds Network II. Definition and scope of the problem III. Treating co-occurring depression and alcohol abuse IV. Discussion

50. Discussion Questions So much has been done to increase alcohol awareness and binge-drinking prevention on college campuses, yet it still appears to be ineffective statistically in the grand scheme. What do you think is the key for targeting students before it become is true issue/disorder/intervention? What is the ideal treatment model for a University to have in regard to treating clients with substance abuse and depression. Right now we have a substance abuse counselor in the Wellness Center which is a separate agency from the Counseling Center. What would you recommend?

51. More Information The Healthy Minds Network: www.healthymindsnetwork.org healthyminds@umich.edu Depression Clinical Research program: www.massgeneral.org/psychiatry/services/dcrp_home.aspx

52. References Brown SA et al. Neurocognitive functioning in adolescents: Effects of protracted Alcohol use. Alcohol Clin Exp Res. 2000; 24(2): 164-171. De Bellis MD et al. Hippocampal Volume in Adolescent Onset Alcohol Use Disorders. Am J Psych. 2000; 157 (5): 737-744. Kanny, D., Liu, Y., & Brewer, R.D. (2009). Binge Drinking – United States, 2009. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a22.ht m Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593.

53. References Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27. Michaud, C. M., McKenna, M. T., Begg, S., Tomijima, N., Majmudar, M., Bulzacchelli, M. T.,... Kreiser, J. G. (2006). The burden of disease and injury in the united states 1996. Popul Health Metr, 4(11), 11. Miller SC. Risk for Addiction Related Disorders Following Mild Traumatic Brain Injury in a Large cohort of Active Duty Airmen. Am J Psych. 2013; 170 (4): 383-390. National Survey on Drug Use and Health 2011: http://www.samhsa.gov/data/nsduh/2k11results/NSDUHresult s2011

54. References U.S. Department of Education (2012). Integrated Postsecondary Education Data System (IPEDS), "Fall Enrollment Survey" (IPEDS-EF:90-99), and Spring 2001 through Spring 2011, Enrollment component. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/ White AM et al. Many College Freshman Drink at Levels Far Beyond the Binge Threshold. Alc Clin Exp Research. 2006; 30 (6): 1006-1010.