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

2. Alcohol in Young Adults Alcohol increases at a young age Alcohol common age 21-25 70% consume alcohol 2© AMSP 2015 HED Current Frequent HED

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

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

5. Definition Standard drink = 10-12 g pure ethanol

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

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

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

9. 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

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

11. 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

12. 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. 13© AMSP 2015 AUD in College Students 24% ♂ have AUD 13% ♀ have AUD

14. 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 201514

15. 16 © AMSP 2015 Predictors of HED

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

17. 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

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

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

20. Problems with Dep Sx Mild dep sx ↑ early school drop out Mild dep sx ↑ psychosocial problems SI present at sub-threshold MDD © AMSP 201520

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

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

23. 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 201523

24. Social Learning Theory © AMSP 201525 Alcohol is used: To ↓ negative emotional states With expectation ↑ mood Belief no alternative ways to cope

25. Jackie Drinks to feel better Behind in school due to HED Regrets actions during HED © AMSP 201525

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

27. Settings for Screenings Throughout school College counseling centers Primary care Emergency care © AMSP 201527

28. 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 201528

29. Screening Tool for Depression Patient health questionnaire (PHQ-9) - 9 items ask frequency of sx - Responses are summed - Score >10 indicates MDD © AMSP 201529

30. 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 201530

31. 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 201531

32. CBT Thoughts  feelings  behaviors Brief and time-limited Structured Educational Collaborative relationship Socratic method Includes homework © AMSP 2015 32

33. CBT Tenets Dep sx relate to negative views of: -Themselves -The future -The world © AMSP 201533

34. CBT Techniques Change unhelpful thoughts - Evidence for and against thoughts - Reduce catastrophizing - Identify mind reading ↑ Enjoyable activities © AMSP 201534

35. MI Therapy ~ partnership Patient-centered Directive method communication Elicit own motivation to change Explores ambivalence re change Guide pt towards change © AMSP 201535

36. MI Therapist Express empathy of current behavior Examine inconsistencies Promote belief that change is possible Roll with resistance © AMSP 201536

37. 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 201537

38. CBT For Jackie Changed thoughts: - “I am flawed” - “My friends do not like me” Increased pleasant activities: - Encouraged resuming piano - Encouraged resuming exercising © AMSP 201538

39. Jackie: Results Attending classes consistently ↑ Exercising and playing piano Seeing friends daily Drink < 4 drinks per occasion © AMSP 201539

40. Conclusion/Summary In college students: Depressive symptoms + HED are common Screening important Combined Tx more effective CBT+MI example of combined Tx © AMSP 201540