Addressing Co-Occurring Mood and Alcohol Use Disorders in

College Populations

The Healthy Minds Network Webinar Series Session #6, February 2014

Today’s 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!

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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

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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)

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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)

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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

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

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

Standard Drink

College Student Standard Drink

Prevalence of Binge Drinking

Binge Drinking in Adults Aged 18 to 22

Consequences of High-Risk College Drinking

Co-occurring Drug Use and Binge Drinking

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

Prevalence of Mental Health Problems (Depression:

~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 perHED episode

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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

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

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)

Psychological Distress and Alcohol Related Problems

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

Critical Components of Tx

Screening

Combined treatment (CBT+MI)

Tailored aspects

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?”

AUDIT

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

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

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

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”

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 individual’s statement towards increase discrepancy (roll with resistance)

Decisional Balance

MI Techniques

BASICS

Personalized feedback

Normative feedback

Estimate BAC

Gender specific effect of alcohol

Personalized feedback on alcohol-related problems

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.

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.

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.

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.

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

Cognitive Triad

CBT Techniques

Thought Record

TAY Problem List

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?

Special Considerations

Negative consequences may not be severe yet

Less committed to therapy

College myths

Family involvement

Confidentiality

M-therapy

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

Web Resources

Healthy Minds (American Psychiatric Association)

Ulifeline (Duke University Medical Center)

Half of Us

The JED Foundation

Campus Calm

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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

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?

More Information

The Healthy Minds Network: www.healthymindsnetwork.org

healthyminds@umich.edu

Depression Clinical Research program: www.massgeneral.org/psychiatry/services/dcrp_home.asp

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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.htm

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.

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/NSDUHresults2011

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.