General Hospital Psychiatry 28 (2006) 169–173

Prevalence of major depressive disorder in Nigerian

college students with alcohol-related problems

Abiodun O. AdewuyaT

Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Wesley Guild Hospital, ILESA 233001, Osun state, Nigeria

Received 9 July 2005; accepted 12 September 2005

Abstract

Objectives: The study aimed to estimate the prevalence of major depressive disorder (MDD) among Nigerian college students with alcohol-

related problems (ARP) and compare the estimated prevalence with their counterparts without ARP.

Method: A cross-sectional survey of a representative sample of students (n =2658) in six colleges in Osun state, Western Nigeria. The

students were independently assessed for ARP and MDD with the Mini International Neuropsychiatric Interview (MINI).

Results: The current (2 weeks) prevalence of MDD in college students with alcohol dependence is 23.8%; alcohol abuse 17.2%

and hazardous use 12.4%. Compared with total abstainers, major depressive disorder is significantly more likely to be associated with

diagnosis of alcohol dependence (OR 3.14, 95% CI 1.42–6.96), alcohol abuse (OR 2.27, 95% CI 1.38–3.72) and hazardous use (OR 1.64,

95% CI 1.12–2.38), but less associated with alcohol users without ARP (OR 0.93, 95% CI 0.69–1.25).

Conclusion: Nigerian college students with ARP are significantly more at risk of depressive disorders than those without ARP. Early

recognition and treatment of depression are important considerations when planning preventive strategies for alcohol-related problems in

college students.

D 2006 Elsevier Inc. All rights reserved.

Keywords: Depression; Prevalence; Alcohol dependence; Alcohol abuse

1. Introduction

Alcoholism and depressive disorders are intimately

associated. Studies have shown that the rate of depression

is increased in adolescents and young adults with alcohol-use

disorders (AUD) in the general population [1–4] and among

college students [5,6]. In Western countries, approximately

30% to 40% of alcoholics experience a comorbid depressive

disorder [7,8].

Alcohol use earlier in life has been noted to significantly

predict later major depressive disorder (MDD) [9]. Prior

alcohol dependence has been reported to increase the risk of

current depressive disorder by four times [10]. Comorbid

MDD has been associated with early relapse to alcohol

among adolescents with AUDs [11]. Alcohol dependence is a

potent risk factor for suicide, with MDD being a key

precipitating factor [12].

0163-8343/$ – see front matter D 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.genhosppsych.2005.09.002

T Tel.: +234 8055617605.

E-mail address: biodunwuya@yahoo.com.

Most of these studies have concentrated on formal AUDs

(alcohol dependence and alcohol abuse), but most alcohol-

related problems appear in non-alcohol-dependent individu-

als who fall into categories of hazardous drinkers according

to the WHO terminology [13]. Studies have shown that

drinking above the WHO recommendations [14,15] raises

the risk of alcohol-related physical and psychosocial prob-

lems. Anxiety and mood disorders have been found to

correlate highly with heavy alcohol use at threshold and

subthreshold levels [1,16].

A review of the studies on alcohol use in Nigeria shows

that there has been a rapid increase in alcohol availability and

consumption in recent times in universities and colleges

mainly concerning young adults [17]. Colleges are a critical

context for studying youthmental health [6]. College students

are often undergoing role transitions— such as moving away

from the family home for the first time, residing with other

students and experiencing reduced adult supervision— these

changes may increase the risk of alcohol use and depression

[18]. Transition to college may be particularly difficult in

Nigeria where living and academic conditions in the colleges

A.O. Adewuya / General Hospital Psychiatry 28 (2006) 169–173170

are poor. Nigerian students are constantly faced with

problems of accommodation, overcrowded lecture halls,

unavailable learning materials, repeated disruptions of

academic calendar and poverty.

A search of the literature, both electronic and manual,

revealed a dearth of literature on the relationship between

AUDs and depression in Nigeria [19–22]. Although some

studies have reported on the prevalence and correlates of

alcohol use in Nigerian colleges [20–22], they have not

examined the relationship between alcohol and depression.

The aim of this study was to estimate the prevalence of

MDD among Nigerian college students with alcohol-related

problems and compare it with their counterparts without

alcohol-related problems.

2. Materials and methods

2.1. Study population

The study group consisted of students from six colleges in

Osun state in western Nigeria, including one university, three

polytechnic colleges and two colleges of education. The

combined population of students in the six colleges is about

100,000. The students are from various ethnic and religious

groups in the country. All colleges have residence halls that

can accommodate about 50% of their student population.

2.2. Sampling technique and sample size

The students were approached through their halls of

residence. A multi-staged sampling technique was adopted.

In the first phase, the blocks of flats in each of the halls of

residence in each college were mapped out. After that, even

numbered rooms in each flat were subsequently selected. In

the third stage, two students were selected at random from

each of the even-numbered rooms for the interview. There

were a total of 58 halls, 332 blocks and 3102 rooms. This

sampling scheme produced a sample with approximately

equal probability of selection of each member. A final

sample of 3102 was therefore obtained. Out of this number,

444 refused to participate, leaving a sample size of 2658

(86% response rate). The average age of the participants was

23.72 years (S.D.=6.54) with a range of 15 to 44 years.

There were 1913 (72.0%) males. There were 1680 (63.2%)

participants from the Yoruba ethnic group, 520 (19.5%) from

the Igbo ethnic group, 302 (11.4%) from the Hausa ethnic

group and the rest, 156 (5.9%), consisted of other ethnic

groups and foreigners.

2.3. Procedure

The Ethics and Research Committee of the Obafemi

Awolowo University Teaching Hospital Complex approved

the study protocol, and informed consents were obtained

from the participants after the aims and objectives of the

study had been explained.

Research assistants (consisting of medical students in

psychiatry posting) who had received a 2-week training

session in the use of AUDs and depression modules of the

Mini International Neuropsychiatric Interview (MINI) [23]

from a qualified psychiatrist conducted the interviews. The

participants first completed socio-demographic question-

naires. A first set of research assistants (n=10) explained the

size of a standard drink to the participants. A standard drink

was defined as equivalent volumes containing an average of

13.5 g ethanol. The research assistants then used the MINI

[23] to assess all participants who had used alcohol in the

past 12 months for DSM-IV diagnosis of alcohol dependence

and alcohol abuse. The MINI [23] was designed as a brief

structured interview for the major Axis I psychiatric

disorders in DSM-IV [24] and ICD-10 [25]. Validation and

reliability studies have been done for MINI with the results

showing that the MINI has acceptably high validation and

reliability scores. Clinicians can use it, after a brief training

session, but lay interviewers require more extensive training.

Also, all participants whose weekly alcohol consumption

was above the WHO recommendation (280 mg for men and

168 mg for women) [13] were diagnosed as having

hazardous alcohol intake. The mean inter-rater reliability

between the interviewers, measured with Cohen’s k, is 0.87.

Another set of research assistants (n=23) also assessed all

the participants for DSM-IV current (within 2 weeks)

diagnosis of MDD. The mean inter-rater reliability between

this second set of interviewers by Cohen alpha is 0.91. The

use of separate interviewers to assess MDD was to avoid

investigators’ bias in the relationship between the diagnosis

of MDD and AUD.

The interviews were conducted in English, which is the

official and the most common language in Nigeria, a

multilingual country with over 200 languages and dialects.

Since the MINI is structured in a simple, lay language that is

easy to understand and the participants were students in

tertiary institutions, no problem was encountered in

administering the instrument.

2.4. Data analysis

The Statistical Package for the Social Sciences 11 program

was used for statistical analysis. Pearson’s v2 was used in

calculating the differences between groups. All tests

were two-tailed, and the level of significance was set at Pb  

.05. Odds ratio (OR) and 95% confidence intervals (95% CI)

were calculated.

3. Results

3.1. Prevalence of alcohol use and alcohol-related problems

Out of the 2658 participants, 1642 (61.8%) reported using

of alcohol in the past 12 months. This population consists of

1415 men and 227 women, giving a 12-month prevalence for

alcohol use of 53.2% for men and 30.5% for women.

The prevalence of alcohol dependence is 0.8% (male=

1.1%, female=0.13%). The prevalence of alcohol abuse is

3.5% (male=4.4%, female=1.1%), while the preva-

Table 1

The point prevalence of MDD in various categories of college students according to their alcohol-use categories and gender

Categories Male Females Total OR and 95% CI

Total Depressed Total Depressed Total Depressed

Abstainers from alcohol 498 34 (6.8%) 518 43 (8.3%) 1016 77 (7.6%) 1 (reference)

Alcohol users without

alcohol-related problems

1070 69 (6.4%) 176 19 (10.8%) 1246 88 (7.1%) 0.93 (0.69–1.25)

Hazardous alcohol users 240 25 (10.4%) 42 10 (23.8%) 282 35 (12.4%) 1.64 (1.12–2.39)

Alcohol abuse 85 12 (14.1%) 8 4 (50.0%) 93 16 (17.2%) 2.27 (1.38–3.72)

Alcohol dependence 20 4 (20.0%) 1 1 (100.0%) 21 5 (23.8%) 3.14 (1.42–6.96)

Total 1913 144 (7.5%) 745 77 (10.3%) 2658 221 (8.3%)

A.O. Adewuya / General Hospital Psychiatry 28 (2006) 169–173 171

lence of hazardous alcohol use is 10.6% (male=12.5%,

female=5.6%). The prevalence of all alcohol-related prob-

lems is 14.9% (male=18.0% and female=6.8%).

3.2. Prevalence of depression

A total of 221 (8.3%) participants were identified as

bcasesQ of MDD by the MINI. Table 1 shows the prevalence

of depression in various categories of participants according

to gender. There is a statistically significant difference

(v2=20.725, df=1, Pb.001) in the prevalence of depression

between participants without alcohol-related problems

(7.3%, n=2262) and participants with alcohol-related prob-

lems (14.1%, n=396). However, there is no statistically

significant difference (v2=3.030, df=2, P=.220) in the

prevalence of depression among hazardous alcohol users

(12.4%, n=282), alcohol abusers (17.2%, n=93) and those

dependent on alcohol (23.8%, n=21).

Comparing males and females, there is no statistically

significant gender difference in the prevalence of depression

among those diagnosed as abstainers from alcohol

(v2=0.787, df =1, P = .375) and alcohol dependent

(v2=3.360, df=1, P=.067). However, a statistically signif-

icant gender difference in the prevalence of depression is

present in alcohol users without alcohol-related problems

(v2=4.351, df =1, P= .037), hazardous alcohol users

(v2=5.898, df=1, P=.015) and alcohol abusers (v2=6.609,

df=1, P=.010).

4. Discussion

This study is the first to estimate the prevalence of

depression in college students with alcohol-related problems

in Nigeria. The 17.2% and 23.8% prevalence of depression

in college students with alcohol abuse and alcohol

dependence, respectively, found in this study is comparable

to depression rates of 11.3% for alcohol abuse and 27.9 %

for alcohol dependence found in the United States [1].

The study clearly showed that depression was more

prevalent in college students with alcohol-related problems

than in abstainers from alcohol or moderate drinkers with-

out alcohol-related problems. Although there was no

significant difference between the prevalence of depression

among abstainers from alcohol and alcohol users without

alcohol-related problems, the difference between the prev-

alence of depression in those with hazardous alcohol use and

alcohol users without alcohol-related problem was quite

significant. This stresses the importance of including

hazardous users of alcohol in future studies of alcohol-

related morbidity.

College students with alcohol abuse or hazardous alcohol

use and students with alcohol dependence were, respective-

ly, two and three times more likely to be diagnosed with

depressive disorder than abstainers or those without alcohol-

related problems.

The prevalence of depression was slightly higher in

females for all the categories, and this reflects the higher

prevalence of depression in females in the general commu-

nity. It should be noted that, although there was no significant

gender difference in the prevalence of depression in the

abstinence group, the difference became statistically signif-

icant with the alcohol users (with or without alcohol-related

problems). This could suggest that women are more liable to

the depressive effects of alcohol.

The precise cause-and-effect relationship between de-

pression and alcoholism is still controversial. Depressive

episodes may predate the onset of alcoholism, especially in

women [1,26,27]. A larger percentage of alcoholics

experiencing a major depressive episode, especially men,

meet the criteria for an alcohol-induced mood disorder with

depressive features [28], and the remaining others likely to

have an independent MDD.

The prevalence of alcohol abuse (3.5%) and alcohol

dependence (0.8%) from this study is much lesser than

7–21% and 6–9%, respectively, from Western studies

involving college students [29,30]. Because of the multi-

centered nature of the present study, the findings could be

generalized to Nigeria and other regions of Africa.

Unfortunately, the absence of other studies in Nigeria

regarding students’ alcohol-related problems and depression

made comparison difficult. This study, however, seemed to

substantiate earlier findings regarding dramatic increases in

the rates of alcohol consumption among young adults in

colleges in Nigeria.

It is to be noted that the cultural views of AUDs are

influenced by prevailing norms in the society. Even though

some similarities exist with respect to the definition of

problematic use of alcohol in ethnically diverse societies,

very substantial differences also exist. A number of core

concepts underpinning diagnosis of disorders relating to the

use of alcohol have no equivalent in the local languages of

A.O. Adewuya / General Hospital Psychiatry 28 (2006) 169–173172

various cultures, while others lacked cultural applicability

because of their relative bdistanceQ from cultural and ethnic

norms of drinking [31]. Also, in Nigeria where approximately

50% of the population are Muslims, a religion that prohibits

the use of alcohol, the prevalence of AUD is expected to be

lesser than in the Western world.

There are some limitations to this study. The study group

consisted of college students living in halls of residence

alone, and those living elsewhere had no chance of being

sampled. Another limitation is that separate sets of inter-

viewers assessed both AUDs and depression in this study.

Typical psychiatric interviews are completed by a single

individual who uses clinical judgment, observation of

patients and an understanding of the complete picture of the

patient to reach a final diagnostic conclusion. Also, the use of

two separate sets of interviewers would make it harder to

determine whether a co-occurring depressive disorder was

independent or an alcohol-induced mood disorder. The

probability therefore exists that alcohol-induced mood

disorders account for some of the prevalence of MDD in

students with AUDs.

The study had related depressive disorders to categories

of alcohol users instead of using a continuous measure of

alcohol consumption. However, the various measures such

as the Alcohol Use Disorders Identification Test have not

been validated in Nigeria. Whereas a 12-month diagnosis of

alcohol-related problems was assessed, the current (2 weeks)

prevalent of MDD was examined. This might result in

missing some depressed subjects who may not be symp-

tomatic in the 2 weeks prior to the interview. The study

was also cross-sectional in nature, making temporal associa-

tions difficult.

The strength of the study, however, lies in it being the

first in Nigeria to examine the relationship between

depressive disorders and alcohol-related problems with

particular inclusion of the group of hazardous alcohol, its

large sample size and its multi-centered nature.

It is noteworthy that out of the six colleges, only one (the

university) has a standard health center run by doctors and an

effective referral system. The others were being run by

nurses and other paramedical staff. Mental health-related

services are virtually unavailable on the campuses. There are

two hospital units offering mental health services in the state

(both run by the university teaching hospital). As part of this

study, the symptomatic students were referred for further

treatment at the mental health units, and the staffs of the

health centers were counseled on the recognition and prompt

referral of the students in need of mental health-related

services, especially MDD and AUD.

In conclusion, Nigerian college students with alcohol-

related problems are significantly more at risk of depressive

disorders than those without alcohol-related problems.

Studies of comorbid depressive disorders and alcohol should

include hazardous use of alcohol. Early recognition and

treatment of depression are important considerations when

planning preventive strategies for alcohol-related problems

in college students. Mental health-related services are

necessary in Nigerian college campuses to help students

with depression and alcohol-related problems.

Acknowledgment

I wish to thank all the medical students in psychiatry

posting who went through the training on use of MINI and

data collection for the study.

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