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: [email protected].
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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