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Addressing Co-Occurring Mood and Alcohol Use Disorders in
College Populations
The Healthy Minds Network Webinar Series Session #6, February 2014
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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
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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
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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
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Standard Drink
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College Student Standard Drink
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Prevalence of Binge Drinking
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Binge Drinking in Adults Aged 18 to 22
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Consequences of High-Risk College Drinking
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Co-occurring Drug Use and Binge Drinking
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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
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Prevalence of Mental Health Problems (Depression:
~17%)
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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
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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
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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)
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Psychological Distress and Alcohol Related Problems
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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
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Critical Components of Tx
Screening
Combined treatment (CBT+MI)
Tailored aspects
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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?”
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AUDIT
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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
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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
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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
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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”
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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)
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Decisional Balance
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MI Techniques
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BASICS
Personalized feedback
Normative feedback
Estimate BAC
Gender specific effect of alcohol
Personalized feedback on alcohol-related problems
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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.
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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.
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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.
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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.
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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
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Cognitive Triad
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CBT Techniques
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Thought Record
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TAY Problem List
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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?
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Special Considerations
Negative consequences may not be severe yet
Less committed to therapy
College myths
Family involvement
Confidentiality
M-therapy
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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
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Web Resources
Healthy Minds (American Psychiatric Association)
Ulifeline (Duke University Medical Center)
Half of Us
The JED Foundation
Campus Calm
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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
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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?
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More Information
The Healthy Minds Network: www.healthymindsnetwork.org
Depression Clinical Research program: www.massgeneral.org/psychiatry/services/dcrp_home.asp
x
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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.
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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
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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.