depression, alcoholism and ageing: a brief review

EDITORIAL

Depression, Alcoholism and Ageing: A Brief ReviewROLAND ATKINSON

Oregon Health Sciences University, Portland, Oregon, USA

Depression and alcohol use disorders (AUDs)are strongly linked across the lifespan, and thiscomorbid association persists into later life (Grantand Harford, 1995). Alcoholism and suicide alsoare linked in late middle life and old age (Blazer,1982; Canetto, 1992; Conwell et al., 1990; Grabbeet al., 1997; Martin and Streissguth, 1982; Osgoodand Manetta, 1998; Shah and Ganesvaran, 1997).But questions remain about the causal connectionsbetween these disorders. Is depression in later life arisk factor for drinking problems? Does excessiveuse of alcohol contribute to depression in olderdrinkers? What relationship exists between drink-ing and complicated bereavement? These are issuesI want to address, while emphasizing the generalpoint that it is important for geriatric psychiatriststo be aware of the not uncommon association ofheavy drinking and alcohol problems with depres-sion in older patients.

DEFINITIONS

Confusing use of terms tends to complicateany discussion of clinical problems related toalcohol. `Heavy drinking' and `risky drinking' areterms that imply high alcohol consumption inpersons who have only mild or no current alcohol-related problems. De®nitions vary, but tend tomean drinking in excess of 14±20 standard drinks aweek (older men) or 10±14 drinks a week (olderwomen), or drinking more than 4±5 drinks on agiven drinking occasion (sometimes de®ned byAmerican alcohologists as a `binge'). By an alcoholuse disorder (AUD) I mean alcohol depend-ence as de®ned in DSM-IV or ICD-10, alcoholabuse (DSM-IV) or harmful alcohol use(ICD-10). `Problem drinking' is a more inclusivecategory that also counts speci®c or `focal' social,behavioral or health problems caused by excessive

or inappropriate drinking that may not meetcriteria for a formal AUD diagnosis. I will fornarrative ease at times use the term `alcoholism' asa synonym for AUDs and problem drinkinginclusively. Similarly, I will use the terms `majordepression' and `dysthymic disorder' as they arede®ned in DSM-IV, but at times will also referto these depressive disorders, adjustment dis-order with depressed mood and subsyndromaldepressive symptoms collectively as `depression'.Studies based on groups age 60 and older will bedistinguished from those based on mixed-agegroups.

EPIDEMIOLOGY

In 1992 the largest US household survey everconducted on the association of syndromal depres-sion and alcoholism indicated that among personsage 65 and older with lifetime DSM-IV majordepression, 13.3% also met criteria for a lifetimeAUD, while just 4.5% without a history of majordepression had had an AUD (Grant and Harford,1995). The odds ratio for this comorbidity (3.25;95% con®dence limits 2.00, 5.36) was similar tothat found for other age groups. Two single-sitepopulation-based studies also show an associationbetween alcohol consumption and depression inthe elderly. In the Liverpool longitudinal survey ofmental health among community-dwelling elderly,men who had consumed alcohol heavily in the pastwere nearly four times more likely to have a currentdiagnosable depressive disorder than other men(Saunders et al., 1991). A survey of two-thirds ofall persons age 65 and older (N � 826) living in aCanadian town showed an association betweencurrent alcohol consumption and depressionscores on the CES-D scale (Graham and Schmidt,1999).

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INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriat. Psychiatry 14, 905±910 (1999)

Clinical studies of ageing alcoholics in treatmentalso indicate that comorbid a�ective disordersare common. Major depression was diagnosed in8±12% of elderly cohorts (Blow et al., 1992;Finlayson et al., 1988), rates far higher than seenin the general ageing population, for whom lifetimeprevalence of major depression is about 2% (Grantand Harford, 1995). Dysthymic disorder is re-ported in 5±8% of ageing alcoholics in treatment(Blow et al., 1992; Speer and Bates, 1992),compared to perhaps 2% in community surveysof the elderly (Blazer et al., 1987).

PRIMARY VERSUS SECONDARYDEPRESSION IN PERSONS WITH AUDs

These terms refer to the temporal order of incid-ence of the comorbid disorders. That is, if the ®rstepisode of major depression occurred earlier in lifethan the time when the criteria for an AUD were®rst met, depression is said to be primary, but if the®rst episode of depression occurred later than theinitial onset of an AUD, the depression is termedsecondary. Unfortunately, these terms imply causalrelationships that are not proven simply by order ofincidence.

No study has examined the primary±secondarydistinction in ageing alcoholics comorbid for adepressive disorder. A recent large mixed-agepopulation study of alcoholics with comorbidmajor depression demonstrated that the primaryand secondary depression groups were of equival-ent size (41% and 42.5%, respectively, of comorbidrespondents; the remaining 16.5% had concurrentonset of both disorders) and that, no matter whichdisorder occurred ®rst, both the depression and theAUD tended to be more severe than in cases whereone disorder occurred in the absence of the other(Grant et al., 1996; Hanna and Grant, 1997). The®ndings of this study are at odds with a number ofclinical studies of alcoholics in treatment that havefound more secondary depression than primarydepression among mixed-age comorbid cases, mostlikely representing treatment sampling bias (Grantet al., 1996).

DOES DEPRESSION CAUSE ALCOHOLISM?

There is no convincing evidence that depressioncauses alcohol use disorders, but in establishedalcoholics depression often in¯uences drinking

behavior. Data from one recent study of oldernonalcoholics suggest that increased drinking inresponse to depressive symptoms can lead to sub-syndromal alcohol-related problems. Early onsetalcoholism is well known to be familial in mostcases, and the heavier the family `saturation' ofalcoholics, the earlier and more virulent thedrinking problems. In the 1992 US mixed-agepopulation survey conducted by Grant and herassociates, there was signi®cantly more familyalcoholism in persons with comorbid alcoholdependence and major depression (whetherdepression was primary, secondary or concurrentin onset) than among those with alcohol depen-dence alone, with family alcoholism rates beinglowest in persons with major depression alone(Dawson and Grant, 1998). This ®nding (morealcoholic relatives in comorbid cases than in casesof alcohol dependence alone) is at odds withmuch of the earlier literature that showed equiv-alent rates of family alcoholism in comorbid andnon-comorbid alcoholics (see discussion in Grantet al., 1996). Family alcoholism, not depression,seems to be the major determinant of alcoholdependence, evenÐindeed, especiallyÐin co-morbid cases.

With regard to late onset alcoholism (late de®nedas incident cases occurring in late middle life orbeyond age 60), family alcoholism is far lesscommon (Atkinson et al., 1990). A popular notionfor years was that such cases were likely to besecondary to depression or organic mental dis-orders. But recent cross-sectional clinical studiestend to refute that belief (Atkinson, 1994). Self-reported depression scores in newly admitted lateonset ageing alcoholics are typically lower (Atkin-son et al., 1990; Schonfeld and Dupree, 1991), or atleast no higher (Finlayson et al., 1988), than intheir early onset counterparts. Among factors thatmight engender late onset problem drinking are anearlier pattern of heavy alcohol consumption,greater approval of drinking by one's friends,more reliance on avoidance to cope with problems,and a history of responding to stressors andnegative a�ects with increased alcohol consump-tion (Schutte et al., 1998).

Is it likely that (primary) depressed personsmight use alcohol to assuage depressive symptomsand thereby engender (secondary) alcoholism?Vaillant (1993) has reviewed this issue recentlyand rejected the `self-medication' hypothesis as anexplanation for secondary alcoholism. A di�erentbut pertinent question is whether, among already

Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 905±910 (1999)

906 EDITORIAL

established alcoholics, depression might in¯uencedrinking behavior. Clinical follow-up studiesof mixed-age groups of treated alcoholics havedemonstrated highly variable e�ects of lifetimecomorbid depression on drinking outcomes andrelapse. Drinking outcomes in comorbid patientswere worse than in non-comorbid patients in somestudies (Hesselbrock, 1991; Rounsaville et al.,1987); better in others (Kranzler et al., 1996;Schuckit and Winokur, 1972); or una�ected instill others (Miller et al., 1996, 1997; Sellman andJoyce, 1996). Apart from methodological problemsin comparing these studies, lifetime depression mayinclude many cases in which the last depressiveepisode occurred years before recent alcoholtreatment. Recently, three case series have beenreported in which currently depressed mixed-agealcoholics in treatment were given antidepressantmedication (desipramine, imipramine and ¯uox-etine, respectively) and followed for 3±12 months.Not only did antidepressant treatment amelioratedepression in these studies, but alcohol consump-tion was also signi®cantly reduced (reviewed inLitten and Allen, 1998). The design in two of thestudies made it possible to demonstrate that, whilethe antidepressant drug may have exerted somedirect e�ect on drinking, most of its bene®t seemedrelated to the reduction of depression. (There is noconsistent evidence that drinking behavior in non-depressed alcoholics is a�ected by antidepressantdrugs.)

A variation on the `self-medication' theme hasbeen examined in one study of ageing alcoholics,using a cognitive-behavioral analysis (Dupree andSchonfeld, 1998). A group of 214 older alcoholicoutpatients (mean age 64 years) were assessed.About half had onset of alcohol problems after age50. Initial Beck Depression Inventory scoresaveraged 12.2, and 56% had scores of 10 or higher,suggesting at least mild clinical depression. Askedto endorse items about emotions they experiencedprior to the ®rst drink on a `typical' drinking day,51% reported feeling depressed, lonely, sad, boredor withdrawn prior to taking the ®rst drink.Similarly, when asked about how they felt afterthe ®rst drink, only 8% reported such feelings. Incontrast, while only 21% reported positive feelingsbefore the ®rst drink, 71% reported positivefeelings after the ®rst drink. In this more `micro-scopic' assessment of events, it would appear thatself-medication with alcohol for depressed feelingscan indeed occur in older alcoholics, providingdramatic, if very temporary, relief that is highly

reinforcing. This illustrates the manner in whichdepression, while perhaps not causing alcoholism,may be a highly signi®cant factor in sustainingproblem drinking or inducing relapse in ageingalcoholics.

Most recently, Schutte et al. (1998) have reportedon a cohort (N � 274) of community-dwellingolder adults who had never had alcohol problemsin the past or at baseline (age 55±65) and who werethen followed for 7 years (to age 62±72). Signi®-cantly more of those persons who subsequentlydeveloped new alcohol-related problems (N � 77)reported at baseline that, before the age of 50, theyhad tended to increase their alcohol consumptionin response to negative a�ects or stress, comparedto the group (N � 197) that did not developnew alcohol-related problems. Given a particular`reactive' pattern of alcohol use, it is possible forsome older drinkers to cross the line from non-problem drinking to at least subsyndromal alcohol-related problems.

DOES ALCOHOLISM CAUSE DEPRESSION?

Drinking bouts induce depressive symptoms inmany primary alcoholics. These symptoms, whichmay be subsyndromal or meet criteria for majordepression, spontaneously remit with abstinenceover a few weeks' time in the majority of cases with-out antidepressant treatment. Whether longlastingdepressive syndromes are caused by alcoholism isnot clear from available studies, but a plausiblecase can be made that heavy drinking is likely toaggravate existing depressive disorders.

Depressive symptoms are highly prevalentamong recently drinking mixed-age primary alco-holics when they enter alcoholism treatment, but inmost instances these symptoms resolve spon-taneously within 2±4 weeks (Brown and Schuckit,1988; Brown et al., 1995). For example, in one studyof 177 newly admitted male alcoholics (agerange 22±74 years, mean age 46+11 years), 42%had clinically signi®cant levels of depression asmeasured by a score of 520 on the HamiltonDepression Rating Scale, but only 12% still scoredthis high after 2 weeks and only 6% after 4 weeksduring alcoholism treatment that did not includeantidepressant drugs (Brown and Schuckit, 1988).In a study of 135 newly enrolled outpatients in aspecial treatment program for older alcoholics (agerange 55±79, mean age 62), my colleagues, J. A.Turner and R. L. Tolson, and I found that 54%


EDITORIAL 907

initially had elevated depression scale scores on theMMPI (T score5 70), even though an attempt hadbeen made not to enroll persons with clinicalevidence of current major depression (unpublisheddata, 1990). But among a comparable group of50 older outpatients (age range 60±79, mean age 65)untreated with antidepressants and clinicallyreassessed 1±6 months after their last drink, only20% showed clinical evidence of current depression(Atkinson and Tolson, 1992). Symptoms ofalcohol-induced depression are similar to independ-ent or primary depression (Schuckit et al., 1997),complicating accurate diagnosis. The high preva-lence and rapid resolution of depressive symptomsin many recently drinking alcoholics suggest thatdepression is caused by alcohol e�ects (Nakamuraet al., 1983; Schuckit et al., 1997), alcohol with-drawal e�ects (Brown and Schuckit, 1988; Littenand Allen, 1998; Schuckit et al., 1997) and/orassociated drug use (Schuckit, 1983; Schuckit et al.,1997). Taken together, the ®ndings suggest that inmixed-age groups, an òrganic' depressive mooddisorder is engendered by excessive alcohol use,alcohol withdrawal and/or associated substanceuse.

What distinguishes the cases in which depressioncontinues beyond the ®rst few weeks of sobriety?Among factors that have been shown to predictpersistent depression in recently detoxi®ed mixed-age alcoholics are decreased social support (Brownand Schuckit, 1988; Nakamura et al., 1983; Overallet al., 1985) and recent major life problems, bothalcohol-related and independent (Schuckit, 1983;Roy, 1996). The proximate direct cause of persist-ent secondary depression in recently drinkingalcoholics may thus be psychosocial stressors onlyindirectly or in part in¯uenced by drinking.Vulnerability to depression is another factorpredicting persistent depression in recently detox-i®ed mixed-age alcoholics, including prior historyof a depressive disorder (Brown et al., 1995) orsuicide attempts (Roy, 1996) and family history ofdepression and/or suicidal behavior (Roy, 1996).Given the evidence for direct (òrganic'-induced)and indirect (psychosocial stressors related toalcoholism) e�ects of drinking on depression, it ishighly plausible to argue that in already depressedindividuals alcohol use can aggravate or intensifytheir depression. It is even arguable that sub-syndromal depression might be aggravated bydrinking to the point of meeting criteria for adepressive disorder.

BEREAVEMENT, ADJUSTMENTDISORDERS AND ALCOHOL EFFECTS

Major depression associated with bereavementmight o�er one example where alcohol use canescalate depressive symptoms to syndromalproportions in older persons. Late life adjustmentdisorders with depressed mood could be another.Elsewhere I have described a case in which alcohole�ects complicated preexisting depression (Atkin-son, 1998). A likely sequence of events mightproceed along these lines: a life event (loss of lovedone, housing change, ®nancial or health problem)produces depressed feelings in an older person. Forwhatever reasons (patient might have been alifelong heavy drinker or former alcoholic, or bein¯uenced by a drinking partner), this individualdrinks to assuage such feelings and ®nds immediaterelief. But the reinforcing e�ects of this self-medication with alcohol lead to increased alcoholuse, which, in turn, may produce further, morelonglasting depressive symptoms both directly(òrganic'-induced symptoms) and indirectly(through alcohol-related psychosocial stressors,such as rejection by friends because of drinking).A spiralling of a `depression . . . drink . . . depres-sion . . . drink . . . depression . . .' sequence mightfollow, leading in time to a major depression. Ofinterest in this regard is the large study of majordepression associated with widowhood (N � 276,mean age 62 years) conducted by Zisook andShuchter (1993), in which the best predictors ofpersistent major depression 25 months after deathof a spouse were ®ndings of major depression at7 months following the loss, family history ofdepression and the number of (alcohol) drinkingdays per month at 2 months. Also consistent withthis model are the ®ndings of Cook et al. (1991)that in a cohort of 58 older (age 55±84) maleinpatients with unipolar depression, those with ahistory of alcoholism had symptoms of a more`neurotic-reactive' depressive pattern, while thenon-alcoholics had a more èndogenous' symptompattern.

TREATMENT ISSUES

While not ®rmly grounded in evidence-basedreports, several issues should be considered whenplanning treatment of depressed alcoholics. Earlytreatment with antidepressant agents (before theend of the third week of sobriety) raises the


908 EDITORIAL

possibility that subsequent improvement in moodwill, more often than not, be falsely attributed todrug therapy, because improvement would haveoccurred spontaneously. Unnecessary prescribingof antidepressants has several potentially unfavor-able consequences, eg unjusti®ed prescribing of acostly and hazardous agent over the longer term,prescribing to persons known to use substancesunreliably, and entrenching a questionable diag-nosis of an independent depressive disorder. On theother hand, depression undoubtedly should betreated early when the history suggests an inde-pendent disorder, eg history of prior depressiveepisodes during abstinent periods, strong familyhistory of depression, or when there is no sign ofeven slight spontaneous improvement in the ®rst7±14 days, or when there is strong suicidal intentthat persists after the ®rst few days (Corneliuset al., 1995). No one would disagree that syndromaldepression, when it persists beyond 3±4 weeks'sobriety in primary alcoholics, constitutes a true`dual diagnosis' that requires antidepressant treat-ment (Brown et al., 1995).

CONCLUDING REMARKS

Heavy drinking and problem drinking are commonin people age 60±75 years in western heavy-drinking societies, especially men (Atkinson,1990). For those who currently or in the pasthave used alcohol in an excessive or problematicmanner, renewed or increased alcohol use in laterlife, to ameliorate temporarily feelings of depres-sion, demoralization, grief and loneliness, can overtime intensify depression and result in a more severealcohol problem. Further studies are warranted inolder persons to better delineate the relationshipsamong depression, alcohol consumption and alco-hol use disorders. Geriatric psychiatrists shouldalways be curious about the role alcohol usecurrently plays in the lives of their depressedpatients.

ACKNOWLEDGEMENTS

Conversations with Larry W. Dupree and Ira R.Katz helped shape several of my perspectives aboutthe relationship between depression and drinkingproblems in older people.

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910 EDITORIAL

depression, alcoholism and ageing: a brief review

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