Article, Psychiatry

Alcohol misuse and report of recent depressive symptoms among ED patients

Original Contribution

Alcohol misuse and report of recent depressive symptoms among ED patients B

Shahrzad Bazargan-Hejazi PhDa,b,?, Mohsen Bazargan PhDa,c,

Tommie Gaines MSd, Michael Jemanez MDe

aDepartment of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095, USA

bDavid Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA

cResearch Centers in Minority Institutions, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095, USA

dDepartment of Biostatistics, University of California, Los Angeles, Los Angeles, CA 90095, USA

eSchool of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095. USA

Received 1 July 2007; revised 16 August 2007; accepted 18 August 2007


Objective: This study examined the magnitude of association between alcohol misuse and recent depressive symptoms.

Methods: We conducted a cross-sectional study of 412 randomly selected patients at least 18 years old and seeking emergency department (ED) care.

Results: Of the patients, 51.0% reported depressive symptoms. At-risk drinking was reported by 26.0%, and 28.2% scored positive on the Rapid Alcohol Problems Screen 4. Alcohol abuse and binge drinking were reported by 25.1% and 28%, respectively, of the patients. According to our results, at-risk drinking (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.47-4.20, P <= .001), problem drinking (OR = 2.11, 95% CI = 1.27-3.51, P <= .004), drinking abuse (OR = 2.58, 95% CI = 1.51-4.40, P b .001), and

binge drinking (OR = 1.89, 95% CI = 1.13-3.15, P b .001) were all related to the manifestation of depressive symptoms.

Conclusions: The findings of this study yield information that could be used by ED health care practitioners and health educators to educate ED patients at risk for alcohol misuse and depression.

(C) 2008


? Data collection was funded by the National Institute on Alcohol Abuse and Alcoholism (U24AA11899-5). Analysis and manuscript development were supported by the Agency for Health Care Research and Quality (1RZ4-HS014022-01A1), National Center for Research Resources (G12-RR03026), and the National Center on Minority Health and Disparities (P20MD000148).

* Corresponding author. Department of Psychiatry, Charles R. Drew

University of Medicine and Science, Los Angeles, CA 90059.

E-mail address: [email protected] (S. Bazargan-Hejazi).

It is well documented that depression is a risk factor for a number of physical, functional, and social impair- ments [1]. However, some evidence suggest that depressed patients may not meet the diagnostic criteria for depression and instead present vague somatic complaints [2] that preclude clinical assessment or self- assessment of mental health illness. These subsyndromal depressive symptoms nonetheless could lead to serious distress [3].

0735-6757/$ – see front matter (C) 2008 doi:10.1016/j.ajem.2007.08.019

Although alcohol use is common in the United States, there are many forms of excessive drinking that lead to significant medical and mental health problems; these include high-level drinking each day, repeated episodes of drinking to intoxication (binge drinking), drinking that results in physical or mental harm (alcohol abuse), and drinking that results in chemical dependence on alcohol (alcohol dependence) [4].

Longitudinal studies have been inconclusive in identify- ing alcohol as a risk factor for depression [5]. Some studies documented an elevated frequency of Depressive disorders in alcohol-dependent clinical and community populations [1,6,7], young adults with hazardous and harmful consump- tion [8], and elderly populations with heavy drinking and binge drinking. Even among former alcohol users, specific associations between prior alcohol dependence and current or recent major depression exist [9].

Studies have documented the relationship between depressive symptoms and level of alcohol use [10-13]. Graham et al suggested that lack of consistency in the relationship between alcohol consumption and depression could in part be related to the way these variables are measured. For example, depression has been measured as recent depressive symptoms with the use of the Center for Epidemiological Studies Depression Scale (CES-D) [10] or as Psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental disorders, Third Edition (DSM-III) criteria, such as those used in the Diagnostic Interview Schedule [14]. Studies using the impact of these measures on alcohol have shown various findings [11,15]. Similarly, studies that measured alcohol consumption as volume of consumption [12,13], frequency of drinking [16], and quantity per occasion [14,17] have shown varying results. Studies of emergency department (ED) populations have been especially important in discerning the relation- ship between the level of alcohol use and recent depressive symptoms given the high prevalence of alcohol use among ED patients [18,19] and the lack of access to primary care to receive necessary treatment [20]. In fact, primary care providers are often the sole contacts for more than 50% of patients with Mental illness. Furthermore, numerous studies point to significant episodes of underrecognized and untreated depression in

African American and Hispanic communities [21-23].

The overall goal of this study was to find out if the association between alcohol misuse and recent symptoms of depression is sensitive to the level of alcohol consumption. The specific aim of this study was to examine the association between 4 levels of alcohol misuse (ie, at-risk drinking, problem drinking, alcohol abuse, and binge drinking) and recent depressive symptoms as measured by the CES-D among a random sample of ED patients receiving care from an inner-city hospital. The study null hypothesis was that there is no statistically significant association between levels of alcohol misuse and recent symptoms of depression.

Materials and methods


Data for this study were collected continuously for 24 hours per day over 35 days between March and April 2001 in an inner-city ED (King/Drew Medical Center Emergency Department [KDMC-ED]). This hospital is the primary provider of health care services for the 1.7 million residents in South Central Los Angeles, with an annual census of 50000 to 60000 ED visits. South Central Los Angeles is one of the most heavily populated and ethnically, socially, and economically diverse counties in the United States. The community serviced by the KDMC-ED is predominantly Latino (60.0%) and African American (23%). Approximately 32.0% of the residents live below the federal poverty level, and 36% of adults are uninsured.

Selection of participants

Patients were considered to be eligible for the study if they were aged 18 years or older and were in the KDMC-ED to receive medical care. Patients were considered to be ineligible for the study if they showed any sign of cognitive impairment, spoke a language other than English or Spanish, and were in police custody. Patients who required immediate medical attention as determined by the attending physician were approached and asked to participate in the study after their treatment. Interviewers delayed their work with sampled patients who showed signs of intoxication. Patients who gave written informed consent to participate were included. Hispanic respondents were given a choice of being interviewed in English or in Spanish. The KDMC-ED’s computerized logs were used to select the study sample. These logs reflected consecutive patients who arrived and registered in the ED triage area. The list was continuously generated and updated. Every other consecutive patient was selected as a potential candidate. Every other consecutive patient was selected to avoid overload of potential candidates on study staff. A total of 412 eligible patients provided informed consent and completed the 45-minute face-to-face study survey. This study received full review and approval by the institutional review board of our institution.

Study measures

The main outcome variable for this study was “recent depressive symptoms,” which was measured using the CES- D [10], providing an estimate of depressive symptom prevalence over the last 7 days, such as frequency of experiencing Loss of appetite, feeling happy or depressed, lack of energy, and having crying spells. Numerous studies found the scale to be valid and reliable (? = .80) for this purpose [24]. The final score was constructed from a list of 20 items scored from 0 to 3 based on the frequency of a

symptom’s occurrence (0 = rarely,3 = most of the time), with the possible range of 0 to 60. The responses for all items were summed. Respondents with an overall sum score of 15 or lower were classified as “not having depressive symptoms” (coded as 0) and were set as the reference group, whereas respondents whose overall sum score was 16 or higher were classified as “having symptoms of depression” (coded as 1).

Alcohol measures

Five validated and widely used measures of alcohol consumption were used to depict a continuum of alcohol misuse in the last 12 months.

At-risk drinking was measured by the Alcohol use disorders Identification Test (AUDIT), which is a 10-item index with validated psychometric properties [25]. Items are scored from 0 to 4, with the composite index ranging from 0 to 40. A cutoff point of 8 is set to reflect at-risk drinking.

The Rapid Alcohol Problems Screen 4 (RAPS4) [26,27] is a screening test that measures problem drinking using 4 items scored as 0 (no) or 1 (yes). A positive score on any of the questions reflected being positive for problem drinking. Alcohol abuse symptoms were measured by 6 items reflecting significant negative physical, social, legal, and psychosocial consequences of drinking [28]. These items operationalized DSM-IV criteria for alcohol abuse [27] and

included the following:

  1. Have you continued to drink although you knew it was causing trouble with your family or friends?
  2. Did you drive a car, a motorcycle, a truck, a boat, or other vehicles after having too much to drink?
  3. Did you get into a situation while drinking or after drinking that increased your chances of getting hurt, such as swimming, using machinery, and walking in a dangerous area or around heavy traffic?
  4. Did you get arrested or held at a police station because of your drinking?
  5. Did you get drunk or have a hangover when you were supposed to be doing something important such as being at work, being in school, and taking care of your home or family?
  6. Did you get drunk or have a hangover when you were actually doing something important such as being at work, being in school, and taking care of your home or family?

Each item was scored as 0 or 1. A positive score on one or more of the items reflected being positive for alcohol abuse. Binge drinking was measured by asking respondents to report the number of standard drinks they usually take at one time/occasion. Those who reported consuming 5 or more drinks at one time during the last 12 months were classified as binge drinkers (coded as 1), with the reference group including those who reported consuming 4 or fewer drinks at

one time during the same period (coded as 0).

Sociodemographic measures

The demographic variables used in this study were as follows (with the category specified as the comparison group shown in italics): sex (female vs male), age (coded as 3 categories: 18-35, 36-55, >=56 years), education (lower than high school vs high school or higher), marital status (married or living with someone vs single, separated, divorced, or widowed), and employment (employed full time/employed part time/self-employed vs unemployed). Ethnicity was categorized as African American vs Latino. Patients who identified themselves as white, Asian, Middle Eastern, or Native American Indian and refused to answer this question were excluded from the analysis.

Primary data analysis

Descriptive statistics were generated for the demographic and main variables in the study. Bivariate associations between each of the 4 alcohol measures were calculated with the use of the ? coefficient. This statistic can be interpreted as a correlation coefficient for variables in a 2 x 2 table in which values near 0 indicate little association and those near 1 indicate perfect predictability. To assess the impact of each alcohol measure on depressive symptoms, we performed Pearson’s ?2 tests. These analyses establish whether the independent variables are related to the main outcome. A series of multiple logistic regression analyses were conducted to predict the relationship between depres- sive symptoms and alcohol predictors controlling for socio- demographic characteristics. A variable was retained in the model as a confounder if it altered the odds ratio (OR) of one or more variables in the model by 10% or greater [29] or remained to be a significant independent risk factor at the 0.10 level upon entry into the model. All analyses were performed using SPSS version 12.0 (2004, SPSS, Chicago, Ill). A P value <=.05 was considered to be statistically significant.


From a sample of 579 eligible patients, 412 consented to be interviewed, representing a 71% completion rate. Among the eligible patients, the primary reason for nonresponse was refusal (n = 133, 23%) resulting from discomfort, hearing difficulties, and medical condition interfering with ability to talk. No statistically significant difference was detected in sex, ethnicity, and age between those interviewed and those not interviewed.

Characteristics of study subjects

Table 1 includes the overall characteristics of the sample and the results of bivariate associations between the independent variables and depression. Of the study sample,

Table 1 Overall sample (N = 412) characteristics and their bivariate associations with depression

Variable F % Not depressed (n = 201, CES-D score b16)

Depressed (n = 208, CES-D score >=16)

F % F %









African American







Marital status








Not married






















Age (y)






















Education ?

High school or greater







Lower than high school







Employment status ?















Depression status

Not depressed






At-risk drinking ?






























Alcohol abuse ?















Binge drinking ?















* Statistically significant, P b .05.

58.9% were female and 41.1% were male; most were not married (61.0%). In addition, 53.2% were Latino and 46.8% were African American. Nearly 46% (45.9%) of the participants were between 18 and 35 years old, and 64.0% were unemployed, with nearly half of the sample (49.8%) having greater than a high school education.

A large percentage of the sample reported depressive symptoms (51.0%). Among the alcohol users (n = 364, 88.0%), at-risk drinking was reported by 26.0%, whereas 28.2% scored positive on the RAPS4. Furthermore, alcohol abuse and binge drinking at least once during the past 12 months were reported by 25.1% and 28%, respectively, of the respondents.

Characteristics of study subjects by depression

Results of the ?2 tests (Table 1) revealed that patients with depressive symptoms (CES-D score >=16) were more likely

to be at-risk drinkers based on their AUDIT score (64.9%) and to be problem drinkers based on their RAPS4 scores (61.8%) (P <= .001). Furthermore, patients with depressive symptoms were more likely to report abusing alcohol (65.9%) and binge drinking (47.5%) (P <= .005) (Table 1). Among the Sociodemographic variables, we found statisti- cally significant associations among education, employment, and symptoms of depression. Slightly more than 56% (56.1%) of the patients with lower than a high school education and 55.2% of those with an unemployment status reported symptoms of depression (P <= .05).

Associations among the alcohol measures

The ? coefficient was used to measure the degree of association between each of the alcohol measures as shown in Table 2. The values range from 0.51 to 0.76, indicating an appreciable magnitude of association between each of the



Alcohol abuse

Binge drinking










Alcohol abuse



Binge drinking


alcohol measures. Although these values do not indicate perfect predictability, they do provide moderately strong support that a person identified as meeting criteria for alcohol misuse on one measure will also be meeting the criteria for alcohol misuse on the remaining alcohol measures.

Recent depression and at-risk drinking

Results of the adjusted regression analysis with the AUDIT as the main independent alcohol measure along with other sociodemographic variables in the study are reported in model 1 of Table 3. According to this table, at-risk drinking (OR = 2.49, 95% confidence interval [CI] 1.47-4.20, P <=

.001), being male (OR = 1.86, 95% CI = 1.16-2.97, P <=

.009), having lower than a high school education (OR = 1.72, 95% CI = 1.05-2.82, P <= .031), being unemployed (OR = 0.554, 95% CI = 0.345-0.891, P <= .015), and being younger (OR = 2.34, 95% CI = 1.24-4.88, P <= .023) are all

independent predictors of reporting depressive symptoms.

Recent depression and problem drinking

Model 2 of Table 3 shows results of the regression analysis with the RAPS4 as the main independent alcohol variable along with other sociodemographic variables. These results reveal a statistically significant association between problem drinking and reporting depressive symptoms while controlling for other variables in the model (OR = 2.11, 95% CI = 1.27-3.51, P <= .004). Similar to the previous model, being male (OR = 1.83, 95% CI = 1.14-2.91, P <= .011),

Table 3 Multiple logistic regression models presenting the association between alcohol misuse and self-report of depressive symptoms

Model 1: AUDIT

OR a b

Model 2: RAPS4

OR a, b

Model 3: alcohol abuse

Model 4: binge drinking

95% CI

95% CI

OR a, b

95% CI

OR a, b

95% CI

having lower than a high school education (OR = 1.66, 95% CI = 1.01-2.72, P <= .042), being unemployed (OR = 0.579, 95% CI = 0.362-0.927, P <= .023), and being younger (OR = 2.51, 95% CI = 1.21-5.22, P <= .013) remained to be independent predictors of symptoms of recent depression.

Recent depression and alcohol abuse

Table 2 Distribution of ? coefficients among the 4 alcohol measures

Results for the independent association between alcohol abuse and reporting recent depression are reported in model 3 of Table 3. These results reveal that alcohol abusers are 2.5 times more likely to report symptoms of depression than nonabusers (OR = 2.58, 95% CI = 1.51-4.40, P b .001).

Furthermore, being male (OR = 1.87, 95% CI = 1.17-2.98, P b .009), being unemployed (OR = 0.565, 95% CI = 0.352- 0.907, P b .018), and being younger (OR = 2.31, 95% CI = 1.11-4.82, P b .025) remained to be independent predictors of symptoms of depression.

Recent depression and binge drinking

The last model of Table 3 reveals the association between binge drinking and depression while controlling for other sociodemographic variables. This model also points to a statistically significant association between binge drinking and reporting depressive symptoms. Binge drinkers are nearly 2 times more likely to report symptoms of depression than non-binge drinkers (OR = 1.89, 95% CI = 1.13-3.15, P b .001). Furthermore, being male (OR = 1.83, 95% CI = 1.14-2.94, P b .014), having lower than a high school education (OR = 1.73, 95% CI = 1.06-2.83), being unemployed (OR = 0.563, 95% CI = 0.351-0.900, P b

.017), and being younger (OR = 2.43, 95% CI = 1.17-5.04, P b .014) remained to be independent predictors of symp- toms of depression.


In this study, we tested if different measures of alcohol misuse impact recent depressive symptoms in a similar

Alcohol variable









Age in years































Marital status














NS indicates not significant.

a Odds ratio displayed if statistically significant (P b .05).

b Exponentiated ? value.

manner among a sample of ED patients. Our findings indicate a high prevalence of recent depressive symptoms (51%) in this sample. This rate is twice as high as that of depressive symptoms in adult populations (24%), suggesting that a diagnosis of depressive symptoms in ED patients may present unique challenges for Health care delivery systems, health care providers, and patients.

Across measures of alcohol misuse, the highest preva- lence of alcohol misuse is found for problem drinking based on the RAPS4 (28.6%), with an appreciable association among the 4 measures. In addition, our findings reveal a statistically significant association between alcohol misuse as measured by the 4 Screening tools (ie, RAPS4, AUDIT, DSM-IV-Abuse, binge drinking) and recent symptoms of depression. Furthermore, we observed an overlap between the 95% CIs of the 4 measures (Table 3), suggesting a common magnitude of association between alcohol misuse and recent depression. This was expected because we observed a moderately strong association between all 4 alcohol measures.

In general, our results are consistent with current findings pertaining to the role of alcohol in the presentation of some level of depression, although the data for this study are 6 years old. In a sample of 14063 Canadian residents using 4 types of alcohol measures (frequency, usual and maximum quantity per occasion, volume, and heavy episodic drinking) and 2 types of depression measures (major depression and recent depressed affect), Graham et al [16] revealed that major depression was primarily related to drinking large quantities of alcohol per occasion, less related to drinking volume, and unrelated to drinking frequency. In another study, Blow et al [30] reported that an individual’s at-risk and problem drinking elevated the risk for depressive symptoms. Results of a 14-year longitudinal study revealed that at baseline and at the 14-year follow-up, alcohol consumption was linearly and positively associated with depressive symptoms; prevalence of symptoms increased with greater alcohol consumption [31]. Goldstein and Levitt [32], using a community survey, showed that the prevalence of depression increased significantly across drinking groups (ie, 25% among minimal drinkers to 30% among moderate drinkers to 44% among heavy drinkers). Furthermore, results from the 2005 National Survey on Drug Use and Health pointed to the associations between mental disorders and alcohol use behaviors that do not meet the criteria for Substance use disorders, such as heavy drinking (ie, consuming >=5 drinks on the same occasion) [33].

It is difficult to compare our findings with those in the

literature because we examined a different population and used different measures of alcohol and depression. How- ever, we can conclude that there is statistically significant evidence of an association between alcohol misuse and depressive symptoms and that the magnitude of this association is consistent across our measures of alcohol consumption (ie, RAPS4, AUDIT, DSM-IV-Abuse, and binge drinking).

The results of this study caution ED health professionals not to overlook the evaluation of depressive symptoms among ED patients who experience problems related to alcohol misuse but do not meet the criteria for alcohol dependence. Emergency department care providers should be wary about the mental outcomes of at-risk drinking as much as they should be concerned about problem drinking, binge drinking, and drinking abuse. This is especially important among their patients because they are more likely to be at higher risk for alcohol misuse and depression [34-36] but are unwilling to disclose these problems to their physicians for fear of being stigmatized [37]. For example, African Americans have significantly lower rates of treatment seeking and are less likely than whites to find the use of conventional Antidepressant medication acceptable [38]. Therefore, screening for alcohol misuse in the ED may expose patients to early evaluation, prevention, and treatment of depression, which otherwise may go undetected for these patients [35,39,40]. Shared responsibilities of the ED sector regarding patients’ mental health needs may curtail the disparity gap that exists in depression treatment as a result of lack of access to health care services [41,42].

In this study, we were also able to show the differences between ED patients who reported symptoms of depression and those who did not report such symptoms with respect to age, sex, education, and employment status. Overall, our findings reveal that among this sample of ED patients, those who were male, were younger, had lower than a high school education, and were unemployed were more at risk for symptoms of depression. Previous studies have highlighted female sex, younger age, and low socioeconomic status (eg, unemployment and lower education) to be among other numerous risk factors for depression.

There exist an opportunity and a need for ED health care providers to ensure access to different mental treatment modalities among patients who would benefit. The findings of this study regarding the coexistence of alcohol misuse and depressive symptoms for the ED population will have implications for prevention and treatment for this population. The results of this study may also elucidate some of the inconsistency issues that exist in the literature regarding expression of alcohol misuse on depressive symptoms.

One major limitation of this study is related to the inherent nature of cross-sectional studies: not allowing separation of cause from effect and only allowing discussion of the association between 2 variables, without respect to their direction. In addition, our study has the following limita- tions: self-report bias related to respondent recall and social desirability of responses. This study used standardized measures and intensive training of research assistants to minimize any such bias. In addition, the study instruments included several alcohol-related measures for assessing each subject’s alcohol consumption to guard against acquiescence bias (subject’s tendency to express agreement or disagree- ment toward a statement regardless of its content) [43]. The

reliability of self-reported Alcohol intake is based on evidence for a close correlation between Biological markers and self-report of alcohol intake [44,45].


This study attempted to evaluate the role of various levels of alcohol misuse in depressive symptoms among ED patients with the use of a variety of widely used measures of alcohol intake. We conclude that there is statistically sig- nificant evidence of an association between alcohol misuse and depression and that the magnitude of this association is consistent across all measures of alcohol consumption (ie, RAPS4, AUDIT, DSM-IV-Abuse, and binge drinking). The findings of this study yield information that could be used by ED health care practitioners and health educators to educate ED patients at risk for alcohol misuse and depression, cautioning ED providers that the roles of at-risk drinking, binge problem drinking, and drinking abuse in depressive symptoms should not be underestimated. The focus on minority populations, systematic sampling, collection of data on a 24-hour basis, and high rates of participation are among the other factors that strengthen the results of this study.


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