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What comes first the chicken or the egg?
In alcohol dependence, the question becomes; what comes first, the depression or alcoholism? And, I suppose what needs to be tackled first?
Alcohol through its effect on neurotransmitters and behaviours can cause depression, but surely depression can cause heavy drinking or relapse as a person tries to attempt to escape the dark feelings.
There are dozens of studies now giving positive associations between AA membership and improved drinking outcomes. AA itself addresses the importance of managing mood and feelings in its literature.
In a paper about to be published in the journal Addiction (you can catch it in early view at the moment), Dr Kelly and colleagues take a look at whether AA membership helps with depression.
They used data from the massive Project Match study in the US to test this out, analysing data from over 1700 folk. They assessed depression in this group and compared it to rates in the general population, then they monitored how the study group did in terms of depression over 15 months of follow up.
Next they monitored what the relationship was between depression and AA attendance over time and whether reductions in depression affected AA related reductions in drinking.
Finally they really wanted to know whether AA was associated with reductions in depression over and above what might be expected just from reducing alcohol.
I can tell you that these are quite complex questions and unfortunately need quite complicated statistical tools and methods. This section of the paper is hard going. The authors are also quick to point out that the study has limitations, so caution is required.
The first thing they found was that alcoholic clients were a lot more depressed than the average population. No surprises there.
Then something many studies have found: AA attendance was robustly associated with reductions in alcohol consumption. Going to meetings more frequently was associated with reductions in depression.
However the authors reckon that this improvement was mostly explained because of the AA effect on drinking rather than a primary direct effect on depression. Put simply sorting out the drinking through AA seemed to be fundamental to sorting out the depression.
Although women in the sample were more depressed than men at the start of the study, their depression lifted to the same degree. I thought of the recent DDN article about Women and AA (see the contentious blog discussion here). The women in this sample did very well in AA which is reassuring given the concerns that have been expressed. The authors postulate that women are more sensitive to alcohol’s depressing effect than men. This fits in with the observation that they are more sensitive to its other harmful effects too.
I’ll finish with a paragraph from the discussion section of the paper:
“AA’s association with reduced drinking and reduced depression is encouraging, as AA’s emphases on ‘powerlessness’, ‘surrender’ and ‘character defects’ could be conceived as perpetuating a pessimistic world-view cultivated by subjugation of will. On the contrary, in keeping with AA’s emphasis on reducing negative affect and increasing subjective wellbeing, attending AA appears to relate not only to improved drinking outcomes, but also to improved psychological adjustment. It is possible that AA attendance alleviates depression through the group therapy principles of instilling hope, universality, group cohesiveness and catharsis”.
Now this is interesting, particularly in the light of recent blogs on depression and its links with alcohol and cannabis.
It seems to me that a sense of belonging, of community, of routine and familiarity are things which can help lift mood.
These are things that mutual aid, along with other forms of peer support, can offer.
So in my opinion, peer support can help with depression and low mood in more ways than in just helping to reduce drinking/drug use.
Another question that is worth asking is “How much does the situation and environment of a substance abuser contribute to depression?”. When I was very early in recovery I was assessed by a Psychiatric social worker who told me that I had “low mood which has been made worse by your social environment” (or words to that effect). She said that I was NOT clinically depressed, although I’m not entrely sure I agree. I suspect there is a fine line between this (A Prolonged case of low mood) and clinical depression, and that the two conditions are often intertwined and/or misdiagnosed.
Really interesting read David
Thanks
Matt
Pucker to read and digest, interesting to read women tend to be more depressed than men, is that because they are more open and sensitive and have roles in being a mother?
I can see this is way out of my league to digest and must be very complexed to unravel.
Interesting read David. Picking up on something in that last paragraph quote. In my (albeit) limited experience of the process people go through as they work through the steps, ‘powerlessness’, and ‘surrender’ are often described as being associated with a feeling of freedom rather than a pessimistic world view. People have described how they were able to ‘let go’ and although they believe they are powerless over their addiction – they are able to make decisions to support recovery. Perhaps this new found freedom could also act to lower depression, as well as reduce drinking outcomes.
Can I just ask one question.
What exactly are the things that all these people are depressed about ?
David,
Thanks for sharing this interesting study. Though my own personal experience is that AA helps me to build resilience, it does not surprise me to learn that AA doesn’t really “treat” depression. If we accept that depression is a brain disease, and that most talk therapies (except CBT) don’t make much of a dent in it, why would we expect that AA would make any difference. AA promises us a satisfying life without alcohol — and to my mind it delivers — but it neither promises nor delivers happiness or contentment. That as they say in the rooms is an inside job.
Guy
Pucker question for you to ask Charlie F, depression is a huge comlex poic and a individual one for the person, david Macartney is a addiction docter and hopefully he will elaborarate.
For myself depression came well early in my life, I didn’t realise it and no one notised it. The way I coped was by drink and drugs, working, looking outwards in helping others.
There must be loads more for others to add to this list, yet when I fimally gave up my drugs and alcohol, I sure in a real pucker way became depressed, I had lost my friend, something I had used most of my life, drink and alcohol.
Hope of use.
Thanks for all the comments.
I think at times we doctors blur the line and we medicalise unhappiness. Antidepressants are not going to do much for you if there are a dozen reasons in life to be unhappy, we need to identify the problems and focus on solutions.
Charlie, the focus of the study was on the symptoms of depression and not on the causes. It’s a sensible question, but not one the study was designed to answer.
Depression is so common in those dependent on alcohol and drugs that it is almost normal and I don’t feel that I can make an assessment of it properly until a period of sobriety has gone by.
Guy is right to point out that CBT (and Interpersonal therapy) can have benefits particularly in mild to moderate depression, where antidepressants are not so effective. In fact the NICE guidelines suggest doctors don’t rush in with antidepressants in this group.
I like Martin’s reference to the grieving process that some need to go through when they say goodbye to their best friend.
A good discussion. Firstly I should like to applaud what S Davies stated above with regard to perceiving powerlessness as a positive, which is a hard bone to chew for anyone new to recovery like myself. Bravo powerlessness is the key!
Secondly, the chicken and egg debate. Personally I am inclined to categorise and put my (often ill found) opinions in neat little boxes. However, I am struggling to do so here. The only way in my mind I can reconcile which ( if any ) is a dominant factor, depression or the effects of excessive alcohol, is to look upon the question as one would a venn diagram. Three circles;
…in circle No.1, I would suggest there are a group of people with whom depression comes first and potentailly a desire to change ones mood. What may follow is an increased likelihood of addiction to an unwittingly self prescribed drug in alcohol (especially as it usually works short term); DEPRESSION FIRST MODEL.
.. in circle No.2 I would include the excessive (ostensibly harmless) use of alcohol in non depressed persons which can lead to damage to nerotransmitters and the onset of depression; ALCOHOL CAUSED MODEL.
…if one accepts the loose argument above, that both drinking (albeit ostensibly harmlessly) OR depression may be the pre-cursor to addiction, It must be the case that the 3rd circle in my venn diagram include a group of people who fit both within MODELS. The cross over.
To conclude,.. the question.. which comes first? Alcohol or Depression… An important question, one which will and should remain open to debate. But in this writers ( humble) opinion [they] both could be present at any one time. Further, they could both stand alone and/or feed into one another.
As to the gender issue.. a personal view.. women are more open to suggestion than men. They have less ( negative) pride and are more willing to accept they cannot control the world than men. I wont ( as a man) ask directions when I am lost kind of thing. Women are not afraid to. Maybe this is evolutionary.. shall I go on?.. I wont good noght
Now… just to deal with my addiction to the excessive use of brackets………….
Venn diagrams? Takes me back to first year maths. Nice illustration.
