The prevalence and impact of alcohol problems in major depression: A systematic review


      Major depression and alcohol problems are common in primary care, yet little is known about the prevalence of alcohol problems in patients with depression or alcohol’s effect on depression outcomes. We strove to answer the following questions: How common are alcohol problems in patients with depression? Does alcohol affect the course of depression, response to antidepressant therapy, risk of suicide/death, social functioning and health care utilization? In which alcohol categories and treatment settings have patients with depression and alcohol problems been evaluated? English language studies from MEDLINE, PsychINFO, and Cochrane Controlled Trial Registry were reviewed. Studies were selected using predefined criteria if they reported on the prevalence or effects of alcohol problems in depression. Thirty-five studies met criteria and revealed a median prevalence of current or lifetime alcohol problems in depression of 16% (range 5–67%) and 30% (range 10–60%), respectively. This compares with 7% for current and 16–24% for lifetime alcohol problems in the general population. There is evidence that antidepressants improve depression outcomes in persons with alcohol dependence. Alcohol problems are associated with worse outcomes with respect to depression course, suicide/death risk, social functioning, and health care utilization. The majority of the studies, 34 of 35 (97%), evaluated alcohol abuse and dependence, and 25 of 35 (71%) were conducted in psychiatric inpatients. We conclude that alcohol problems are more common in depression than in the general population, are associated with adverse clinical and health care utilization outcomes, and that antidepressants can be effective in the presence of alcohol dependence. In addition, the literature focuses almost exclusively on patients with alcohol abuse or dependence in psychiatric inpatient settings, and excludes patients with less severe alcohol problems and primary care outpatient settings.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Narrow W.E.
        One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. 1998 (Unpublished)
      1. Murray C.L.A. Lopez A.D. The Global Burden of Disease a Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Harvard University Press, Cambridge, Massachusetts1996
      2. Depression in Primary Care: Volume 1, Detection and Diagnosis. U.S. Department of Health and Human Services, Rockville, Maryland1993 (Clinical practice guideline no. 5, Depression guideline panel (AHCPR publication no. 93-0550, Vol. 1))
        • Simon G.E.
        • Von Korff M.
        Recognition, management, and outcomes of depression in primary care.
        Arch Fam Med. 1995; 4: 99-105
        • Katon W.
        • Von Korff M.
        • Lin E.
        • et al.
        Collaborative management to achieve treatment guidelines. Impact on depression in primary care.
        JAMA. 1995; 273: 1026-1031
        • Katon W.
        • Robinson P.
        • Von Korff M.
        • et al.
        A multifaceted intervention to improve treatment of depression in primary care.
        Arch Gen Psychiatry. 1996; 53: 924-932
        • Katz S.J.
        • Kessler R.C.
        • Lin E.
        • Wells K.B.
        Medication management of depression in the United States and Ontario.
        J Gen Intern Med. 1998; 13: 77-85
        • Regier D.A.
        • Narrow W.E.
        • Rae D.S.
        • Manderscheid R.W.
        • Locke B.Z.
        • Goodwin F.K.
        The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services.
        Arch Gen Psychiatry. 1993; 50: 85-94
        • Pincus H.A.
        • Tanielian T.L.
        • Marcus S.C.
        • et al.
        Prescribing trends in psychotropic medications.
        JAMA. 1998; 279: 526-531
        • U.S. Department of Health and Human Services
        The Physicians’ Guide to Helping Patients with Alcohol Problems. U.S. Department of Health and Human Services PHS, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Washington, DC1995
        • Feighner J.P.
        • Robins E.
        • Guze S.B.
        • Woodruff Jr, R.A.
        • Winokur G.
        • Munoz R.
        Diagnostic criteria for use in psychiatric research.
        Arch Gen Psychiatry. 1972; 26: 57-63
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV). American Psychiatric Association, Washington, DC1994
        • National Institute of Alcohol Abuse and Alcoholism
        Prevalence of Alcohol Abuse and Alcohol Dependence. National Institute of Alcohol Abuse and Alcoholism, Bethesda, Maryland1992
        • Fleming M.F.
        • Manwell L.B.
        • Barry K.L.
        • Johnson K.
        At-risk drinking in an HMO primary care sample.
        Am J Public Health. 1998; 88: 90-93
        • Dawson D.A.
        • Grant B.F.
        • Chou S.P.
        • Pickering R.P.
        Subgroup variation in U.S. drinking patterns.
        J Substance Abuse. 1995; 7: 331-344
        • Archer L.
        • Grant B.F.
        • Dawson D.A.
        What if Americans drank less? The potential effect on the prevalence of alcohol abuse and dependence.
        Am J Public Health. 1995; 85: 61-66
        • Grant B.F.
        ICD-10 harmful use of alcohol and the alcohol dependence syndrome.
        Addiction. 1993; 88: 413-420
        • Hilton M.E.
        Drinking patterns and drinking problems in 1984.
        Alcohol Clin Exp Res. 1987; 11: 167-175
        • Regier D.A.
        • Farmer M.E.
        • Rae D.S.
        • et al.
        Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study.
        JAMA. 1990; 264: 2511-2518
        • Grant B.F.
        • Harford T.C.
        Comorbidity between DSM-IV alcohol use disorders and major depression.
        Drug Alcohol Depend. 1995; 39: 197-206
        • Atkinson R.
        Depression, alcoholism and ageing.
        Int J Geriatr Psychiatry. 1999; 14: 905-910
        • Kessler R.C.
        • Crum R.M.
        • Warner L.A.
        • Nelson C.B.
        • Schulenberg J.
        • Anthony J.C.
        Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey.
        Arch Gen Psychiatry. 1997; 54: 313-321
        • Feinstein A.R.
        Principles of Medical Statistics. Chapman & Hall/CRC, London, UK2002
        • Leonard K.E.
        • Bromet E.J.
        • Parkinson D.K.
        • Day N.
        Agreement among Feighner, RDC and DSM III criteria for alcoholism.
        Addict Behav. 1984; 9: 319-322
        • Hirschfeld R.M.
        • Kosier T.
        • Keller M.B.
        • Lavori P.W.
        • Endicott J.
        The influence of alcoholism on the course of depression.
        J Affect Disord. 1989; 16: 151-158
        • Cook B.L.
        • Winokur G.
        • Garvey M.J.
        • Beach V.
        Depression and previous alcoholism in the elderly.
        Br J Psychiatry. 1991; 158: 72-75
        • Kessing L.V.
        The effect of comorbid alcoholism on recurrence in affective disorder.
        J Affect Disord. 1999; 53: 49-55
        • Mueller T.I.
        • Lavori P.W.
        • Keller M.B.
        • et al.
        Prognostic effect of the variable course of alcoholism on the 10-year course of depression.
        Am J Psychiatry. 1994; 151: 701-706
        • Rounsaville B.J.
        Experience with ICD-10/DSM-IV substance use disorders.
        Psychopathology. 2002; 35: 82-88
        • Jadad A.R.
        • Moore R.A.
        • Carroll D.
        • et al.
        Assessing the quality of reports of randomized clinical trials.
        Control Clin Trials. 1996; 17: 1-12
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Black N.
        Why we need observational studies to evaluate the effectiveness of health care.
        BMJ. 1996; 312: 1215-1218
        • Feinstein A.R.
        Clinical Epidemiology. The Architecture of Clinical Research. W.B. Saunders, Philadelphia, Pennsylvania1985
        • West S.K.
        • King V.
        • Carey T.S.
        • et al.
        Systems to Rate the Strength of Scientific Evidence. Agency for Healthcare Research and Quality, Rockville, Maryland2002
        • Cornelius J.R.
        • Salloum I.M.
        • Cornelius M.D.
        • et al.
        Fluoxetine trial in suicidal depressed alcoholics.
        Psychopharmacol Bull. 1993; 29: 195-199
        • Sanderson W.C.
        • Beck A.T.
        • Beck J.
        Syndrome comorbidity in patients with major depression or dysthymia.
        Am J Psychiatry. 1990; 147: 1025-1028
        • Zimmerman M.
        • Chelminski I.
        • McDermut W.
        Major depressive disorder and axis I diagnostic comorbidity.
        J Clin Psychiatry. 2002; 63: 187-193
        • Alpert J.E.
        • Fava M.
        • Uebelacker L.A.
        • et al.
        Patterns of Axis I comorbidity in early-onset versus late-onset major depressive disorder.
        Biol Psychiatry. 1999; 46: 202-210
        • Hanna E.Z.
        • Grant B.F.
        Gender differences in DSM-IV alcohol use disorders and major depression as distributed in the general population.
        Compr Psychiatry. 1997; 38: 202-212
        • Fava M.
        • Abraham M.
        • Alpert J.
        • Nierenberg A.A.
        • Pava J.A.
        • Rosenbaum J.F.
        Gender differences in Axis I comorbidity among depressed outpatients.
        J Affect Disord. 1996; 38: 129-133
        • Oslin D.W.
        • Katz I.R.
        • Edell W.S.
        • Ten Have T.R.
        Effects of alcohol consumption on the treatment of depression among elderly patients.
        Am J Geriatr Psychiatry. 2000; 8: 215-220
        • Blettner M.
        • Sauerbrei W.
        • Schlehofer B.
        • Scheuchenpflug T.
        • Friedenreich C.
        Traditional reviews, meta-analyses and pooled analyses in epidemiology.
        Int J Epidemiol. 1999; 28: 1-9
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). American Psychiatric Association, Washington, DC1980
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R). American Psychiatric Association, Washington, DC1987
        • Spitzer R.L.
        • Williams J.B.W.
        • Gibbon M.
        Structured Clinical Interview for DSM-III-R (SCID). New York State Psychiatric Institute, Biometrics Research, New York, New York1987
        • Spitzer R.L.
        • Endicott J.
        • Robins E.
        Research diagnostic criteria.
        Arch Gen Psychiatry. 1978; 35: 773-782
        • Spitzer R.L.
        • Endicott J.
        Schedule for Affective Disorders and Schizophrenia (SADS). 3rd edn. New York State Psychiatric Institute, Biometrics Research, New York, New York1979
        • Endicott J.
        • Spitzer R.L.
        A diagnostic interview.
        Arch Gen Psychiatry. 1978; 35: 837-844
        • World Health Organization
        Glossary of Mental Disorders and Guide to their Classification for use in Conjunction with the International Classification of Diseases. 8th Rev. 1974 (Geneva, Switzerland)
        • Sherbourne C.D.
        • Hays R.D.
        • Wells K.B.
        • Rogers W.
        • Burnam M.A.
        Prevalence of comorbid alcohol disorder and consumption in medically ill and depressed patients.
        Arch Fam Med. 1993; 2: 1142-1150
        • Melartin T.K.
        • Rytsala H.J.
        • Leskela U.S.
        • Lestela-Mielonen P.S.
        • Sokero T.P.
        • Isometsa E.T.
        Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study.
        J Clin Psychiatry. 2002; 63: 126-134
        • Labbate L.A.
        • Doyle M.E.
        Recidivism in major depressive disorder.
        Psychother Psychosom. 1997; 66: 145-149
        • Leibenluft E.
        • Fiero P.L.
        • Bartko J.J.
        • et al.
        Depressive symptoms and the self-reported use of alcohol, caffeine, and carbohydrates in normal volunteers and four groups of psychiatric outpatients.
        Am J Psychiatry. 1993; 150: 294-301
        • Brady K.
        • Casto S.
        • Lydiard R.B.
        • Malcolm R.
        • Arana G.
        Substance abuse in an inpatient psychiatric sample.
        Am J Drug Alcohol Abuse. 1991; 17(4): 389-397
        • Cornelius J.R.
        • Salloum I.M.
        • Cornelius M.D.
        • et al.
        Preliminary report.
        Psychopharmacol Bull. 1995; 31: 297-303
        • Cornelius J.R.
        • Salloum I.M.
        • Ehler J.G.
        • et al.
        Fluoxetine in depressed alcoholics.
        Arch Gen Psychiatry. 1997; 54: 700-705
        • Cornelius J.R.
        • Salloum I.M.
        • Haskett R.F.
        • et al.
        Fluoxetine versus placebo in depressed alcoholics.
        Addict Behav. 2000; 25: 307-310
        • Cornelius J.R.
        • Salloum I.M.
        • Mezzich J.
        • et al.
        Disproportionate suicidality in patients with comorbid major depression and alcoholism.
        Am J Psychiatry. 1995; 152: 358-364
        • Bartels S.J.
        • Coakley E.
        • Oxman T.E.
        • et al.
        Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use.
        Am J Geriatr Psychiatry. 2002; 10: 417-427
        • Fortney J.C.
        • Booth B.M.
        • Curran G.M.
        Do patients with alcohol dependence use more services? A comparative analysis with other chronic disorders.
        Alcohol Clin Exp Res. 1999; 23: 127-133
        • Rae A.M.
        • Joyce P.R.
        • Luty S.E.
        • Mulder R.T.
        The effect of a history of alcohol dependence in adult major depression.
        J Affect Disord. 2002; 70: 281-290
        • Roberts R.E.
        • Lee E.S.
        Occupation and the prevalence of major depression, alcohol, and drug abuse in the United States.
        Environ Res. 1993; 61: 266-278
        • Reid M.C.
        • Fiellin D.A.
        • O’Connor P.G.
        Hazardous and harmful alcohol consumption in primary care.
        Arch Intern Med. 1999; 159: 1681-1689
        • Partonen T.
        • Sihvo S.
        • Lonnqvist J.K.
        Patients excluded from an antidepressant efficacy trial.
        J Clin Psychiatry. 1996; 57: 572-575
        • Loo H.
        • Rein W.
        • Souche A.
        • Dufour H.
        • et al.
        Psychopathological and sociodemographic characteristics of 1231 depressed patients with and without co-existing alcoholism.
        Psychiatr Psychobiol. 1990; 5: 249-255
        • Speer D.C.
        • Bates K.
        Comorbid mental and substance disorders among older psychiatric patients.
        J Am Geriatr Soc. 1992; 40: 886-890
        • Mulder R.T.
        • Joyce P.R.
        • Cloninger C.R.
        Temperament and early environment influence comorbidity and personality disorders in major depression.
        Compr Psychiatry. 1994; 35: 225-233
        • D’Mello D.A.
        • Boltz M.K.
        • Msibi B.
        Relationship between concurrent substance abuse in psychiatric patients and neuroleptic dosage.
        Am J Drug Alcohol Abuse. 1995; 21: 257-265
        • Salloum I.M.
        • Mezzich J.E.
        • Cornelius J.
        • et al.
        Clinical profile of comorbid major depression and alcohol use disorders in an initial psychiatric evaluation.
        Compr Psychiatry. 1995; 36: 260-266
        • Fischer E.H.
        • Goethe J.W.
        Anxiety and alcohol abuse in patients in treatment for depression.
        Am J Drug Alcohol Abuse. 1998; 24: 453-463
        • Lin C.-C.
        • Bai Y.-M.
        • Hu P.-G.
        • Yeh H.-S.
        Substance use disorders among inpatients with bipolar disorder and major depressive disorder in a general hospital.
        Gen Hosp Psychiatry. 1998; 20: 98-101
        • Winokur G.
        • Turvey C.
        • Akiskal H.
        • et al.
        Alcoholism and drug abuse in three groups—bipolar I, unipolars and their acquaintances.
        J Affect Disord. 1998; 50: 81-89
        • Parikh S.V.
        • Lesage A.D.
        • Kennedy S.H.
        • Goering P.N.
        Depression in Ontario.
        J Affect Disord. 1999; 52: 67-76
        • Lyketsos C.G.
        • Taragano F.
        • Treisman G.J.
        • Paz J.
        Major depression and its response to sertraline in primary care vs. psychiatric office practice patients.
        Psychosomatics. 1999; 40: 70-75
        • Mueser K.T.
        • Yarnold P.R.
        • Bellack A.S.
        Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder.
        Acta Psychiatr Scand. 1992; 85: 48-55
        • Malone K.M.
        • Haas G.L.
        • Sweeney J.A.
        • Mann J.J.
        Major depression and the risk of attempted suicide.
        J Affect Disord. 1995; 34: 173-185
        • Abraham H.D.
        • Fava M.
        Order of onset of substance abuse and depression in a sample of depressed outpatients.
        Compr Psychiatry. 1999; 40: 44-50