Adolescent Depression, Alcohol and Drug Abuse
EVA Y. DEYKIN, DRPH, JANICE C. LEVY, MD, AND VICTORIA WELLS, MD, DRPH
Abstract: The Diagnostic Interview Schedule was employed to
ascertain the prevalence of major depressive disorder (MDD),
alcohol and substance abuse in a sample of 424 college students aged
16 to 19 years. Applying DSM III criteria, the prevalence of MDD
was 6.8 per cent; of alcohol abuse, 8.2 per cent; and of substance
abuse 9.4 per cent. Alcohol abuse was associated with MDD, but not
Introduction
The clinically observed association of alcohol or drug
abuse and depression',2 is well known, but its temporal
sequence is difficult to determine. Alcohol as well as many
illicit drugs are depressogens, the repeated use of which
produces both the subjective feelings of depression and the
neurovegetative signs such as sleep and appetite disturbance,
cognitive impairment, and decreased energy characteristic of
the depressed syndrome.
The differentiation of the antecedents of alcohol and drug
abuse from their sequelae is an important issue in adoles-
cence when substance abuse usually begins. Several longi-
tudinal studies3-5 have investigated the demographic and
pyschosocial correlates of drug abuse, but the findings have
been somewhat conflicting. Kaplan reported that among
adolescents, lowered self-esteem initiated drug use which
then produced an improvement in self-esteem.5 This would
suggest that depressive symptomatology preceded drug use.
Conversely, Kandel found that depressive mood was only a
weak predictor of marijuana initiation among non-drug users,
but an important factor in the first use of other illicit drugs
among adolescents who were already marijuana users.4
The distinction between depression as a primary disor-
der and as a consequence of substance abuse may become
blurred after many years of alcohol and/or drug abuse,
resulting in a state of chronic disability in which it is
impossible to unravel the sequence of symptom evolution,
state of psychologic functioning, or pattern of substance
abuse.6 The nature of this complex association may be more
readily determined in adolescence, before the onset of
personality disorder or depressive states secondary to chron-
ic substance abuse. Furthermore, adolescents' recall, as
assessed in cross-sectional prevalence studies of drug use,
has proved quite reliable, confirming reports of longitudinal
studies.7
The recent availability of the Diagnostic Interview
Schedule, a research assessment interview based on accept-
ed diagnostic criteria, facilitates the ascertainment of the
occurrence of depressive disorder, alcohol and substance
abuse in the adolescent age group, allows for the quantifica-
tion of the association and temporal sequence of these
conditions among teenagers.
Address repnrnt requests to Eva Y. Deykin, DrPH, Associate Professor,
Department of Maternal and Child Health, Harvard School of Public Health,
677 Huntington Avenue, Boston, MA 02115. Dr. Levy is with the Department
of Psychiatry, Massachusetts General Hospital, Boston; Dr. Wells is with the
Department of Epidemiology, Harvard School of Public Health. This paper,
submitted to the Journal March 10, 1986, was revised and accepted for
publication June 18, 1986.
© 1987 American Journal of Public Health 0090-0036/87$1.50
178
with other psychiatric diagnoses. Substance abuse was associated
both with MDD and with other psychiatric diagnoses as well. The
onset of MDD almost always preceded alcohol or substance abuse
suggesting the possibility of self-medication as a factor in the
development of alcohol or substance abuse.Am J Public Health 1986;
76:178-182.)
Methods
Study Sample
The present investigation was part of a cross sectional
study designed to identify the manifestations and correlates
of major depressive disorder (MDD) in adolescence. The
sample for this investigation consists of 424 (271 females and
153 males) college students aged 16 to 19 attending two
Boston area colleges, and represents 42 per cent of students
invited to participate. An additional 10 per cent refused
participation, and the remainder did not respond. A subse-
quent mailing to non-responders revealed that loss of the
original letter and conflict with study time were two most
common reasons for non-response. We have few data on
which to compare the negative and positive responders. The
preponderance of females in the sample is due to the inclusion
of an all female school. Although a few subjects were
younger, nearly all (94 per cent) were 18 to 19 years old. As
might be expected in a college sample, 72 per cent of the
subjects came from the two highest social classes as defined
by the Hollingshead classification of paternal occupation.8
Racially, the sample was predominantly White; 6 per cent
were non-Caucasian.
All students aged 16 to 19 years were sent a letter
describing the purpose of the study and inviting their partic-
ipation. Students who responded negatively on an enclosed
self-addressed postcard were not contacted further; others
were telephoned and an interview time arranged. The inter-
view lasted about an hour: subjects were remunerated five
dollars for their time. The study protocol was reviewed and
approved by the institutional review boards of the Harvard
School of Public Health, and by the appropriate authorities at
the two participating colleges.
Data Collection
Data for the study were obtained by means of the
Diagnostic Interview Schedule (DIS), a structured, standard-
ized interview developed for epidemiologic purposes,9 and
previously used in the Epidemiologic Catchment Area
Project involving 20,000 subjects.'0 The reliability of the DIS,
measured by diagnostic agreement between psychiatrists and
by lay interviews both using the DIS, was high with the
overall Kappa statistic of .69.9 The accuracy of the DIS was
measured by the degree of concordance between DIS-
generated diagnoses and those resulting from psychiatric
interview. Concordance rates ranging between 79 and 96 per
cent, depending on specific diagnoses, indicated the diagnos-
tic validity of the DIS." The DIS can provide diagnoses
based on Research Diagnostic Criteria, on Feighner criteria,
and on DSM-III criteria. This study uses the DSM III criteria,
the official classification system of the American Psychiatric
Association. Only subjects who met definite criteria were
considered positive for psychiatric illness. Major depressive
A1JPH February 1987, Vol. 77, No. 2
 ADOLESCENT DEPRESSION, ALCOHOL AND DRUG ABUSE

TABLE 1-Alcohol Abuse and Major Depressive Disorder (MDD) TABLE 2-Substance Abuse and Major Depresive Disorder (MDD)

MDD MDD

Alcohol Abuse Yes No Total Substance Abuse Yes No Total

Total Sample Total Sample

Yes 8 27 35 Yes 8 32 40
No 27 362 389 No 27 357 384
Total 35 389 424 Total 35 389 424
Odds ratio: 3.6 Odds ratio: 3.3
95% C.l.: 1.7-5.4 95% C.1.: 1.4-7.5
Males Males
Yes 2 17 19 Yes 3 16 19
No 5 129 134 No 4 130 134
Total 7 146 153 Total 7 146 153
Odds ratio: 3.0 Odds ratio: 6.1
95% C.1.: 0.5-15.6 95% C.1.: 1.5-25.0
Females Females
Yes 6 10 16 Yes 5 16 21
No 22 223 255 No 23 227 250
Total 28 243 271 Total 28 243 271
Odds ratio: 6.4 Odds ratio: 3.1
95% C.1.: 2.4-17.1 95% C.1.: 1.1-8.9

TABLE 3-Alcohol Abuse among Adolescents with MDD, Other Diag-

disorder (MDD) was determined by the presence of nose, and No Diagnoses
dysphoria lasting two weeks or longer and by at least four of
a possible eight vegetative symptoms. Alcohol abuse was Alcohol Abuse MDD Other Dx No Dx Total
determined by either a pattern of pathologic alcohol use or by
impairment in social/occupational functioning due to alcohol Yes 8 8 19 35
use. A diagnosis of drug abuse was based on a pattern of No 27 73 289
309
389
424
pathologic use, and impairment of social and occupational Total 35 81
MDD vs No Dx Other Dx vs No Dx
functioning lasting at least one month. Age of onset for any Odds ratio 4.5 1.6
DSM III psychiatric classification was obtained by the DIS 95% C.1. 1.8-10.0 0.7-3.7
interview for those subjects whose responses for relevant
symptoms were positive. Data collected by the Diagnostic
Interview Schedule were entered directly into the computer
and the specially designed SAS program was applied to more than six times as likely to have experienced MDD if
determine the presence or absence of psychiatric disorders. they are alcohol abusers than if they are not.
Data Analyses Drug Abuse and Major Depressive Disorder
Associations of alcohol or drug abuse with other psy- Subjects who met DSM III criteria for abuse of any
chiatric diagnoses were estimated by computing the odds prescription drug were classified as drug abusers, irrespec-
ratios and their accompanying 95 per cent confidence inter- tive of what drug they used. Marijuana was the drug most
vals. To establish whether alcohol or drug abuse preceded or frequently abused. Report of heroin and cocaine abuse was
followed other diagnoses, the age of onset for alcohol or drug rare and tended to be part of poly drug abuse.
abuse was compared to the age of onset of other diagnoses Like alcohol, drug abuse is strongly associated with a
among subjects in which both alcohol or drug abuse and lifetime prevalence of MDD (Table 2). Overall, subjects who
another psychiatric disturbance were present. qualified as drug abusers were 3.3 times as likely as non-
abusers to have history of MDD.
Results Alcohol, Drug Abuse, MDD, and other Psychiatric Disorders
Alcohol Abuse and Major Depressive Disorder To assess whether alcohol or drug abuse were uniquely
The lifetime prevalence of alcohol abuse/dependence associated with MDD or whether they were also correlates of
was 8.2 per cent and of substance abuse/dependence, 9.4 per other psychiatric illnesses, we tested the association of
cent. The lifetime prevalence of major depressive disorder alcohol and drug abuse, each separately, with other DSM III
was 6.8 per cent. Since stringent DSM III criteria were diagnoses (exclusive of MDD). Whereas alcohol abuse has no
applied to establish diagnoses, the prevalence reported here strong association with psychiatric diagnoses other than
represent conservative estimates of occurrence. For exam- MDD (Table 3), drug abuse is markedly associated with other
ple, the prevalence of MDD would have been doubled had the psychiatric classifications as well (Table 4).
DSM III criteria specified only three rather than four symp- A total of eight subjects met DSM III criteria both for
toms in addition to dysphoria. alcohol and drug abuse. Five of these eight subjects also had
In our adolescent sample, subjects who report a history another psychiatric diagnosis (MDD in three; obsessive
of alcohol abuse are almost four times as likely to have a compulsive and phobic disorder in the other two). Four of the
history of MDD as the subjects who have not abused alcohol eight had two or more other psychiatric diagnoses indicating
(Table 1). The association between these two diagnostic an extraordinary high load of psychopathology in this small
classifications is particularly striking among females who are subgroup of poly drug abusers.

179
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DEYKIN, ET AL.

TABLE 4-Substance Abuse among Adolescents with MDD, Other Dag-
noses, and No Diagnoses
Substance Abuse MDD Other Dx No Dx
Yes 8 13 19
No 27 68 289
Total 35 81 308
MDD vs No Dx Other Dx vs No Dx
Odds ratio 4.5
95% C.1. 1.7-11.6 1.4-6.0
Sequence of Alcohol or Substance Abuse and Other Psychiatric
Disorders
The data in Table 5 indicate that the initiation of alcohol
abuse tends to follow, rather than precede the onset of other
psychiatric disturbances. Among the eight subjects who had
MDD, six had a history of MDD that began an average of 4.5
years prior to onset of alcohol abuse. For four of the eight,
the diagnosis of MDD preceded even the first exposure to
alcohol. Similarly, among the six subjects who had a psy-
chiatric diagnoses exclusive of MDD, five experienced their
first psychiatric disturbance either prior to or concurrently
with alcohol abuse.
Similar data (Table 6) were evident when the age of onset
of drug abuse was compared to age at the beginning of other
psychiatric disturbances. Of the 19 subjects who had both
drug abuse and another psychiatric disturbance, eight also
had MDD. Among these eight subjects, MDD had preceded
or occurred concurrently with drug abuse in six subjects,
with an average interval between the two disorders of 1.7
years. In half of the subjects with both MDD and drug abuse,
depressive illness had occurred prior even to the first instance
of illicit drug use.
Among the remaining 11 subjects who had drug abuse
and another psychiatric diagnosis exclusive of MDD, the
psychiatric illness preceded or occurred concurrently with
the drug abuse in nine cases. The average interval between
psychiatric illness and subsequent drug abuse was 6.2 years,
and in most cases the psychiatric diagnosis preceded the first
instance of illicit drug use.
Early Alcohol Use
The prevalence of early problem drinking (defined as
being drunk more than twice before age 15) for the entire
sample was 17.5 per cent. However, for subjects with MDD,
TABLE 5-Subjects with Alcohol Abuse and Other PsychIaric Diagnoses*
Age/Sex Other Psychiatric Dx
the occurrence of early problem drinking was 1.7 times as
great as for subjects without MDD (28.7 vs 16.5 per cent)
Total
suggesting that repeated drunkenness at a young age might be
an early marker of MDD.
40 Not surprisingly, early problem drinking was strongly
384 associated both with a diagnosis of alcohol abuse and drug
424 abuse. Subjects who met criteria for a diagnosis of alcohol
abuse were four times as likely to have had early problem
2.9 drinking as subjects without such a diagnosis. The associa-
tion was even more marked for drug abusers who were 5.5
times as likely to have experienced early problem drinking.
Discussion
The life-time prevalence of major affective disorder (6.8
per cent), alcohol abuse (8.2 per cent), and drug abuse (9.4
per cent) in our sample are very similar to those reported (6.0
per cent, 1 1.6 per cent, and 5.8 per cent) by the Epidemiologic
Catchment Area (ECA) study based on 1,550 college gradu-
ates aged 18 and over.'0 The higher life-time prevalence of
drug abuse in our sample relative to the ECA study may
reflect time changes in the use of illicit drugs. The ECA study
assessed the prevalence of drug abuse in college graduates
aged 18 and over while our study sample consisted of
individuals currently aged 16 to 19. The higher occurrence of
alcohol abuse in the ECA study may indicate that the period
of risk for this disorder extends beyond age 19.
Data obtained from 424 apparently healthy, well-func-
tioning young college students suggest that alcohol is a potent
marker of major depressive disorder among females. The
association of depression and alcohol abuse in our sub-
sample of college coeds is not due to a concomitant higher
prevalence of these disorders among women. The data from
the ECA study clearly indicate that while depression is more
common among females, alcohol abuse is typically a male
disorder. 10 Thus, the observed association is not confounded
by gender, nor is alcohol abuse associated with other psy-
chiatric diagnoses. Because of the small number of males in
the sample, the magnitude of the association among males
requires further verification. In contrast, drug abuse in both
sexes is highly associated both with MDD and other psychi-
atric diagnoses.
College students who meet criteria for MDD and for
alcohol or drug abuse are almost always subject to depressive
illness first and alcohol/substance abuse subsequently. This
temporal sequence applies to other diagnostic classfiications
Age of Onset of Age of Age of
Psychiatric Dx Alcohol Abuse 1st drink

18/F MDD 9 16 12
19/F MDD 13 15 11
18/F MDD 8 18 16
18/F MDD 16 18 18
18/F MDD 17 16 16
18/F MDD 9 16 unknown
18/F MDD 18 16 15
19/M MDD 14 14 13
18/F Phobic disorder 5 15 15
18/F Phobic disorder 9 16 16
18/F Phobic disorder 17 16 14
19/M Phobic disorder 8 17 17
19/M Phobic disorder 7 18 16
19/M Obsessive/compulsive disorder 18 18 18

*Two subjects with alcohol abuse had substance abuse as their only other psychiatric diagnosis and are eliminated from this table.

180 AJPH February 1987, Vol. 77, No. 2

 ADOLESCENT DEPRESSION, ALCOHOL AND DRUG ABUSE

TABLE S-Subjects wth Subsbtnce Abuse and Other Psychiatric Dlagneses*

Age of Onset of Age of Onset Age of First
Age/Sex Other Psychiatric Dx Psychiatric Dx Substance Abuse Use of Drugs

18/F MDD 9 15 15
19/F MDD 13 14 12
18/F MDD 14 15 15
18/F MDD, Bipolar II 15 unknown 13
19/F MDD, Phobic 16 18 14
19/F MDD 17 17 16
19/M MDD 17 13 13
19/M MDD 14 14 14
18/F Dysthymia 12 18 16
18/F Panic disorder 14 18 12
18/F Phobic disorder 5 18 16
19/F Phobic disorder 14 18 12
18/F Phobic disorder 16 16 14
19/M Phobic disorder 17 19 18
19/M Phobic disorder 2 17 14
19/F Obsessive/compulsive disorder 18 16 16
19/M Obsessive/compulsive disorder 18 19 14
19/M Obsessive/compulsive disorder 18 15 15
18/M Schizophrenia 18 18 16

*Two subjects with substance abuse had alcohol abuse as their only other psychiatric diagnosis and are eliminated from this table.

as well as to MDD. Lastly, the data indicate that early
drunkenness constitutes an important risk factor both for
substance abuse and for major depressive disorder.
The distinction between primary and secondary depres-
sion'2"3 offers a means of clarifying the nature of the
relationship between alcohol/drug abuse and depression in
adolescents. According to this distinction, primary depres-
sion is defined as depression occurring in a patient whose
previous psychiatric history is negative, or positive only for
pre-existing mania or depression. Secondary depression is
defined as a depressive episode in a patient who has a
pre-existing, diagnosable psychiatric disorder (for example,
alcoholism and/or drug abuse in this study). The key to the
classification is the chronology of the onset of the disorders.
In our sample, 79 per cent of both alcohol and drug abusers
had another primary psychiatric disorder anteceding the
alcohol or drug abuse. While others4 have identified specific
psychosocial or personality attributes antecedent to drug
abuse among adolecents, we believe this study is the first to
document the association and sequence of psychiatric disor-
ders, alcohol and drug abuse, rigorously defined and ascer-
tained in a normal adolescent population.
Our data are consistent with the "self-medication"
hypothesis first elaborated by psychoanalysts'4 and more
recently summarized by Khantzian.'5 The use of drugs as a
coping strategy to regulate painful affects, most often that of
moderate to severe depression, may explain the observation
that the "amotivational syndrome" with resultant lethargy,
social, and personal deterioration'6 initially thought to be a
consequence of marijuana use, instead appears to precede it.4
Evidence of gender differences in the strength and nature
of the association between alcoholism and depression has
been noted before.2"7'9
The association between early and repeated drunken-
ness ("problem drinking") and other drug abuse is consistent
with Hamburg's notion of a hierarchy of substance use,20
with problem drinking high on the ladder, and with other
findings that early use of any illicit drug is associated with
greater use of all drugs. This particular high-risk group should
be the focus of early clinical attention, in view of the high
occurrence of associated multi-problem behaviors. Some
evidence suggests that drug abusing adolescents continue to
exhibit deviant behavior patterns as young adults2' and data
from the present study highlight the need for comprehensive,
sophisticated psychiatric evaluation.
ACKNOWLEDGMENTS
This investigation was supported by the Charles A. King Trust and by a
Biomedical Scientific Research Grant.
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Nine Cities Selected for New Initiative in Mental Health Services

The Robert Wood Johnson Foundation and the US Department of Housing and Urban Development
recently announced that nine cities have been selected to participate in a new initiative to improve the
delivery of services to the chronically mentally ill. Contributions will total more than $10 million per city
under this national program. The Progran for the Chronically Mentally Ill is a unique public/private
partnership sponsored in cooperation with the US Conference of Mayors, the National Governor's
Association, the National Association of Counties, and the National Conference of State Legislatures.
The nation's 60 largest cities were eligible to apply for the Program.
The nine cities selected for the Progran for the Chronically Mentally Ill are:
Austin, Texas Cincinnati, Ohio Honolulu, Hawaii
Baltimore, Maryland Columbus, Ohio Philadelphia, Pennsylvania
Charlotte, North Carolina Denver, Colorado Toledo, Ohio
The Foundation will provide approximately $29 million in grants and loans over five years to support
the development of city-wide mental health authorities that offer a range of community services and
supervised housing. The cities will also be eligible for federal rent subsidies valued at approximately $85
million over a 15-year period. The National Institute of Mental Health and the Foundation will share
in the cost of an extensive scientific evaluation of the Program's effectiveness.
Spokespersons for the sponsoring groups emphasize the focus of the program is to:
* improve access by the chronically mentally ill to appropriate medical care, housing, and
rehabilitation services;
* spur collaboration between public and private agencies at the local and state levels;
* help improve community programs throughout the country through the knowledge gained from
this program.
The nine cities selected for funding under the Program share the following elements: a tight and
clearly defined organizational structure; assignment of continuing responsibility for each chronically
mentally ill person in the community; a comprehensive set of services that provides realistic alternatives
to institutional care; and budgetary control over the broad range of relevant services and settings, with
fiscal incentives for providing appropriate and cost-effective care.
Examples of services that might be initiated or expanded uner this program include: new residential
facilities with varying levels of treatment and supervision, innovative case management and treatment
teams, model vocational and employment programs, new public corporations to finance and manage care
for the chronically mentally ill, and outreach for locating and assisting the homeless mentally ill.
Technical assistance and direction for the Program for the Chronically Mentally Ill is being provided
by Miles F. Shore, MD, Bullard Professor of Psychiatry at the Harvard Medical School, area director
and superintendent of the Massachusetts Mental Health Center of the Massachusetts Department of
Mental Health, and a senior program consultant to the Johnson Foundation.

182 AJPH February 1987, Vol. 77, No. 2