Articles of Public Interest

Abstract

Researchers have identified anxiety and depression symptom trajectories that may help explain the high relapse rates for people who quit drinking. A study published in Alcohol: Clinical and Experimental Research found that almost a third of people in treatment for alcohol use disorder had symptoms of anxiety or depression, which improved more slowly than is typical–or didn’t improve at all. The study suggests that identifying these symptom trajectories early in treatment may provide important clues as to who may benefit from intensive interventions to reduce the risk of relapse.

More than half of people treated for alcohol use disorder start drinking again within a year. Chronic drinkers often experience symptoms of anxiety and depression when they stop drinking–symptoms that may lead them to start drinking again. Prior studies have found that when people start treatment for alcohol use disorder, they generally have high depression and anxiety symptoms, but those symptoms dissipate within the first few weeks after stopping drinking.

Researchers for this study, however, found that 30 percent of participants did not fit this trajectory–their symptoms either dissipated more slowly or remained high throughout treatment. The large-scale study analyzed electronic medical records of one thousand people who received treatment for alcohol use disorder at a large alcohol treatment program to understand any individual characteristics associated with different trajectories of anxiety and depression during treatment that might explain the high relapse rates. Participants, who had an average age of 43, were assessed for anxiety and depression symptoms during the first week of treatment and then approximately weekly thereafter.

The analysis identified three distinct trajectories of anxiety and depression among participants. A low trajectory group began with lower scores of depression and anxiety, which rapidly declined. A high trajectory group started treatment with higher scores, which declined more slowly over time, and a sustained trajectory group had high scores at intake and minimal reduction in symptoms throughout treatment. While about 70 percent of participants were in the low trajectory groups, about a quarter were in the high trajectory groups, and about five percent were in the sustained trajectory group.

People in this sustained trajectory group may be particularly good candidates for more intensive treatment approaches, such as anti-anxiety medication and anxiety-focused psychotherapy. This group was also more likely to have more severe symptoms of post-traumatic stress disorder at intake, an anxiety disorder, or a depressive disorder. However, symptoms of depression and anxiety at intake, not just diagnoses, more reliably predicted symptom trajectory.

Findings also indicated that women may be at higher risk of relapse than men. Women were more likely to be in the high trajectory compared to the low trajectory group for depression symptoms, and women experienced more severe depression symptoms in early abstinence than men. The authors recommend interventions for women that focus on both depression and relapse prevention.

The authors suggest further study factoring in relapse rates for the different subgroups and the role of various types of treatment individuals received, such as medication, group, or individual therapy. The study is limited by the participant pool, which, though large, was primarily white and male.

Subgroups of anxiety and depression trajectories during early abstinence in alcohol use disorder. M. Gopaldas, E. A. Flook, N. Hayes, M. Benningfield, J. Blackford. (https://doi.org/10.1111/acer.70032)

Personalized feedback interventions (PFIs), a common strategy for helping college students moderate their alcohol use, can reduce drinking and its negative consequences. But such interventions vary by length and complexity, and targeting them strategically—considering users’ level of attentiveness—is an important determinant of outcomes, a new study has sound. Drinking attitudes and behaviors among young adults are influenced by their peers. Students are known to overestimate their peers’ alcohol use, potentially aspiring to match misperceived levels of consumption. This likely contributes to heavy episodic (binge) drinking and its negative consequences. Consequently, interventions for high-risk drinkers commonly aim to correct those misperceptions and provide students with tailored information about their drinking compared to their peers’—an approach that uses personalized normative feedback (PNF). PFIs vary in length and complexity and are often delivered via the internet or text messaging. Understanding the role of users’ attentiveness can potentially help hone and target intervention strategies, maximizing their effectiveness. For the study in Alcohol: Clinical & Experimental Research, US investigators compared levels of attentiveness and drinking outcomes among college students using interventions of varying thoroughness.

The researchers worked with 1,137 students aged 18–24 (mean age 20, 63% non-Hispanic White) who reported at least one binge drinking episode in the past month. The participants were randomized into groups receiving varying online PFIs. The interventions ranged from 4 to 27 pages of content. Simpler, single-component interventions compare an individual's drinking behavior with their peers. More comprehensive approaches incorporate elements such as what users expect of alcohol, factors influencing tolerance, and protective behavioral strategies. The participants filled out surveys assessing their alcohol use and any negative consequences, and their attentiveness during the intervention, after their initial use of PFIs, and at 3- 6- and 12- months post-intervention. The investigators used linear regression models to explore possible links between intervention types, attentiveness, and alcohol use outcomes.

Attentiveness was higher among those taking the simpler intervention. Among participants who reported low attentiveness, these more focused interventions led to reduced drinking and fewer alcohol-related consequences. More complex PFIs, however, led to little change in drinking behavior for these students, or even a slight worsening 6 months later. Among participants with higher levels of attentiveness, however, the multicomponent PFIs were more effective than the simpler interventions at reducing the number of drinks and negative alcohol consequences. The single-component interventions led to improvements even at low levels of attentiveness. The more complex interventions generated greater benefits, but only for those with higher attentiveness levels. Not all the follow-up outcome measures pointed to attentiveness as a relevant factor. The findings suggest that students who drank more heavily paid more attention to interventions regardless of complexity or length.

The study underscores that simpler interventions have practical advantages and remain a valuable public health tool—and that multicomponent PFIs may be more effective for students with higher attentiveness, including heavier-drinking students. Those interventions could incorporate strategies such as reflective questions and quizzes to promote higher levels of attentiveness. More research is needed involving diverse populations and refined measures of attentiveness, accounting for other cognitive influences and varying types of delivery devices.

When less is more: How attentiveness impacts the efficacy of online personalized feedback interventions for college student alcohol use. D. Kang, S. Graupensperger, M. Piccirillo, M. Lewis, K. T. Foster, M. Larimer. (https://doi.org/10.1111/acer.70033)

A person's ability to hold on to positive emotions seems to reduce the risk of problems after drinking, independent of how much alcohol is consumed. A study of college students published in Alcohol: Clinical and Experimental Research found that there was a stronger link between drinking and problems like blackouts, fights, or driving under the influence in students who had a negative mood before drinking. In students with a positive affect, that link was weaker, and students who had a greater ability to savor enjoyable moments experienced fewer problems regardless of their drinking patterns. The findings suggest that helping students develop coping skills for negative emotions, as well as cultivating a positive mindset, may reduce their experiences with drinking-related problems.

Researchers looked at data from 160 Colorado college students aged 18 to 24 who drank at hazardous levels to understand the link between drinking and experiencing problems after drinking on an occasion-by-occasion basis and how the student's mood affected this link. Students were prompted via smartphone at four random times each day for two weeks to report their emotions and drinking behavior at that moment. Happy, excited, calm, relaxed, or grateful feelings were considered a ‘positive affect’; sad, anxious, angry, lonely, or stressed feelings indicated ‘negative affect’. Students’ capacity to ‘savor’ enjoyment was also assessed through questions such as ‘when something good happens, there are things I can do to make my enjoyment last longer.’ Getting into a fight, doing something embarrassing, getting hurt, being confused, blacking out, feeling nauseous, passing out, being impulsive, doing something they regret, neglecting responsibilities, damaging property, and driving intoxicated were considered problems. A total of seventy-five hundred momentary surveys from all participants were analyzed.

Students who reported drinking in one survey had a 75 percent increase in problems in the next survey. Positive and negative affect were each associated with differences in post-drinking problems, but in different ways, supporting prior research which has found that positive and negative affect are distinct factors, rather than opposite ends of the same spectrum. On occasions when students reported a more negative affect than was typical for them, drinking at the following report was likely to be associated with more problems. Having a more positive affect on any particular occasion did not influence how many problems they had in their subsequent report, but students’ overall average positive affect did influence the link between drinking and problems–those who were less positive in their overall affect had more problems after drinking. Similarly, those with higher savoring capacity experienced fewer problems throughout the study.

Treatment for problem alcohol use typically does address negative affect; this study suggests that treatment should also address low positive affect to reduce negative drinking-related consequences. The study authors point to a theory that increasing experiences of positive affect promotes behavioral flexibility, which allows students to employ strategies to prevent negative consequences of drinking.

While the study is designed to capture in-the-moment responses, it may not have captured all alcohol-related problems, as consequences are sometimes delayed. Additionally, the demographics of the study population–predominantly white and 70 percent female college students–may limit the generalizability of the study.

Examining the moment-to-moment association between drinking and problems: The moderating role of emotional functioning N. Emery, H. A. Carlon, K. J. Walters, S. Mei, A. Sung, A. DeFalco, S. Baumgardner, M. J. Mataczynski, M. Prince. (https://doi.org/10.1111/acer.70035)

Alcohol's negative effect on women's working memory is somewhat mitigated when their estrogen levels are higher, a novel study suggests. The findings imply that phases of the menstrual cycle may influence women's vulnerability to the acute effects of alcohol on certain cognitive functions. Working memory is vital for understanding, reasoning, and learning. Studies have shown that drinking impairs working memory, with higher blood alcohol concentrations (BAC) linked to worse performance. Women may experience less alcohol-related working memory impairment than men, though this is unclear, and the potential relevance of hormonal factors is largely unknown. Some research suggests that heightened estradiol—the most prominent form of estrogen among women of reproductive age—might benefit working memory most in situations when that cognitive function is compromised, such as after menopause or drug use. For the study in Alcohol: Clinical & Experimental Research, investigators at the University of Kentucky explored alcohol's impact on working memory across phases of the menstrual cycle characterized in part by varying levels of estradiol.

The researchers worked with 75 women aged 21–34 who drank alcohol at least once a week (but did not have alcohol use disorder) and who did not use hormonal birth control. The participants reported their alcohol consumption over the previous month. In the lab, they underwent two testing sessions scheduled according to their menstrual cycles. During each session, they consumed a drink (alcoholic or placebo), completed some cognitive tests, consumed the other drink, and repeated the tests. The first testing session occurred within their early follicular phase, days 4–7 of their cycles (commonly the tail end of a menstrual period). The second testing session took place within the late follicular phase, days 11–14 when estradiol levels rise in preparation for ovulation. The women underwent computerized tests of working memory and a pegboard test assessing motor coordination. Their hormone levels were assessed via saliva samples, and their BAC was assessed via a breathalyzer. They reported how intoxicated, stimulated, or sedated they felt after drinking. The researchers used statistical analysis to identify associations between alcohol use, cycle phase, and cognitive performance.

The participants reported an average of 25 alcoholic drinks consumed over about 9 days during the previous month. Their estradiol levels were higher during the late follicular phases of their menstrual cycles than the early follicular phases. During testing, their BAC levels were similar across different cycle phases, and their working memory performance was worse after consuming alcohol than placebo. During the late follicular phases of their cycles, however, when their estradiol levels were higher, the women's working memory scores were somewhat less affected by alcohol than during their early follicular phases. While sober, their working memory performance did not vary by cycle phase. Their motor skills were worse after consuming alcohol, but the scale of that impairment did not differ by cycle phase. Their perceptions of their alcohol intoxication, stimulation, and sedation were similarly not affected by cycle phase.

The findings add to evidence that the late follicular cycle phase of the menstrual cycle may protect against certain cognitive vulnerabilities to alcohol and that the benefits of heightened estradiol on working memory may be especially evident when that cognitive process is impaired. It's possible that women's ability to regulate their drinking—a process involving working memory—varies according to cycle phase. Further research is needed involving women using hormonal birth control or hormone therapy and postmenopausal women.

Menstrual cycle phase affects alcohol impairment of working memory. W. J. McGarrigle, A. K. Griffith, M. Martel, M. Fillmore. (https://doi.org/10.1111/acer.70031)