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Keywords Abstract
Alcohol dependence; depression; general
systems theory. Purpose: To identify alcohol dependence, depression, and their comorbidity as
common health problems in the United States. To emphasize advance practice
Correspondence nurse (APN) interventions including screening, treatment, and outcome eval-
Tracey L. Fowler, RN, MSN, PMHNP, 220 uations for individuals and their families suffering with alcohol dependence and
Hamilton Run Road, Port Allegany, PA 16743.
depression.
E-mail: tfowler@pennswoods.net,
tlfowler@buffalo.edu
Data sources: Scientific literature on alcohol dependence, depression, and their
comorbidity as well as general systems theory.
Received: May 2005; accepted: Conclusions: APNs have the opportunity to successfully intervene with indi-
February 2006. viduals and their family with alcohol dependence, depression, and their comor-
bidity. These complex health conditions need to be screened for, treated, and
doi:10.1111/j.1745-7599.2006.00135.x evaluated to ensure positive outcomes for the individual and their family system.
Implications for practice: APNs are in an excellent position to intervene at
every contact with the individual and family with alcohol dependence and
depression. Interventions aimed at the individual and family system are detailed
in order to assist the individual and family to optimal health.
Journal of the American Academy of Nurse Practitioners 18 (2006) 303–308 ª 2006 The Author(s) 303
Journal compilation ª 2006 American Academy of Nurse Practitioners
Alcohol dependence and depression T.L. Fowler
General systems theory help individuals and their families living with alcohol
dependence and depression.
The self-regulation mechanism, a component of general
Table 1 summarizes how self-regulatory components
systems theory, is useful in understanding how the family
influence the impact of alcohol dependence and depres-
attempts to maintain homeostasis, even when impacted by
sion, and APN interventions. The following sections
alcohol dependence and depression. Self-regulation is
expand upon the concepts presented above and relate
achieved through four interacting forces, input, through-
them to the situation of individuals with comorbid diag-
put (processing of input), output, and an external feedback
noses of alcohol dependence and depression with a focus
loop. Von Bertalanffy (1951) explains self-regulation as
on advanced practice nursing. Because most individuals
input being a stimulus, throughput is the actual message,
and families are cared for within a primary care setting and
output is the response to that message, and feedback is the
not by specialists in mental health, it is important that
certain amount of information that is led back to the input.
clinicians in any primary care setting recognize and treat
These self-regulation components comprise a system. In-
these serious conditions.
put is the matter, energy, and information a system re-
ceives and processes (Friedman, Bowden, & Jones, 2003;
Input
Von Bertalanffy).
The impact of alcohol dependence and depression pro- Alcohol dependence and depression are the input (stimuli)
vides the input into the family system. The input can also in the family system. Alcohol dependence can lead to
be transmitted to the offspring because there is a genetic illness, disabilities, and even death. Alcohol dependence
predisposition for alcohol dependence and depression. is associated with health problems and negative con-
Throughput is how the system processes the input sequences (Martens et al., 2004). Alcohol-related prob-
(Friedman et al., 2003; Von Bertalanffy, 1951). The family lems include social (i.e., loss of job, divorce, intimate
will be impacted by the physical, social, and psychological partner violence), legal (i.e., driving under the influence,
consequences of alcohol dependence and depression. violence, homicides), physical dependence related (i.e.,
The output is the result of the system’s processing of the hand tremors, impaired control over alcohol), morbidity
input and the matter, energy, or information that is (i.e., cirrhosis, alcohol-related cancers), and mortality (i.e.,
released into the environment (Friedman et al., 2003; increased risk for suicide) (Caetano, 2003).
Von Bertalanffy, 1951). In this case, output is associated Depression can be a source of suffering and disability and
with the outcomes of the individual with alcohol depen- can complicate and/or exacerbate other medical condi-
dence and depression, as well as the health and well-being tions in individuals. Gaynes, Burns, Tweed, and Erickson
of the family. (2002) note that depression has a negative physiological
The family receives, processes, and responds to the and psychological impact on an individual. Individuals
output via the feedback loop (Friedman et al., 2003). who suffer with depression have an increased risk for
The overall goal of feedback, whether positive or negative, hypertension, type II diabetes, and stroke (Gaynes et al.,
is to help the system adapt, regulate, or otherwise maintain 2002). Depression is often associated with cognitive im-
equilibrium (Friedman et al.; Von Bertalanffy, 1951). Both pairments, deficits with perceptual, attention, motor, and
the individual and their family system are impacted by communication tasks (Airaksinen, Larsson, Lundberg, &
alcohol dependence and depression. The balance in a sys- Forsell, 2004).
tem is not static but is dynamic and ever changing. APNs One disorder, alone, is challenging for an individual, but
can intervene at any point in the self-regulatory process to the combination of alcohol dependence and depression is
304
T.L. Fowler Alcohol dependence and depression
even more so. Compared with depressed individuals who Preventative interventions include identifying risks,
are not alcohol dependent, individuals who are depressed counseling, and monitoring (Aira, Kauhanen, Larivaara, &
with alcohol dependence have greater impairments in Rautio, 2004). Alcohol has been acknowledged as one of
functioning and have a higher utilization of healthcare the oldest mood-enhancing drugs that can induce depres-
resources (Le Fauve et al., 2004). Poorer outcomes have sion (Dongier, 2005). If alcohol dependence and depres-
been associated with comorbid alcohol dependence and sion coexist, it is imperative for APNs to identify and
depression. Individuals with comorbid alcohol depen- integrate treatments for both alcohol dependence and
dence and depression have a decreased chance of remis- depression. Early recognition and initiation of treatment
sion from depression and are more likely to relapse to help decrease complications. The National Institute of
alcohol use (Le Fauve et al.). Dongier (2005) concludes Alcohol Abuse and Alcoholism recommends that screen-
that comorbid alcohol dependence and depression have ing for alcohol dependence be part of a routine physical
neurobiological concomitants and increase impairments to screening, before prescribing medications that interact
the individual. Brown, Evans, Miller, Burgess, and Mueller with alcohol, and in response to potential alcohol-related
(1997) report comorbid depression has been associated problems. The CAGE screening test is an easy screening
with elevated drinking rates, alcohol-related problem tool to use and is administered by asking the client four
behaviors, more medical problems, and relapse. There is a questions. The CAGE questionnaire is considered a useful
direct connection between alcohol consumption and one’s screening tool for alcohol dependence because it is brief
mood. Nurnberger, Foroud, Flury, Meyer, and Wiegand and simple to use in primary care settings (Harwood,
(2002) concur that some individuals drink alcohol to treat 2005). Self-report screening questionnaires can help APNs
their depression, and others develop depression secondary screen for depression. The Beck Depression Scale is the
to alcohol dependence. The risk for suicide attempts most widely used self-rating scale and has received support
increases when alcohol dependence and depression coex- in the literature for acceptable sensitivity and specificity
ist (Aharonovich, Liu, Nunes, & Hasin, 2002), making this (Viinamaki et al., 2004). A genogram can be constructed to
combination of disorders quite lethal. begin to understand the occurrence of and comorbid
There is recent evidence suggesting a genetic link for medical problems in the family. The data gathered in
alcohol dependence and depression. First-degree relatives the construction of the genogram can be used for genetic
of individuals with alcohol disorders, compared with those counseling as well as education regarding genetic risks. It is
without alcohol dependence are at greater risk for coex- crucial to use screening tools such as the CAGE question-
isting alcohol dependence and depression (National Insti- naire and Beck Depression Scale to help identify individ-
tute on Alcohol Abuse and Alcoholism, 2005). One or uals with alcohol dependence and depression so that the
more genes are likely associated with different pheno- indicated treatment can be initiated.
types. It is posited that the phenotype of alcohol depen- Pharmacotherapy and psychotherapy are interventions
dence and depression is located on chromosome 1 that APNs can utilize to help individuals with alcohol
(National Institute on Alcohol Abuse and Alcoholism; dependence and depression. Pharmacological treatment
Nurnberger et al., 2001, 2002). Others identify chromo- for alcohol dependence and depression has been shown in
some 7 (Wang et al., 2004). Adoption and twin studies also the literature to be effective (Le Fauve et al., 2004).
support the genetic predisposition for alcohol dependence Acamprosate indicated for alcohol dependence was
and perhaps depression (Bierut et al., 2002). Collectively, approved by the U.S. Food and Drug Administration
these studies show that there is mounting evidence for the recently (Dongier, 2005). Acamprosate decreases negative
genetic basis for co-occurrence of alcohol dependence and craving for alcohol in the abstinent individual, which helps
depression, alone and in combination. prevent relapse. Selective serotonin reuptake inhibitors
It is important that APNs have an understanding of how (SSRIs) such as fluoxetine and sertraline have been shown
alcohol dependence, depression, and their comorbidity effective in decreasing both alcohol use and depression
influence the health of the individual. Additionally, an (Le Fauve et al., 2004). Some additional benefits with the
understanding that some ethnic groups are at higher risk is SSRIs include their clean side effect profile and minimal
also important. Hesselbrock, Hesselbrock, Segal, Schuckit, risk of lethality when taken in overdose.
and Bucholz (2003) show that Caucasians consistently Also, cognitive behavioral therapy (CBT) has provided
have higher rates of alcohol use and comorbid psycho- benefits for individuals with alcohol dependence and
pathology of major depression compared with African depression (Brown et al., 1997; Le Fauve et al., 2004).
Americans, Alaska Natives, and Hispanics. Basic education CBT is based on the premise that individuals lack the
including prevalence, risk factors, and symptoms of alco- appropriate and adequate affective, emotional, and behav-
hol dependence and depression will help APNs understand ioral skills to deal with negative and distressing situations
the importance of intervening at the earlier possible point. (Longabaugh et al., 2005). Individuals need to be included
305
Alcohol dependence and depression T.L. Fowler
in planning their care to enhance compliance, thus making However, APNs are in an optimal position to provide
interventions individualized. APNs are in the position to family-focused interventions. Family health is influenced
screen, identify, and initiate treatment in individuals with by its members and routine behaviors in addition to
alcohol dependence and depression. These complicated medical providers (Denham). Individuals in the family
disorders first require detection and then if the APN is not system provide holistic care for their members, teach
able to give the indicated treatment, the individual and health behaviors, establish health routines, and use the
their family should be referred to a psychiatric provider, routines to obtain, maintain, and regain members’ health
such as a counselor, psychiatric mental health nurse prac- (Denham). Miklowitz (2004) acknowledges the need for
titioner, psychologist, or psychiatrist. education to assist family members in coping and under-
standing the course of illness. Finnell (2000) explains that
the aim of psychoeducation about the neurobiological
Throughput
underpinnings of alcohol dependence is to reduce the
How the family system is impacted by alcohol depen- stigma, ease defenses, and empower the individual and
dence and depression is the throughput. Because individ- their family.
uals with alcohol dependence and depression are part of APNs need to assess readiness for learning and then gear
a larger family system, the social, legal, physical, psycho- interventions on an as-needed basis. Alcohol dependence
logical, morbidity, and mortality problems associated with and its medical consequences can be significantly reduced
alcohol dependence and depression will impact the family through brief interventions specific to alcohol cessation
environment. Friedman et al. (2003) note the interrela- (Harwood, 2005). Saunders, Hypri, Walters, Laforge, and
tionships in a family system are so close that a change in Larimer (2004) indicate motivational feedback as a brief
any part results in changes to the whole family system. The effective intervention which reports risk factors (i.e.,
individual and family system are interrelated and inter- tolerance, dependence, genetic risk), peak blood alcohol
connected in some way (Friedman et al.). An illness in one levels, information about quantity and frequency of con-
family member affects the psychological health and rela- sumption, comparison of general or local norms, money
tionships of other members, and in turn, these responses spent on alcohol, and associated risk behaviors (i.e., drink-
influence the individual (Miklowitz, 2004). ing and driving, smoking).
The use of alcohol has a direct effect on fetal growth and Identification of a problem with alcohol dependence
the overall development of children, including psycholog- and depression is an important finding. However, it is
ical problems as well as physical. According to Hanson and imperative that APNs then take the appropriate steps to
Ting-Kai (2003), prenatal exposure to alcohol has been follow up, such as providing a referral for treatment if
linked to cognitive, psychological, and physical problems. indicated (D’Amico, Paddock, Burnam, & Kung, 2005).
Kelley, Cash, Grant, Miles, and Santos (2004) indicates that APNs may also incorporate support groups, such as Al-
alcohol-dependent parents might not provide the accep- Anon/Alateen into the plan of care for individuals and
tance and nurturance necessary for children to develop their families. Support groups offer hope, assist individuals
secure psychological adjustments. Parental alcohol depen- and their families in coping with alcohol dependence and
dence is associated with problematic outcomes for children, depression, and provide a social support network. Scheid-
including problems with cognition, academic performance, linger (2004) proclaims support groups to be cost effective,
substance use in adolescence, emotional problems, and a unique motivational element to promote change and
behavioral difficulties (El-Sheikh & Buckhalt, 2003). growth, flexible, and proven to be an effective treatment.
The effects on the family when a member has depression
can also be profound. Benazon and Coyne (2000) point
Output
out those individuals who interact with depressed persons
are at greater risk for psychological distress. Children who Output is how the family system responds to the alcohol-
have a depressed parent, compared with children of dependent or depressed individual. At each contact with
parents without a depression history, have been found the individual and family, the APN should monitor
to have negative outcomes relating to social, psychiatric, progress and evaluate outcomes. Symptom reduction
and overall health (McCarty & McMahon, 2003). The needs to be assessed to detect if additional treatment
combination of alcohol dependence and depression places initiation is indicated. The APN should evaluate and detect
the individual and family at higher risk for adverse con- through subjective and objective findings a decrease in risk
sequences related to their health and well-being. factors and symptomatology. For example, individuals
Unfortunately, in today’s society, healthcare services should report and display less alcohol consumption and/
are mainly aimed at the individual client, ignoring the or alcohol-related problems (social, legal, and physical
processes and context of the family unit (Denham, 2003). dependence). Symptoms of depression, such as depressed
306
T.L. Fowler Alcohol dependence and depression
307
Alcohol dependence and depression T.L. Fowler
Brown, R. A., Evans, M., Miller, I. W., Burgess, E. S., & Mueller, Longabaugh, R., Donavan, D. M., Karno, M. P., McCrady, B. S.,
T. I. (1997). Cognitive behavioral treatment for depression in Morgenstern, J., & Tonigan, J. S. (2005). Active ingredients:
alcoholism. Journal of Consulting and Clinical Psychology, 65(5), How and why evidence-based alcohol behavioral treatment
715–726. interventions work. Alcoholism: Clinical and Experimental
Caetano, R. (2003). Alcohol-related health disparities and Research, 29(2), 235–247.
treatment related epidemiological findings among whites, Martens, M. P., Taylor, K. K., Damann, K. M., Page, J. C.,
blacks, and Hispanics in the United States. Alcoholism: Clinical Mowry, E. S., & Cimini, M. D. (2004). Protective behavioral
and Experimental Research, 27(8), 1337–1339. strategies when drinking alcohol and their relationship to
D’Amico, E. J., Paddock, S. M., Burnam, A., & Kung, F. Y. negative alcohol-related consequences in college students.
(2005). Identification of and guidance for problem drinking Psychology of Addictive Behaviors, 18(4), 390–393.
by general medical providers: Results from a national survey. McCarty, C. A., & McMahon, R. J. (2003). Mediators of the
Medical Care, 43(3), 229–236. relation between maternal depressive symptoms and child
Denham, S. A. (2003). Familial research reveals new practice internalizing and disruptive behavior disorders. Journal of
model. Holistic Nursing Practice, 5–6, 143–151. Family Psychology, 17(4), 545–556.
Dongier, M. (2005). Psychopharmacology for the clinician. Miklowitz, D. J. (2004). The role of family systems in severe and
Psychiatric Neuroscience, 30(3), 224. recurrent psychiatric disorders: A developmental
El-Sheikh, M., & Buckhalt, J. A. (2003). Parental problem psychopathology view. Development and Psychopathology, 16,
drinking and children’s adjustment: Attachment and family 667–688.
functioning as moderators and mediators of risk. Journal of National Institute of Mental Health. (2005). Depression.
Family Psychology, 17(4), 510–520. Retrieved February 15, 2005, from http://www.nimh.gov/
Finnell, D. S. (2000). The case for teaching patients about the healthinformation
neurobiological basis of addiction. Journal of Addictions National Institute on Alcohol Abuse and Alcoholism. (2005).
Nursing, 12(3/4), 149–158. Collaborative studies on genetics of alcoholism (COGA). Retrieved
Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family February 4, 2005, from http://www.niaaa.hih.gov
nursing: Research, theory, and practice (5th ed.). Upper Saddle Nurnberger, J. I., Foroud, T., Flury, L., Meyer, E. T., & Wiegand,
River, NJ: Pearson Education. R. (2002). Is there a genetic relationship between
Gaynes, B. N., Burns, B. J., Tweed, D. L., & Erickson, P. (2002). alcoholism and depression? Alcohol Research and Health, 26(3),
Depression and health-related quality of life. The Journal of 233–240.
Nervous and Mental Disease, 190(12), 799–806. Nurnberger, J. I., Foroud, T., Flury, L., Su, J., Meyer, E. T.,
Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, P., Dufour, Hu, K., et al. (2001). Evidence for a locus on chromosome 1
M. C., Compton, W., et al. (2004). Prevalence and that influences vulnerability to alcoholism and affective
co-occurrence of substance use disorders and independent disorder. American Journal of Psychiatry, 158(5), 718–724.
mood and anxiety disorders: Results from the National Saunders, J., Hypri, K., Walters, S. T., Laforge, R. G., & Larimer,
Epidemiologic Survey on Alcohol and Related Conditions. M. E. (2004). Approaches to brief intervention for hazardous
Archives of General Psychiatry, 61, 807–816. drinking in young people. Alcoholism, Clinical and Experimental
Hanson, G. R., & Ting-Kai, L. (2003). Public health implications Research, 28(2), 322–329.
of excessive alcohol consumption. Journal of the American Scheidlinger, S. (2004). Group psychotherapy and relating
Medical Association, 289(8), 1031–1032. helping groups today: An overview. American Journal of
Harwood, G. A. (2005). Alcohol abuse screening in primary Psychotherapy, 58(3), 265–280.
care. The Nurse Practitioner, 30(2), 56–61. Staton, A. R., & Lucey, C. L. (2004). The family construction
Hesselbrock, M. N., Hesselbrock, V. M., Segal, B., Schuckit, project. Journal of Family Psychotherapy, 15(3), 87–91.
M. A., & Bucholz, K. (2003). Ethnicity and psychiatric Viinamaki, H., Tanskanen, A., Honkalampi, K.,
comorbidity among alcohol-dependent persons who receive Koivumaa-Honkanen, H., Haatainen, K., Kaustio, O., et al.
inpatient treatment: African Americans, Alaska natives, (2004). Is the Beck Depression Inventory suitable for
Caucasians, and Hispanics. Alcoholism: Clinical and screening major depression in different phases of the disease?
Experimental Research, 27(8), 1368–1373. Nordic Journal of Psychiatry, 58(1), 49–53.
Kelley, M. L., Cash, T. F., Grant, A. R., Miles, D. L., & Santos, Von Bertalanffy, L. (1951). General systems theory: A new
M. T. (2004). Parental alcoholism: Relationships to adult approach to unity of science. Human Biology, 23(4),
attachment on college women and men. Journal of Addictive 336–361.
Behavior, 29, 1633–1636. Wang, J. C., Hinrichs, A. L., Stock, H., Budde, J., Allen, R.,
Le Fauve, C. E., Litten, R. Z., Randall, C. L., Moak, D. H., Bertelsen, S., et al. (2004). Evidence of common and specific
Salloum, I. M., & Green, A. I. (2004). Pharmacological genetic effects: Association of the muscarinic acetylcholine
treatment of alcohol abuse/dependence with psychiatric receptor M2 (CHRM2) gene with alcohol dependence and
comorbidity. Alcoholism: Clinical and Experimental Research, major depressive syndrome. Human Molecular Genetics, 13(7),
28(2), 302–312. 1903–1911.
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