Gender Differences in the Relationship between Alcohol Use and Depressive Symptoms in St. Petersburg, Russia
Weihai Zhan1, Alla V. Shaboltas2,3, Roman V. Skochilov2,3, Andrei P. Kozlov2,3, Tatiana V. Krasnoselskikh2,4 and Nadia Abdala1*
1Yale School of Public Health, Yale University, New Haven, USA
2The Biomedical Center, St Petersburg, Russian Federation, Russia
3Saint Petersburg, State University, St Petersburg, Russian Federation, Russia
4Pavlov State Medical University, St Petersburg, Russian Federation, Russia
*Corresponding author:
Nadia Abdala
Department of Epidemiology and Public
Health
Yale University, 60 College Street, New Haven, CT, 06520, USA Tel: +1-
203-785-2747 Fax: +1-203-785-3260 E-mail: nadia.abdala@yale.edu
Received April 11, 2012; Accepted May 16, 2012; Published May 20, 2012
Citation: Zhan W, Shaboltas AV, Skochilov RV, Kozlov AP, Krasnoselskikh TV
(2012) Gender Differences in the Relationship between Alcohol Use and Depressive
Symptoms in St. Petersburg, Russia. J Addict Res Ther 3:124. doi:10.4172/2155-6105.1000124
Background: Gender differences in the relationship between alcohol use and depressive symptoms are inconsistent,
and few studies have addressed this issue in Russia. Because this finding may have important implications for
interventions to reduce alcohol misuse or alcohol related problems in Russia, we conducted a study to investigate whether
the association between alcohol use and depressive symptoms differs by gender among people at high risk for HIV
Methods: We used the Alcohol Use Disorders Identification Test (AUDIT) and the 10-item Center for Epidemiological
Studies Depression Scale to measure alcohol use and depressive symptoms among 307 patients who attended a clinic
for sexually transmitted infections in St. Petersburg, Russia. Logistic regression models were applied for the analysis.
Results: The comparison of data between men and women revealed a significant quadratic term of alcohol use and
significant interactions between alcohol use and gender on depressive symptoms. Men with an AUDIT score in the first
and fourth quartiles were more likely to report depressive symptoms in comparison to men in the second quartile. Their
Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were 7.54 (2.00-28.51) and 5.06 (1.31-19.63), respectively.
Among women, a linear trend was observed such that those who misused alcohol were three times more likely to have
depressive symptoms than those who did not misuse alcohol (OR = 3.03, 95% CI, 1.05-8.80).
Conclusion: The association between alcohol use and depressive symptoms differed by gender. Additional
research is needed to investigate this relationship in Russia. Strategies to reduce alcohol-related problems in Russia
may need to consider these differences.
Keywords
Alcohol; Depression; Depressive symptoms; Gender
differences; Russia
Abbreviations
AUDIT: Alcohol Use Disorders Identification
Test; CES-D: Center for Epidemiological Studies Depression Scale;
CI: Confidence Interval; OR: Odds Ratio; STI: Sexually Transmitted
Infection
Introduction
Studies outside Russia have demonstrated that the association
between alcohol problems and depression is well established [1-5]. Several possible explanations for this relationship have been
proposed [2,6,7]. First, both alcohol problems and depression might
share common environmental or genetic causes [8]. Second, alcohol
problems may affect the development of depression through metabolic
changes (e.g., alcohol problems reduce folate metabolism, which
is linked to an increased risk of depression) or through the negative
effects that alcoholism has on a drinker’s social, economic and legal
circumstances (e.g., partner-relationship disruptions) [2,9]. Third,
because people with depression are more likely to drink alcohol to
cope with negative feelings , depression might lead to alcohol problems
[10]. Finally, although there appear to be more studies that support an
alcoholism to depression pathway [2], there is also evidence that this
association may be bidirectional; that is, both disorders simultaneously
increase the risk of the other [11].
Moreover, studies in the US have shown that both alcohol use
and depression may differ by gender [12-16]. In general, men tend
to consume more alcohol than women, and women are more likely
to have depression than men [15,16]. Results from studies that have
examined the association between alcohol use and depression by
gender show mixed and inconclusive results [17-20]. For example, one cross-sectional study observed a non-linear U-shaped relationship
for men but a linear trend for women [17]. In this study, the mean
HADS (Hospital Anxiety and Depression Scale) scores for depression
were 4.4, 2.9, 2.6 and 5.6 for men who were non-drinker, moderate,
hazardous, and harmful drinkers, respectively, suggesting a non-linear
U-shaped relationship for men [17]. Another study observed a nonlinear
relationship among women [21], and a third study found a nonlinear
relationship among both men and women [7]. To our knowledge,
no study in Russia has examined the existence of gender differences
in the relationship between alcohol use and depression, particularly
in men and women at high risk for HIV [1,22]. A clarification of
the relationship between alcohol use and depression may provide
important information for interventions aimed at reducing alcohol use
or alcohol related health risks.
To address these questions, we conducted a study to investigate
whether the association between alcohol use and depressive symptoms
differed by gender and whether a U-shaped relationship was present
among 307 participants who visited a STI (Sexually Transmitted infection) clinic and were enrolled in a randomized intervention trial
in St. Petersburg, Russia between July 2009 and November 2010. This
special group was selected because both alcohol use and depression
have been linked to HIV-related behaviors and few studies have
examined the association between alcohol use and depression in HIV
high risk groups [23].
Materials and Methods
Participants and procedures
Four hundred seventy patients who visited a public clinic for sexually
transmitted infections (STIs) in St. Petersburg, Russia were screened
for participation in a behavior intervention study. The institutional
review boards of the Biomedical Center in St. Petersburg, Russia and
Yale University in Connecticut, United States approved this study.
An invitation was extended to the 338 adults who met the inclusion
criteria of having multiple sexual partners or at least one casual partner
three months prior to the interview. These potential participants
were informed of the purpose of the study and were assured that the
study was confidential and voluntary. Thirty-one patients refused to
participate. Three hundred seven patients provided written informed
consent and completed a baseline assessment between July 2009 and
November 2010. We used the baseline data before intervention for the
present analysis.
A self-administered questionnaire collected data on demographics,
alcohol use, drug use, sexual risk behaviors, and psychological factors.
The demographics consisted of age, sex, marital status, education level,
employment status, and monthly income. The Alcohol Use Disorders
Identification Test (AUDIT) which includes 10 questions with a total
score that ranges from 0 to 40 was used to measure alcohol use [24]. A
score of 8 or higher is usually indicative of hazardous drinking [24].
The Cronbach’s α for the AUDIT is 0.85 in the current sample.
The ten-item Center for Epidemiological Studies Depression Scale
(CES-D-10), which is a shorter version of the 20-item CES-D that is
widely used to screen for depression [25,26], identified depressive
symptoms. Each item on the CES-D-10 has 4-point response options
that range from 0 to 3. Thus, the total CES-D-10 score ranges from
0 to 30. A score of 10 or more is usually used as the cut-off value
for depressive symptoms. The CES-D-10 has demonstrated good
predictive accuracy when screening for depression in comparison to
its full version [25]. The Cronbach’s α for the CES-D-10 is 0.84 in the
current sample.
Statistical analyses
Chi-square tests were used to examine whether the characteristics
differed by gender. Fisher’s exact test was used to compare these
variables when the Chi-square test was inappropriate (i.e., in cases
of small expected frequencies). A graph was plotted to preliminarily
examine the effect of alcohol use on depressive symptoms by dividing
the AUDIT score into quartiles and calculating the prevalence of
depressive symptoms at each quartile. The quartiles were separately
calculated for men and women because men and women might have
different drinking patterns. The Mantel-Haenszel Chi-square test was
used to preliminarily examine whether there was a linear relationship
between the quartiles of alcohol use and depressive symptoms.
Multivariate logistic regression was used to examine the relationship
between alcohol use and depressive symptoms. Higher order terms
of continuous AUDIT scores and interaction terms between AUDIT
scores and gender on depressive symptoms were included in the
models to test whether there was a U-shaped relationship and whether the relationship differed by gender. If a significant interaction effect
was observed, separate multivariate logistic regressions were used
to determine whether alcohol use was associated with depressive
symptoms for men and women. For the purpose of interpretation of
the study results, AUDIT quartiles were used in the final model when
a U-shaped relationship was observed, and dichotomized AUDIT
(alcohol misuse vs. non-misuse) was used when a linear relationship
was observed. The significance level was set at p < 0.05 and the data
were analyzed using SAS 9.1 (SAS Institute Inc., Cary, NC).
Results
Of the 307 participants, 220 were men and 87 were women (Table
1). Men were less likely to be married and to have monthly income
< 15,000 rubles (about 530 US dollars) in comparison to women.
No significant gender differences were observed for age, education,
employment status, history of STIs, ever being a commercial sex
worker, and intravenous drug use.
Table 1:Participant characteristics by gender in St. Petersburg, Russia (N = 307).
The mean (median) AUDIT scores for men and women were 13.4
(13.0) and 9.0 (7.0), respectively, and men were nearly twice as likely
as women to misuse alcohol (84.1% of men vs. 44.8% of women, p <
0.0001). The mean (median) CES-D-10 scores for men and women
were 5.7 (5.0) and 6.9 (6.0), respectively, and men were less likely to
have depressive symptoms in comparison to women (17.3% of men vs.
27.6% of women, p = 0.04).
The prevalence rates of depressive symptoms were 28.6%, 5.2%,
10.9% and 25.5% across the 1st to 4th quartiles of alcohol use in men,
respectively (Figure 1). The Mantel-Haenszel linear trend test on these
data was not significant (p = 0.82). The prevalence rates of depressive
symptoms were 12.0%, 21.7%, 40.0% and 42.1% across the 1st to 4th
quartiles of alcohol use in women, respectively. The Mantel-Haenszel
linear trend test on these data, however, was significant (p = 0.01).
Figure 1:Prevalence of depressive symptoms by quartiles of alcohol consumption
among men and women in St. Petersburg, Russia (N = 307). The
p-values of Mantel-Haenszel Chi-square test for a linear trend were 0.82 and
0.01 for men and women, respectively.
In the model with men and women included, the regression
coefficients for the interaction between the first-order AUDIT score
and gender (p = 0.001) and the interaction between quadratic term of AUDIT score and gender (p = 0.004) were significant. Stratification
analysis was then conducted by gender.
To facilitate the interpretation of the results, we replaced the
continuous AUDIT score with quartile levels of AUDIT score (Table
2). The model revealed that men in the 1st and 4th alcohol use quartiles
were more likely to have depressive symptoms in comparison to those
in the 2nd quartile (odds ratio [OR; and 95% CIs] for the 1st quartile: 7.54
[2.00-28.51]; for the 4th quartile: 5.06 [1.31-19.63]) after controlling for
significant covariates, such as employment status, as well as history of
STIs and intravenous drug use. There were no significant differences
between the 2nd and 3rd alcohol use quartiles.
Table 2:Odds ratios (ORs) and 95 percent confidence intervals between alcohol use and depressive symptoms among men and women in St. Petersburg, Russia (N =
307) .
Given the linear trend between continuous AUDIT score and
depressive symptoms among women, a multivariate analysis directly
investigated this relationship using alcohol misuse in place of
continuous AUDIT score in order to obtain more intuitive results. In
the multivariate analysis, women who misused alcohol were 3.03 times
more likely to have depressive symptoms in comparison to those who did not misuse alcohol (95% CI = 1.05-8.80) after controlling for the
number of sexual partners these women had in the past three months
(a significant covariate).
Discussion
The present study found a significant association between alcohol
use and depressive symptoms, and this association differed by gender.
Specifically, a non-linear, U-shaped relationship was present among
men, whereas a linear trend was observed among women. To the best
of our knowledge, this study is the first to specifically examine the
existence of a non-linear relationship and gender differences between
alcohol use and depressive symptoms in Russia.
The U-shaped relationship that was observed in the present study
suggests that men who had higher AUDIT scores were associated with
fewer depressive symptoms up to a point; above this threshold, men
who had higher AUDIT scores were associated with more depressive
symptoms. Although this U-shaped relationship has also been observed
in previous studies, the mechanisms remain unclear [7,17,27-29]. The
two sides of the curve might have different underlying mechanisms
[29]. First, it is possible that alcohol misuse may lead to depressive
symptoms on the right side of the curve (moderate to heavy drinking),
whereas alcohol use might have a protective effect on the left side of
the curve (light to moderate drinking) [28]. Second, it is possible that
depressive symptoms might lead to either abstinence or the heavy use
of alcohol [7]. For example, some people with depressive symptoms
might cope with these symptoms with heavy alcohol use, whereas
others might activate a self-evaluation process that motivates them to
reduce their alcohol use [2,30]. It is also possible that people who use
alcohol at both ends of the curve might share common risk factors for
depression (e.g., unemployment and social isolation). For example,
unemployment might cause either heavy drinking due to increased
stress or abstinence due to financial hardship [31,32]. Although we
controlled for important potential confounders in the association
between alcohol use and depressive symptoms, we missed others, such
as economic or employment related stresses among those who were employed [33-35]. Future studies might need to elucidate the potential
mechanisms that may affect the association between alcohol and
depression.
Contrary to the studies that have observed a U-shaped relationship
among both men and women [7], the present study observed a
linear trend among women, which suggests that more alcohol use is
associated with a greater likelihood of depressive symptoms. One
previous study reported similar gender differences [17]. This gender
difference indicates that the relationship between alcohol use and
depressive symptoms is different for men and women. Recent evidence
also suggests that women who consume alcohol develop depressive
symptoms faster than men [2]. Our results suggest that there is a need
for additional longitudinal studies to investigate and confirm the gender
differences in the relationship between alcohol use and depression in
Russia. Prevention programs to reduce the negative consequences of
alcohol use might benefit from considering these differences.
The results from the present study should be interpreted in the
context of several limitations. First, although the CES-D-10 scale is
widely used to screen for depression, it is not a clinical evaluation.
Furthermore, although the CES-D has been used and validated in many
countries, including Russia [36,37], the validity of the CES-D-10 has
not been examined in Russia. Second, the participants (STI patients)
were highly selective; thus, these findings should not be generalized
to other populations such as non-clinic samples. Third, the different
patterns of alcohol use and depression in the men and women might
simply be due to different motivations for alcohol use. For example, it
is possible that the more women self-medicate with alcohol the more
depressed they become, thus generating a linear positive slope [38].
Men’s depression on the other hand might be situationally brought on
by the drinking. For example, in Russia, teetotalers might be depressed
because they feel excluded from men’s peer groups [39]; those who
are excessive drinkers may be unable to function in the economy
and family life – making them depressed [32,34]. We did not collect
drinking motivation in the present study and thus we could not exclude
these possibilities.
In summary, the present study demonstrated a non-linear
U-shaped relationship between alcohol use and depressive symptoms
among men and a linear trend among women. Additional research
is needed to investigate relationships among alcohol use, depressive
symptoms, gender differences, and other alcohol related risk factors in
Russia. Preventive strategies for reduction of alcohol-related problems
in Russia should consider these differences.
Acknowledgements
This work was funded by Grant Number R01AA017389 from the National
Institute on Alcohol Abuse and Alcoholism (PI: N. Abdala).
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