East Asian Arch Psychiatry 2017;27:18-25

ORIGINAL ARTICLE

Ms Rosemary Nourse, BS, RN, CCRC, St. Luke’s University Hospital, Bethlehem, Pennsylvania, United States.
Dr Pamela Adamshick, RN, PhD, Moravian College, Bethlehem, Pennsylvania, United States.
Dr Jill Stoltzfus, PhD, Research Institute, St. Luke’s University Hospital, Bethlehem, Pennsylvania, United States.

Address for correspondence: Ms Rosemary Nourse, St. Luke’s University Hospital, Behavioral Health, 801 Ostrum Street, Bethlehem, Pennsylvania, United States 18105.
Tel: (1-484) 526 4421; Fax: (1-484) 526 3840; Email: rinorse@aol.com

Submitted: 2 March 2016; Accepted: 8 August 2016

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Introduction

At an estimated national rate of 39% to 44%, and with some schools reporting significantly higher rates, binge drinking (BD) among college students remains an obstinate health crisis in the US.^1-7 As studies report two thirds of college students drink alcohol, that nearly half of all freshman binge drink, and about half of all students who use alcohol are also binging, BD is a primary public health problem in the US college campuses.^1,2,4,6,8 Furthermore, despite the considerable research that has been conducted to better understand, predict / prevent, combat, and treat the college BD phenomenon and despite the deployment of evidence- based methods, rampant campus BD persists.^4,6,7,9-11

Binge drinking (heavy episodic drinking) is defined as ≥ 5 consecutive drinks in ≤ 2 hours for males and ≥ 4 consecutive drinks in ≤ 2 hours for females.^1,3,4 Binge drinking is associated with impulsive decision-making, sensation-seeking, and high-risk behaviours with the most harmful events occurring at the level of 4 to 5 drinks.^10,12

The deleterious effects and consequences that BD can have on students’ health range from mild to severe and transient to permanent with the most resolute consequence being death: there are approximately 1400 to 1700 alcohol-related student deaths per year.^1,4,10

Past studies have elucidated the most common negative / harmful issues associated with BD as sexual assault or participating in regretted sexual activity, physical injuries (falling, fighting, drunk driving), hangover symptoms, blacking out (conscious / functioning but amnesic) or passing out (unconscious or sleeping), and academic compromise (drop in grade point average, dropping out, being expelled).^2,4,6,11-14 Particularly alarming is the frequency of “blackout” experiences. One study indicated that 13.8% of student participants reported ≥ 5 blackouts a full half or more of their college career.⁹ Additionally, BD can induce or contribute to student behavioural or emotional changes such as uncharacteristic aggressiveness or the development or exacerbation of anxiety, depressive feelings, or even suicidal ideation.^13,15-17 The National Institute on Alcohol Abuse and Alcoholism states that 1.2% to 1.5% of college students who attempt suicide have drinking or drug use problems and that suicide is the second leading cause of death in the student population.^1,16 More troubling is that students at risk for suicide who are heavy drinkers tend to minimise their need for mental health services, regardless of their symptom severity.¹⁸

Despite the serious situations and implications that have resulted from BD, studies have shown that most students will continue to binge drink.^4,6,10,11,19 Prior research has identified factors that contribute to the initiation and continuation of BD as well as to the amount of alcohol students consume; these components are associated with the students’ perception of peer alcohol use habits and desiring the approval of those peers close to them or those considered important / influential.^8,10 Other motivators for BD are the positive expectations students associate with it: many students consider intoxication fun or funny and believe that it enhances their social abilities or the events attended and that it may increase their chances for a sexual encounter / sexual attractiveness.^13,15,20,21 Studies have also linked BD to cultural masculinity roles and stereotypes as males continue to BD more than females and also to those who are prone to impulsivity / sensation seeking.^5,15,21-23 Additionally, some students drink to cope with emotional issues such as depression, bullying, stress, worry, social anxiety disorder, general anxiety, or suicidal ideation.^{5,17,19,24-26}

Past studies have shown that college students have poor insight with regard to their alcohol use patterns / habits and are resistant to seeing them as problematic or excessive as evidenced by the less than 4% to 5% of students who seek any type of alcohol counselling or treatment.^{1,4,10-12,19,27}

Furthermore, although 1 in 4 students report that BD negatively affects their academic life, they do not view their drinking as problematic; nonetheless regretted sexual activity, arrests, drinking alone, and increased weekly drinking have led some students to cite their drinking as problematic while another study showed that students only identified their alcohol use as “binging” or excessive if they blacked out or vomited.^1,11,27

Similarly, depression and anxiety are common in the college population but only 36% to 38% of students with these symptoms seek treatment. One study reported that fewer than 20% of students with anxiety sought professional help. Students often assume it is “normal” to experience distressful emotions during college and that symptoms will be transient; furthermore, they would rather deal with symptoms alone or talk to a friend or family member rather than seek professional help and feel the process of seeking treatment takes too much time.^18,28,29 Ergo, in light of students’ limited insight regarding BD, mental health issues or need for treatment, one might question their ability to discern whether the motivation driving their alcohol use might transit from “socially fun” purposes to a means of self-medicating or coping with stressors and / or mental health problems. Studies suggest that “drinking to cope” is a dangerous technique and that there is an association between those students who drink alone to cope and suicidal ideation.^5,17,18 Conflicting research exists about the association of BD with anxiety, depression, and suicidal ideation.^{5,13,16-18,24,30,31} Some studies have identified an association between BD and depression and / or suicidal ideation while other studies have found no association between BD and depression or psychopathology.^{5,16,28,30,31}

One study showed that students with higher levels of suicidal ideation engaged in heavy drinking alone and used alcohol to cope; other studies indicated that BD and depression were associated in men and not women but that it was associated with school-related stressors in both men and women.^13,16,17

Nonetheless students who have binged and then suffered a mental health crisis with suicidal ideation or gestures have been admitted to hospital psychiatric units. While some students have experienced depression, anxiety or suicidal ideation prior to their alcohol usage, BD may exacerbate these symptoms.^32-35 Alcohol-related events and their consequent complications reach beyond the affected student and family to impact the entire campus and community.^11,21

In struggling to address campus BD problems, colleges have enacted empirically based methods and protocols intended to decrease and / or eradicate BD and promote awareness through alcohol education, alcohol / mental health counselling and screenings, community / business involvement, campus and town police involvement, campus sober support / social groups, student privileges / opportunities restriction, or even college ejection.^{6,10,19,20,36}

Additionally, some colleges have individualised their interventions according to their specific student population needs in order to increase their benefit / outcome.^{6,10,19,20,36}

Nonetheless regardless of increased awareness and interventions, BD remains a poorly controlled problem on many campuses and more research is required. This study aimed to obtain data regarding the current rates of BD in a college campus in relation to the national rate, to examine the association of BD with anxiety and depression, and to elucidate the consequences for students of such alcohol use.

Methods

Participants

Questionnaires and scales were distributed to and completed by 201 students at a small private college in the northeastern United States in May 2015. Participants consisted of 201 young adults, 51 males (25.4%) and 150 females (74.6%) with a mean (± standard deviation) age of 21.1 ± 3.8 years who gave informed consent in accordance with the college’s Institutional Review Board regulations. Some participants in this study received 1 extra credit point and all participants were included in a draw for 8 gift cards valued $25 each; there was no reported financial conflict of interest associated with this research. Participants were considered to be at minimal risk regarding their involvement and participation in this study.

Measures

Participants completed questionnaires and validated psychometric scales: the 7-item Generalised Anxiety Questionnaire (GAD-7)³⁶ is a validated and reliable tool designed to measure severity of anxiety symptoms. The 9-item Patient Health Questionnaire (PHQ-9)³⁷ is a validated and reliable tool designed to measure severity of depressive symptoms. The Alcohol Use Disorders Identification Test (AUDIT)³⁸ is a validated 10-item screening questionnaire designed to identify hazardous alcohol consumption and alcohol abuse. The Brief Young Adult Alcohol Consequences Questionnaire (YAACQ)³⁹ is a validated 24-item tool designed to assess the broad range of consequences of heavy drinking.

Additionally, participants were asked to provide demographic information and answer questions regarding the presence of any anxiety and depressive symptoms before and after drinking alcohol, and whether these symptoms were affected by alcohol (made better or worse).

Procedure

Participants were recruited and invited to participate during classroom visits by the principal investigators to student athletes, and psychology and nursing students. They were informed that participation was voluntary; students who did not wish to participate did not remain after class to complete study materials. For study participation and screening purposes, students were eligible if they were currently attending college and were aged ≥ 18 years. Students were excluded if they currently abused prescription drugs, painkillers, or illegal drugs. Informed consent was then obtained from eligible study participants. Instructions were given to participants prior to their completion of study packets that comprised questions on demographics, questionnaires, and scales. Additionally, following study participation, participants were debriefed and reminded to contact the various health services listed on the consent should they experience any present or future emotional distress or mental health issues. Study packets were in paper format and anonymised.

Data Analyses

Descriptive outcomes were reported for the demographic variables of age, gender, ethnicity, and class year, as well as for items D5-D9 of the questionnaire and the Brief YAACQ. For the GAD-7 and PHQ-9 scales, “mild”, “moderate”, and “severe” categories were reported as frequencies and percentages. For the AUDIT, “hazardous drinking”, “need for counselling and monitoring”, and “alcohol dependence” categories were reported as frequencies and percentages.

All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS Windows version 22.0; IBM Corp, Armonk [NY], US). Separate Chi- square tests were calculated to determine the associations between gender and GAD-7 and PHQ-9 categories, while separate Mann-Whitney rank-sum tests were conducted to compare GAD-7, PHQ-9, and Brief YAACQ score medians and general distributions. Finally, correlations between AUDIT scores and GAD-7, PHQ-9, and Brief YAACQ scores were calculated using Spearman’s rank correlation coefficients. For all analyses, p ≤ 0.05 denotes statistical significance, with no adjustment for the multiple comparisons.

Results

The study sample (n = 201) was not ethnically diverse as Caucasians represented 82% of participants, 9% were Black or African American, 5% were Hispanic or Latino, 2% were Pacific Islander or Asian, and 2% were “Other” or did not reply. Except for the freshman class (14.4%) and graduate students (3.5%), the sample was relatively evenly spread between sophomore (26.9%), junior (28.4%), and senior (26.9%) classes.

Regarding the questionnaire about alcohol’s effects on depressive symptoms, 29.4% of students reported they had experienced problems with depression before they had ever started drinking alcohol; 14.9% reported feelings of depression after they drank; 8.5% felt that drinking made their feelings of depression worse; and 15.9% felt that drinking lessened their feelings of depression (Table 1).

Regarding the questionnaire on alcohol’s effects on anxiety symptoms, 36.3% of students reported they had experienced anxiety problems before they had ever started to drink alcohol; 13.4% reported anxiety feelings after they drank; 8% felt that drinking made their anxiety symptoms worse; and 18.9% felt that drinking made their anxiety symptoms better. Socially, 98% of participants stated they had places on campus to “hang out,” be with friends, and comfortably attended gatherings where alcohol was not involved (Table 1).

The validated GAD-7 assessment tool for anxiety revealed that 45.3% of our student sample had experienced mild anxiety symptoms, 29.4% with moderate anxiety symptoms, and 25.4% with severe anxiety (Table 2). The median GAD-7 score for females was 6 (range, 0-20) and for males was 5 (range, 0-17); this was not significantly different, although it trended towards significance (p = 0.08) [Table 3]. No significant association was found between the GAD-7 and AUDIT scores (r = –0.03, p = 0.68) [Table 4]. The GAD-7 items that were most often scored in the moderate and severe range were questions 1, 2, 3, and 4; these questions deal with nervousness, worrying, and inability to relax.

The validated PHQ-9 assessment tool for depression revealed that 58.7% of our student participants had experienced mild depressive symptoms, 23.9% with moderate symptoms, and 17.4% with severe symptoms (Table 2). The median score for females was 5 (range, 0-24) and for males was 4 (range, 0-17); this was not significantly different, although it trended towards significance (p = 0.07) [Table 3]. No significant association between the PHQ-9 and AUDIT scores was noted (r = 0.09, p = 0.20) [Table 4]. The PHQ-9 items that were most often scored in the moderate and severe range were questions 3, 4, and 5; these questions deal with insomnia or hypersomnia, energy level, and appetite.

The AUDIT assessment showed that 93% of students engaged in hazardous drinking (scored 8-15), 3.5% required monitoring and counselling (scored 16-19), while 3.5% were categorised as alcohol-dependent (scored ≥ 20) [Table 2]. There was statistically significant difference in AUDIT scores by gender (median [range], 5 [0-26] in female vs. 8 [0-23] in male; p = 0.01) but such scores did not differ significantly by class (5 [0-23] in freshmen; 6 [0-25] in sophomore; 6 [0-18] in junior; 6 [1-26] in senior; p = 0.44) [Table 5]. Using Spearman’s rank correlation coefficient, a moderately positive significant correlation (r = 0.61) was found between YAACQ and AUDIT scores (Table 4). This is evidence of a greater likelihood of consequences as a student drinks more.

The YAACQ showed some variance in responses by gender. In order of commonality, females most often checked off question 1 (“I have said or done embarrassing things”, 57.3%), question 2 (“I have had a hangover [headache, sick stomach] the morning after I had been drinking”, 56%), question 3 (“I have felt very sick to my stomach or thrown up after drinking”, 42.7%), question 17 (“I have had less energy or felt tired because of my drinking”, 36.0%), and question 4 (“I often have ended up drinking on a night when I had planned not to drink”, 35.3%). Similarly, males most often checked off question 1 (64.7%), question 2 (58.8%), question 3 (39.2%), question 17 (39.2), question 4 (31.4%), and question 9 (“I have not been able to remember large stretches of time while drinking heavily”, 31.4%).

Discussion

Despite the application of comprehensive evidence- based interventions and policies specifically designed to effectively address and curb the problem of BD among the college student population, campuses across the United States continue to struggle with this pestilent issue.^4,6,7,9-11

Our study results support this statement as 93% of our sample engaged in hazardous drinking with 3.5% of students categorised as in need of counselling / monitoring and 3.5% satisfied the criteria for alcohol dependence. Overall, the majority of students were drinking 2 to 4 times a month (47.3%) and were having 3 to 4 drinks on their typical day of drinking (36.8%).

Regarding BD, 35.8% of all students reported having ≥ 5 drinks on one occasion less than monthly with 25.4% stating that they never drink that amount of alcohol on one occasion. Nonetheless 19.4% of students reported binging monthly and 19.4% reported binging weekly. Therefore, our estimated BD rate is 38.8% and mirrors the approximated national rate of 39% to 44%.^1-7 Disturbingly, 13.9% of our students reported on a monthly basis that they could not remember what happened the night before due to drinking; this indicates that the majority of students who are binging are experiencing memory issues. No recall or short-term memory ability suggests that students had either passed out or blacked out and were therefore vulnerable to harmful events. Similar to previous studies, our results also indicated a positive relationship between alcohol use and negative consequences.^2,4,6,11-14

While it appears that both males (43.1%) and females (48.7%) were mostly drinking 2 to 4 times per month, males were drinking more per week, more per month, and were also binging more often than females; ergo, our study agrees with prior research that indicates male students drink significantly more than female students.^{4,5,13,15,16,21-24}

Additionally, remarkably more male (21.6%) students than female (11.3%) could not remember what happened the night before due to drinking, on a monthly basis.

Congruently, colleges are dealing with a student population who present with serious mental health issues; furthermore, many students arrive on campus with these problems that may or may not be affected by their alcohol use.^24,40-42 Unfortunately, prior research has cited a low rate of students who recognise or show insight into their alcohol misuse or mental health problems as well as for students who obtain professional treatment or counselling.^{1,4,10,11,18,19,24,27-29}

Our sample exhibited questionable insight as 15.9% felt that drinking helped their depressive symptoms and 18.9% felt that drinking helped their anxiety symptoms. Due to the high rates of depression and anxiety that have been reported on this campus, it does not appear that alcohol use was helpful for either problem. Rates of depression and anxiety in our sample may have been somewhat inflated due to the timing of the study: the end of the spring semester / end of the college year. Nonetheless recent studies have shown an increase in anxiety and depression in college students with a survey reporting that within a 12-month time period, 32.6% of students reported feeling so depressed that it was hard for them to function and 54% reported feeling overwhelmed by anxiety.⁴²

Interestingly, there were significant differences in responses to the non-validated questionnaire that measured anxiety and depression versus the validated tools. While 36% of students reported they had experienced anxiety as per the questionnaire, a total of 54.8% satisfied the criteria for moderate or severe anxiety as per the GAD-7. Also, while 29% of students reported they had felt depressed as per the questionnaire, a total of 41.3% fulfilled the PHQ-9 criteria for moderate or severe depression. These remarkable differences suggest that students’ casual opinions or estimations of their anxiety and depression symptoms do not reflect the real level.

Past studies have identified multiple factors associated with the initiation and continuation of BD^{8,10,13,15,20-23}; research has also elucidated the common negative effects and consequences of drinking on students’ lives.^2,4,6,11-14

Identified via the YAACQ, our sample cited problematic issues in the areas of behavioural changes, hangover symptoms, regretful and risky / impulsive behaviours, and passing out or blacking out.

As illustrated by the YAACQ, both female and males reported their most common drinking consequences as feelings of embarrassment regarding things they had said or done, hangover symptoms of headache, vomiting and stomach upset, drinking on nights when they had not planned to drink, and feeling more tired / having less energy due to drinking. Males (31.4%) more often indicated not remembering large stretches of time (vs. 20.7% in females). Alarmingly, both males and females reported having taken foolish risks when drinking (29.4% vs. 22.7%) and having done impulsive things that were later regretted (29.4% vs. 29.3%).

Interestingly, the answers to 3 YAACQ questions differed significantly by gender (males vs. females): “I have passed out from drinking” (21.6% vs. 8.7%), “I have become very rude, obnoxious or insulting after drinking” (21.6% vs. 8.0%), and “I have woken up in an unexpected place after heavy drinking” (17.7% vs. 4.7%).

Discussion

Past research has yielded conflicting results about the association of BD with depression and anxiety.^{5,13,16-18,24,30,31} Our results agree with those studies that did not find an association between BD or hazardous alcohol use and depression or anxiety.^24,29,31 Our student sample may not have experienced a clinically significant onset or exacerbation of anxiety or depressive symptoms due to their alcohol use. Despite this, it is of definite concern that on this campus, 25.4% of students experienced severe anxiety symptoms and 17.4% experienced severe depressive symptoms; these numbers indicate that a substantial proportion of students have endured mental health issues. Additionally, our statistics were trending towards a gender significance with females reporting more anxiety and depression than males.

Although some students believe that alcohol can effectively reduce their emotional discomfort in the form of anxiety or depressive feelings, our results suggest that the majority of alcohol use on this campus is more likely to be linked to students’ perceived positive expectancies and cultural norms than to self-medication / mood regulation.

Males on this campus are drinking more and suffering more memory loss than females and should therefore receive alcohol education sensitive to social and cultural masculine expectations, pressures, and stereotypes.

Limitations

The main limitation of this study was the small sample size that comprised mostly Caucasian females and was not ethnically or gender diverse. Furthermore, the college setting was a smaller suburban Mid-Atlantic university so the generalisability of results is limited. Response bias was a consideration as students may have wanted to be represented in a positive / academically acceptable manner. Some abbreviated measurement tools were utilised in order to reduce the time required for participation and to dissuade apathetic or rushed responses.

Conclusions

The results of this study have revealed the specific problematic issues of our student population in the areas of BD, accompanying dangerous consequences and behaviours (especially for males), and high rates of depression and anxiety. Current interventions available to students will be reviewed and updated. Also, hospital staff — particularly emergency department and behavioural health unit clinicians — must be better informed about BD (its symptoms and contributors) to improve screening methods, patient education / counselling, and treatment. Hospitals and their local colleges should work in unison to improve and promote BD programmes, education / awareness, and counselling. Research in this specific population should be ongoing in order to stay current with the alcohol use trends and mental health issues of emerging adults because their behaviour, problems, and beliefs are a reflection of our continuously changing society and perceived cultural norms. Strategies and services utilised by colleges must also stay current, specific, and adaptable to the needs of students.

Acknowledgements

We would like to thank Ms Sophia Arroyo from St. Luke’s University Hospital and Mr Ben Watchous from St. Luke’s University Health Network for their contributions of recording statistical information.

Declaration

The authors declared no conflicts of interest in this study.

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