P R ACT I C E

Alcohol dependence and depression: Advance practice

nurse interventions
Tracey L. Fowler, RN, MSN, PMHNP (Psychiatric Mental Health Nurse Practitioner)
The University at Buffalo School of Nursing, Buffalo, New York

Keywords
Alcohol dependence; depression; general
systems theory.
Correspondence
Tracey L. Fowler, RN, MSN, PMHNP, 220
Hamilton Run Road, Port Allegany, PA 16743.
E-mail: tfowler@pennswoods.net,
tlfowler@buffalo.edu
Received: May 2005; accepted:
February 2006.
doi:10.1111/j.1745-7599.2006.00135.x
Abstract
Purpose: To identify alcohol dependence, depression, and their comorbidity as
common health problems in the United States. To emphasize advance practice
nurse (APN) interventions including screening, treatment, and outcome eval-
uations for individuals and their families suffering with alcohol dependence and
depression.
Data sources: Scientific literature on alcohol dependence, depression, and their
comorbidity as well as general systems theory.
Conclusions: APNs have the opportunity to successfully intervene with indi-
viduals and their family with alcohol dependence, depression, and their comor-
bidity. These complex health conditions need to be screened for, treated, and
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.

Introduction in identifying and treating alcohol dependence and

Alcohol dependence and depression are commonly diag-
nosed health problems by advance practice nurses (APNs)
in the United States. According to the American Psychi-
atric Association (2000), alcohol dependence is a malad-
aptive pattern of alcohol use that leads to significant
distress or clinical impairment. Depression is a serious
medical condition that results from abnormal functioning
of the brain, which can affect individuals’ feelings,
thoughts, and the ability to function in everyday life
(National Institute of Mental Health, 2005). Depression
has been identified as the leading cause of disability in the
United States and worldwide (National Institute of Mental
Health). Alcohol dependence and depression not only
impact the person who is afflicted but also affect the client’s
entire family. The alarming rates of alcohol dependence
and depression should encourage APNs to be diligent in
their screening and detection of these problems. Alcohol
dependence, depression, and their comorbidity can be
identified by the APN during a history and physical if
a thorough psychosocial history is completed. Dongier
(2005) reports that a careful history is the first step to take
depression. APNs should provide interventions for alcohol
dependence and depression that include the family to
assist the individual in combating these complex disorders.
The general systems theory is used to examine the impact
of these comorbid problems on the individual and family
and illustrates how focused interventions can be imple-
mented with every contact with the individual.
The largest comorbidity study to date (National Epide-
miologic Survey on Alcohol and Related Conditions
[NESARC]) reported prevalence rates of co-occurrences
of alcohol, drug, mood, and anxiety disorders (Grant et al.,
2004). The NESARC study reports that approximately
3.8% of adult (18 years of age or older) Americans meet
diagnostic criteria for an alcohol dependence disorder.
While there are a number of diagnoses related to depres-
sion, an estimated 7.2% of adult Americans meet diag-
nostic criteria for a major depression mood disorder
(Grant et al., 2004). Over 20% of individuals with alcohol
dependence have comorbid depression and 11% of clients
with major depression have alcohol dependence comorbid
(Grant et al., 2004).

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
General systems theory
The self-regulation mechanism, a component of general
systems theory, is useful in understanding how the family
attempts to maintain homeostasis, even when impacted by
alcohol dependence and depression. Self-regulation is
achieved through four interacting forces, input, through-
put (processing of input), output, and an external feedback
loop. Von Bertalanffy (1951) explains self-regulation as
input being a stimulus, throughput is the actual message,
output is the response to that message, and feedback is the
certain amount of information that is led back to the input.
These self-regulation components comprise a system. In-
put is the matter, energy, and information a system re-
ceives and processes (Friedman, Bowden, & Jones, 2003;
Von Bertalanffy).
The impact of alcohol dependence and depression pro-
vides the input into the family system. The input can also
be transmitted to the offspring because there is a genetic
predisposition for alcohol dependence and depression.
Throughput is how the system processes the input
(Friedman et al., 2003; Von Bertalanffy, 1951). The family
will be impacted by the physical, social, and psychological
consequences of alcohol dependence and depression.
The output is the result of the system’s processing of the
input and the matter, energy, or information that is
released into the environment (Friedman et al., 2003;
Von Bertalanffy, 1951). In this case, output is associated
with the outcomes of the individual with alcohol depen-
dence and depression, as well as the health and well-being
of the family.
The family receives, processes, and responds to the
output via the feedback loop (Friedman et al., 2003).
The overall goal of feedback, whether positive or negative,
is to help the system adapt, regulate, or otherwise maintain
equilibrium (Friedman et al.; Von Bertalanffy, 1951). Both
the individual and their family system are impacted by
alcohol dependence and depression. The balance in a sys-
tem is not static but is dynamic and ever changing. APNs
can intervene at any point in the self-regulatory process to
Table 1 Self-regulatory influence on alcohol dependence, depression, and APN interventions
Self-regulatory component Impact of alcohol dependence and depression
Input Physiological and psychological impact
Genetic predisposition
Throughput Impact on child growth and development
Disruptions in relationships
Output Positive outcomes
Negative outcomes
Feedback Family as mediator and moderator
304
T.L. Fowler
help individuals and their families living with alcohol
dependence and depression.
Table 1 summarizes how self-regulatory components
influence the impact of alcohol dependence and depres-
sion, and APN interventions. The following sections
expand upon the concepts presented above and relate
them to the situation of individuals with comorbid diag-
noses of alcohol dependence and depression with a focus
on advanced practice nursing. Because most individuals
and families are cared for within a primary care setting and
not by specialists in mental health, it is important that
clinicians in any primary care setting recognize and treat
these serious conditions.
Input
Alcohol dependence and depression are the input (stimuli)
in the family system. Alcohol dependence can lead to
illness, disabilities, and even death. Alcohol dependence
is associated with health problems and negative con-
sequences (Martens et al., 2004). Alcohol-related prob-
lems include social (i.e., loss of job, divorce, intimate
partner violence), legal (i.e., driving under the influence,
violence, homicides), physical dependence related (i.e.,
hand tremors, impaired control over alcohol), morbidity
(i.e., cirrhosis, alcohol-related cancers), and mortality (i.e.,
increased risk for suicide) (Caetano, 2003).
Depression can be a source of suffering and disability and
can complicate and/or exacerbate other medical condi-
tions in individuals. Gaynes, Burns, Tweed, and Erickson
(2002) note that depression has a negative physiological
and psychological impact on an individual. Individuals
who suffer with depression have an increased risk for
hypertension, type II diabetes, and stroke (Gaynes et al.,
2002). Depression is often associated with cognitive im-
pairments, deficits with perceptual, attention, motor, and
communication tasks (Airaksinen, Larsson, Lundberg, &
Forsell, 2004).
One disorder, alone, is challenging for an individual, but
the combination of alcohol dependence and depression is
APN interventions
Screening
Genogram construction
Pharmacotherapy
Psychotherapy
Education regarding neurobiological basis
Brief interventions
Referral to treatment
Support groups
Monitoring
Evaluating responses
Communication skills
T.L. Fowler
even more so. Compared with depressed individuals who
are not alcohol dependent, individuals who are depressed
with alcohol dependence have greater impairments in
functioning and have a higher utilization of healthcare
resources (Le Fauve et al., 2004). Poorer outcomes have
been associated with comorbid alcohol dependence and
depression. Individuals with comorbid alcohol depen-
dence and depression have a decreased chance of remis-
sion from depression and are more likely to relapse to
alcohol use (Le Fauve et al.). Dongier (2005) concludes
that comorbid alcohol dependence and depression have
neurobiological concomitants and increase impairments to
the individual. Brown, Evans, Miller, Burgess, and Mueller
(1997) report comorbid depression has been associated
with elevated drinking rates, alcohol-related problem
behaviors, more medical problems, and relapse. There is a
direct connection between alcohol consumption and one’s
mood. Nurnberger, Foroud, Flury, Meyer, and Wiegand
(2002) concur that some individuals drink alcohol to treat
their depression, and others develop depression secondary
to alcohol dependence. The risk for suicide attempts
increases when alcohol dependence and depression coex-
ist (Aharonovich, Liu, Nunes, & Hasin, 2002), making this
combination of disorders quite lethal.
There is recent evidence suggesting a genetic link for
alcohol dependence and depression. First-degree relatives
of individuals with alcohol disorders, compared with those
without alcohol dependence are at greater risk for coex-
isting alcohol dependence and depression (National Insti-
tute on Alcohol Abuse and Alcoholism, 2005). One or
more genes are likely associated with different pheno-
types. It is posited that the phenotype of alcohol depen-
dence and depression is located on chromosome 1
(National Institute on Alcohol Abuse and Alcoholism;
Nurnberger et al., 2001, 2002). Others identify chromo-
some 7 (Wang et al., 2004). Adoption and twin studies also
support the genetic predisposition for alcohol dependence
and perhaps depression (Bierut et al., 2002). Collectively,
these studies show that there is mounting evidence for the
genetic basis for co-occurrence of alcohol dependence and
depression, alone and in combination.
It is important that APNs have an understanding of how
alcohol dependence, depression, and their comorbidity
influence the health of the individual. Additionally, an
understanding that some ethnic groups are at higher risk is
also important. Hesselbrock, Hesselbrock, Segal, Schuckit,
and Bucholz (2003) show that Caucasians consistently
have higher rates of alcohol use and comorbid psycho-
pathology of major depression compared with African
Americans, Alaska Natives, and Hispanics. Basic education
including prevalence, risk factors, and symptoms of alco-
hol dependence and depression will help APNs understand
the importance of intervening at the earlier possible point.
Alcohol dependence and depression
Preventative interventions include identifying risks,
counseling, and monitoring (Aira, Kauhanen, Larivaara, &
Rautio, 2004). Alcohol has been acknowledged as one of
the oldest mood-enhancing drugs that can induce depres-
sion (Dongier, 2005). If alcohol dependence and depres-
sion coexist, it is imperative for APNs to identify and
integrate treatments for both alcohol dependence and
depression. Early recognition and initiation of treatment
help decrease complications. The National Institute of
Alcohol Abuse and Alcoholism recommends that screen-
ing for alcohol dependence be part of a routine physical
screening, before prescribing medications that interact
with alcohol, and in response to potential alcohol-related
problems. The CAGE screening test is an easy screening
tool to use and is administered by asking the client four
questions. The CAGE questionnaire is considered a useful
screening tool for alcohol dependence because it is brief
and simple to use in primary care settings (Harwood,
2005). Self-report screening questionnaires can help APNs
screen for depression. The Beck Depression Scale is the
most widely used self-rating scale and has received support
in the literature for acceptable sensitivity and specificity
(Viinamaki et al., 2004). A genogram can be constructed to
begin to understand the occurrence of and comorbid
medical problems in the family. The data gathered in
the construction of the genogram can be used for genetic
counseling as well as education regarding genetic risks. It is
crucial to use screening tools such as the CAGE question-
naire and Beck Depression Scale to help identify individ-
uals with alcohol dependence and depression so that the
indicated treatment can be initiated.
Pharmacotherapy and psychotherapy are interventions
that APNs can utilize to help individuals with alcohol
dependence and depression. Pharmacological treatment
for alcohol dependence and depression has been shown in
the literature to be effective (Le Fauve et al., 2004).
Acamprosate indicated for alcohol dependence was
approved by the U.S. Food and Drug Administration
recently (Dongier, 2005). Acamprosate decreases negative
craving for alcohol in the abstinent individual, which helps
prevent relapse. Selective serotonin reuptake inhibitors
(SSRIs) such as fluoxetine and sertraline have been shown
effective in decreasing both alcohol use and depression
(Le Fauve et al., 2004). Some additional benefits with the
SSRIs include their clean side effect profile and minimal
risk of lethality when taken in overdose.
Also, cognitive behavioral therapy (CBT) has provided
benefits for individuals with alcohol dependence and
depression (Brown et al., 1997; Le Fauve et al., 2004).
CBT is based on the premise that individuals lack the
appropriate and adequate affective, emotional, and behav-
ioral skills to deal with negative and distressing situations
(Longabaugh et al., 2005). Individuals need to be included
305
Alcohol dependence and depression
in planning their care to enhance compliance, thus making
interventions individualized. APNs are in the position to
screen, identify, and initiate treatment in individuals with
alcohol dependence and depression. These complicated
disorders first require detection and then if the APN is not
able to give the indicated treatment, the individual and
their family should be referred to a psychiatric provider,
such as a counselor, psychiatric mental health nurse prac-
titioner, psychologist, or psychiatrist.
Throughput
How the family system is impacted by alcohol depen-
dence and depression is the throughput. Because individ-
uals with alcohol dependence and depression are part of
a larger family system, the social, legal, physical, psycho-
logical, morbidity, and mortality problems associated with
alcohol dependence and depression will impact the family
environment. Friedman et al. (2003) note the interrela-
tionships in a family system are so close that a change in
any part results in changes to the whole family system. The
individual and family system are interrelated and inter-
connected in some way (Friedman et al.). An illness in one
family member affects the psychological health and rela-
tionships of other members, and in turn, these responses
influence the individual (Miklowitz, 2004).
The use of alcohol has a direct effect on fetal growth and
the overall development of children, including psycholog-
ical problems as well as physical. According to Hanson and
Ting-Kai (2003), prenatal exposure to alcohol has been
linked to cognitive, psychological, and physical problems.
Kelley, Cash, Grant, Miles, and Santos (2004) indicates that
alcohol-dependent parents might not provide the accep-
tance and nurturance necessary for children to develop
secure psychological adjustments. Parental alcohol depen-
dence is associated with problematic outcomes for children,
including problems with cognition, academic performance,
substance use in adolescence, emotional problems, and
behavioral difficulties (El-Sheikh & Buckhalt, 2003).
The effects on the family when a member has depression
can also be profound. Benazon and Coyne (2000) point
out those individuals who interact with depressed persons
are at greater risk for psychological distress. Children who
have a depressed parent, compared with children of
parents without a depression history, have been found
to have negative outcomes relating to social, psychiatric,
and overall health (McCarty & McMahon, 2003). The
combination of alcohol dependence and depression places
the individual and family at higher risk for adverse con-
sequences related to their health and well-being.
Unfortunately, in today’s society, healthcare services
are mainly aimed at the individual client, ignoring the
processes and context of the family unit (Denham, 2003).
306
T.L. Fowler
However, APNs are in an optimal position to provide
family-focused interventions. Family health is influenced
by its members and routine behaviors in addition to
medical providers (Denham). Individuals in the family
system provide holistic care for their members, teach
health behaviors, establish health routines, and use the
routines to obtain, maintain, and regain members’ health
(Denham). Miklowitz (2004) acknowledges the need for
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
underpinnings of alcohol dependence is to reduce the
stigma, ease defenses, and empower the individual and
their family.
APNs need to assess readiness for learning and then gear
interventions on an as-needed basis. Alcohol dependence
and its medical consequences can be significantly reduced
through brief interventions specific to alcohol cessation
(Harwood, 2005). Saunders, Hypri, Walters, Laforge, and
Larimer (2004) indicate motivational feedback as a brief
effective intervention which reports risk factors (i.e.,
tolerance, dependence, genetic risk), peak blood alcohol
levels, information about quantity and frequency of con-
sumption, comparison of general or local norms, money
spent on alcohol, and associated risk behaviors (i.e., drink-
ing and driving, smoking).
Identification of a problem with alcohol dependence
and depression is an important finding. However, it is
imperative that APNs then take the appropriate steps to
follow up, such as providing a referral for treatment if
indicated (D’Amico, Paddock, Burnam, & Kung, 2005).
APNs may also incorporate support groups, such as Al-
Anon/Alateen into the plan of care for individuals and
their families. Support groups offer hope, assist individuals
and their families in coping with alcohol dependence and
depression, and provide a social support network. Scheid-
linger (2004) proclaims support groups to be cost effective,
a unique motivational element to promote change and
growth, flexible, and proven to be an effective treatment.
Output
Output is how the family system responds to the alcohol-
dependent or depressed individual. At each contact with
the individual and family, the APN should monitor
progress and evaluate outcomes. Symptom reduction
needs to be assessed to detect if additional treatment
initiation is indicated. The APN should evaluate and detect
through subjective and objective findings a decrease in risk
factors and symptomatology. For example, individuals
should report and display less alcohol consumption and/
or alcohol-related problems (social, legal, and physical
dependence). Symptoms of depression, such as depressed
T.L. Fowler Alcohol dependence and depression

mood, decreased interest in pleasure, weight loss or gain, Conclusion

insomnia or hypersomnia, psychomotor agitation, fatigue,
APNs have the opportunity to successfully intervene
feelings of worthlessness or inappropriate guilt, dimin-
with individuals and their families suffering with comorbid
ished ability to think or concentrate, or suicidal ideations,
alcohol dependence and depression. These complex health
should be decreased or be less frequent. Positive outcomes
conditions need to be screened for, treated, and evaluated
from CBT include a decrease in depressive symptoms as
to ensure positive outcomes for the individual and their
a result of a reduction of alcohol consumption, increased
family system. APNs can intervene at each point of the self-
expectancies regarding the benefits of quitting alcohol,
regulatory mechanism in the family system. Primary inter-
and the acquirement of coping skills to avoid drinking
ventions, such as screening for alcohol dependence,
situations (Longabaugh et al., 2005).
depression, and genetic counseling, can be provided in
Educating individuals and families on the neurobiolog-
the input phase of self-regulation. Pharmacotherapy and
ical basis of alcohol dependence can promote management
psychotherapy interventions are also implemented in this
of symptoms (Finnell, 2000). Brief interventions incorpo-
phase. Educating individuals and families about the neu-
rating motivational feedback have been noted to reduce
robiological basis of alcohol dependence and depression is
alcohol drinking, thus reducing the negative consequen-
an important intervention for the APN to provide in the
ces that accompanies drinking alcohol (Saunders et al.,
throughput component. The use of brief interventions
2004). Referral for psychotherapy (i.e., CBT) or self-help
may help effect change in the individual and, in turn,
support groups are also important to assist the individual
the family system. Referrals for additional treatment and
and family. Ongoing evaluation and intervention by the
the utilization of support groups will also increase positive
APN can decrease negative outcomes (i.e., drinking alco-
outcomes for individuals and families with alcohol depen-
hol, depressive symptoms). It is imperative that APNs
dence and depression. At each contact, the APN can
monitor, specify, differentiate, and evaluate how the indi-
monitor the outcomes, or the output of the family system
vidual and family system is functioning (Denham, 2003).
to evaluate the family’s response to various interventions.
APNs need to continually monitor drinking frequency and
Finally, the APN can foster good communication through
quantity, depressive symptoms, and family communica-
teaching and modeling. This feedback intervention can
tion patterns.
strengthen healthy communication and interactions with-
in the family and thus improve outcomes of alcohol depen-
Feedback dence and depression in individuals and their families.
Feedback is the certain amount of information that is led
back to the self-regulatory component of input. The family
environment plays a key role as a moderator of alcohol
dependence and depression (Miklowitz, 2004). The family References
can respond in such a way to promote health or foster
alcohol dependence and depression. The family system Aharonovich, E., Liu, X., Nunes, E., & Hasin, D. S. (2002).
organizes itself and reacts to alcohol dependence and Suicide attempts in substance abuse: Effects of major
depression; these reactions can be protective, or contribute depression in relation to substance use disorders. American
to the problem (Miklowitz). The family system with alco- Journal of Psychiatry, 159(9), 1600–1602.
Aira, M. A., Kauhanen, J., Larivaara, P., & Rautio, M. S. (2004).
hol dependence and depression is altered; the family tries
Differences in brief interventions on excessive drinking and
to adapt to maintain homeostasis and equilibrium through
smoking by primary care physicians: Qualitative study.
self-regulation. Ideally, this process can promote positive
Preventive Medicine, 38, 473–478.
outcomes. Feedback from the family helps build motiva-
Airaksinen, E., Larsson, M., Lundberg, I., & Forsell, Y. (2004).
tion for the individual to change behavior (Finnell, 2000).
Cognitive functions in depressive disorders: Evidence from
This motivation provided by the family system can be a
a population-based study. Psychological Medicine, 34, 83–91.
mediator in the struggle with alcohol dependence and de- American Psychiatric Association. (2000). Diagnostic and
pression. On the other hand, these interactions may rein- statistical manual of mental disorders, text revision (4th ed.).
force dysfunctional behavior inadvertently (Miklowitz). Washington, DC: Author.
APNs can intervene at this point by teaching good com- Benazon, N. R., & Coyne, J. C. (2000). Living with a depressed
munication skills. Identifying dysfunctional communica- spouse. Journal of Family Psychology, 14(1), 71–79.
tion patterns and then altering the destructive patterns Bierut, J. L., Saccone, N. L., Rice, J. P., Goate, A., Foroud, T.,
within the family system can enhance positive commu- Edenberg, H., et al. (2002). Defining alcohol-related
nication among the family, which is essential to the overall phenotypes in humans. Alcohol Research and Health, 26(3),
functioning of the family system (Staton & Lucey, 2004). 208–213.

307
Alcohol dependence and depression
Brown, R. A., Evans, M., Miller, I. W., Burgess, E. S., & Mueller,
T. I. (1997). Cognitive behavioral treatment for depression in
alcoholism. Journal of Consulting and Clinical Psychology, 65(5),
715–726.
Caetano, R. (2003). Alcohol-related health disparities and
treatment related epidemiological findings among whites,
blacks, and Hispanics in the United States. Alcoholism: Clinical
and Experimental Research, 27(8), 1337–1339.
D’Amico, E. J., Paddock, S. M., Burnam, A., & Kung, F. Y.
(2005). Identification of and guidance for problem drinking
by general medical providers: Results from a national survey.
Medical Care, 43(3), 229–236.
Denham, S. A. (2003). Familial research reveals new practice
model. Holistic Nursing Practice, 5–6, 143–151.
Dongier, M. (2005). Psychopharmacology for the clinician.
Psychiatric Neuroscience, 30(3), 224.
El-Sheikh, M., & Buckhalt, J. A. (2003). Parental problem
drinking and children’s adjustment: Attachment and family
functioning as moderators and mediators of risk. Journal of
Family Psychology, 17(4), 510–520.
Finnell, D. S. (2000). The case for teaching patients about the
neurobiological basis of addiction. Journal of Addictions
Nursing, 12(3/4), 149–158.
Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family
nursing: Research, theory, and practice (5th ed.). Upper Saddle
River, NJ: Pearson Education.
Gaynes, B. N., Burns, B. J., Tweed, D. L., & Erickson, P. (2002).
Depression and health-related quality of life. The Journal of
Nervous and Mental Disease, 190(12), 799–806.
Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, P., Dufour,
M. C., Compton, W., et al. (2004). Prevalence and
co-occurrence of substance use disorders and independent
mood and anxiety disorders: Results from the National
Epidemiologic Survey on Alcohol and Related Conditions.
Archives of General Psychiatry, 61, 807–816.
Hanson, G. R., & Ting-Kai, L. (2003). Public health implications
of excessive alcohol consumption. Journal of the American
Medical Association, 289(8), 1031–1032.
Harwood, G. A. (2005). Alcohol abuse screening in primary
care. The Nurse Practitioner, 30(2), 56–61.
Hesselbrock, M. N., Hesselbrock, V. M., Segal, B., Schuckit,
M. A., & Bucholz, K. (2003). Ethnicity and psychiatric
comorbidity among alcohol-dependent persons who receive
inpatient treatment: African Americans, Alaska natives,
Caucasians, and Hispanics. Alcoholism: Clinical and
Experimental Research, 27(8), 1368–1373.
Kelley, M. L., Cash, T. F., Grant, A. R., Miles, D. L., & Santos,
M. T. (2004). Parental alcoholism: Relationships to adult
attachment on college women and men. Journal of Addictive
Behavior, 29, 1633–1636.
Le Fauve, C. E., Litten, R. Z., Randall, C. L., Moak, D. H.,
Salloum, I. M., & Green, A. I. (2004). Pharmacological
treatment of alcohol abuse/dependence with psychiatric
comorbidity. Alcoholism: Clinical and Experimental Research,
28(2), 302–312.
308
T.L. Fowler
Longabaugh, R., Donavan, D. M., Karno, M. P., McCrady, B. S.,
Morgenstern, J., & Tonigan, J. S. (2005). Active ingredients:
How and why evidence-based alcohol behavioral treatment
interventions work. Alcoholism: Clinical and Experimental
Research, 29(2), 235–247.
Martens, M. P., Taylor, K. K., Damann, K. M., Page, J. C.,
Mowry, E. S., & Cimini, M. D. (2004). Protective behavioral
strategies when drinking alcohol and their relationship to
negative alcohol-related consequences in college students.
Psychology of Addictive Behaviors, 18(4), 390–393.
McCarty, C. A., & McMahon, R. J. (2003). Mediators of the
relation between maternal depressive symptoms and child
internalizing and disruptive behavior disorders. Journal of
Family Psychology, 17(4), 545–556.
Miklowitz, D. J. (2004). The role of family systems in severe and
recurrent psychiatric disorders: A developmental
psychopathology view. Development and Psychopathology, 16,
667–688.
National Institute of Mental Health. (2005). Depression.
Retrieved February 15, 2005, from http://www.nimh.gov/
healthinformation
National Institute on Alcohol Abuse and Alcoholism. (2005).
Collaborative studies on genetics of alcoholism (COGA). Retrieved
February 4, 2005, from http://www.niaaa.hih.gov
Nurnberger, J. I., Foroud, T., Flury, L., Meyer, E. T., & Wiegand,
R. (2002). Is there a genetic relationship between
alcoholism and depression? Alcohol Research and Health, 26(3),
233–240.
Nurnberger, J. I., Foroud, T., Flury, L., Su, J., Meyer, E. T.,
Hu, K., et al. (2001). Evidence for a locus on chromosome 1
that influences vulnerability to alcoholism and affective
disorder. American Journal of Psychiatry, 158(5), 718–724.
Saunders, J., Hypri, K., Walters, S. T., Laforge, R. G., & Larimer,
M. E. (2004). Approaches to brief intervention for hazardous
drinking in young people. Alcoholism, Clinical and Experimental
Research, 28(2), 322–329.
Scheidlinger, S. (2004). Group psychotherapy and relating
helping groups today: An overview. American Journal of
Psychotherapy, 58(3), 265–280.
Staton, A. R., & Lucey, C. L. (2004). The family construction
project. Journal of Family Psychotherapy, 15(3), 87–91.
Viinamaki, H., Tanskanen, A., Honkalampi, K.,
Koivumaa-Honkanen, H., Haatainen, K., Kaustio, O., et al.
(2004). Is the Beck Depression Inventory suitable for
screening major depression in different phases of the disease?
Nordic Journal of Psychiatry, 58(1), 49–53.
Von Bertalanffy, L. (1951). General systems theory: A new
approach to unity of science. Human Biology, 23(4),
336–361.
Wang, J. C., Hinrichs, A. L., Stock, H., Budde, J., Allen, R.,
Bertelsen, S., et al. (2004). Evidence of common and specific
genetic effects: Association of the muscarinic acetylcholine
receptor M2 (CHRM2) gene with alcohol dependence and
major depressive syndrome. Human Molecular Genetics, 13(7),
1903–1911.