RESEARCH

Relationships between aggression, depression, and alcohol,

tobacco: Implications for healthcare providers in student health
Susan J. Roberts, DNSc, ANP, FAAN (Professor)1 , Carol A. Glod, PhD, APRN, FAAN (Dean)2 ,
Reo Kim, BS (Student)3 , & Julie Hounchell, MS, RN (Family Nurse Practitioner)4
1 School of Nursing, Northeastern University School of Nursing, Boston, Massachussets
2 School of Graduate Studies, Salem State University, Salem, Massachusetts
3 University of Massachusetts Amherst, Amherst, Massachusetts
4 Fletcher Allen Health Care, Burlington, Vermont

Keywords Abstract
Depression; student health; behavior; college
students. Purpose: To determine the prevalence of aggression, depression, and at-risk
health behaviors in a random sample of undergraduate college students and to
Correspondence explore the relationship between these variables.
Susan J. Roberts, DNSc, ANP, FAAN, Data sources: The study survey was sent to 2500 undergraduate students;
Northeastern University School of Nursing, 211 428 participated, responding to items from the National College Health Risk
Robinson Hall, Huntington Avenue, Boston,
Behavior Survey about alcohol, drug and tobacco, violence and aggression, the
MA 02115.
Tel: 617-373-3130;
Beck Depression Inventory II, and items adapted from the Overt Aggression
Fax: 617-373-8675; Scale.
E-mail: s.roberts@neu.edu Conclusions: Almost one third of the sample reported cigarette smoking, 22%
moderate depression, 81% drink alcohol, with 58% drinking more than five
Received: September 2008;
drinks at least once in the last month. Reports of verbal and physical aggres-
accepted: February 2009
sion were also common. Moderate depression was related to cigarette smoking,
doi: 10.1111/j.1745-7599.2010.00521.x physical, and verbal aggression, but not to heavy alcohol use. An understand-
ing of these relationships can be utilized to screen and intervene with students
at risk.
Implications for practice: The results call for increased screening and treat-
ment of depression in college students, and suggest that students with aggres-
sive behaviors are at the highest risk for depression, and should be a group to
receive specific attention for screening.

Research has shown that college students engage in be-
haviors that put their health at risk (American College
Health Association [ACHA], 2005; 2007). A large per-
centage of college students smoke cigarettes, can be char-
acterized as heavy alcohol users, and have sexual and
aggressive behaviors that put them at risk for morbidity
and mortality (Douglas et al, 1997; Morbidity and Mortal-
ity Weekly Report [MMWR], 1997; ACHA, 2005; 2007).
Similarly, rates of depression in college students have in-
creased over the last decade. The purpose of this study
was to determine the prevalence of aggression, depres-
sion, and at-risk health behaviors in a sample of under-
graduate college students and to explore the relationship
between these variables. An understanding of these rela-
tionships is important to nurse practitioners (NPs) work-
ing with college students because it assists in assessment
of risk of those students most likely to be depressed and
in need of intervention.
Background literature
Adolescent and college student alcohol
and drug use
Heavy alcohol use and abuse have been found to be
a major area of risky behavior on college campuses.
Thirty-six percent of students in one study reported that
they had binged with alcohol in the previous month
(Patrick et al., 1997) and, in another, the same percent-
age reported alcohol-related problems (accidents, black-
outs, etc.; Werner, Walker & Greene, 1994). The Harvard
School of Public Health Alcohol Study found that 44%

Journal of the American Academy of Nurse Practitioners 22 (2010) 369–375 

C 2010 The Author(s) 369
Journal compilation 
C 2010 American Academy of Nurse Practitioners
College student depression and health behaviors
of students consistently reported binge drinking over the
10 years of the study (Wechsler et al., 2002) and 31% of
the students in a recent survey met the criteria for alcohol
abuse (Knight et al., 2002). Binge drinking, drug use, and
being sexually active were found to be significant predic-
tors of fighting (Valois et al., 1993) and negative mood
regulation (Kassal, Jackson, & Unrod, 2000). Impulsivity
and irrational beliefs have been significantly correlated
with alcohol use and quantity consumed, and problems
as a result of alcohol, as well as depression (Carmatta &
Nagoshi, 1995).
One study found that the use of marijuana had in-
creased 22% between 1993 and 1999, and that mari-
juana use was related to using other illicit drugs, smoking
cigarettes, and/or engaging in binge drinking (Gledhill-
Hoyt et al., 2000). One third of the students had initiated
marijuana use in college. The data available on steroid use
among students found a relationship between steroids,
aggressive behavior, consuming more alcohol, and higher
rates of binge drinking (Meilman et al., 1995). Steroid
users also reported greater use of tobacco, marijuana, co-
caine, amphetamines, sedatives, hallucinogens, opiates,
inhalants, and designer drugs.
Cigarette smoking
Cigarette smoking is a common habit among college
students that puts them at risk for morbidity and mor-
tality. One study found that nearly half of students had
used a tobacco product in the last year and one third
were currently using tobacco (Rigotti, Lee, & Wechsler,
2000). A recent review of the literature on smoking and
American college students found that rates of cigarette
smoking have increased, with 28% reporting daily smok-
ing across studies (Patterson et al., 2004). Smokers have
been found to consume more alcohol (Reed et al., 2007).
Smoking was also associated with being white, living in
housing where smoking is permitted, using alcohol and
other substances, having a lower sense of efficacy and
well being, depression, life satisfaction, and coping style.
Almost one third stated that they used smoking to man-
age depression. Students with a history of depression
were seven times more likely than other students to use
tobacco (Lenz, 2004). Other studies have also found that
the number of days smoked was associated with depres-
sive symptoms (Kenney & Holahan, 2008; Ridner, Staten,
& Danner, 2005).
College student depression
One study found that the number of students seen
with depression in a student counseling center had dou-
bled over the last decade and the number of suicidal stu-
370
S.J. Roberts et al.
dents had tripled (Benton, Robertson, Tseng, Newton, &
Benton, 2003). Several studies have found rates of de-
pression in college students of 12%–15% (Wechsler,
Rohman, & Solomon, 1981; Rosenthal & Schreiner,
2000), while others reported as high as one third of stu-
dents meeting criteria for depression (Wells, Klerman,
& Deykin, 1987; Allgower, Wardle, & Steptoe, 2000).
Severity of depression may account for the differences,
with mild depression being found in the greater num-
ber of students (Allgower, Wardle, & Steptoe 2000). De-
pression in college students has been found to be asso-
ciated with female gender, lack of physical activity and
nonsports participation, and a variety of health behaviors,
such as nonuse of birth control, poor eating and sleeping
behaviors, smoking cigarettes, binge drinking, and engag-
ing in physical fights (Allgower, Wardle, & Steptoe, 2000;
Patten et al., 2001; Brooks et al., 2002; Glied & Pine,
2002; Weitzman, 2004; Ellis & Trumpower, 2008).
Aggression in college students
Aggression has not been well researched in relation to
health-risk behaviors, except for the documented rela-
tionships with alcohol use (Valois et al., 1993; Parks et al.,
2008) and depression (Patten et al., 2001; Brooks et al.,
2002). Qualitative evidence suggests that males exhibit
depression through irritability, fighting and other aggres-
sion, and drug/alcohol use and abuse (Pollack, 1998;
Real, 1998). Another area of aggression that has been
studied in adolescents is dating violence. One study of
adolescents found that one in five female students had
been physically and/or sexually abused by a dating part-
ner, and that the abuse was related to increased risk of
substance abuse, unhealthy weight control behavior, sex-
ual risk behaviors, pregnancy, and suicidality (Silverman
et al., 2001). No other studies could be found that have
examined the relationship between aggression, depres-
sion, and health-risk behaviors.
Several large national surveys have pointed to the need
to explore multiple risk factors in college students as a re-
sult of their prevalence. The National College Risk Behav-
ior Survey (NCRBS) in 1995 found that almost one third
of the participants smoked cigarettes and over a third
reported episodic heavy drinking, while 14% had used
marijuana (Douglas et al., 1997; MMWR, 1997). Seven-
teen percent of male students had been in a physical fight
and 1% had to receive medical attention for fight injuries
during a year prior to the study. Ten percent of students
had seriously considered suicide during that year. The
ACHA National College Health Assessment has more re-
cently found that up to 35% use cigarettes, 35% mari-
juana, and 80% use alcohol; 34% of students had been
diagnosed with depression in the last year in the 2003
S.J. Roberts et al. College student depression and health behaviors

sample and 39% in 2006 (ACHA, 2005; 2007). Ten per- Table 1. Demographics
cent had considered suicide and 1.4% had attempted it Sample University
in both samples. Six percent of the 2006 sample reported
having been in a physical fight in the last year, and 3.5% Gender
Male 35% (n = 148) 51% (n = 7219)
having been physically assaulted. Based on data to date,
Female 63% (n = 266) 51% (n = 7273)
this research project was developed to understand rela-
Class
tionships between these prevalent variables in order to Freshman 18% (n = 75) 23% (n = 3364)
form the basis for developing interventions aimed at re- Sophomore 21% (n = 88) 21% (n = 2921)
ducing risk in college student populations. Middler 19% (n = 81) 23% (n = 3117)
Junior 16% (n = 69) 17% (n = 2339)
Senior 24% (n = 101) 17% (n = 2403)
Research questions and methods Age
Under 18 1% (n = 3) 2% (n = 39)
This research project was developed to examine the re-
18–19 28% (n = 116) 37% (n = 5280)
lationships of aggression, depression, and health-risk be- 20–21 40% (n = 167) 39% (n = 5447)
haviors in a group of undergraduate college students. The Over 21 30% (n = 127) 26% (n = 3726)
specific research questions were (a) What is the preva- Ethnicity
lence of aggression? (b) What is the prevalence of signif- White 67% (n = 291) 79% (n = 10,427)
icant depression? (c) What is the prevalence of cigarette Asian 11% (n = 47) 9% (n = 1148)
Black 5% (n = 22) 6% (n = 903)
smoking, heavy alcohol use, and drug use? (d) What are
Hispanic/Latino 4% (n = 17) 5% (n = 684)
the relationships between demographic variables, aggres-
Indian/Alaskan 1% (n = 5) .3% (n = 35)
sion, health behaviors, and depression? Hawaiian/Islander 1% (n = 4) Not asked
The study was approved by the University Institu- Mixed 1% (n = 3) Not asked
tional Review Board. Return of the anonymous ques-
tionnaire after reading the informed consent was con-
sidered consent. The University, a large, private research Descriptive statistics were calculated and differences
university located in an urban area of the Northeast, were assessed using Pearson chi-square and Pearson
had 14,144 undergraduates most of whom lived on cam- correlation.
pus. A random sample of 2500 undergraduate students
was selected by the registrar from the 14,144 registered
Results
at the University in the fall semester. The self-report
survey was distributed to the 2500 undergraduate stu- From the computer-generated random sample of 2500
dents, randomly selected by the registrar; 428 partici- student names and addresses, 164 were returned as not
pated. The survey included 30 selected items from the deliverable. Of the available sample of 2336, 428 surveys
NCRBS survey about alcohol, drug and tobacco, vio- were completed and returned, resulting in an 18% re-
lence, and aggression (Centers for Disease Control [CDC], sponse rate. The sample had more female respondents
1995). Items were selected from the categories of tobacco and an equal variation across classes. Table 1 shows
use, sexual behaviors, alcohol and drug use, and behav- the demographics of the sample, and the comparison of
iors that may result in unintentional injuries and vio- the sample with the larger University demographics. The
lence including suicide. Depression was measured by the sample had more females, more seniors, and students
21-item Beck Depression Inventory II (BDI-II; Beck, over 21 years of age, and fewer white students, fresh-
Steer, & Brown, 1996). Each item of the BDI-II is rated men, and students who were 1–19 years of age than the
on a 4-point scale, ranging from 0 to 3, with a maximum University at large.
score of 63 ( Beck, Steer, & Brown). Aggression was mea-
sured by five items adapted from the Overt Aggression
Aggression
Scale (Yudofsky, Silver, Jackson, Endicott, & Williams,
1986). The items measured the frequency of verbal ag- We examined several types of aggression: physical
gression and physical aggression against objects, self, and fighting, kicking/breaking an object, hurting others in a
others. Students who returned the survey could receive disagreement, and verbal aggression toward others. Over-
a $3 certificate for use at the student center. A second all, there were 618 reports of at least one episode of one
follow-up mailing was carried out 2 months later to im- of these four types of aggression. Thirty-six percent of
prove return rate. students reported at least one episode of any aggressive
The data were entered into a spreadsheet, verified for episode. Fourteen percent (n = 58) reported that they
accuracy, and then transferred and analyzed using SPSS. had been in at least one physical fight. Forty percent

371
College student depression and health behaviors S.J. Roberts et al.

(n = 170) had kicked or hit a wall or smashed and bro- Table 2. Moderate depression and alcohol/drug use
ken an object, but only 3% (n = 14) reported medical Moderate No Sig.
treatment for an injury related to this. Thirty-two per- Drug use in last 30 days depression depression level
cent (n = 135) reported that they had hurt someone else
Tobacco 44% 27% .003
in a disagreement or argument at least once, but only
Binge drinking Alcohol >5 60% 60% .49
4% (n = 18) reported this happening with a boyfriend or
Marijuana 42% 27% .02
girlfriend. Sixty percent (n = 255) reported at least one Cocaine 10% 2% .003
episode of verbal aggression, 19% (n = 80) six or more Psychostimulants 11% 3% .007
times.

Tobacco, alcohol, and other drug use
Thirty-two percent (n = 108) were current cigarette
smokers. Fourteen percent (n = 58) reported that they
smoked under 10 days in the last 30, while 12% (n = 50)
smoked 10–30 days of the month. Eighty-one percent
(n = 345) reported that they drink alcohol, 15% (n = 66)
reported drinking 1–2 days/ month, 47% (n = 199) 3–9
days/month, 15% (n = 62) 10–19 days/month, and 4%
(n = 18) drink 20 or more days per month. Fifty-eight
percent (n = 246) report that they had drunk more than
five drinks at one time in the last month, 15% (n = 64)
once, 36% (n = 153) 2–9 times, 7% (n = 28) 10–19
times, and one student reported binge drinking 20 or
more times each month.
Twenty-nine percent (n = 123) had smoked marijuana
in the last month, 13% (n = 54) one or two times,
11% (n = 48) 3–19 times, and 5% (n = 21) more than
20 times. Four percent (n = 15) had used cocaine, 3%
(n = 3) one or two times, 1% (n = 3) 3–9 times, and
one student had used it more than 20 times. Five per-
cent (n = 18) had used psychostimulant medication, 3%
(n = 8) only once or twice, 2% (n = 5) 3–19 times, and
one student had used them more than 20 times. Less than
1% reported using steroids.
pression scores (r = .23; p = .001). The relationship
between students with moderate depression and use of
drugs in the last 30 days is displayed in Table 2. Stu-
dents with moderate levels of depression reported signifi-
cantly more use of cigarettes, stimulants, and cocaine, al-
though only a small percentage of students used cocaine.
BDI scores were positively correlated with both verbal
(r = .33; p = .001) and physical aggression (r = .31;
p = .001). Students who reported moderate levels of
depression (on the BDI) were more likely to report a
history of forced sexual activity compared with those
without depression (14% vs. 4.8%; p = .001). Simi-
larly, a significant difference emerged between students
with moderate depression and other aggression mea-
sures. Higher rates of verbal aggression, kicking/ break-
ing objects, and other physical aggression emerged in
students who reported moderate levels of depression
(Table 3).
Gender differences were found in the relationship be-
tween depression and aggression. Moderately depressed
males were significantly more likely to report kicking/
breaking and fighting behaviors and, while females re-
ported more verbal aggression (Table 4). No significant
relationships were found between other major variables
of health behavior, depression, and aggression.

Depression
Discussion
Twenty-two percent (n = 92) of the sample reported
moderate depression that was defined by a score of 20 or Of the 2500 undergraduates selected for this study, only
greater on the BDI-II. There was a statistically significant 428 participated, representing an 18% response rate. The
difference between females and males (25% vs. 17%; p <
.03). There was no significant difference by class level. In
Table 3. Moderate depression and aggression
the past 12 months, 10% (n = 41) had suicidal thoughts,
8% (n = 35) had a suicide plan, and 4% (n = 6) had at- Moderate No Sig.
tempted suicide. Two reported that they had sought treat- Aggression depression depression level

ment for the attempt. Forced sex (victim) 14% 5% .001

Verbal 78% 58% .001
Kick/break 69% 38% .001
Relationship of depression, health behaviors, Fighting 23% 12% .03
and aggression BF/GF Physical 9% 3% .02
Hurt another person in 48% 29% .000
Of daily smokers, 47% reported being moderately de-
disagreement or argument
pressed. Frequent smokers had significantly higher de-

372
S.J. Roberts et al.
Table 4. Moderate depression, gender, and aggression
Aggression Male Female Sig. level
Verbal 71% 80% .001
Kick/break 75% 67% .000
Fighting 33% 20% .03
Hurt another person in a 50% 48% .78
disagreement or argument
sample may not have been representative of this univer-
sity or other university populations. Thus, the ability to
generalize to other schools is highly limited by the small
response rate of those who actually participated. Despite
these limitations, the study represents an attempt at ex-
ploring variables noted to be important in the literature
and forms the basis for future studies that contain more
adequate samples. This is one of the first studies to be-
gin to explore aggressive behaviors, depression, and their
relationship to other health-risk behaviors in one college
sample.
Aggressive behaviors were commonly reported in this
college student sample. Verbal and physical aggression,
fighting, kicking, and breaking were significantly related
to moderate depression, but not to other health behav-
iors. These are the first data to explore and document
the rates of different types of aggressive behaviors and
their relationship to depression, although previous stud-
ies had found a relationship between fighting and depres-
sion (Brooks et al., 2002; Patten et al., 2001). Gender
differences were found, with depressed females utilizing
more verbal aggression and males more physical aggres-
sion. These findings are consistent with the clinical liter-
ature that suggests that males who are depressed display
aggression and violence, but do not report depressed af-
fect (Pollack, 1998; Real, 1998). Although there is an as-
sumption that depression leads to aggression, these data
do not determine the direction of this relationship. Ag-
gressive behaviors were not significantly related to alco-
hol use, heavy drinking, or drug use, as found in earlier
studies (Parks et al., 2008; Valois et al., 1993).
These relationships are particularly important because
this survey also found higher rates of moderate depres-
sion in college students than were found in all but one
previous study (Wells, Klerman, & Deykin, 1987). The
rates were almost a third higher than some earlier studies
(Allgower, Wardle, & Steptoe, 2000; Wechsler, Rohman,
& Solomon, 1981). Although this finding may be spe-
cific to this campus or to use of the BDI rather a psychi-
atric interview, it is consistent with other research that
reported that depression and suicidal thoughts and be-
haviors are increasing among college students (Benton,
et al., 2003). Also of concern is that one tenth of the sam-
College student depression and health behaviors
ple had suicidal thoughts, consistent with national survey
data (ACHA, 2005; 2007; Douglas et al., 1997; MMWR,
1997), but a low rate of use of services for their distress.
These findings call for increased screening and develop-
ment of programs to find and treat students with depres-
sion in student health settings.
Interestingly, depressed students were not significantly
more likely to use and abuse alcohol. Marijuana and co-
caine use in this sample was higher, almost three times
greater than in the 1995 NCRBS (Douglas et al., 1997;
MMWR, 1997) and more consistent with current data
(ACHA, 2005; 2007). Higher rates of depression were
found in students who reported marijuana, cocaine, and
psychostimulant use than had been found in previous
studies (Glied & Pine, 2002; Weitzman, 2004). The results
reinforce previous findings that cigarette smoking is a se-
rious problem on college campuses, with nearly one third
of students currently smoking (ACHA, 2005; 2007; Dou-
glas et al., 1997; MMWR, 1997; Rigotti, Lee, & Wechsler,
2000). As in other studies, students who were moderately
depressed were significantly more likely to be cigarette
smokers (Lenz, 2004; Patterson et al., 2004; Audrain-
McGovern, 2004; Kenney & Holahan, 2008). Almost half
of the daily smokers reported moderate depression, sug-
gesting that this is a group that is most at risk for depres-
sion. These data do not address the issue of whether the
cigarette smoking is related to causing decrease in mood
or is utilized to cope with negative mood. The relationship
also suggests the need to develop strategies for college
students that include treatment for both smoking cessa-
tion and depression.
The findings of this study are important for NPs in
college health to understand and incorporate into their
work. Especially, necessary is consideration of depression
in male students who sustain injuries in fights and for
females who develop problems as a result of verbal ag-
gression. Exploration of depression while treating these
students may lead to an undisclosed depression and op-
portunity for treatment. Although students may deny
depression and may not even be aware that they are
depressed, a careful assessment may disclose it. The re-
lationship between depression and aggression, and espe-
cially the gender differences, are also areas of importance
for future research. Intervention trials such as cognitive
behavioral therapy, which take into account the connec-
tion between depression and aggression, may have the
potential to decrease the prevalence of both.
These results call not only for increased availability of
mental health services for college students, but also more
aggressive and innovative screening and outreach to stu-
dents to encourage use of services. As noted earlier, it
may be especially productive to screen students for de-
pression when they come to the attention of student
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College student depression and health behaviors
services professional as a result of injuries related to ag-
gressive behaviors and for smokers. Connections between
mental health services and primary care services to de-
velop innovative ways to identify and treat students with
depression may be necessary in light of the low rates of
seeking traditional services demonstrated in this study.
Education of students about depression and the relation-
ship with other behaviors may also increase the num-
ber of students seeking treatment (Moilanen & Bradbury,
2002). More research is needed to explore and test in-
novative screening and treatment programs focused on
depression, smoking cessation, aggressive behaviors, and
alcohol and drug use with college students. A holistic fo-
cus may be useful in dealing with multiple facets of the
student rather than focusing on changing one isolated
behavior.
Limitations
The results of this study are limited by the small sample
size, the sensitivity of the measurement tools that were
utilized, and variation in instruments decreases compar-
isons to previous research. While the BDI and NCRBS
have been used with multiple populations and exten-
sively tested, the Overt Aggression Scale has not been
utilized with college students. Also, this sample was gen-
erated in the fall and winter in New England, which may
have altered the responses, especially the prevalence of
depression and aggression.
An increased response rate could have been achieved
by utilizing different methodologies for easier response,
such as the Internet, or substituting a convenience sam-
ple such as a class or orientation, because use of the mail
service proved to be problematic. This approach may also
lead to a limited response, and students may have self-
selected out of the study for a variety of reasons. The
study needs to be expanded to a more adequate sample
to determine if the same results emerge.
Conclusions
This is one of the few studies to investigate and find that
a variety of aggressive behaviors are common in college
students. Depression is also found in almost one quarter
of the students, and only a few students sought care for
depression, even for suicidal ideation. Moderate depres-
sion was related to verbal aggression in females and to
physical aggression in males. This study also found that
cigarette smoking, which puts students at risk for a vari-
ety of current and future health problems is common and
related to depression. Consumption of alcohol and heavy
drinking was also common, but unrelated to depression
or aggression.
374
S.J. Roberts et al.
This research informs NPs in student health services
and calls for the development of innovative clinical
and research efforts to deal with aggression, depression,
cigarette smoking, and alcohol use, major problems in
this population. Increased efforts by NPs to screen col-
lege students for depression who present as smokers or
with injuries or problems related to aggressive behav-
iors can assist with early detection, treatment, and suicide
prevention.
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