Risk factors for depression and anxiety in abstainers, moderate drinkers and heavy drinkers

Addiction (2000) 95(12), 1833–1845

RESEARCH REPORT

Risk factors for depression and anxiety inabstainers, moderate drinkers and heavydrinkers

BRYAN RODGERS, AILSA E. KORTEN, ANTHONY F. JORM,HELEN CHRISTENSEN, SCOTT HENDERSON &PATRICIA A. JACOMB

Centre for Mental Health Research, The Australian National University, Canberra, Australia

AbstractAims. To identify risk factors for depression and anxiety that are more prevalent in abstainers than inmoderate drinkers and to estimate their contribution to U-shaped relationships of depression and anxiety withalcohol consumption. Design. Cross-sectional general population sample. Setting. Canberra, Australia.Participants. 2725 subjects completed questionnaires, including 1128 men and 1258 women aged 18–59years. Measurements. Consumption categories from AUDIT quantity/frequency items: (1) non-drinkers(no alcohol in the past year), (2) occasional drinkers (monthly or less), (3) lower-level drinkers (up to 14standard drinks per week for men and seven for women), (4) higher-level drinkers (up to 28 and 14 standarddrinks per week, respectively), and (5) those drinking at hazardous or harmful levels (over 28 and 14standard drinks per week, respectively). Goldberg and DSSI/sAD depression and anxiety scales. A range ofdemographic, socio-economic, socio-environmental and personality factors. Findings. Non-drinkers weremore likely than lower-level drinkers to have low status occupations, poor education, current � nancialhardship, poor social support and recent stressful life events, and scored lower on extraversion, fun-seeking anddrive. Many of these characteristics also applied to hazardous/harmful drinkers. In multivariate models, theserisk factors accounted for a substantial part of the higher depression and anxiety scores of non-drinkers andoccasional drinkers relative to lower-level drinkers. Conclusions. Abstainers have a range of characteristicsknown to be associated with anxiety, depression and other facets of ill health, and these factors may contributesigni� cantly to their elevated levels of depression and anxiety.

IntroductionThere is a considerable literature describing theassociations of alcohol abuse and dependencewith mood and anxiety disorders, based on bothclinical and general population studies.1 Someattempts have also been made to explain thecausal mechanisms underlying these associa-

tions, although they are imperfectly under-stood.2–4 The focus of attention in relation todrinking has, understandably, been on the men-tal health of those with high consumption levelsor problems associated with use, especially de-pendence. In contrast, few studies have pre-sented � ndings on the mental health of

Correspondence to: Bryan Rodgers, Centre for Mental Health Research, The Australian National University,Canberra, ACT 0200, Australia.

Submitted 16th June 1999; initial review completed 27th January 2000; � nal version accepted 15th March 2000.

ISSN 0965–2140 print/ISSN 1360–0443 online/00/121833–13 Ó Society for the Study of Addiction to Alcohol and Other Drugs

Carfax Publishing, Taylor & Francis Limited

DOI: 10.1080/09652140020011135

1834 Bryan Rodgers et al.

abstainers other than the special case of ex-alcoholics. Some investigations suggest that ab-stainers may have higher levels of psychologicaldistress than moderate drinkers [The term mod-erate drinking is used throughout to denotedrinking that is more than occasional but is notat a level of consumption thought to be hazard-ous to health.].5–9 However, the � ndings areinconsistent, often non-signi� cant or of smalleffect size, and sometimes uncorrected for simpleconfounding with gender, i.e. women are morelikely to be non-drinkers and more likely toreport higher distress than men.6,7

Two recent studies, one British10 and oneAustralian,1 with samples drawn from the gen-eral population, have demonstrated clear U-shaped relationships of measures of negativeaffect (i.e. depression, anxiety or mixed psycho-logical distress) with alcohol consumption. Non-drinkers and occasional drinkers, as well as heavyand problem drinkers, had elevated risks of highlevels of negative affect. Such a pattern is re-vealed only when alcohol use is represented as acontinuum, but most investigations of co-morbidity have identi� ed alcohol abuse and/ordependence as discrete outcomes. Consequently,there is little in this literature to help explain theassociation between abstinence and negative af-fect. As well as being a topic of study in its ownright, this relationship has further signi� cance inthat it is reminiscent of the well-established U-shaped or J-shaped relationship between mor-tality and alcohol consumption,11–14 whereabstainers have higher mortality rates than mod-erate drinkers. The link with anxiety and de-pression may provide clues to the basis of theassociation with mortality. If the similarity ofpattern is more than just coincidence, this couldbe of theoretical and practical importance. Therelationship in the British study10 was evident inyoung adults, at age 33, long before mortalitydifferentials are manifested. That study, too,found other U-shaped relationships of self-reported general health and limiting illness withalcohol consumption in early adulthood.

Two possible explanations of the U-shape fornegative affect have been considered and foundwanting. First, the “sick quitter” hypothesis wastested directly in the British sample, i.e. whetherhigh levels of negative affect in ex-heavy or ex-problem drinkers could account for the raisedsymptom levels in abstainers.10 The U-shapedpattern remained even after the exclusion of

individuals who had reported heavy drinking atprevious interviews or who had ever experienceddrinking problems (as indicated by the CAGEscreening instrument). Furthermore, the Aus-tralian study found no evidence that the U-shapewas more pronounced in older compared withyounger subjects and, indeed, suggested that itmay be absent in the elderly. To address asecond possible explanation, the Australianstudy considered whether the U-shape could bean artefact of the superimposition of two distinctpopulations, (1) a group where depression andanxiety were positively and monotonically associ-ated with drinking level and (2) a group ofnon-drinkers and occasional drinkers whosesymptomatology re� ected the full range of de-pression and anxiety found in the general popu-lation. This explanation predicts a raising of theleft arm of the curve (as observed) but alsopredicts that the mean symptom score for ab-stainers will never exceed the mean for the totalpopulation, as abstainers would consist of onegroup with average depression and anxiety and asecond subgroup with low depression and anxi-ety. In fact, abstainers were found to have scoresabove the general mean,1 arguing against theartefactual explanation.

The failure to account for the U-shape byreference to the sick quitter hypothesis or to anartefactual explanation points to other possibleexplanations. Three general models have beenused to account for co-morbidity: (1) alcoholabuse leads to higher levels of depression andanxiety by contributing to the inception, dur-ation or recurrence of these disorders;15–18 (2)depression and anxiety lead to increased levels ofalcohol consumption17–20 and the persistenceof alcohol dependence21 as a form of self-medication; (3) there are common determinants,environmental or genetic, for alcohol abuse/dependence and other disorders.22–25 Thesegeneral models can be modi� ed to accommodatethe � nding of a U-shaped curve. The mostparsimonious description of an effect of drinkingon negative affect, given the U-shape � nding, isthat moderate consumption has a protectiveeffect, whether arising from alcohol use initself or from social factors connected withdrinking behaviour. For the second model,where negative affect impacts on consumption, itis necessary to include the possibility that dis-tress may increase or decrease intake. A fullaccount would therefore need to specify the

Risk factors for depression/anxiety in abstainers 1835

personal or situational moderating factors thatdetermine whether individuals show increased ordecreased consumption. Third factor models canbe of two types, where either the same factor isimplicated in the raised negative affect of bothabstainers and heavy drinkers or different factorsare implicated for the two groups. An example ofthe former type would be if � nancial hardship ledto either abstinence (because of lack of money)or heavy drinking (because of stress) and also in-creased negative affect. An example of the lattertype would be if lower sociability increased nega-tive affect and contributed to abstinence, whereasstressful life events increased both negative affectand alcohol consumption. The three generalmodels outlined are not mutually exclusive andcould all contribute to the overall pattern.

Longitudinal studies would be especially valu-able in assessing the relative contributions ofthese different potential explanations. However,cross-sectional studies can help to focus the lineof inquiry by looking for risk factors (for negativeaffect) that are more prevalent in abstainers andoccasional drinkers than in those who drink atmoderate levels, an integral feature of third fac-tor models. The present study aims to identifysuch factors and also to estimate the extent towhich they account for the difference in negativeaffect between abstainers and moderate drinkers.

MethodSampleThe target population was community-dwellingadult residents of Canberra, Australia. Potentialparticipants for the study, known as the Stressand Well-Being Project,26 were randomly se-lected from those indicated to be between 18and 79 years old on the electoral roll for Can-berra. Registration for voting is compulsory forAustralian citizens aged 18 years and over withvery few exceptions (being of unsound mind,serving a prison sentence of 5 years or more andhaving been convicted of treason or treachery).Information from the 1996 Census of Populationand Housing showed that 87.5% of persons aged18 years and over were Australian citizens.27

Detailed information on the content and purposeof the present investigation and invitations toparticipate were sent by post to 5226 individualsand were followed-up by telephone or personalcalls from interviewers. Contact could not bemade with 1172 individuals and this was at-

tributed in part to the interval since the roll hadlast been updated and to the level of migrationout of the area during that period. People whohad left the area could not be included in datacollection because the project also required col-lection of DNA from cheek swabs. Of thosecontacted, 67% (1294 men and 1431 women)consented to participate. The mean age of theachieved sample at the time of data collection,based on self-reports, was 42.6 years with 44.3%aged 18–39, 43.3% aged 40–59 and 12.4% aged60–80. This is close to the age distribution of theCanberra adult population, but with some un-der-representation of the youngest group andover-representation of the intermediate group.

Analyses for the present paper were restrictedto participants aged 18–59 years because ourearlier work1 had failed to identify a U-shapedrelationship between negative affect and alcoholconsumption in the group aged 60 and over.This left 2396 participants, 1128 men and 1258women.

Data collection and measuresParticipants responded to a self-completionquestionnaire in the presence of the interviewer.The questionnaire reiterated the voluntary na-ture of the study and the con� dential nature ofall responses. Participants’ names did not appearon the questionnaire and they were identi� edonly by a study number. They sealed their ques-tionnaire in an envelope before handing it backto the interviewer. The Committee on the Ethicsof Human Experimentation at The AustralianNational University had approved the protocolfor the � eldwork and the procedure compliedwith the National Health and Medical ResearchCouncil guidelines on human experimentation.

The questionnaire included the Australian ver-sion28 of the WHO Alcohol Use DisordersIdenti� cation Test (AUDIT),29 a 10-item instru-ment that covers recent alcohol intake, depen-dence, and consequences of drinking in respectof the reactions of others, amnesia and injury.This version has small modi� cations to the re-sponse categories of the intake items and it omitsmention of family members from the item onother people expressing concern or suggestingthe respondent should cut down on drinking. Ameasure of consumption was constructed fromthe questions on frequency of alcohol intake andnumber of standard drinks consumed on typical


drinking days, following procedures used forquantity–frequency assessment.30,31 The Aus-tralian de� nition of a standard drink (i.e. con-taining 10 g alcohol) is larger than that used inBritain (8 g). Individuals were classi� ed into � vecategories of (1) non-drinkers (had not drunkalcohol in the past year), (2) occasional drinkers(monthly or less), (3) lower-level drinkers (up to14 standard drinks per week for men and sevenper week for women), (4) higher-level drinkers(up to 28 standard drinks per week for men and14 per week for women), and (5) those drinkingat hazardous or harmful levels (over 28 and 14standard drinks per week, respectively) asde� ned by the National Health and MedicalResearch Council.32 Although the upper limit forthe category of occasional drinkers was notde� ned in terms of weekly consumption, it wasknown that 94% of these individuals typicallydrank less than 1 unit per week and that most ofthe remaining 6% drank less than 2 units perweek. In the participants aged 18–59 years, per-centages falling into these � ve groups were, formen: 8.3% non-drinkers, 18.4% occasionaldrinkers, 55.9% lower-level drinkers, 13.0%higher-level drinkers, 4.3% hazardous/harmful-level drinkers; and, for women: 13.0% non-drinkers, 27.2% occasional drinkers, 44.4%lower-level drinkers, 10.0% higher-leveldrinkers, 5.3% hazardous/harmful-level drinkers.

The questionnaire also contained four mea-sures of negative affect: the Goldberg33 de-pression and anxiety scales, with nine items perscale, and the state of depression and anxietyscales of the Delusions-Symptoms-States Inven-tory (DSSI/sAD),34,35 also known as the PersonalDisturbance Scale, with seven items per scale.Summary scores were derived in accordancewith speci� cations for the original measures. Thetwo Goldberg scores have a possible range of0–9, and the DSSI/sAD of 0–21. The factorstructure of these scales in the present samplehas been described in detail elsewhere.36

Other measures included in the questionnairethat are known to be risk factors for depressionand anxiety, either from other studies or fromthe present investigation,26 included demo-graphic information, educational background,socio-economic factors, stressful circumstancesand events, childhood adversity, social supportand a range of personality factors. Dummy vari-ables representing the never married and thosewho were separated or divorced were derived

from the question on marital status. Similarly,dummy variables representing any post-secondary education and degree levelquali� cations were obtained from responses tothe question on education. Present or most re-cent occupation was coded using Daniel’s37

status ratings. Financial hardship was indicatedby an item on whether participants or partici-pants’ families had had to go without things theyreally needed in the last year because they wereshort of money, with responses of “sometimes”or “often” being combined. Other variables indi-cated whether the participant had main carerresponsibility for someone aged or with a long-term illness or disability, and whether the partici-pant had young children (aged 5 or less) livingwith them.

Measures of social support from friends andfamily were obtained from the Provisions of So-cial Relationships scales in accordance with theoriginal scoring procedures.38 Number of stress-ful life events in the past 6 months was the sumof items endorsed in the 12-item List of Threat-ening Experiences.39,40 The original scoringmethods were also used for four subscales of theBehavioral Inhibition System/Behavioral Acti-vation System (BIS/BAS) scales,41 i.e. BIS score,BAS reward responsiveness, BAS fun-seekingand BAS drive, and the extraversion and psy-choticism scales of the short form of the EysenckPersonality Questionnaire–Revised (EPQ–R).42

The EPQ–R neuroticism scale, although avail-able, was not used for this study because it isknown to re� ect state as well as trait componentsof negative affectivity.43–47

Data analysisThe data analysis was conducted in two stages,� rst looking at the association of risk factors withdrinking categories and then incorporating anysigni� cant factors into models estimating howmuch they accounted for the pattern of associ-ation between consumption and negative affect.In the � rst stage, each risk factor was examinedas a dependent variable with alcohol consump-tion level, gender and age group as explanatoryvariables along with the interaction of genderand age. Logistic regression analysis was em-ployed for categorical risk factors and univariateanalysis of variance for continuous risk factors,using procedures within SPSS Version 8.0. Forvariables found to be signi� cantly related to


consumption level overall, additional paired con-trasts indicated which factors were signi� cantlydifferent for non-drinkers or for occasionaldrinkers, using the lower-level drinking group asa reference point. Only those risk factors meetingboth criteria of statistical signi� cance were in-cluded in the next stage of analysis.

The second-stage analysis used univariateanalysis of variance with the measures of nega-tive affect as dependent variables. These analyseswere conducted separately for men and womenbecause of previously demonstrated gender in-teractions.1 A simple initial model (Model 1)included age group as the only independent vari-able. Two alternative models were then assessed,one using the signi� cant variables relating to thesocio-economic and social environment in ad-dition to age (Model 2) and the other using thesigni� cant personality factors (Model 3). A � nalmodel introduced both sets of variables and ageconcurrently (Model 4). At each step, estimatedmarginal means (and their standard errors) wereobtained for the � ve de� ned levels of alcoholconsumption, and paired contrasts were againmade using the lower level drinking group as thereference point.

ResultsU-shaped relationships of negative affect with alcoholconsumptionOur previous work identi� ed U-shaped relation-ships of negative affect with alcohol consumptionin participants aged 18–59 years.1 There were nosystematic differences in this pattern over thefour measures of negative affect, i.e. the de-pression and anxiety scales from the Goldbergquestionnaire and the Delusions-Symptoms-States Inventory. The � ndings for the Goldbergdepression scale (the most representative of thefour measures) are presented as Model 1 in Fig.1. The graphs are shown separately for men andwomen and are adjusted for age group. Summa-rizing across measures, non-drinkers and hazard-ous/harmful drinkers were often found to havesigni� cantly higher negative affect scores thanthe lower-level drinkers. There were also someinstances where occasional drinkers and thehigher-level drinkers showed signi� cantly greaternegative affect compared with the lower-leveldrinking group, but such differences were typi-cally smaller than observed for the completeabstainers and heavier drinkers.

Alcohol consumption and risk factors for depressionand anxietyThe � rst stage of our new analyses examinedrelationships between consumption level and riskfactors for depression and anxiety. The threeavailable risk factors in the domain of socio-economic status were each signi� cantly associ-ated with drinking level. Lower-level drinkerswere more educated than all other drinkinggroups, adjusted for age and gender (Table 1).The � ndings were particularly strong whenquali� cations at degree level or above were con-sidered, but also applied to any post-school edu-cation. Occupational level was also signi� cantlyassociated with consumption and paired con-trasts with the lower-level drinking group weresigni� cant for both non-drinkers and occasionaldrinkers, with the latter groups having jobs oflower status. These � ndings are shown in Table2, where all differences from the reference grouphave been expressed as proportions of the stan-dard deviation of each measure. The third socio-economic factor, unemployment, did not differsigni� cantly for non-drinkers or occasionaldrinkers compared with lower level drinkers butwas signi� cantly more common in those drinkingat hazardous/harmful levels. There was also asigni� cant interaction with age group and therelationship held only for those aged 40–59 years(OR 5 5.62, p , 0.001).

Three family risk factors were examined (be-ing separated or divorced, being never married,and having children aged 5 or below), but nonemet the criteria of being signi� cantly related toconsumption and of being signi� cantly moreprevalent in non-drinkers or occasional drinkerscompared to lower-level drinkers. However, be-ing separated or divorced was more common inthose drinking at hazardous/harmful levels (ad-justed OR 5 1.94, p 5 0.016).

Social support, with regard to both family andfriends, was associated with alcohol consumptionand was poorer in non-drinkers and hazardous/harmful drinkers by comparison with the lower-level drinking group (Table 2).

Of three available measures of contemporarystressors, both � nancial hardship (Table 1) andlife events in the past 6 months (Table 2) weresigni� cantly associated with consumption andwere more frequent in non-drinkers, occasionaldrinkers and hazardous/harmful drinkers com-pared to the lower-level drinking group. How-ever, having a caring responsibility for someone


Figure 1. Adjusted mean Goldberg depression scores by alcohol consumption level (lower-level drinking group as point ofcomparison).

with a long-term illness or disability was notassociated with alcohol consumption. Childhoodfamily adversity was related to drinking level(F(4, 2341) 5 3.85, p 5 0.004), but only thosewith the higher level of consumption (p 5 0.001)and those drinking at hazardous/harmful levels(p 5 0.022) differed signi� cantly from the lower-level consumption group, both reporting agreater frequency of adversity. This pattern wasalso seen for the individual variables representingfathers’ and mothers’ problems with drinking orother drug use, although the relationship withmothers’ problems was only evident in the olderparticipants (40–59 years). There was no sugges-tion that non-drinkers or occasional drinkers hadan increased likelihood of reporting drinking orother drug problems in their parents.

Three of the six personality measures showed

no signi� cant relationship with alcohol con-sumption level, speci� cally the psychoticismscale of the EPQ–R, the BAS reward responsive-ness scale and the BIS scale. Both EPQ–R ex-traversion and BAS fun-seeking were associatedwith consumption (Table 2). These measuresshowed more linear associations with drinkinglevel than other risk factors, non-drinkers beingthe most introverted and least fun-seeking, butthe non-monotonic nature of these relationshipswas still seen in that the higher level-drinkinggroup was the most extraverted and fun-seekingrather than those drinking at hazardous/harmfullevels. Some similarity in the � ndings for the twoscales was anticipated, as the correlation betweenthem was 0.44 in the present sample.48 However,a difference between the results was the � ndingof an interaction with age group only for BAS


Table 1. Odds ratios for categorical risk factors by alcohol consumption levels (adjusted for gender and agegroup)

Non- Occasional Lower- Higher- Hazardous/drinkers drinkers level† level harmful

(N 5 258) (N 5 549) (N 5 1188) (N 5 273) (N 5 116)

Post-school education 0.81 0.73** 1.00 0.90 0.66*Degree quali� cation 0.73* 0.62*** 1.00 0.72* 0.45***Financial hardship 1.35* 1.35** 1.00 0.97 1.76**

†Reference group for estimation of odds ratios and paired contrasts. *p , 0.05; **p , 0.01;***p , 0.001.

Table 2. Standardized differences in means for continuous risk factors by alcohol consumption levels (adjustedfor gender and age group)

Non- Occasional Lower- Higher- Hazardous/drinkers drinkers level† level harmful

(N 5 258) (N 5 549) (N 5 1188) (N 5 273) (N 5 116)

Occupational level 2 0.25*** 2 0.26*** 0.00 2 0.12 2 0.10Family support 2 0.25*** 2 0.04 0.00 2 0.10 2 0.30**Friend support 2 0.39*** 2 0.09 0.00 0.02 2 0.30**Life events 0.20** 0.10* 0.00 0.04 0.29**EPQ–R extraversion 2 0.38*** 2 0.11* 0.00 0.17* 2 0.07BAS fun-seeking (all) 2 0.21** 0.00 0.00 0.21*** 0.06

18–39 years 2 0.45*** 2 0.11 0.00 0.24* 2 0.0240–59 years 2 0.01 0.14 0.00 0.20* 0.13

BAS fun-seeking (all) 2 0.09 0.01 0.00 0.11 0.11Men 0.08 0.04 0.00 0.00 0.04Women 2 0.17* 0.00 0.00 0.27** 0.16

†Reference group for differences in estimated means and paired contrasts. *p , 0.05; **p , 0.01;***p , 0.001.

fun-seeking, where the pattern described abovewas largely derived from the younger partici-pants, aged 18–39 years (Table 2). The BASdrive scale was also associated with drinkinglevel, but there was a signi� cant gender interac-tion such that this relationship was prominent inwomen and not evident in men (Table 2). Forwomen, the pattern was similar to that alreadydescribed for extraversion and fun-seeking, i.e.non-drinkers had the lowest drive scores with apeak for the higher-level drinking group.

Risk factors and the relationship between consump-tion and negative affectThe second stage of analysis determined theextent to which the 10 risk factors identi� ed inthe � rst stage (Tables 1 and 2) contributed tothe U-shaped relationship between alcohol con-sumption and negative affect, with particularreference to the differences between non-drinkers, occasional drinkers and those whodrank at the lower level of consumption.

Table 3 shows the results of the paired con-trasts for non-drinkers and occasional drinkers(relative to the lower-level drinking group) foreach measure of negative affect used in thestudy. These estimates were obtained from thefour statistical models described in the methodsection, carried out for men and women sepa-rately. Positive values indicate that groups hadhigher mean scores on the outcome measurethan the lower-level drinkers, after adjusting forthe other variables indicated. Participants wereincluded in analyses only if they had valid dataon all the independent variables used in thesemodels.

The � gures for Model 1, i.e. adjustment forage group only, show higher mean negative affectscores for non-drinkers compared to the refer-ence group (indicated by positive values in the� rst column) and, to a lesser extent, higherscores for occasional drinkers (second column)consistent with the U-shaped relationship re-ported previously.1 When adjustments weremade for socio-economic and other social vari-


Tab

le3.

Pai

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mea

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22M

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33M

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Sex

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0.4

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180.

240.

030.

320

.11

0.21

0.01

dep

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ion

F0

.84*

**0.

38*

0.34

0.19

0.71

**0

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0.30

0.20

Gol

dbe

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20

.01

0.11

20.

152

0.04

20.

100

.03

20.

192

0.06

anxi

ety

F0

.66*

*0.

29**

0.16

0.12

0.59

*0

.28

0.15

0.12

DS

SI/

sAD

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.73*

0.07

0.45

20.

170.

62*

20

.01

0.40

20.

20d

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1.2

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0.17

0.50

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0.4

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130.

202

0.06

0.32

0.0

60.

162

0.09

anxi

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.17*

**0.

360.

530.

170.

99**

*0

.34

0.45

0.17

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1


ables (occupational status, education, current� nancial hardship, social support from familyand friends and recent life events) in Model 2,these differences were greatly reduced and manybecame non-signi� cant. By contrast, adjustmentfor personality factors (EPQ–R extraversion,BAS fun-seeking and BAS drive) in Model 3 hadmuch less impact on differences in estimatedmeans. Consistent with this, the � gures forModel 4 (adjustment for all factors) are littledifferent to those from Model 2, i.e. the additionof personality factors is not of great importancewhen socio-environmental factors have alreadybeen taken into account. A further feature of thetable worth noting is that the majority of differ-ences for non-drinkers in Model 4 are still posi-tive, even if not statistically signi� cant, indicatingthat adjustment for all the risk factors identi� eddoes not completely account for their elevatednegative affect scores relative to the group drink-ing at lower consumption levels.

Table 3 concentrates on non-drinkers and oc-casional drinkers, but it is also instructive to seehow adjustments for the 10 risk factors impacton the U-shaped relationships seen across thefull range of alcohol consumption. This is illus-trated in Fig. 1, using the example of the Gold-berg depression scale, where estimated meansfrom Models 1 and 4 have been plotted across all� ve consumption levels, for both men andwomen. The lower-drinking level group wasagain used as a reference point, by adjustingestimated means so that values for that group aresuperimposed in the � gure. The graph con� rmsthe way in which adjustment for the set ofidenti� ed risk factors attenuated the relation-ships of Goldberg depression score with non-drinking and occasional drinking, but it alsoshows how a substantial (and statisticallysigni� cant) part of the association with hazard-ous/harmful drinking remained. This was con-sistent across all four measures of negative affect.In other words, the risk factors identi� ed andincluded in these models accounted for only asmall part of the elevated negative affect in thosedrinking at hazardous/harmful levels.

DiscussionThese analyses have shown, in a general popu-lation sample, that non-drinkers differ fromthose drinking at moderate levels on a range ofsocio-economic, social and personality measures,

factors that are known correlates of anxiety, de-pression and general psychological distress. Fur-thermore, statistical adjustment for these riskfactors, especially the socio-economic and othersocial variables, accounted for a large part of thedifferences in negative affect between non-drinkers and moderate drinkers and all residualdifferences were non-signi� cant. Adjustment forthe same set of risk factors accounted for some ofthe differences in negative affect between heavydrinkers and moderate drinkers, but substantialand signi� cant differences remained. Beforeelaborating on the implications of these � ndingsthere are some limitations of the present study toconsider.

The � rst limitation is that the measure ofalcohol consumption derived from the AUDIT issomewhat crude. However, misclassi� cation ofconsumption as a consequence of randommeasurement error would tend to reduce ob-served differences between groups in both thepresence of risk factors and the levels of negativeaffect. Furthermore, the U-shaped relationshipbetween negative affect and drinking level is seento be robust for different measures of consump-tion.1,10

A second limitation is the high non-contactrate in the study (22%), partly attributed topotential participants having moved out of theregion but remaining on the electoral roll, andthe additional non-participation rate even whencontact was made (26%). There is a furthershortfall in covering adult residents, arising fromthe 12.5% of the adult population that are notAustralian citizens.27 Some of this proportion ismade up of temporary visitors and temporaryresidents but there are also many permanentresidents who have not quali� ed for or have nottaken up citizenship. However, there is no evi-dent reason for why non-contact, refusal oromission of non-citizen residents should result ina U-shaped relationship of negative affect withconsumption. This would require either thatmoderate drinkers with high negative affect weredisproportionately likely to leave the area or thatabstainers and heavy drinkers with low negativeaffect were more likely to leave. Neither of theseaccounts appears plausible. Similarly, it is notevident how selective non-participation couldlead to non-monotonic relationships betweenrisk factors and consumption level.

A third limitation is that the present studymakes no distinction for subtypes of non-


drinkers or occasional drinkers. It has beendemonstrated that non-drinkers are a heteroge-neous group and that ex-drinkers (or ex-problemdrinkers) and never-drinkers differ on factorsother than just their consumption histories.9,49–52

Although a longitudinal study10 has shown thatthis is not a satisfactory explanation for differ-ences in negative affect in relation to currentconsumption level, there is still the possibilitythat differences in risk factors may be attribu-table to one or more subtypes of non-drinkers.This issue could not be addressed directly in thepresent investigation but a general point can bemade here. Although concern has been ex-pressed about the heterogeneity of non-drinkers,the likely heterogeneity of other consumptiongroups has been overlooked. Goldman & Naj-man’s50 study in Boston indicated that the pro-portion of ex-problem drinkers among abstainers(9%) was no greater than among “occasional tomoderately frequent” drinkers (10%). In theBritish longitudinal study10 at age 33, the pro-portion of ex-heavy drinkers and ex-problemdrinkers was greater in light drinkers than innon-drinkers and substantially greater still inthose with higher, but still moderate, drinkinglevels. The issue, therefore, is not simply one ofheterogeneity within abstainers but a more gen-eral one of past drinking history, whatever thelevel of current consumption. The absence ofdata on drinking history is indeed a shortcomingof the present study, but the evidence availablesuggests that failure to account for this wouldtend to underestimate the differences betweennon-drinkers and moderate drinkers rather thanexaggerate them.

A fourth limitation is that the sample size didnot permit detailed analyses within subgroups ofthe population (with the exception of gender).Even the strati� cation into age bands necessi-tated broad categories, as there was insuf� cientpower to test interaction terms involving smallergroups. We are currently investigating age differ-ences in the U-shaped pattern using larger sam-ples.

A � fth limitation is that the present study isrestricted to a single geographical location andculture. The similarity in � ndings betweenBritain and Australia1,10 suggests that the latter isthe more important, certainly for the relationshipbetween consumption and negative affect. Itseems very likely that the character of abstainerswill vary across different cultural groups, and

may differ according to associations with re-ligious beliefs and economic prosperity and berelated to the prevalence of abstinence in par-ticular populations.

A sixth, and most important limitation is thatthe present study is cross-sectional and so itcannot be assumed that the differences found inrates of risk factors have a causal impact onnegative affect. The only defence in this respectis that many of these risk factors have long beenconsidered to be important determinants ofmental and physical health outcomes,53–56 but itis also plausible that the causal in� uence occursin the reverse direction. In other words, non-drinkers may have poorer socio-economic cir-cumstance and social support and experiencemore life events as a consequence of their higherlevels of negative affect. This interpretation im-plies that some other mechanism is necessary toexplain the elevation in negative affect.

Accepting these limitations this investigationdoes, nevertheless, identify a number of riskfactors that can be utilized in longitudinal inves-tigations to see if they precede or follow therelationship between negative affect and absti-nence. The domains of socio-economic circum-stances, social support and life events appearmore relevant than personality factors in theirpossible contribution to the different levels ofdepression and anxiety across consumptiongroups. The absence of any difference in BISscores between non-drinkers and moderatedrinkers is especially signi� cant as this impliesthat there is no difference in emotional predis-position to anxiety and depression between thesegroups. However, personality factors in generalshould not be completely ignored in regard toother possible outcomes, such as physical healthand mortality, where they could perhaps play amore important role. Of course, there may beadditional relevant factors that were not includedin the data collection for the Canberra Stress andWell-Being Project. The results as to which indi-vidual social factors differ between non-drinkersand moderate drinkers are largely as expected.The lower socio-economic status and educationof non-drinkers is a common � nding in theliterature over time and across locations9,57–61

and, although there appears to be less empiricalevidence, the association between abstinence andlower sociability is also consistent with earlierwork.63,63 The elevated frequency of recentstressful life events in non-drinkers was not so


readily anticipated, either intuitively or from pre-vious research, but J-shaped curves in relation toconsumption level can be derived from the� gures presented by Bell et al.,6 similar to the� ndings from the present study. If the risk fac-tors identi� ed in the present study prove to beinstrumental in raising levels of depression andanxiety in abstainers compared with moderatedrinkers, then other putative explanations (suchas a protective effect of alcohol consumption)would make a relatively minor contribution inaccounting for the left arm of the U-shapedcurve.

Although not a primary objective of this study,the relationship between negative affect and haz-ardous/harmful consumption is demonstratedvery clearly and it persists after adjustment forthe other risk factors included in multivariatemodels. A part of the residual association may beattributable to other confounding factors omittedfrom these models (e.g. childhood adversity andmarital status) and there could also be directcausal links, in either direction, as outlined in theintroduction to this paper. The general impli-cation of this � nding is that different explana-tions are required for elevated negative affect innon-drinkers and heavy drinkers, respectively.

Above all, this study shows that abstainersdiffer from moderate drinkers on a wide range ofcharacteristics and that many of these factors areknown to be linked with poorer health. Non-drinkers have been a neglected group in alcoholresearch, as pointed out by Goldman & Naj-man,50 with few investigations of their character-istics in regard to personality and lifestyle. In the15 years since the Boston study,50 an accumula-tion of evidence has indicated that abstainers areat greater risk of mental and physical healthproblems, hypertension and mortality than aremoderate drinkers.11–14,64,65 A substantial part ofthe U-shaped relationship for mortality arisesfrom the protective effect of alcohol consump-tion on coronary heart disease, which is evidenteven for relatively high drinking levels,61,66–68 inconjunction with increasing rates of death fromother causes with increasing consumption. How-ever, other causes of death also reveal someadvantages for moderate drinkers compared toabstainers, and the reasons for this are not fullyknown.12,13,61 The new evidence on self-ratedhealth and negative affect adds to this pictureand the magnitude of the differences found, non-drinkers having approximately double the preva-

lence of poorer health than light or moderatedrinkers,10 suggests that this is not a trivialphenomenon. Abstinence is relatively commonin the general population (e.g. rates of 10–30%in younger cohorts of industrial societies) com-pared to drinking at levels recognized as hazard-ous or harmful, and this contributes to its publichealth signi� cance. However, the paucity ofknowledge on the broader characteristics of non-drinkers stands in stark contrast to the infor-mation now gathered on their health status.Some of the factors identi� ed in the presentinvestigation may help to account for theirpoorer health.

AcknowledgementThis work was supported by a Unit Grant fromthe National Health and Medical ResearchCouncil (No 973302).

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Risk factors for depression and anxiety in abstainers, moderate drinkers and heavy drinkers

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