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Stress, Alcohol & Depression Time Tool
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A Resource from the American College of Preventive Medicine


ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Stress, Alcohol and Depression Clinical Reference for more information.

This Time Tool is designed for adult patients in primary care who do not meet the criteria for an alcohol use disorder (abuse or dependence).

Breaking Cycles that Sustain Depression and Threaten Quality of Life

The trends are alarming:

  • Stress: 7 in 10 patients say it interferes at least moderately with their lives; over half feel it has increased in the past year.
  • Alcohol: 6 in 10 adults drink; 1 in 6 adults (1 in 5 men) binge drinks at least once a month, episodes per person are increasing.
  • Depression: 1 in 12 adults with current symptoms; projected to be the second leading cause of disability worldwide in next 10 years; use of anti-depressant medications has tripled since the early 1990s.

Interactions between stress, alcohol and depression are clear and insidious.

  • Stress doesn’t make people drink more often but it does cause them to drink excessively when they do drink.
  • Excessive alcohol accentuates the stress response.
  • Many use alcohol to improve mood or reduce anxiety.
  • Risk for depression increases as alcohol consumed per episode increases.
  • Excessive alcohol also makes baseline depressive symptoms worse.
  • A high level of stress increases susceptibility to depression.
  • Depression increases vulnerability to stress.
  • All of these interactions may be affected by genetic predisposition.

An enormous challenge for primary care...one that is not being met very well.

  • 3 out 4 patients feel unprepared to manage stress.
  • Similar proportion of clinicians feels unprepared to counsel in stress management.
  • Primary care physicians fail to recognize 30% to 50% of depressed patients, and in those identified treatment is inadequate in over half. Most on anti-depressant therapy alone still have symptoms and should receive additional treatment.
  • Only half of patients are asked about alcohol use, but only about 1 in 10 clinicians use a validated screening tool to assess excess use.
  • Fewer than 1 in 4 patients with alcohol dependence are ever treated, fewer yet who are binge drinkers.

Screening for alcohol misuse and depression are recommended in primary care.

  • The USPSTF recommends screening all patients for problem drinking, and screening for depression as long as a system is in place to diagnose and treat.

Meeting the Challenge – Implementing a Collaborative Approach with a Lifestyle Component

The Collaborative Care Model improves treatment adherence, patient quality of life, and depression outcomes, including relapse recognition and prevention.

  • Care is provided by a team -- the primary physician, a care manager (nurse), a consulting psychiatrist or clinical psychologist, and other staff to provide specific counseling.
  • Redesign to a team-based collaborative approach involves:
    • Primary physician using evidence-based approach with standard tool for measuring severity and response to treatment
    • Systematic way of tracking patients, monitoring treatment, and providing reminders between visits
    • Care manager uses tracking system, contacts patient to provide education, support, and monitoring
    • Regular communication between physician and psychiatrist (if used) on treatment plan, future needs

A lifestyle approach may be the best prescription for depression … when identified early enough.

A lifestyle approach gets to the root of chronic disease, including depression. It involves extra time BUT patient satisfaction and quality of life are the reward.

The American Medical Association Healthier Life Steps program is an easy-to-implement initiative that includes patient self-assessments and action plans to be completed quickly in the waiting room.

  • Having patients fill out the form at each visit reinforces the importance of these health behaviors and increases the likelihood of improved behaviors over time.
  • This program, however, includes only 4 behaviors: diet, physical activity, alcohol consumption and tobacco use. It does not include stress management.

Guide to a Brief Office Visit

Waiting Room:

Pre-Consult – Nurse (Care Manager if prior diagnosis)

  • Measure/record waist circumference and blood pressure.


  1. Review lifestyle (Life Steps questionnaire)

    • Assess stress as additional lifestyle factor:
    • Ask: How often do you feel nervous, irritable, or are you easily angered?
    • Ask about causes of stress in the patient’s life.
    • Ask about his or her responses to stress, both healthy and unhealthy.
    • Ask about alcohol use with the 3-question AUDIT-C (if full AUDIT not completed in waiting room):
      • How often do you have a drink of alcohol?
      • How many standard drinks do you have on a typical day?
      • How often do you have 6 or more drinks on one occasion?
    • If the response to the last question is one or more, assess for an alcohol use disorder. (NIAAA questionnaire)

  2. Assess depression

    • Ask the 2 questions of the PHQ-2 to screen:
      • Over the past few weeks, have you felt down, depressed, or hopeless?
      • Have you lost interest in or no longer take pleasure in doing things you used to enjoy?
    • If screening is positive, that is, yes to either question above:

    If depression diagnosis is negative
    (i.e., PHQ-9 ≤ 4): Discuss lifestyle changes.

    • Advise lifestyle changes to improve overall health.
    • Agree on changes to target; goals to achieve.
    • Assist with a plan, motivation, skills, anticipating obstacles, and support.
    • Arrange follow-up, along with additional counseling or referral as needed.

  3. If depression diagnosis is positive (e.g., PHQ-9 ≥ 10 suggests moderate to severe depression): Proceed with depression management program.

    • Assess suicidal thoughts and behaviors
    • Explain the basics of depression and keys to managing it:
      • Depression is a medical illness, not a character defect.
      • Treatment is effective; there are options in treatment.
      • The aim of treatment is complete remission.
      • Recovery is the rule, not the exception.
      • The risk of recurrence is significant because it is a chronic condition that needs to be managed, like asthma or diabetes.
      • Patient must be actively involved in management.
      • A healthy lifestyle helps depression, just like most other chronic diseases.
      • Seek treatment early if signs of recurrence occur (need to know these).

  4. Assess other risk factors-- family history, alcohol problems, depression, suicide, addiction.

  5. Assist with a plan to manage depression.

    • Identify and discuss issues with stress:
    • Provide education.
    • Develop plan to respond differently to stressors.
    • Develop stress recovery plan (i.e., exercise, relaxation, etc).
    • Set goals, strategies to overcome barriers.
    • Identify and discuss issues with alcohol:
    • Provide education
    • Develop plan to reduce excessive consumption
    • Set goals, strategies to overcome barriers
    • Discuss other lifestyle changes that would help.
    • Discuss benefits and risks of anti-depressant therapy, patient preferences.
    • Discuss interest in seeing a mental health professional for therapy; explain the benefits of seeing a specialist (i.e., cognitive behavioral therapy).

  6. Agree on overall plan going forward.

    • Review the options.
    • Discuss pros and cons with different approaches.
    • Address preferences, readiness to use different treatment approaches.
    • Agree on an overall plan.

  7. Arrange follow-up, along with additional counseling and/or referral to a mental health professional, if needed.

    • Schedule next visit.
    • Discuss telephone follow-up.
    • Arrange counseling visits and classes as needed.
    • Provide educational materials.

Final Thoughts
Depression is especially challenging because it does not affect a homogenous group of patients, but it undermines lifestyle behaviors and adherence to regimens for all other medical problems. There is no standardized approach to depression. We know that anti-depressants alone are not enough in the majority of cases, but are vital in many to reverse the downward spiral and may facilitate the response to other treatments, such as psychotherapy.

Success depends largely on enabling patients to be active participants in their care. Reducing stress may be the key for many. Stress, or distress, has become a significant part of everyone’s lives, and its role in the onset, course, and management of many chronic diseases is being increasingly recognized. Alcohol misuse is also very common and needs to be considered whenever stress or depression is discussed.

Often a combination of approaches, including lifestyle, cognitive behavioral therapy and social intervention, is needed. It’s why collaborative care models must be implemented.

Supporting references and additional information:

Download printable versions of these resources:

For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.

Recommended Citation

ACPM recommends using the following citation when referencing this educational program.

Excerpted with permission from the American College of Preventive Medicine. Stress, Alcohol and Depression Time Tool: A Resource from the American College of Preventive Medicine2009. Retrieved from http://www.acpm.org/?StressAlcoDepresTT..

To better serve our membership and other constituents, we would like to know how information from our website is being used.  Please send a short email to info@acpm.org with a short description of what information you are citing and for what purpose.

Copyright 2009. American College of Preventive Medicine. All Rights Reserved.

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