The men's drinking behaviors prior to making their most recent juramento were self-reported, and as such, were not solicited or measured using a diagnostic nosology, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Self-reports have been found to be valid in assessing drinking practices [54, 55]. Based on their self-reports, we categorized their drinking according to one of the following drinking types: binge drinking, heavy drinking, problem drinking, alcohol dependence, and alcohol abuse, as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA). These are the five drinking types that increase one's risks for harmful consequences, including an alcohol use disorder, or AUD, such as alcohol dependence. In categorizing the men's drinking, we used one or more of the following criteria, as found in the definitions of the five drinking types: frequency of drinking, the amount of alcohol consumed, the intent behind the drinking, and the harm caused by the drinking. According to NIAAA, binge drinking is the consumption of alcohol with the intent to become inebriated. For the men, it was defined as at least five alcoholic drinks in two hours [56]. Heavy drinking is when an individual binge drinks five or more days in the last month [56]. Problem drinking may include binge drinking and heavy drinking and results in accidents, injuries, and other issues resulting from drinking alcohol [57]. Alcohol dependence, or alcoholism, is when an individual loses his or her control over alcohol intake [58]. It is characterized by intense alcohol cravings, high tolerance, and withdrawal symptoms when a person quits using alcohol. Alcohol abuse occurs when a person is not physically dependent upon alcohol, but drinking is resulting in serious health issues and problems at home or work [58]. Alcohol dependence and alcohol abuse are considered alcohol use disorders because they result in chronic

### *The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

relapsing brain disease characterized by compulsive drinking, loss of control over alcohol intake, and a negative emotional state when not using alcohol.

NVivo software was used to code text and to store, sort, and retrieve relevant text generated from questions in the priest and *jurado* semi-structured interviews. The data was coded by two members of the team, at first independently from each other, and later together for consistency. Inductive coding was used to identify themes, especially emerging themes. When coding, we assigned labels to words and phrases that represent important (and recurring) text in each response. A thematic analysis of the coded text was then performed, as is standard in qualitative research. Themes around drinking were developed around the quantity of alcohol consumed, especially prior to making a *juramento*, frequency, and drinking problems that emerged as a consequence. The drinking was then identified and categorized as binge drinking, heavy drinking, problem drinking, alcohol dependence, and alcohol abuse using standard definitions of each type of drinking. The core elements of the *juramento* were also identified and analyzed, as were ad hoc themes related to making a *juramento*, such as religious beliefs and family and community religious practices as shared by the *jurados*, the nature of religious catharsis of the pledge, and examples of the challenges and moral fortitude needed in keeping the promise of abstinence. Recurrent themes were identified in each category as they emerged through repeated review of the textual data. Descriptive reports were prepared around the different themes and subthemes that were used to prepare manuscripts for publication.

### **4. Findings**

Although records are not kept, the priests report that anywhere from 30 to over 50 *juramentos* are made in any given month at our research site. Despite this high number, the *juramento* is not part of the church's structure because, as discussed earlier, it is not recognized by Catholic Church doctrine. Instead, the *juramento* falls under pastoral care—the visiting, counseling, and helping parishioners who are experiencing a difficult hardship. The church where the *juramentos* are made is part of the first national parish for Hispanics of the region's archdiocese. Prior to its construction a decade ago, the Latinx community attended services at local church parishes, and the *juramentos* were made at a nearby Catholic mission for this community, which housed the offices of the priests who looked after the spiritual welfare of the Latinx population and offered social services. This national parish was established to accommodate the rapidly growing Latinx population in the region, which consists primarily of Mexican immigrants and their U.S.-born children, many of whom are now adults with their own children. Puerto Ricans and Guatemalans comprise other significant Latinx groups in the area. The parish serves an estimated 12,000 Latinx parishioners from several local communities.

### **4.1 The** *juramento* **process**

The *juramento*, as administered at our site, is a highly ritualized brief intervention around a counseling session and the pledge to Our Lady of Guadalupe to abstain from alcohol use. It is a private affair and only includes the priest and the *jurado*, and occasionally a family member who is present to provide support. Unlike a formal brief intervention, such as SAMSHA's Screening, Brief Intervention and Referral to Treatment, or SBIRT [59], it does not include a screening instrument to assess the drinking problem nor a referral to formal treatment [6]. Four general steps are involved in making a *juramento*. It starts with a counseling session with

a priest at his office or in private at the church. The purpose of this session is to discuss the individual's drinking and the problems that it creates for him and his family. The severity of drinking is identified through an informal discussion about his behaviors and any resulting problems. Additionally, they discuss the seriousness of making a pledge to Our Lady of Guadalupe, and the importance of seeking additional help. The second step involves determining an abstinence period, usually no more than one year, and preparing an *estampita*, or prayer card. On one side of the card is the image of Our Lady of Guadalupe, and on the other, a *juramento* prayer, which is written as a pledge with the name of the *jurado*, the abstinence period, and the signature of both the *jurado* and the priest. The prayer card is a symbolic contract to enter and keep a sacred pledge. The third step is the reciting of the *juramento* prayer, together with the priest, preferably in front of the image of Our Lady of Guadalupe. The fourth and last step is the *bendición*, the priest's blessing of the *jurado*. There is no follow-up after the intervention. During the abstinence period, the pledge is fortified with prayers to the saint and with regular attendance at mass. The *juramento* is renewable once it is completed and may be repeated as many times as deemed necessary.

The men made *juramentos* not only in southeastern Pennsylvania, but also in Mexico. While living in Mexico, one man traveled to Mexico City to make two *juramentos* at the Chapel of the Juramentos at the Shrine of Our Lady of Guadalupe. Regardless of where they were made, nearly all the *juramentos* were made to this saint. Only two of those made in Mexico were made to a different religious figure—one to El Señior de las Maravillas and the other to El Señor de Chalma. On average, the men each made two *juramentos*, but individually this number ranged from one to five per person. The abstinence periods were from forty days to five years; however, the majority were for a year. Most of the men remained abstinent after completing their *juramento*, some for years, and did not make another until they saw it necessary, either to fend off the temptation to drink or to stop drinking after having resumed. Nearly all completed their *juramentos* only two *juramentos*, both made in Mexico, were not fulfilled by the *jurados*. In these two cases, the men sought absolution from the priest who performed the *juramento* and made another.

### **4.2 Drinking behaviors and prevention**

The drinking behaviors of the fifteen men in our sample, prior to making a *juramento*, ranged from occasional binge drinking to heavy drinking. In all, three of the men were classified as occasional binge drinkers and three as binge drinkers, eight as heavy drinkers, and one as an alcohol abuser. None suffered from alcohol dependence. We also did not find any problem drinkers, as defined in the literature.

We divided the binge drinkers into two general types—occasional binge drinkers and binge drinkers. Occasional binge drinkers did not binge drink every week. They were social drinkers who engaged in casual drinking with friends and relatives on a weekly basis, usually on the weekends, and who only engaged in binge drinking once or twice a month without doing so again for weeks and months. Unlike the binge drinkers, their intent in drinking was not to get inebriated but to relax and enjoy the moment socially. However, during certain times of the year, such as Christmas or visits to the homeland, occasional binge drinkers would depart from their established drinking pattern and would binge drink in two or more weeks consecutively. Binge drinkers binged every weekend, with a few exceptions. The drinking would start on a Friday night, after work, and continued through Saturday night. The rest of the week they may have a beer or two after work.

*The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

### *4.2.1 Occasional binge drinkers and secondary prevention*

The three occasional binge drinkers only made one *juramento*, either for six months or a year. The men fulfilled their *juramentos* and afterwards remained abstinent. Although their binge drinking was infrequent in comparison to the other binge drinkers, occasional binge drinkers sought a *juramento* because they were concerned about their drinking getting out of hand and resulting in problems over time. There was no evidence that they were harming themselves or others with their drinking, but according to them, the potential to do so was there. Notably, the men did not want their drinking to interfere with work and the sending of remittances back home. These monies cover basic needs for their families, such as shelter, food, and medicine. The money transfers are also used to build a house or start a small business, such as a small general store in the neighborhood or a food eatery, and to invest in the education of their children.

Miguel (pseudonym), an immigrant worker in his thirties from the state of Mexico, is one of the occasional binge drinkers. He is married with four children, all of whom live with him locally. Miguel has 10 siblings: half live in Mexico, and half in the United States. Miguel left Mexico in his late twenties because he could not find gainful employment there. Although he lives in Pennsylvania with his immediate family, Miguel continues to send remittances to his parents on a regular basis.

Miguel only made one *juramento* and is currently fulfilling it. It was made in Pennsylvania. He made the *juramento* for a few reasons, not just one. One of them was his concern about his increased drinking over time. Although he did not drink every week, as do some of his co-workers, he felt that his drinking was getting out of hand. Every time he drank socially, his drinking was no longer limited to a beer or two, as it was when he first started drinking. Miguel had two other major concerns: one was his temptation to drink when he was around others who were indulging, and the other was his general health. He was a diabetic, and he knew that alcohol was not good for him.

Prior to making a *juramento*, Miguel tried several times to stop drinking on his own, but after two or three months, he would return to drinking. After making the *juramento*, this was no longer the case. He now is two months shy of completing it. Miguel credits Our Lady of Guadalupe for his abstinence. In his words,

*I have always believed in the Virgen of Guadalupe, since I was a child. I have faith in others, other saints, but since I can remember, my mother always had her virgincitas, as is customary. You can say that she is my preferred saint. I always entrust myself to the Virgen of Guadalupe.*

Our Lady of Guadalupe provided him with the necessary strength to abstain. She was present during temptation, as he shared. He used his *juramento* prayer card for strength and to ward off peer pressure to drink. As he puts it,

*Sometimes, I would have to tell them that I am jurado [under the pledge to Our Lady of Guadalupe] … If they did not believe me, I would show them my card. I always carry the virgincita with me.*

For Miguel and the two other occasional binge drinkers, it is possible that their *juramentos* contributed to prevention, although more research on the causality between making a *juramento* and prevention is needed. We discuss the need for additional research on this subject later in chapter. The men were already exhibiting early symptoms of harmful drinking, but not signs of heavy drinking or worse. No screening instrument is used in the *juramento* process to determine whether

their drinking is harmful or not; the two priests in our sample hold the *juramento* counseling sessions and employ a variation of motivational interviewing to get the men to reflect on their drinking and to consider making changes. The men reach their own conclusions about their drinking and choose what type of help they desire. Risk factors for more serious alcohol use were also identified in the session and discussed. The resulting *juramento* gives them strength to remain abstinent for months, if not years, which is a major goal in achieving sobriety and recovery. The abstinence period may serve to stop the progression of the men's drinking from occasional binge drinking to heavy drinking. During their hiatus from drinking, the men learn that there is another way of living. Instead of drinking or spending time fighting the urge to drink, they focus on themselves and their families, return to their religious convictions, and reaffirm their place in the larger community.

### *4.2.2 Heavy drinkers, alcohol abusers, and tertiary prevention*

The heavy drinkers in our sample made more than one *juramento*, and not always consecutively. Some made a *juramento* immediately after completing one, while others would remain abstinent for months or years before making another. *Juramentos* were made as needed. The heavy drinkers, including the one individual who was abusing alcohol, exhibited evidence of tertiary prevention benefits of the *juramento*—mainly slowing the progression of harmful drinking. The drinking of these men was beyond the level of the occasional binge drinkers, and they were no longer showing early signs of harmful drinking. They were already exhibiting a serious drinking problem, and as such they were outside of the realm of secondary prevention benefits.

Juan Manuel (pseudonym), a migrant in his fifties from the State of Hidalgo, near Mexico City, is one of the heavy drinkers in our sample. He is separated from his wife and has five adult children who live in the same community. Like the other *jurados* in our sample, Juan Manuel is from a rural region with a depressed economy, and like many men there, he migrates to the United States to work. He migrates as needed and periodically spends months and years away from Mexico.

Juan Manuel started drinking at a young age. By the age of 18, he was already binge drinking, and by his twenties, he was drinking heavily when he could afford to buy alcohol. Juan Manuel made his first *juramento* in his thirties, after seeking help with Alcoholics Anonymous in his hometown for five months. He wanted to stop drinking because he was having problems at home. The *juramento* was made at the Chapel of Juramentos at the Shrine of Our Lady of Guadalupe, during a pilgrimage on her feast day. He remembers the counseling session with the priest there, especially the questioning about his commitment to fulfilling the pledge. The second *juramento* was also made there after another pilgrimage, four months after he had completed the first. The abstinence period was for five years. This length of abstinence is unusual, but the priest at the chapel allowed him to make a *juramento* for this time period because Juan Manuel had successfully completed his first one. He chose to make a 5-year *juramento* because he was planning to migrate to the United States for work, and he did not want his drinking to interfere with his stay abroad. Juan Manuel completed the *juramento* while in the United States and did not drink again for another year. However, he resumed drinking again when he returned home and discovered that his wife had been cheating on him while he was away. Six months later, he made his third and last *juramento* in his hometown; it was for one year. Since his last *juramento* he has not consumed alcohol and has no desire to do so.

Luis (pseudonym), also a migrant worker in his fifties, and from a state adjacent to Juan Manuel's home state, is the only one in our sample whose drinking was

### *The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

determined to qualify as alcohol abuse. He is married with four children, all of whom live in Mexico. Luis is an experienced migrant worker who has spent many years working elsewhere in Mexico and the United States. Luis provides for his family by sending remittances on a regular basis.

Luis' drinking trajectory was like Juan Manuel's. He, too, started drinking at a young age and was drinking heavily in his 20s before making his first *juramento*. In all, he has made five: three in Mexico and two in Pennsylvania. Luis made his first *juramento* in his twenties, as Juan Manuel did. The pledge was for a year and a half and was made because his drinking was disrupting his home life. Luis would miss work and lose his employment, and consequently, his family was left in dire straits. He made four other *juramentos*—the second for one year, the third for five years, and the fourth for a year, as was his fifth and last. Like Juan Manuel, Luis made the five-year *juramento* because he was planning to migrate to the United States, and he did not want his alcohol consumption to interfere with work and with his ability to save enough money to construct a house for his family in Mexico. He completed this lengthy *juramento* in the United States, and a year later made another after he started drinking again. At the time of the interview for the study, he had just made his fifth *juramento*.

For Juan Manuel and the other heavy drinkers, including Luis, who were already engaged in harmful drinking and at risk for alcohol dependence, the *juramento* may have played a role in preventing it from occurring. It may have kept them from causing further harm to themselves and their families. In Luis's case, he made several *juramentos* to maintain sobriety over time. These men underwent the same counseling session with the priest as did Miguel and the other occasional binge drinkers. The session did not target them as heavy drinkers in danger of suffering from alcohol dependence, but it did focus on the particulars of their drinking. The priests are not familiar with the different types of harmful drinking, as defined by the NIAAA, and so do not apply such classifications. Like all the counseling sessions, the motivational interviewing centered around getting the men to think of the many perils of their drinking and to consider taking action to change their lives. Moreover, as in the case of Miguel and the other occasional binge drinkers, the abstinence made possible by the *juramento* may have kept the men's drinking from progressing during the *juramento,* and in some cases, for months or years of the post-*juramento* period. It provided them with the necessary time to reflect and work on their drinking.

### **5. Discussion**

Our study suggests that the *juramento* may only be beneficial to those who are religious and turn to their beliefs when troubled. The DUREL scores of all the men were high across the three major dimensions of religiosity: organizational religious activity, non-organizational religious activity, and intrinsic religiosity (or subjective religiosity). The DUREL has an overall score range from 5 to 27, and men's score ranged from 26 to 27. All are devout to their faith, and in particular, to Our Lady of Guadalupe. They practice a religion, Catholicism, that teaches that one is never alone in life and that the saints are always present to help. Crucially, sinners are not excluded from this divine assistance, which means that they can always turn to the saints, even if they feel ashamed or embarrassed to seek help from other people. They were taught this at an early age as children and are reminded of it daily in their communities in Mexico and the United States.

The men's religiosity is of no surprise when their religious backgrounds are considered. All were raised in a religious household where Catholicism was an integral part of daily life. Their childhood homes had altars devoted to Our Lady of Guadalupe and other saints. The altars, as they explained, were sacred spaces for reflection, prayer, and paying homage to saints. Their families regularly attended church and observed the different feast days of the saints and other religious events. As children and adolescents, the *jurados* attended catechism and learned about Catholic doctrine, and completed the Sacraments of Initiation, such as baptism, confirmation, and the Eucharist. The Sacrament of Penance, or confession, was also commonplace. Some were not always devoted to their faith during their adolescence or later in life, especially when drinking, but they never strayed far from their religious beliefs.

Although the *juramento* is not a formal public health intervention, it goes beyond just facilitating abstinence. It may also result in secondary and tertiary prevention, stopping the progression of the men's drinking. In our sample, the *juramento* may have kept occasional binge drinkers from becoming heavy drinkers and heavy drinkers from becoming alcohol dependent. None of the men were in this drinking category before making their *juramento*. Consequently, we did not get an opportunity to see if the *juramento* also served as an intervention with prevention benefits for those suffering from alcohol dependence, i.e., whether it kept men with alcohol dependence from continuing to drink. However, research shows that abstinence is unlikely to be successful for individuals who already meet the criteria for dependence without some type of formal treatment. This kind of drinker may need more attention than what the *juramento* can provide for achieving abstinence and preventing a return to drinking.

To grasp how the *juramento* intrinsically works and how it could result in secondary and tertiary prevention, you must understand the sacred pledge and dyadic relationship entered with Our Lady of Guadalupe. It starts early in the juramento process, during the making of the vow to Our Lady of Guadalupe. As a 34-year-old immigrant makes clear, she is at the center of the *juramento*:

*"You keep the pledge because you made it to the virgin, and for Mexicans and Catholics the virgin is like your mother.  You value and respect your mother". … "this is the power of the juramento, when you are truly committed to changing and have strength in your faith …".*

This saint is the symbolic mother of all Mexicans, including those living abroad. Mothers are revered in Mexican culture and society. In fact, the two most important celebrations in the country are December 12, the feast day of Our Lady of Guadalupe, and May 10th, Mother's Day. The importance of Our Lady of Guadalupe in Mexican life is obvious to the faithful and is not reserved for only the *juramento*. It is believed that she intercedes on their behalf and are close enough to God to prompt an intercession with a difficult problem, including granting a miracle when needed.

The vow made to Our Lady of Guadalupe reconnects the *jurados* to their faith and results in a powerful, religious-based catharsis. It sets the right frame of mind for recovery. The *juramento* creates a sense of hope in both the *jurado* and his family that the drinking will stop, as will the problems that come with it. The men shared that it releases them from shame of drinking and the harm committed to others, and in turn, gives them hope for turning their lives around and gaining lost respect in their families and communities. Further, this spiritual awakening allows them to reconcile with their church, religion, and ultimately God, which they were estranged from because of their drinking. Feeling unworthy of God's grace, they had distanced themselves from their religious beliefs. Now, the men have a renewed sense of worthiness in the eyes of God.

### *The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

The juramento also gives the *jurados* the necessary fortitude to keep their vows and abstain from alcohol use. The men are no longer alone in dealing with their drinking problem. Instead, the *jurado* now has divine support, and with it, the necessary fortitude to abstain from alcohol use and to work on his drinking problem. From this, he draws the strength to change his life and to atone for the harms committed to self and others. Once a juramento is made, there is an additional moral obligation to subordinate one's drinking indulgences to one's commitments to the saint and God. According to the men, not keeping a vow is a sin. A broken vow is an affront to Our Lady of Guadalupe and God. In light of this, the *jurado* tries his best to persevere in his abstinence because he fears committing an ultimate offense in his religion.

Some benefits are more tangible. Once a *juramento* is made, the *jurado's* reputation is at stake, as is his trustworthiness within his family, community, and church. He knows that he must keep the vow, or risk social as well as divine consequences. The *estampita*, or prayer card, contributes to his resolve: for example, during moments of weakness, reciting the *juramento* prayer on the card helps the men resist temptation. Prayer reminds the men that our Lady of Guadalupe is looking after them, and that they are not alone. It gives them strength. The *estampita* also helps to control peer pressure to drink. When friends offer them a drink, the men reply that they are not drinking because they have made a *juramento* and show their prayer card. In these situations, the *estampita* serves as a credential, a form of proof. It proves that the men are telling the truth and obligates others to respect the *jurado*'s promise.

There is a general debate in the substance abuse field regarding whether sobriety alone results in the life changes needed to stop drinking overtime or whether it needs to be combined with treatment to achieve recovery. Sobriety is often defined as the continued state of being sober, i.e., not drinking, while according to SAMHSA [60], recovery is "a process of change through which individuals improve their health and wellness, live self-directed lives and strive to reach their full potential." Some argue that without additional treatment and/or participation in 12-step meetings, such as those in Alcohol Anonymous, you will not be able to start the journey of recovery or develop a healthy mind, sound body, and supportive relationships. Treatment involves identifying and working on the causes of your harmful drinking. You need to know yourself, understand your true persona, and recognize behaviors that may have contributed to your drinking. Knowing who you are and understanding why you drank may also help you to discover personal strengths that can help in your recovery. Not addressing this will just make you a "dry drunk," an expression used in AA to refer to an individual who is not drinking but is not addressing behaviors and the problems of the past that contributed to harmful drinking.

Our study did not address recovery *per se*, but the findings indicate that the men are making changes in their lives, and they are doing this without treatment. This is distinctly significant to a population that has little or no access to formal health resources. None of the men in our study sought treatment or attended AA meetings after making the *juramento*, as the priest suggested during the *juramento*'s counseling session. While this may be the result of multiple contributing factors, one clear reason is that no alcohol treatment programs exist that are affordable, within a reasonable driving distance, and culturally and linguistically appropriate for Mexican and other Latinx immigrants. Formal treatment is simply not available to this population, in this region.

Nonetheless, there is evidence that, with the divine intervention of Our Lady of Guadalupe, the men are not only staying sober, they are also working on their recovery. The power of religion cannot be underestimated: research has found

that the lack of a spiritual or religious connection contributes to the escalation of substance misuse [61]. These men demonstrate some of the four indicators of recovery that accompanied the above definition: 1) addressing problems as they happen, without using, and without getting stressed out; 2) having at least one person he can be completely honest with; 3) having personal boundaries; and 4) taking time to restore physical and emotional states when not tired [60]. Their recovery is not based on a personal catharsis reached in treatment, but on a religious catharsis. This special relationship with Our Lady of Guadalupe enhances the men's coping, confers hope for the future, and provides a heightened sense of control, security, and stability. When asked about how the *juramento* has changed their lives, the men are quick to respond that it has improved their social ties and outlook on life; they no longer feel alone in their quest to live alcohol-free. The *jurados* severed unhealthy relationships, especially with those who continue to drink, and reconnected with family. These renewed bonds, in addition to newly established friendships with others in the community, become important sources of support. Healthier thinking and a new way of living prevails. For example, they try not to be consumed by problems that arise at home or at work, especially those that they cannot do anything about. Prayer helps. Some of the men returned to the church and are learning how to trust again and become part of a larger community. Reconnecting to their religion, through the *juramento*, makes a difference.

### **6. Limitations**

Despite its contributions, our chapter has limitations. The primary objective of our qualitative study was to examine the *juramento* as practiced in a single region to understand how it is used to curtail harmful drinking in the Latinx community. We generated data that allowed us to characterize the *juramento*, how it is made, who makes it, why, and how it works. Prevention was not one of the larger aims, but our data also allowed us to address its potential prevention benefits. More research is needed on this subject if we are to understand the *juramento's* contributions to prevention. In particular, we need to focus on some of the findings presented in the chapter. And as such, more attention needs to be paid to how the *juramento* prevents the men's drinking from progressing, by looking closer at the duration of the *juramentos*, the number of *juramentos* made and the reasons for making more than one, and the time period between the *juramentos*. Specifically, attention should be paid to the abstinence periods between *juramentos*, and how abstinence was achieved, including how the different components of the *juramento* contributed to abstinence. We also need to consider if the *juramento* alone is responsible for bringing about this change or if other social factors also contribute, such as the need to meet family responsibilities in the United States and Mexico. Additionally, our sample only included men who had just made a *juramento* or were abstinent after completing one. It did not include individuals who did not complete their juramento or were drinking again after completing one. These individuals must also be included in the research. Prevention benefits, such as stronger marital and family relations and gainful employment, should also be considered. These inquiries will require going beyond an ethnographic and cross-sectional study such as ours and launching a longitudinal study. Cross-sectional studies do not provide definite information about cause-and-effect relationships because such studies focus on a single moment in time; they do not consider what happens before or after that moment.

*The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

### **7. Conclusions**

For decades now, public health has called for the development of cultural and linguistically appropriate prevention and treatment programs for alcohol and substance use. It realizes that there is a need for these programs in the country's increasingly diverse population, especially in regions with concentrations of immigrants, migrants, and refugees. For the most part, this same campaign has overlooked grassroots interventions for these health problems. The *juramento* is one of several grassroots interventions for alcohol and substance use in Latinx communities, which include *anexos*, or 24-hour AA groups, *grupos de cuarto y quinto pasos*, or fourth and fifth step AA groups, and *curanderismo*, or traditional medicine [1]. Like the *juramento*, they are organic, arising from within the community, and they consider cultural traditions and beliefs and language as it is practiced daily. Latinx immigrants have introduced these grassroots interventions to the United States not necessarily because they are trying to recreate as much as possible of their homeland culture in new lands, but because there is a need for them in their U.S. communities. Because of their immigrant status in a country whose federal and state governments are increasing limiting services to all immigrants, they have limited government-sponsored health care and nearly no access to formal alcohol and substance use treatments [1, 62]. For Latinx immigrants, grassroots interventions such as the *juramento* are the only source of help for harmful drinking. Attention to such grassroots practices in public health can support the ways that they already provide care to marginalized populations and help connect the interventions with those who need them.

### **Author details**

Victor Garcia1,3\*, Katherine Fox2 , Emily Lambert1 and Alex Heckert1,4

1 Mid-Atlantic Research and Training Institute for Community and Behavioral Health, Indiana University of Pennsylvania, Indiana, PA, USA

2 Department of Anthropology, Southern Methodist University, Dallas, TX, USA

3 Department of Anthropology, Indiana University of Pennsylvania, Indiana, PA, USA

4 Department of Sociology, Indiana University of Pennsylvania, Indiana, PA, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Garcia V, Lambert E, Fox K, Heckert D, Pinchi NH. Grassroots interventions for alcohol use disorders in the Mexican immigrant community: A narrative literature review. J Ethn Subs Abuse. 2020;6:1-20. Available from: https://doi.org/10.1080/15332640. 2020.1803781.

[2] Murrary DM, Villani J, Vargas AJ, Lee JA, Myles RL, Wu J, et al. NIH primary and secondary prevention research in humans during 2012-2017. Am J Prev Med. 2018;55(6):915-925.

[3] WHO, UNDCP. *Primary prevention of substance abuse: A workbook for project operators*. World Health Organization. 2000. Available from: https://www.who. int/substance\_abuse/activities/global\_ initiative/en/primary\_prevention\_17. pdf.

[4] Garcia V, Gonzalez L. Juramentos and mandas: Traditional Catholic practices and substance abuse in Mexican communities of Southeastern Pennsylvania. NAPA Bulletin. 2009;31(1):47- 63. Available from: https://doi. org/1111/j.1556-4797.2009.01018.x.

[5] Cuadrado M, Lieberman L. The Virgin of Guadalupe as an ancillary modality for treating Hispanic substance abusers: Juramentos in the United States. Journal of Religion and Health. 2011;50(4):922-930.

[6] Garcia V, Heckert DA, Lambert E, Hidalgo Pinchi N. Using the juramento as a brief AUD intervention for Mexican immigrant farmworkers. *Hispanic Health Care International*. 2020.

[7] Ridenour TA, Stormshak EA. Introduction and rationale for individualized substance abuse prevention from an ontogenetic perspective. Am J Drug Alcohol Abuse. 2009;35(4):206-208.

[8] Moulahoum H, Zihnioglu F, Timur S, Coskunol H. Novel technologies in detection, treatment and prevention of substance use disorders. J Food Drug Anal. 2019;27(1):22-31.

[9] Volkow ND, Li T. Drugs and alcohol: Treating and preventing abuse, addiction and their medical consequences. Pharmacol Ther. 2005;108(1):3-17.

[10] Peterson NA, Reid RJ. Paths to psychological empowerment in urban community: Sense of community and citizen participation in substance abuse prevention activities. Journal of Community Psychology. 2003;31(1).

[11] Brooks MJ, Marshal MP, McCauley HL, Douaihy A, Miller E. The relationship between hope and adolescent likelihood to endorse substance use behaviors in a sample of marginalized youth. Substance Use & Misuse. 2016;51(13):1815-1819.

[12] D'Amico EJ, McCarthy DM. Escalation and initiation of younger adolescents' substance use: The impact of perceived peer use. Journal of Adolescent Health. 2006;39(4):481-487.

[13] Salazar AM, Noell B, Cole JJ, Haggerty KP, Roe S. Incorporating self-determination into substance abuse prevention programming for youth transitioning from foster care to adulthood. Child & Family Social Work. 2018;23(2):281-288.

[14] Low NC, Lee SS, Johnson JG, Williams JB, Harris ES. The association between anxiety and alcohol versus cannabis abuse disorders among adolescents in primary care settings. Family practice. 2008;25(5):321-327.

[15] Jiang S, Wu L, Gao X. Beyond face-to-face individual counseling: A systematic review on alternative

*The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

modes of motivational interviewing in substance abuse treatment and prevention. Addict Behav. 2017;73:216-235.

[16] Hopson L, Wodarski J, Tang N. The effectiveness of electronic approaches to substance abuse prevention for adolescents. J Evid Inf Soc Work. 2015;12(3):310-322.

[17] Mutamba BB, van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D. Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: A systematic review. BMC Health Services Research. 2013;13(412):1-11.

[18] Nygaard P. Focus on secondary prevention: Implications of a study on intervention in social networks. Substance Use & Misuses. 2006;41(13):1719-1733.

[19] Trova AC, Paparrigopoulos T, Ginieri-Coccossis M. Prevention of alcohol dependence. Psychiatriki. 2015;26(2):131-140.

[20] Kagle JD. Secondary prevention of substance abuse. Social Work. 1987;32(5):446-448.

[21] Orford J. Empowering family and friends: A new approach to the secondary prevention of addiction. Drug and Alcohol Review. 1994;13(4):417-429.

[22] Elliott L, Orr L, Watson L, Jackson A. How effective are secondary prevention interventions for young drug users? Family Therapy. 2005;32(1):15-30.

[23] Fernandez Mondejar E, Guerrero Lopez F, Quintana M, Alted E, Minambres E, Salinas Gabina I, et al. Secondary prevention of alcohol and/or drug abuse in trauma patients: Results

of a national survey in Spain. Med Intensiva. 2009;33(7):321-326.

[24] DeMatteo DS, Marlowe DB, Festinger DS. Secondary prevention services for clients who are low risk in drug court: A conceptual model. Crime & Delinquency. 2006;52(1):114-134.

[25] DiClemente CC. Prevention and harm reduction for chemical dependency: A process perspective. Clinical Psychology Review. 1999;19(4):473-486.

[26] Carroll JFX, Tanneberger MA, Monti TC. A tertiary prevention strategy for drug-dependent clients completing residential treatment. Alcoholism Treatment Quarterly. 1998;16(3):51-61.

[27] McAnally HB. Addressing host factors: Primary, secondary, and tertiary prevention of opioid dependence. Opioid Dependence. 2018:265-290.

[28] Treloar C, Laybutt B, Carruthers S. Using mindfulness to develop health education strategies for blood borne virus prevention in injecting drug use. *Drugs: Education,* Prevention & Policy. 2010;17(4):431-442.

[29] Marlatt GA, Witkiewitz K. Relapse prevention for alcohol and drug problems. In: Marlatt A, Donovan DM. (eds.). *Relapse prevention: Maintenance strategies in the treatment of addictive behaviors*. New York, New York: The Guilford Press; 2005. p.1-44.

[30] Van Heeringen KC. The prevention of drug abuse – state of the art and directions for future actions. J Toxicol Clin Toxicol. 1995;33(6):575-579.

[31] Levy MS. Listening to our clients: The prevention of relapse. Journal of Psychoactive Drugs. 2008:167-172.

[32] Jason LA, Olson BD, Ferrari JR, Majer JM, Alvarez J, Stout J. An

examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment. Addiction. 2007;102(7):1114-1121.

[33] Schonfeld L, Dupree LW, Dickson-Fuhrmann E, Royer CM, McDermott CH, Rosansky JS, et al. Cognitive-behavioral treatment of older veterans with substance abuse problems. Journal of Geriatric Psychiatry and Neurology. 2000;13(3):124-129.

[34] Bowen S, Chawla N, Collins SE, Witkiewitz K, Hsu S, Grow J, et al. Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse. 2009;30(4):295-305.

[35] Witkiewitz K, Bowen S. Depression, craving, and substance use following a randomized trial of mindfulnessbased relapse prevention. Journal of Consulting and Clinical Psychology. 2010;78(3):362-374.

[36] Amaro H. Implementing mindfulness-based relapse prevention in diverse populations: Challenges and future directions. Substance Use & Misuse. 2014;49(5):612-616.

[37] Greenfield BL, Roos C, Hagler KJ, Stein E, Bowen S, Witkiewitz KA. Race/ ethnicity and racial group composition moderate the effectiveness of mindfulness-based relapse prevention for substance use disorder. Addict Behav. 2018;81:96-103.

[38] Walton MA, Blow FC, Booth BM. Diversity in relapse prevention needs: Gender and race comparisons among substance abuse treatment patients. Am J Drug Alcohol Abuse. 2001;27(2):225-240.

[39] Kearney M, Reynolds L, Blitzstein S, Chapin K, Massey P. Primary prevention of prescription drug misuse

among culturally and linguistically diverse suburban communities. Journal of Community Health. 2019;44(2):238-248.

[40] Patchell BA, Robbins LK, Lowe JA, Hoke MM. The effect of a culturally tailored substance abuse prevention intervention with Plains Indian adolescents. Journal of Cultural Diversity. 2015;22(2):3-8.

[41] Kelley A, Witzel M, Fatupaito B. A review of tribal best practices in substance abuse prevention. Journal of Ethnicity in Substance Abuse. 2019;18(3):462-475.

[42] Straits KJ, deMaria J, Tafoya N. Place of strength: Indigenous artists and indigenous knowledge is prevention science. Am J Community Psychol. 2019;64(1-2):96-106.

[43] Cox RB, Roblyer MZ, Merten MJ, Shreffler KM, Schwerdtfeger KL. Do parent–child acculturation gaps affect early adolescent Latino alcohol use? A study of the probability and extent of use. Substance Abuse Treatment, Prevention, and Policy. 2013 Dec 1;8(1):4.

[44] Castro FG, Stein JA, Bentler PM. Ethnic pride, traditional family values, and acculturation in early cigarette and alcohol use among Latino adolescents. The Journal of Primary Prevention. 2009 Jul 1;30(3-4):265-292.

[45] Lac A, Unger JB, Basáñez T, Ritt-Olson A, Soto DW, Baezconde-Garbanati L. Marijuana use among Latino adolescents: Gender differences in protective familial factors. Substance Use & Misuse. 2011 Mar 15;46(5):644-55.

[46] Marsiglia FF, Miles BW, Dustman P, Sills S. Ties that protect: An ecological perspective on Latino/a urban preadolescent drug use. Journal of Ethnic

*The* Juramento*: Secondary and Tertiary Preventive Benefits of a Religious-Based Brief Alcohol… DOI: http://dx.doi.org/10.5772/intechopen.95545*

and Cultural Diversity in Social Work. 2002 Sep 1;11(3-4):191-220.

[47] Lorenzo-Blanco EI, Schwartz SJ, Unger JB, Zamboanga BL, Des Rosiers SE, Baezconde-Garbanati L, Huang S, Villamar JA, Soto D, Pattarroyo M. Alcohol use among recent immigrant Latino/a youth: acculturation, gender, and the Theory of Reasoned Action. Ethnicity & health. 2016 Nov 1;21(6):609-27.

[48] Cervantes R, Goldbach J, Santos SM. Familia Adelante: A multirisk prevention intervention for Latino families. The journal of primary prevention. 2011 Aug 1;32(3-4):225.

[49] Szapocznik J, editor. A Hispanic-Latino Family Approach to Substance Abuse Prevention. DIANE Publishing; 1998.

[50] Jurkovic GJ, Kuperminc G, Perilla J, Murphy A, Ibañez G, Casey S. Ecological and ethicalperspectives on filial responsibility: Implications for primary prevention with immigrant Latino adolescents. Journal of Primary Prevention. 2004 Sep 1;25(1):81-104.

[51] Marsiglia FF, Ayers S, Gance-Cleveland B, Mettler K, Booth J. Beyond primary prevention of alcohol use: A culturally specific secondary prevention program for Mexican heritage adolescents. Prevention Science. 2012 Jun 1;13(3):241-251.

[52] Shetgiri R, Kataoka S, Lin H, Flores G. A randomized, controlled trial of a school-based intervention to reduce violence and substance use in predominantly Latino high school students. Journal of the National Medical Association. 2011 Sep 1;103(9-10):932-940.

[53] Koenig, H.G.; Büssing, A. The Duke University Religion Index (DUREL): A Five-Item Measure for Use in

Epidemiological Studies. Religions. 2010, *1*, 78-85.

[54] Del Boca, F.K. and Darkes, J. The validity of self-reports of alcohol consumption: state of the science and challenges for research. Addiction. 2003; 98: 1-12. https://doi. org/10.1046/j.1359-6357.2003.00586.x

[55] Solbergsdottir, E., Bjornsson, G., Gudmundsson, L.S., Tyrfingsson, T., & Kristinsson, J. (2004) Validity of Self-Reports and Drug Use Among Young People Seeking Treatment for Substance Abuse or Dependence, Journal of Addictive Diseases, 23:1, 29-38, DOI: 10.1300/J069v23n01\_03

[56] National Institute on Alcohol Abuse and Alcoholism. *Drinking levels defined* [Internet]. (no date). Available from: https://www.niaaa.nih.gov/alcoholhealth/overview-alcohol-consumption/ moderate-binge-drinking

[57] Editorial Staff. *Problem drinking vs. alcoholism* [Internet]. 2020. Available from: https://www.alcohol.org/ alcoholism/or-is-it-just-a-problem/

[58] National Institute on Alcohol Abuse and Alcoholism. *Alcohol use disorder: A comparison between DSM-IV and DSM-5* [Internet]. 2020. Available from: https:// www.niaaa.nih.gov/publications/ brochures-and-fact-sheets/alcohol-usedisorder-comparison-between-dsm

[59] SAMHSA. *Screening, brief intervention, and referral to treatment (SBIRT)* [Internet]. 2017. Available from: https://www.samhsa.gov/sbirt/

[60] SAMHSA. *National and Regional Resources, Region VIII* [Internet]. 2014. Available from: https://www. samhsa.gov/sites/default/files/samhsarecovery-5-6-14.pdf

[61] National Center on Addiction and Substance Abuse. *So help me god: Substance abuse, religion and spirituality*. The National Center on Addiction and Substance Abuse (CASA) at Columbia University. 2001.

[62] Pagano A. Barriers to drug abuse treatment for Latino migrants: Treatment providers' perspectives*.* Journal of Ethnicity in Substance Abuse. 2014;13(3):273-287.

### **Chapter 3**

## Sex Differences between Young Adults in the Czech and Slovak Republics in the Relationship between Alcohol-Related Consequences and Depression

*Beata Gavurova, Martin Rigelsky and Viera Ivankova*

### **Abstract**

In general, the Czech and Slovak Republic are among the countries with increased alcohol consumption. It is clear that increased consumption can predict the occurrence of negative consequences that may subsequently be associated with various mental disorders. One of these mental disorders is depression, which is common in young adults and brings difficulties into their lives that can turn into problems in the future. The study examined the relationship between alcohol-related consequences and depressive symptoms in a sample of university students from the Czech and Slovak Republics in order to map the situation in these regions, where this problem is still ignored (n = 2514; CZE = 47.5%). The research included data from standardized questionnaires, namely the Young Adult Alcohol Consequences Questionnaire (YAACQ), which can predict alcohol use problems, and Health Questionnaire of depression (PHQ-9). The data was collected during the COVID-19 pandemic. Regarding sex differences, a higher YAACQ score was found in males and, conversely, a higher PHQ-9 score was identified in females. The results of correlation and regression analyses revealed significant associations between the scores in the individual YAACQ subscales and the PHQ-9 score, while low to moderate correlations were found in most cases. In all cases, positive trajectories were identified, meaning that the increased risk of depressive disorder can be associated with experience in selected dimensions of alcohol-related consequences. Stronger associations occurred in females than in males. In terms of practical implications, high priority was given to prevention programs and counseling. Professionals' efforts to help young people should be sex-oriented, while females were more vulnerable to depression, males were prone to the consequences of alcohol use.

**Keywords:** alcohol addiction, patterns of unhealthy behavior, depression, youth, sex, mental health inequalities, Czech and Slovak students

### **1. Introduction**

The importance of mental health is irrefutable in the lives of individuals as well as in society. Evidence supports the fact that there is no health without mental

health, as neuropsychiatric disorders such as depression, alcohol and substance use disorders significantly contribute to the global disease burden [1]. Many studies point to a considerable burden of these disorders in all aspects of society, including individuals, their families, workplaces and also the wider economy [2]. On this basis, mental health should not be overlooked, and it is considered important to know its main factors in different population groups. In this sense, depressive disorder and alcohol-related consequences can be considered as two of these risk factors for mental health. Depression is one of the most common mental disorders, and research into alcohol use and its consequences for depressive symptoms can provide useful information to clinicians and professionals. Therefore, the presented research examined the relationship between alcohol-related consequences and perceived depression in the Czech and Slovak young population with sex differentiation.

Alcohol problems at risk of addiction are considered a significant threat and need to be examined in the socio-economic dimension, including education. Sex differences are equally important in examining the community and its inclination to addictive substances. The present time has changed not only the economic but also the legal status of females, thus removing social barriers to their alcohol consumption. As a result, the number of females consuming alcoholic beverages as well as addicted females has significantly increased [3]. There are many reasons to take into account sex differences and specificities in services for addicted females or females at risk of addiction [4], as evidenced by the findings on hospitalizations of males and females in the member states of the European Union (EU) [3]. In any case, it can be considered important to examine this problem, it can also contribute to knowledge in the diagnostic issues of addiction.

There are many international studies examining the variables predicting alcohol use problems in young adults, while depression and sex differentiation have also played an important role in their research [5]. According to their findings, university students often reported depressed mood and alcohol problems. Attention should be paid to any signal that may be related to the problematic drinking and mental disorder of young people. In any case, Slovak and Czech students are no exception to this problem. The knowledge of this issue enables the implementation of active prevention programs that would eliminate the level of addiction in suffering people, or help prevent the emergence of others. The earlier the addiction is treated, the higher the chance of successful abstinence of the individual.

### **2. Alcohol-related consequences and depressive disorder as risk factors in the lives of young adults**

The presented study focused on alcohol-related consequences predicting alcohol use problems, which can lead to a depressed mood in university students. The purpose of the study was to present the alcohol-depression topic in specific geographical regions, to map the situation in these regions and to emphasize the problem at a professional and practical level.

The intensity of alcohol consumption in individual countries is often conditioned by several aspects, while it still remains true that the Slovak Republic is at the forefront of alcohol consumption among OECD countries and alcohol consumption in the Czech Republic is more moderate [6]. Alcohol consumption does not necessarily indicate directly the consequences of drinking, at least in the short term. At this point, it should be noted that the relationship between alcohol use and alcoholrelated consequences is not entirely trivial. In this regard, there is evidence of a similar likelihood of reporting negative alcohol-related consequences at both low

### *Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

and higher levels of alcohol consumption [7]. There are many factors that can play an important role in drinking patterns with consequences. As stated by Rehm and Room [8], the cultural aspect is a determinant of alcohol consumption, while it is possible to speak of differences in the perception of acceptable level of alcohol consumption, up to the level of severity of negative alcohol-related behavior. This study focuses on the consequences of alcohol drinking in young adults, as they are a vulnerable group that may have very noticeable consequences. Several authors [9] attribute to this group an inclination to various types of risky behavior (consequences) associated with alcohol use, from reduced academic performance, through unprotected sex to violent and aggressive behavior. Alcohol consumption alone does not capture these important aspects that are part of problem drinking with the risk of addiction. On the other hand, it was supported that the instrument capturing the consequences of drinking (YAACQ) is also able to predict drinking patterns [10] and to assess the level of drinking risk in university students [11]. This is evidenced by the associations between the YAACQ outcomes and drinking outcomes [12]. These facts offer new opportunities for research into alcohol addiction across the population. The consequences of alcohol use can be a concomitant phenomenon of problem drinking and, at the same time, can indicate addictive behavior.

University students are not just young adults, they are a population group that is the expected driving force of the economy in the future, and they represent potential current and future health care, criminal justice, and social burdens as well. Therefore, it is important to pay special attention to them. In the context of drinking patterns, many university students drink a lot of alcohol and tend to drink more and more heavily than their non-university peers, which has countless negative consequences [13]. These habits of young people can be reflected in various aspects of their lives. Tembo et al. [14] revealed that high levels of alcohol consumption among university students are significantly associated with poor mental health outcomes. In addition, other risky behaviors, use of other addictive substances, psychological symptoms (depression, distress), or low interest in academic activities may prevail among university students with problem drinking at risk of addiction [15]. For all these reasons, many authors call for drinking prevention strategies and interventions in the university environment [16]. The importance of active counseling at universities was emphasized and social support represented a very important aspect [17]. The key factors were also participation in university activities, public discussions on the consequences of excessive alcohol consumption, motivation for healthy behaviors through academic and career success [18]. In other words, evidence from other geographical regions clearly supported effective prevention programs, which, however, have been implemented to a small extent in the Czech and Slovak Republics. Thus, it is essential that research efforts focus on this issue and its implications for the university student population.

It is not difficult to expect various negative alcohol-related problems in the lives of young people [19], while drinking motives play an important role in this issue [20]. The alcohol-related consequences include various negative experiences, such as embarrassing situations, problems with friends and family, problems at school or work, indecent (rude) and risky behavior, excessive drinking, physical symptoms, bad feelings, but also unpleasant sexual situations, physical attacks and blackouts [21]. In the university environment, one of the most appropriate measures to capture alcohol-related consequences is the 48-item Young Adult Alcohol Consequences Questionnaire (YAACQ), the great advantage of which is its subscales providing a method of aggregating the consequences of alcohol use that may be clinically useful [10, 21]. Moreover, its subscales show significant associations with other indices of alcohol involvement (such as drinking frequency or binge drinking frequency) [10], which is also considered important in the issue of alcohol addiction.

In terms of sex, Lemley et al. [22] revealed that the negative consequences of alcohol use differed between male students and female students, while males tended to acquire a higher YAACQ score. This is consistent with the results of Geisner et al. [23], who found more alcohol-related consequences for male students. In this regard, Merrill et al. [20] confirmed significant sex differences in the two dimensions of YAACQ, namely risky behaviors (RISK) and academic/occupational consequences (AC-OCC).

Regarding the results revealed in a study examining the consequences of alcohol use (YAACQ) in Spain, Argentina and the United States, it can be concluded that the obtained score may significantly differ from country to country, but also from subscale to subscale [24]. For example, students from Argentina and Spain acquired greater mean number of alcohol-related consequences than students from the United States [24]. Based on the results of another study from the United States, university students obtained the highest percentage to the maximum score in the subscales, such as blackouts, social interpersonal problems, impaired control and risky behaviors [21].

Depressive disorder is also a frequent psychological burden among university students, which may impair their interpersonal, social and work functioning [25]. Moreover, the prevalence of depression in students increases during their university studies [26]. Feelings of hopelessness and despondency are common to this disorder, which can affect their academic performance [27]. In fact, depressive symptoms along with alcohol use are a serious combination, as there is a risk of suicide proneness [28]. Based on these facts, it is necessary to examine these two critical disorders among university students.

Factors such as lack of social support, heavy alcohol consumption and traumatic experiences can be considered significant predictors [29]. Ibrahim et al. [25] conducted a systematic review of university students and it can be noted that the significant effect of alcohol use was not large. The high prevalence rate of depression among university students (ranging from 10% to 85%) contributes to the perception of students as a high-risk population [25], while females are at higher risk compared to male counterparts [30]. Leppink et al. [31] also revealed that females were significantly predominant in severe depression and this is in line with the findings that sex differences are greater in major depression than in minor depression [25].

One of the most commonly used screening instruments for depression is the Patient Health Questionnaire-9 (PHQ-9) [32, 33]. According to Kroenke and Spitzer [34], the PHQ-9 fulfills a dual purpose, namely to diagnose depression and to assess the severity of depression. In the Slovak Republic, the PHQ-9 measure was used by Hajduk et al. [35], who examined prevalence and correlations of depression and anxiety in university students, they revealed mild depression in their research sample. The authors also found a higher prevalence of depression among students compared to anxiety, and their results showed that students with a higher score tended to perceive their mental health as less satisfactory [35]. The Czech version of the PHQ-9 measure was successfully assessed in the general population by Dansova et al. [36].

Comparing the results in the international studies using the PHQ-9 measure, it can be concluded that 37.7% of students from the United States had mild to moderate depression, and 4.4% of students had severe depression [31]. In Croatia, 60.8% students suffered from depressive disorder, while 30.3% of students reported mild depression, 16.1% of students reported moderate depression, 7.2% of students reported severely moderate depression, and severe depression was identified in 0.2% of students [37]. Interesting results were provided by Honney et al. [38], who compared the prevalence of depression in medical and non-medical students from

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

the United Kingdom. Their results revealed that 32.4%, 10.8%, and 5.6% of medical students suffered from mild, moderate and severe depression. Simultaneously, 28.7%, 17.7%, and 12.7% of non-medical students suffered from mild, moderate and severe depression [38]. This fact indicate that medical students were not at higher risk for moderate to severe depressive disorder than non-medical students.

All of these results suggest that depression is frequent in young people's lives and should not be overlooked; on the contrary, efforts should be made to help people overcome these difficulties. One way is to identify possible risk factors and try to eliminate them. It is the problem of alcohol use with consequences that appears to be an important factor in depressed people, who should be given early intervention. Early interventions in problematic drinking behavior could prevent depressive disorders, which can have other consequences. Every indication of problem drinking is crucial for further action to address and overcome these problems in young people's lives.

### **2.1 The relationship between alcohol-related consequences and depressive disorder**

With a focus on the mentioned behavioral and mental disorders in university students, the findings of several studies revealed that psychological symptoms are associated with drinking consequences and alcohol use [23, 39], while depression is no exception [40, 41]. In this regard, Martens [42] confirmed that depressive symptoms in university students were directly related to the negative consequences of alcohol drinking (using the Rutgers Alcohol Problem Index – RAPI), but not to alcohol consumption itself. This builds on the results of Park and Grant [43], in which the consequences of alcohol drinking were significantly associated with psychological risk as well as protective factors.

The depression-drinking link among university students was examined in several other studies, in which various tools to measure depression and alcohol-related consequences were used. In any case, correlations were clearly found between depressive disorder and drinking consequences [44]. From the perspective of this study, the findings also showed that depressive symptoms were positively and significantly correlated with negative alcohol-related consequences, as measured by the YAACQ score [45]. Similarly, Ruiz et al. [46] confirmed a positive and significant correlation between psychological discomfort and the YAACQ score. Regarding the PHQ-9 measure, several studies can also be found that confirmed a positive association between depression and problem drinking, while Flesch et al. [47] noted that alcohol abuse can be considered a risk factor for a major depressive episode expressed in the PHQ-9 score.

There is also evidence to suggest that depressive symptoms may predict alcohol use and alcohol-related consequences [48, 49], while self-medication plays an important role in this association [50]. On the other hand, problems with alcohol can lead to an increased risk of depression [51, 52]. In this regard, Schutte et al. [53] found that alcohol-related consequences could lead to depression in males, but not in females. This can be explained by the fact that male university students are characterized by higher alcohol consumption and more negative consequences of drinking [23]. As a result, Geisner et al. [23] confirmed a stronger association between psychological symptoms and the negative consequences of alcohol use in males than in females.

On the other hand, Rosenthal et al. [54] used the Brief Young Adult Alcohol Consequences Questionnaire (BYAACQ) in a sample of female university students, and their findings revealed that experiencing negative alcohol-related consequences, regardless of the amount of alcohol consumption, could lead to a higher risk of depression (PHQ-9). With a focus on casual sex, one of the possible alcoholrelated consequences, this experience increased depressive symptoms in female students more than in male students [55]. Accordingly, it can be assumed that female students felt guilty or remorse in this situation and felt that they had violated social expectations [56].

Although indirect evidence has created expectations, the relationship between the YAACQ score and the PHQ-9 score has not yet been examined in some regions. The above-mentioned evidence has suggested that depressive disorder and alcoholrelated consequences may show interesting results in higher education, where the issue of mental health and unhealthy behavior is of undeniable importance. Insufficient examination of this issue can also be observed in the regions of the Czech and Slovak Republics. In these regions, the effects of alcohol-related consequences on depressive symptoms remain unknown. For this reason, the presented study filled this gap and provided public policy makers as well as experts with an inspiring perspective. At present, every country needs up-to-date information for responsible decision-making, the development of effective strategies and the implementation of interventions. In addition, at the time of the COVID-19 pandemic, it is necessary to monitor the patterns of behavior of vulnerable groups of the population, which are certainly also students. It has been shown that the COVID-19 pandemic can negatively contribute to students' psychological discomfort and unhealthy behavior [57, 58]. The main reasons for students' discomfort were worries about their health and the health of their loved ones, difficulty concentrating, sleep disorders, physical distancing and increased academic concerns [58]. These facts can lead to more serious consequences and a risk of substance abuse. In any case, all necessary measures to prevent an increase in alcohol-related problems should be adopted [59].

The purpose of the presented study was to assess the situation of alcohol-related consequences and depressive disorder in the Czech and Slovak Republics and to provide a valuable platform for the development of strategies and interventions in these regions. When developing and optimizing diagnostic procedures, prevention and treatment, it is desirable to specify potential patients. One way in the specification process is to differentiate according to sex characteristics.

### **3. Materials and methods**

The analyses included data obtained using the YAACQ [21] and PHQ-9 [33] measures. The PHQ-9 measure was successfully validated in several studies aimed at university students [60, 61]. Its reliability and psychometric properties are evidenced by the fact that this measure has been included in many studies on the mental health of university students from various countries, such as Australia [62], the United Kingdom [38], the United States [31] or Croatia [37]. In terms of crosscultural comparison, the usefulness of PHQ-9 was supported by a study at universities in Germany and China [63] and a study focusing on young adults from Poland and Korea [64]. The PHQ-9 consisted of nine survey items with a four-point scale (0 not at all; 1 several days; 3 more than half the days; 4 nearly every day) aimed at screening for depressive disorder among university students. This brief measure of depression could reach a score ranging from 0 to 27. On this basis, it was possible to know the probability of major or subthreshold depressive disorder at various cut points defining the lower limits of mild, moderate, moderately severe, and severe depression [32, 33]. The score was decisive in the assessment, while the higher the value, the more intense the depressive disorder. In assessing, several studies used

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

score assigned at intervals (0–4 none; 5–9 mild; 10–14 moderate; 15–19 moderately severe; 20–27 severe). For the purposes of this research (i.e. application of regression and correlation analysis), it was more appropriate to use the gross score obtained by the students.

In general, the YAACQ measure covers from mild to more severe alcohol-related consequences and includes the following eight subscales: (1) social interpersonal problems – SOC, (2) impaired control – CONTR, (3) self-perception – SELF-P, (4) self-care – SELF-C, (5) risky behaviors – RISK, (6) academic/occupational consequences – AC-OCC, (7) physiological dependence – PHYS-DEP, and (8) blackout drinking – BLKOUT. Interestingly, two subscales (impaired control, self-care) take into account problem areas that are not fully assessed by other existing measures [10]. It can also be noted that the total YAACQ score correlated with another similar measure (RAPI), which supports the validity of this measure [21]. The advantages of YAACQ have been proven in several studies conducted among students [9, 20, 65] and the use of this eight-factor structure has been supported across countries and cultures [12, 21]. As in the previous case, the gross score was used for the YAACQ measure. A dichotomous scale is commonly used for this instrument (0 no; 1 yes), but in this research, the scale was extended (1 strongly disagree; 2 disagree; 3 undecided; 4 agree; 5 strongly agree). The total score of YAACQ or its individual subscales was formed by the sum of the individual items. The dichotomous scale had a number of benefits that were evident in the diagnostics, as the overall score reflected a number of consequences and it was not difficult to complete. The conversion to a 5-point scale could be more accurate and offer the use of more statistical methods. The use of an extended scale was more appropriate for research and academic purposes. There was some risk when comparing the results with the dichotomous scale, but this risk was minimal.

### **3.1 Research sample and data collection**

The data collection was performed in two parallel levels. First, university representatives as well as teachers were contacted by e-mail with a request to distribute the questionnaire to students. Second, the questionnaire was distributed through student groups on social networks (universities, faculties, dormitories, student communities). The research sample consisted of university students from the Czech and Slovak Republics, who stated that they had consumed alcohol in the last 3 months. Data collection was conducted in 2020, when it is necessary to take into account the coronavirus disease 2019 (COVID-19) pandemic. The questionnaire was distributed electronically. The total sample consisted of 2514 respondents (CZE: n = 1193, 47.5%). The data were cleaned up. First, respondents who answered doubtfully to the control question (in numerical terms, one million has six zeros – the scale of agreement/disagreement) were excluded (n = 179), then erroneous responses caused by the system (blank items, even if it was a mandatory item) were excluded (n = 27) and last, foreign students were excluded (n = 87).

The collection process can be characterized as quota sampling with a focus on the approximate proportionality of the responses in each country. The field of study can be considered as the main quota criterion (there was an effort to collect at least 30 responses per study field in each country). Efforts have also been made to include most universities (with the exception of foreign universities and foreign detached institutions). The quota sampling criteria were met and the research sample included the vast majority of all universities. **Table 1** provides the basic characteristics of the research sample.

The study and its concept were approved by the ethics committee of the General University Hospital in Prague as individual research (Ref. 915/20 S–IV). All

### **Table 1.**

*Characteristics of respondents.*

respondents who participated in the research confirmed their informed consent at the beginning of the questionnaire. All aspects in this research were conducted with respect to the seventh revision of the World Medical Association–Declaration of Helsinki [66] and the second revision of the Farmington Consensus [67].

### **3.2 Statistical analysis**

The statistical processing in this study consisted of two main parts, namely the first part focused on the statistical description of the data and the second part focused on the examined relationship. Descriptive statistics included the basic characteristics (mean (Mean), median (Median), standard deviation (SD), kurtosis (Kurt), skewness (Skew), minimum (Min), maximum (Max)), which were presented generally without classification of respondents as well as in the sex

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

classification of respondents. Subsequently, Pearson's correlation coefficient (r) and Spearman's correlation coefficient (Spearman's ρ) were used to analyze the associations. Prior to this statistical procedure, normality (the Henze-Zirkler test for multivariate normality) and the presence of outliers (a quantile method based on Mahalanobis distance) were verified. The hypothesis of normality was rejected. However, it should be noted that due to the size of the sample, the normality tests may have been skewed and may have tended to reject the normality hypothesis. This was followed by regression analysis using a simple OLS model, before which the assumptions for use were verified (the Bonferroni outlier test, the Breusch-Pagan test). A simple quantile regression analysis (τ = 0.25, 0.50, 0.75) was applied to assess the effects, and the standard error was estimated by Powell's kernel version for the covariance matrix estimate on the commonly used Hall-Sheather bandwidth rule. IBM SPSS Statistic software (IBM Corp., Armonk, NY, USA) and R v 4.0.2 (RStudio, Inc., Boston, MA, USA) were used for statistical processing.

### **4. Results**

**Figure 1** shows the intensity of the total YAACQ and PHQ 9 scores. This visualization consists of the mean values of the percentage expression to the maximum value in terms of selected indicators. The presented figure provides some information, the most important of which is the low probability that the values of outputs in the Slovak Republic and the Czech Republic have acquired significant differences. This was evidenced by the result of the Wilcoxon nonparametric test, which in both indicators showed a p-value higher than 0.05 for the countries (p-value: YAACQ = 0.156; PHQ-9 = 0.137). On the other hand, it is possible to observe certain differences between regions in both indicators. Thus, a significant difference between the individual regions was found using the Kruskal Wallis test (YAACQ: χ<sup>2</sup> = 36.404, p-value = 0.020; PHQ-9: χ<sup>2</sup> = 33.311, p-value = 0.043). Sex characteristics were also taken into account in terms of differences, and the Wilcoxon test confirmed significant differences between males and females in both indicators at a level lower than 0.001 (mean YAACQ % to max: females = 32.7%, males = 36.8%; mean PHQ-9% to max: females = 23.1%, males = 20.2%). On this basis, the inclusion of sex characteristics in subsequent calculations were warranted. More intense color

### **Figure 1.**

*Relationship between the YAACQ score and the PHQ-9 score (% to max - mean) in the Czech Republic and the Slovak Republic. Note: Color shading of choropleth map – YAACQ (% to max - mean); circles in regions – PHQ-9 (% to max - mean); CZ – Czech Republic; SK – Slovak Republic.*

shading represents a higher value (in the case of the PHQ-9 indicator, the higher value is represented not only by color shading, but also by the size of the circle). In this context, a certain relationship could be observed between the YAACQ and PHQ-9 indicators, as in several regions with a higher intensity of the YAACQ indicator, a higher intensity of the PHQ-9 indicator can also be found. This fact was also supported by Spearman's correlation coefficient (ρ – 0.262; p-value <0.001). This secondarily declared the appropriateness of choosing a quantile regression model.

The first row of **Table 2** (TheoryM) shows the theoretical interval of the analyzed indicators, i.e. the lowest and highest value that the respondent could obtain. In this table, it is also possible to observe descriptive characteristics for all respondents (without classification), as well as separately for males and females. The significance of differences in all indicators was assessed using the Wilcoxon test. As the scales can take on different intervals of values (TheoryM), the results can be seen through the share of the maximum of the theoretical interval. Based on this, the highest score was found in the SOC subscale (mean = 12.376; 41.25% of the TheoryM maximum) and the BLKOUT subscale (mean = 14.585; 41.67% of the TheoryM maximum). On the other hand, the assessment of standard deviations (SD) has the highest added value in terms of comparing the values obtained for males and females. Apart from the PHQ-9 score, all of the cases showed lower values for females, meaning that the responses of females were more constant. As can be seen, the indicators associated with the negative consequences of alcohol use (YAACQ) were more common in males. On the other hand, the indicator of depressive disorder was more common in females.

In general, the PHQ-9 score indicates the level of intensity of perceived depression in five intervals. The results showed that exactly 50% of the students were identified in the "none" interval, a slightly increased depression in the "mild" interval was found in 29.8% of the students, the share of the "moderate" interval showed 11.6%, the share of the students with "moderately severe" depression was 5.5% and the group with the highest level of perception of depressive symptoms in the "severe" interval included 3.1% of the students.

The following part is devoted to the assessment of the associations between the selected indicators of alcohol-related consequences and depression in general, as well as in the sex classification. In the first step, the Henze-Zirkler test for multivariate normality was used, which showed significant deviations from the normal distribution in all of the analyzed cases. Also, the presence of outliers was assessed using a quantile method based on Mahalanobis distance, and a significant proportion of outliers were found. At this point, it should be noted that the research included a relatively large set of data, in which tests tend to reject the hypothesis of normality. For this reason, the results are provided in both parametric (Pearson's r) and nonparametric (Spearman's ρ) alternatives.

As mentioned above, **Table 3** shows both parametric and non-parametric alternatives to the bivariate analysis of associations. The double use of the correlation test minimized the statistical error resulting from the computational processes. In most cases, the parametric alternative of the test (Pearson's r) acquired slightly higher values than the nonparametric alternative (Spearman's ρ). Each analyzed association was significant at the level of α < 0.001. Focusing on the results in the given table, the strength of the association up to 0.30 can be interpreted as low to medium, up to 0.50 as medium to substantial and up to 0.70 as substantial to very strong. Accordingly, most of the associations between the selected YAACQ subscales could be considered as substantial to very strong. The associations between the score in the individual YAACQ subscales and the PHQ-9 score were shown to be low to medium. In general, SELF-P and SELF-C could be considered the most

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

### **Table 2.** *Descriptive statistics.*

predictive subscales in terms of the PHQ-9 score. However, the differences in the correlation of individual scales were often very small. Due to the fact that the increased rate of associations between individual subscales was also confirmed, a simple regression model was applied in the following part focused on regression analysis.

The application of regression analysis (OLS) itself was determined by several tests of assumptions. The Bonferroni outlier test did not show any outliers at the level of α < 0.01, but the Breusch-Pagan test identified all the models as heteroskedastic, at the mentioned level of significance. Therefore, a white estimator of HC3 was used to assess the effect.

The results in **Table 4** show that all the associations were significant at the level of significance α < 0.001. Simultaneously, the coefficients were positive, which

*Note: Above the diagonal is a parametric alternative (Pearson's r) and below the diagonal is a nonparametric alternative (Spearman's ρ). The p-values are not shown, as all of the analyzed relationships were significant at the level of α < 0.001.*

### **Table 3.** *Correlation analyses.*

means that an increased risk of depressive disorder can be associated with experience in selected dimensions of alcohol-related consequences. The multiple R2 showed relatively low values, which can be considered a certain limitation.

The most important output of the presented study is shown in **Table 5**, which is devoted to the assessment of the effects of the score in the individual YAACQ

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

*† p-value <0.001.*

### **Table 4.**

*Assessment of the effects of YAACQ on PHQ-9 (OLS model).*

*Note: SE – standard error;*

*\* p-value <0.1;*

*\*\* p-value <0.05;*

*\*\*\* p-value <0.01;*

*† p-value <0.00;*

*non-significant associations are highlighted in bold.*

### **Table 5.**

*Assessment of the effects of YAACQ on PHQ-9 (quantile regression).*

subscales on the PHQ-9 score. When assessing the results, it is most appropriate to focus on the β coefficients (independent variable). The standard error should also be taken into account when interpreting, while the lower the value, the more stable the model. This has the highest added value when comparing the β coefficients in males and females, while the results revealed lower values predominantly in the female models. Based on the results, the significant effects of alcohol-related consequences on depressive disorder can be clearly confirmed in the vast majority of analyzed cases. The associations that cannot be considered significant at the level of α < 0.05 were found only in ten cases (highlighted in bold). In all cases that supported to be significant, positive regression coefficients were found, which can be understood in the sense that alcohol-related consequences may be a risk factor for depressive disorder. In other words, an increased PHQ-9 score may be associated with an increased score in the YAACQ subscales. By focusing on the differences between females and males, the results suggested that females had a higher intensity of effects based on regression coefficients.

### **5. Discussion**

In order to develop successful addiction diagnosis programs and strategies, it is necessary to know the variables that predict the development of substance use problems. This study contributed to this knowledge, as diagnostic information on university students with alcohol problems in the Czech and Slovak Republics could be useful for the development of effective prevention strategies in addiction issue. Although many countries have effective strategies and can be an inspiration, the countries examined in this study implement active interventions and prevention aimed at students to a very small extent. This issue is little discussed at professional, political and social level, and therefore, the need to address it is overlooked. There is a lack of support for university counseling centres for students and, in addition, information on the current situation is insufficient.

The successful development of addiction prevention policy requires the availability of multidimensional analyses and the creation of specific databases that would make it possible to assess the effectiveness of policy in individual geographically defined areas [68]. Many national researches were initiated within international institutions [69]. These facts were the motivation for conducting research in national conditions. The main aim of the presented study was to assess the relationship between alcohol-related consequences and depressive disorder. This aim was met in a sample of university students from the Czech and Slovak Republics.

Based on the results of the descriptive analysis, it can be concluded that males acquired a higher score in all subscales of alcohol-related consequences. Similarly, Geisner et al. [23] revealed more alcohol-related consequences for male students and Merrill et al. [20] found significant sex differences in risky behaviors (RISK) and academic/occupational consequences (AC-OCC). This is consistent with the findings of Lemley et al. [22], who revealed that sex was a significant predictor for negative alcohol-related consequences, while male students tended to obtain a higher YAACQ score. This may be explained by the fact that male students are more prone to excessive alcohol consumption than female students [23], while their heavier drinking can be associated with alcohol-related consequences [70]. Males also perceived alcohol-related consequences less negatively than females [71]. In this regard, females were less likely to be exposed to risk factors and alcohol-related consequences. In contrast, protective factors against alcohol-related consequences predominated in females, as they perceived greater social sanctions for drinking and they were less likely to have characteristics associated with excessive drinking, such *Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

as aggressiveness, uncontrollable behavior, sensation-seeking, and others [72]. On the other hand, there is also interesting evidence that although female students consumed less alcohol, they were more likely to experience negative consequences when drinking [73]. This can be explained by the fact that females have less alcohol dehydrogenase than males, they are less efficient at metabolizing alcohol and thus more vulnerable to its effects.

In the Czech and Slovak regions, students acquired the highest percentage to the maximum score in blackouts (41.67%), while different values could be found in other countries, such as the United States (56.71%) [21], Argentina (26%) and Spain (29,43%) [24]. In terms of impaired control, Czech and Slovak students obtained a comparable percentage to its maximum score (34.91%) as students from the mentioned countries (the United States = 35.33% [21]; Argentina = 35.8%; Spain = 28.8% [24]). Similar results with students from the United States (32%) [21] could be observed in risky behaviors (the Czech and Slovak Republics = 34.58%).

Regarding depression, female students acquired a higher PHQ-9 score than their male counterparts. This fact follows the evidence that depressive disorder (PHQ-9) is more common in females [74].  Albert [75] tried to explain this on the basis of biological factors that may contribute to a higher prevalence of depression in females as well as to their mental vulnerability. There are also insights into this issue that addressed sex differences in depression during adolescence, and their results showed that the causes of depression were more common in females, who were also more likely to develop risk factors for depressive disorder than males [76]. In the context of the main idea of this study, it should be noted that the main risk factors for depression among female students include low economic status, chronic illness, and unhealthy patterns of behavior [77].

In general, the results in this study also showed that 29.8%, 11.6%, 5.5% and 3.1% of students suffered from mild, moderate, moderately severe and severe depression. This can be compared with the findings of Hajduk et al. [35], who identified depression in 35.5% of Slovak students. For comparison, similar results were found in university students from the United Kingdom [38]. Croatian students also reported depressive disorder with a similar prevalence (mild = 30.3%, moderate = 16.1%, moderately severe = 7.2%, severe = 0.2%) [37]. Students from the United States had mild to moderate depression in a prevalence of 37.7%, and 4.4% of students suffered from severe depression [31]. This suggests that depression in Slovak and Czech students reached a comparable level with other countries even during the COVID-19 pandemic. By comparing depression, the measured scores did not differ much from the scores before the COVID-19 pandemic [35]. Due to the lack of information on the YAACQ score obtained by Czech and Slovak students, it was not possible to compare the values before the COVID-19 pandemic. At the same time, there is a need to compare the reported depression and the consequences of alcohol use after the COVID-19 pandemic.

The results also indicated the existence of significant and positive associations between all the examined indicators (individual alcohol-related consequences, depression), while the associations between the consequences of alcohol use and depressive disorder were identified in low to medium intensity. The findings in this study agree with the findings of other international studies that have revealed that depression is associated with alcohol-related consequences [42, 45]. This was also confirmed between psychological discomfort, such as distress, and the YAACQ score [46]. In this study, a stronger association was found in female students. Also, similar results were revealed in regression models, and the significant effects of alcohol-related consequences on depressive disorder were confirmed in the vast

majority of the analyzed cases. Correlation analysis as well as regression analysis provided an output with positive coefficients, meaning that the increased risk of depressive disorder can be associated with experience in selected dimensions of alcohol-related consequences. Specifically, the findings of Geisner et al. [23] showed a stronger association between psychological symptoms and alcohol-related consequences in males, who were also characterized by higher alcohol consumption and more negative alcohol-related consequences. The results presented in this study partially agree with the findings of Schutte et al. [53], who revealed that alcoholrelated consequences could cause depression in males, but not in females. On the contrary, the results of this study support the findings of Rosenthal et al. [54], who revealed that experiencing negative alcohol-related consequences (BYAACQ) may lead to a higher risk of depression (PHQ-9) among female students. The study conducted by Miller et al. [78] should also be emphasized, while their findings showed that blackouts were associated with other consequences of alcohol use (BYAACQ), which in turn were associated with depressive disorder (PHQ-8). In other words, blackouts showed direct and indirect effects on depression in young adults [78]. Focusing on other alcohol-related consequences, the experience of casual sex also increased depressive symptoms in females more than in males [55], while guilt, remorse, feelings that violated societal expectations played an important role in this situation [56]. Last but not least, the findings of this study are close to the knowledge that alcohol use disorder may increase the risk of subsequent depressive disorder [40, 41].

These findings could be useful to support the development of diagnostic variables for alcohol addiction in Czech and Slovak university students. Effective diagnostic measures and prevention programs exist in many other regions, which can be an inspiration. The examined regions should implement them in the university environment. It seems that strategies should also include monitoring the consequences of alcohol use and subsequent depressive symptoms, while experts should distinguish between the individual dimensions of the consequences. The idea is whether chronic alcohol use causes brain changes associated with depression [79], or whether there are genetic or other variables that could explain the relationship revealed in this study. The findings provide great potential for clinical and diagnostic research, that can build on this study.

### **6. Conclusion and implications**

The results of this study represent valuable outputs for national policy makers, as well as for national and international research communities, whose ambition is to examine psychological and behavioral predictors and sex differences in addictive behaviors. All of the above-mentioned findings suggested that the consequences of alcohol use should be an integral part of policy and professional discussions on young people's mental health, as these consequences can be an important factor in the increased risk of depressive disorder. Also, students represent a group of the population of society that is to become an active productive part of it, and they represent potential current and future health care, criminal justice, and social burdens as well. Therefore, it is necessary to point out these aspects and to support the development of prevention addiction programs for this population group as well.

For this reason, public health policies should be strengthened in order to raise people's awareness of the threats of alcohol use and other consequences that may affect the mental health of individuals. Policy makers should strive to integrate mental health into all aspects of social and health policies, strategies and interventions. This research supports the idea that alcohol use with a risk of addiction and

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

consequences contributes negatively to the symptoms of depression in young people. Specifically, the dimensions of self-perception and self-care appear to be the most important among Slovak and Czech young adults. This fact requires a special attention in the development of diagnostic procedures and the implementation of interventions in the field of addiction in these geographical regions. As the YAACQ is able to predict drinking patterns [10] and the level of drinking risk [11], it is welcome if the dimensions of alcohol-related consequences are also taken into account in alcohol addiction policies. In fact, prevention and education should also play a key role in universities and counseling centres. It would be beneficial if prevention programs for female students focused on coping and overcoming depressive symptoms. On the other hand, there is a need to focus on helping male students with alcohol use disorders and the subsequent consequences of drinking. In general, there is a lack of university counseling centres to help students overcome difficult situations in their lives. Professionals providing adequate help should also focus on the individual alcohol-related consequences as an accompanying aspect of diagnosing alcohol addiction, which would also lead to the prevention of mental disorders such as depression. Promoting an active lifestyle will continue to play an important role in this issue.

In the regions of the Czech and Slovak Republics, alcohol use disorders, together with the consequences of drinking, do not have the necessary attention and are overlooked not only at universities, but also in society as a whole. It is important to be aware of the importance of this issue at both professional and political level. Interventions are urgently needed to prevent young people from becoming addicted.

Health literacy is also considered as an important part of prevention programs at various stages of addiction [80–82]. In the Slovak and Czech Republics, there is no health literacy system that would include specific programs for different population groups [83]. Therefore, it is very difficult to estimate the extent to which the emergence and development of addiction among university students is determined by an insufficient level of health literacy (or its complete absence) and the extent to which it is determined by socio-economic factors. The family and the quality of the previous educational process also play an important role in problem drinking.

In any case, regional differences in addiction need to be examined, while it is also important to examine the consequences of alcohol use, the level of addiction, the mental health of the population and the economic parameters of the region, which may provide greater opportunities for addiction [84]. The ambition in this differentiating perspective was to point out the sex-differentiated effects of problem drinking with consequences, specifically in terms of the higher prevalence of depression in females than in males. Taking these differences into account can also significantly support the development of sex-differentiated services and programs [4, 85, 86]. From an international perspective, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) [87] also pointed to the limited nature of services specialized for females. Although there is at least one such facility in almost every EU country, the demand is much higher and it is therefore necessary to ensure greater availability of specialized health care.

One of the strengths of this study is the fact that the research was conducted in a relatively large geographically area. The sample size is not negligible, as the sample in this study covered the vast majority of Czech and Slovak universities. The study also has several weaknesses that need to be taken into account when interpreting the results. The limitations of the presented research may include the fact that the sample was not random, and thus certain questions may arise regarding the representativeness of the research sample. Given the size of the sample and the fact that quota sampling was used, it was not expected that the findings would be

significantly distorted due to the non-random sampling. Also, the questionnaire was distributed electronically and there is no guarantee that students have read all the attached information, which can be considered a limitation. There was also a possible limitation when comparing the results with the results of other authors, as a multilevel scale was used in this research, which is perceived as more accurate. It is not known how the COVID pandemic influenced access to alcohol, and this may be a weakness of the study.

As already emphasized, there is a need for scientific interest in the issue of addictive behavior and mental disorders. Future research will focus on uncovering other hidden differences in terms of health, mental disorders and alcohol use. In more detail, it is planned to compare these indicators between different fields of study. The ambition is to extend the research sample and to make a comparison between all countries belonging to the Visegrad Group. The time frame of data collection in this research also provides space for comparing the results aimed at evaluating changes in the addictive behavior of university students during the COVID-19 pandemic with the period after this pandemic situation. The international dimension of the research will provide an insight into the strength of the impact of the socio-economic changes caused by the COVID-19 pandemic on the emergence and development of the young generation's addiction.

### **Acknowledgements**

This research was supported by the Internal Grant Agency of FaME Tomas Bata University in Zlin: RVO/2020: "Economic quantification of marketing processes that focus on value increase for a patient in a process of system creation to measure and control efficiency in health facilities in the Czech Republic".

### **Conflict of interest**

The authors have no conflict of interest, financial or otherwise. The funders had no role in preparing the study; in data processing; in writing the manuscript or deciding on the publication of the results.

### **Notes/thanks/other declarations**

We thank the students for their participation in the research. We also thank the university representatives, scientific, pedagogical and administrative workers for their willingness to distribute the questionnaire.

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

### **Author details**

Beata Gavurova<sup>1</sup> \*, Martin Rigelsky<sup>2</sup> and Viera Ivankova<sup>2</sup>

1 Center for Applied Economic Research, Faculty of Management and Economics, Tomas Bata University in Zlin, Zlin, Czech Republic

2 Faculty of Management, University of Presov in Presov, Presov, Slovakia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. The Lancet. 2007;370(9590):859–877. DOI: 10.1016/s0140-6736(07)61238-0

[2] Doran CM, Kinchin I. A review of the economic impact of mental illness. Australian Health Review. 2019;43(1): 42–48. DOI: 10.1071/ah16115

[3] Schnitzerova E, Antonicova L. Gender aspects in the context of cosial work and services for drug users. Alkoholizmus a drogové závislosti - Protialkoholický obzor. 2011;46(4):241– 251. Available from: https://www.adzpo. sk/images/articles/adzpo-2011-46- 4-241-251.pdf [Accessed: 2020-12-29]

[4] Kalina K. Ženy a muži jako specifické cílové skupiny. In: Kalina K, et al. editors. Základy klinické adiktológie. 1st ed. Praha: Grada; 2008. p. 265–274. ISBN 978–80–247-1411-0

[5] Kim SS, Lee HO, Kiang P, Kalman D, Ziedonis DM. Factors associated with alcohol problems among Asian American college students: gender, ethnicity, smoking and depressed mood. Journal of Substance Use. 2013;19(1–2):12–17. DOI: 10.3109/14659891.2012.709912

[6] OECD. Health at a Glance 2019: OECD Indicators [Internet]. 2019. Paris: OECD Publishing. Available from: h ttps://doi.org/10.1787/4dd50c09-en [Accessed: 2020-12-29]

[7] Skogen JC, Bøe T, Thørrisen MM, Riper H, Aas RW. Sociodemographic characteristics associated with alcohol consumption and alcohol-related consequences, a latent class analysis of The Norwegian WIRUS screening study. BMC Public Health. 2019;19(1). DOI:10.1186/s12889-019-7648-6

[8] Rehm J, Room R. The cultural aspect: How to measure and interpret

epidemiological data on alcohol-use disorders across cultures. Nordisk Alkohol- & Narkotikatidskrift. 2017;34 (4):330–341. DOI: 10.1177/<PHONE_NUMBER>704795

[9] Pilatti A, Read JP, Caneto F. Validation of the Spanish version of the Young Adult Alcohol Consequences Questionnaire (S-YAACQ). Psychological Assessment. 2016;28(5): e49–e61. DOI: 10.1037/pas0000140

[10] Read JP, Merrill JE, Kahler CW, Strong DR. Predicting functional outcomes among college drinkers: Reliability and predictive validity of the Young Adult Alcohol Consequences Questionnaire. Addictive Behaviors. 2007;32(11):2597–2610. DOI: 10.1016/j. addbeh.2007.06.021

[11] Read JP, Haas AL, Radomski S, Wickham RE, Borish SE. Identification of hazardous drinking with the Young Adult Alcohol Consequences Questionnaire: Relative operating characteristics as a function of gender. Psychological Assessment. 2016;28(10): 1276–1289. DOI: 10.1037/pas0000251

[12] Keough MT, O'Connor RM, Read JP. Replication and validation of the Young Adult Alcohol Consequences Questionnaire in a large sample of Canadian undergraduates. Alcoholism-Clinical and Experimental Research. 2016; 40(5):1093–1099. DOI: 10.1111/acer.13039

[13] Merrill JE, Carey KB. Drinking over the lifespan: Focus on college ages. Alcohol Research-Current Reviews. 2016;38(1):103–114.

[14] Tembo C, Burns S, Kalembo F. The association between levels of alcohol consumption and mental health problems and academic performance among young university students. Plos One. 2017;12(6):e0178142. DOI: 10.1371/journal.pone.0178142

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

[15] dos Reis TG, de Oliveira LCM. Alcohol consumption among students of a Brazilian public university and consequences associated with this consumption. Bioscience Journal. 2017; 33(5):1371–1380.

[16] Larimer ME, Cronce JM. Identification, prevention, and treatment revisited: Individual-focused college drinking prevention strategies 1999–2006. Addictive Behaviors. 2007; 32(11):2439–2468. DOI: 10.1016/j. addbeh.2007.05.006

[17] Lamis DA, Ballard ED, May AM, Dvorak RD. Depressive symptoms and suicidal ideation in college students: The mediating and moderating roles of hopelessness, alcohol problems, and social support. Journal of Clinical Psychology. 2016;72(9):919–932. DOI: 10.1002/jclp.22295

[18] Murphy JG, Barnett NP, Goldstein AL, Colby SM. Gender moderates the relationship between substance-free activity enjoyment and alcohol use. Psychology of Addictive Behaviors. 2007; 21(2):261–265. DOI: 10.1037/0893-164x.21.2.261

[19] Bravo AJ, Pearson MR, Pilatti A, Read JP, Mezquita L, Ibanez MI, Ortet G. Impulsivity-related traits, college alcohol beliefs, and alcohol outcomes: Examination of a prospective multiple mediation model among college students in Spain, Argentina, and USA. Addictive Behaviors. 2018;81: 125–133. DOI: 10.1016/j. addbeh.2018.02.009

[20] Merrill JE, Wardell JD, Read JP. Drinking motives in the prospective prediction of unique alcohol-related consequences in college students. Journal of Studies on Alcohol and Drugs. 2014;75(1):93–102. DOI: 10.15288/ jsad.2014.75.93

[21] Read JP, Kahler CW, Strong DR, Colder CR. Development and

preliminary validation of the Young Adult Alcohol Consequences Questionnaire. Journal of Studies on Alcohol. 2006;67(1):169–177. DOI: 10.15288/jsa.2006.67.169

[22] Lemley SM, Kaplan BA, Reed DD, Darden AC, Jarmolowicz DP. Reinforcer pathologies: Predicting alcohol related problems in college drinking men and women. Drug and Alcohol Dependence. 2016;167:57–66. DOI: 10.1016/j. drugalcdep.2016.07.025

[23] Geisner IM, Larimer ME, Neighbors C. The relationship among alcohol use, related problems, and symptoms of psychological distress: Gender as a moderator in a college sample. Addictive Behaviors. 2004;29 (5):843–848. DOI: 10.1016/j. addbeh.2004.02.024

[24] Bravo AJ, Pilatti A, Pearson MR, Read JP, Mezquita L, Ibanez MI, Ortet G. Cross-cultural examination of negative alcohol-related consequences: Measurement invariance of the Young Adult Alcohol Consequences Questionnaire in Spain, Argentina, and USA. Psychological Assessment. 2019;31 (5):631–642. DOI: 10.1037/pas0000689

[25] Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research. 2013;47(3):391– 400. DOI: 10.1016/j. jpsychires.2012.11.015

[26] Ludwig AB, Burton W, Weingarten J, Milan F, Myers DC, Kligler B. Depression and stress amongst undergraduate medical students. BMC Medical Education. 2015;15(1):141. DOI: 10.1186/s12909-015-0425-z

[27] Awadalla S, Davies EB, Glazebrook C. A longitudinal cohort study to explore the relationship between depression, anxiety and academic performance among Emirati university students. BMC Psychiatry. 2020;20(1):448. DOI: 10.1186/ s12888-020-02854-z

[28] Dvorak RD, Lamis DA, Malone PS. Alcohol use, depressive symptoms, and impulsivity as risk factors for suicide proneness among college students. Journal of Affective Disorders. 2013;149 (1–3):326–334. DOI: 10.1016/j. jad.2013.01.046

[29] Asante KO, Andoh-Arthur J. Prevalence and determinants of depressive symptoms among university students in Ghana. Journal of Affective Disorders. 2015;171:161–166. DOI: 10.1016/j.jad.2014.09.025

[30] Angst J, Gamma A, Gastpar M, Lepine JP, Mendlewicz J, Tylee A. Gender differences in depression: Epidemiological findings from the European DEPRES I and II studies. European Archives of Psychiatry and Clinical Neuroscience. 2002;252(5):201– 209. DOI: 10.1007/s00406-002-0381-6

[31] Leppink EW, Lust K, Grant JE. Depression in university students: Associations with impulse control disorders. International Journal of Psychiatry in Clinical Practice. 2016;20 (3):146–150. DOI: 10.1080/ 13651501.2016.1197272

[32] Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16(9):606–613. DOI: 10.1046/ j.1525-1497.2001.016009606.x

[33] Kroenke K, Spitzer RL, Williams JBW, Lowe B. The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry. 2010;32(4):345–359. DOI: 10.1016/j.genhosppsych.2010.03.006

[34] Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and

severity measure. Psychiatric Annals. 2002;32(9):509–515. DOI: 10.3928/ 0048-5713-20020901-06

[35] Hajduk M, Heretik A, Vaseckova B, Forgacova L, Pecenak J. Prevalence and correlations of depression and anxiety among Slovak college students. Bratislava Medical Journal. 2019;120(9): 695–698. DOI: 10.4149/BLL\_2019\_117

[36] Dansova P, Masopustova Z, Hanackova V, Kickova K, Korabova I. The Patient Health Questionnaire-9: the Czech version. 2016;60(3):468–481.

[37] Milic J, Skrlec I, Vranjes IM, Podgornjak M, Heffer M. High levels of depression and anxiety among Croatian medical and nursing students and the correlation between subjective happiness and personality traits. International Review of Psychiatry. 2019;31(7–8):653–660. DOI: 10.1080/ 09540261.2019.1594647

[38] Honney K, Buszewicz M, Coppola W, Griffin M. Comparison of levels of depression in medical and nonmedical students. The Clinical Teacher. 2010;7(3):180–184. DOI: 10.1111/ j.1743-498x.2010.00384.x

[39] Weitzman ER. Poor mental health, depression, and associations with alcohol consumption, harm, and abuse in a national sample of young adults in college. The Journal of Nervous and Mental Disease. 2004;192(4):269–277. DOI: 10.1097/01. nmd.0000120885.17362.94

[40] Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011;106(5): 906–914. DOI: 10.1111/ j.1360-0443.2010.03351.x

[41] Li J, Wang H, Li M, Shen Q, Li X, Zhang Y, Peng J, Rong X, Peng Y. Effect of alcohol use disorders and alcohol intake on the risk of subsequent depressive symptoms: a systematic review and meta-analysis of cohort

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

studies. Addiction. 2020;115(7):1224– 1243. DOI: 10.1111/add.14935

[42] Martens MP, Martin JL, Hatchett ES, Fowler RM, Fleming KM, Karakashian MA, Cimini MD. Protective behavioral strategies and the relationship between depressive symptoms and alcohol-related negative consequences among college students. Journal of Counseling Psychology. 2008; 55(4):535–541. DOI: 10.1037/a0013588

[43] Park CL, Grant C. Determinants of positive and negative consequences of alcohol consumption in college students: alcohol use, gender, and psychological characteristics. Addictive Behaviors. 2005;30(4):755–765. DOI: 10.1016/j. addbeh.2004.08.021

[44] Kenney SR, Lac A, LaBrie JW, Hummer JF, Pham A. Mental Health, Sleep Quality, Drinking Motives, and Alcohol-Related Consequences: A Path-Analytic Model. Journal of Studies on Alcohol and Drugs. 2013;74 (6):841–851. DOI: 10.15288/ jsad.2013.74.841

[45] Preonas PD, Lau-Barraco C. Affective factors explaining the association between depressive functioning and alcohol outcomes among college students. Journal of American College Health. 2019. DOI: 10.1080/07448481.2019.1683565

[46] Ruiz P, Pilatti A, Pautassi RM. Consequences of alcohol use, and its association with psychological distress, sensitivity to emotional contagion and age of onset of alcohol use, in Uruguayan youth with or without college degree. Alcohol. 2020;82:91–101. DOI: 10.1016/j.alcohol.2019.09.001

[47] Flesch BD, Houvessou GM, Munhoz TN, Fassa AG. Major depressive episode among university students in Southern Brazil. Revista de Saude Publica. 2020;54:11. DOI: 10.11606/s1518-8787.2020054001540 [48] Dennhardt AA, Murphy JG. Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychology of Addictive Behaviors. 2011;25(4):595– 604. DOI: 10.1037/a0025807

[49] Wang J, Patten SB. A prospective study of sex-specific effects of major depression on alcohol consumption. The Canadian Journal of Psychiatry. 2001;46 (5):422–425. DOI: 10.1177/<PHONE_NUMBER>04600507

[50] Kuo PH, Gardner CO, Kendler KS, Prescott CA. The temporal relationship of the onsets of alcohol dependence and major depression: using a genetically informative study design. Psychological Medicine. 2006;36(8):1153. DOI: 10.1017/s0033291706007860

[51] Fergusson DM, Boden JM, Horwood LJ. Tests of causal links between alcohol abuse or dependence and major depression. Archives of General Psychiatry. 2009;66(3):260. DOI: 10.1001/archgenpsychiatry.2008.543

[52] Hasin DS, Grant BF. Major depression in 6050 former drinkers: Association with past alcohol dependence. Archives of General Psychiatry. 2002;59(9):794. DOI: 10.1001/archpsyc.59.9.794

[53] Schutte KK, Hearst J, Moos RH. Gender differences in the relations between depressive symptoms and drinking behavior among problem drinkers: A three-wave study. Journal of Consulting and Clinical Psychology. 1997;65(3):392–404. DOI: 10.1037/ 0022-006x.65.3.392

[54] Rosenthal SR, Clark MA, Marshall BDL, Buka SL, Carey KB, Shepardson RL, Carey MP. Alcohol consequences, not quantity, predict major depression onset among first-year female college students. Addictive

Behaviors. 2018;85:70–76. DOI: 10.1016/ j.addbeh.2018.05.021

[55] Grello CM, Welsh DP, Harper MS. No strings attached: The nature of casual sex in college students. Journal of Sex Research. 2006;43(3),255–267. DOI: 10.1080/00224490609552324

[56] Foster C, Caravelis C, Kopak A. National College Health Assessment Measuring Negative Alcohol-Related Consequences among College Students. American Journal of Public Health Research. 2014;2(1):1–5. DOI: 10.12691/ ajphr-2-1-1

[57] Panno A, Carbone GA, Massullo C, Farina B, Imperatori C. COVID-19 related distress is associated with alcohol problems, social media and food addiction symptoms: Insights from the italian experience during the lockdown. Frontiers in Psychiatry. 2020;11:577135. DOI: 10.3389/fpsyt.2020.577135

[58] Son C, Hegde S, Smith A, Wang X, Sasangohao F. Effects of COVID-19 on college students' mental health in the United States: interview survey study. Journal of Medical Internet Research. 2020;22(9):e21279. DOI: 10.2196/21279

[59] Ramalho R. Alcohol consumption and alcohol-related problems during the COVID-19 pandemic: a narrative review. Australasian Psychiatry. 2020;28(5):524– 526. DOI: 10.1177/1039856220943024

[60] Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of Affective Disorders. 2006;96(1–2):89–93. DOI: 10.1016/j.jad.2006.05.021

[61] Du N, Yu K, Ye Y, Chen S. Validity study of Patient Health Questionnaire-9 items for Internet screening in depression among Chinese university students. Asia-Pacific Psychiatry. 2016;9 (3):e12266. DOI: 10.1111/appy.12266

[62] Farrer LM, Gulliver A, Bennett K, Fassnacht DB, Griffiths KM. Demographic and psychosocial predictors of major depression and generalised anxiety disorder in Australian university students. BMC Psychiatry. 2016;16(1). DOI: 10.1186/ s12888-016-0961-z

[63] Zhou Y, Xu J, Rief W. Are comparisons of mental disorders between Chinese and German students possible? An examination of measurement invariance for the PHQ-15, PHQ-9 and GAD-7. BMC Psychiatry. 2020;20:480. DOI: 10.1186/s12888-020-02859-8

[64] Zajenkowska A, Jasielska D, Melonowska J. Stress and sensitivity to frustration predicting depression among young adults in Poland and Korea - Psychological and philosophical explanations. Current Psychology. 2019; 38:769–774. DOI: 10.1007/s12144-017- 9654-0

[65] Corbin WR, Waddell JT, Ladensack A, Scott C. I drink alone: Mechanisms of risk for alcohol problems in solitary drinkers. Addictive Behaviors. 2020;102:106147. DOI: 10.1016/j.addbeh.2019.106147

[66] World Medical Association. Declaration of Helsinki—Ethical principles for medical research involving human subjects [Internet]. 2013. Available from: https://www.wma .net/policies-post/wma-declaration-ofhelsinki-ethical-principles-for-medica l-research-involving-human-subjects/ [Accessed: 2020-12-24]

[67] International Society of Addiction Journal Editors. The Farmington Consensus [Internet]. 2017. Available from: http://www.isaje.net/farmingtonconsensus.html [Accessed: 2020-12-24]

[68] Sopko J, Kocisova K. Key indicators and determinants in the context of the financial aspects of health systems in selected countries. Adiktologie. 2019;19

*Sex Differences between Young Adults in the Czech and Slovak Republics… DOI: http://dx.doi.org/10.5772/intechopen.96469*

(4):189–202. DOI: 10.35198/01-2019- 004-0003

[69] Megyesiova S, Gavurova B. Multivariate analysis of alcohol consumption and death rates resulting from alcohol consumption in EU and OECD member states. Adiktologie. 2019;19(4):179–187. DOI: 10.35198/ 01-2019-004-0002

[70] Foster DW, Young CM, Bryan J, Steers MLN, Yeung NCY, Prokhorov AV. Interactions among drinking identity, gender and decisional balance in predicting alcohol use and problems among college students. Drug and Alcohol Dependence. 2014;143:198–205. DOI: 10.1016/j.drugalcdep.2014.07.024

[71] Gaher RM, Simons JS. Evaluations and expectancies of alcohol and marijuana problems among college students. Psychology of Addictive Behaviors. 2007;21(4):545–554. DOI: 10.1037/0893-164x.21.4.545

[72] Nolen-Hoeksema S. Gender differences in risk factors and consequences for alcohol use and problems. Clinical Psychology Review. 2004;24(8):981–1010. DOI: 10.1016/j. cpr.2004.08.003

[73] Rose PA, Schuckman HE, Oh SS, Park EC. Associations between gender, alcohol use and negative consequences among Korean college students: A national study. International Journal of Environmental Research and Public Health. 2020;17(14):5192. DOI: 10.3390/ ijerph17145192

[74] Ngasa SN, Sama CB, Dzekem BS, Nforchu KN, Tindong M, Aroke D, Dimala CA. Prevalence and factors associated with depression among medical students in Cameroon: A cross-sectional study. BMC Psychiatry. 2017;17(1):216. DOI: 10.1186/s12888-017-1382-3

[75] Albert P. Why is depression more prevalent in women? Journal of

Psychiatry & Neuroscience. 2015;40(4): 219–221. DOI: 10.1503/jpn.150205

[76] Nolen-Hoeksema S, Girgus JS. The emergence of gender differences in depression during adolescence. Psychological Bulletin. 1994;115(3): 424–443. DOI: 10.1037/ 0033-29<IP_ADDRESS>4

[77] Acikgoz A, Dayi A, Binbay T. Prevalence of depression among female university students and associated factors. Cukurova Medical Journal. 2018;43(1):131–140. DOI: 10.17826/ cumj.340629

[78] Miller MB, DiBello AM, Merrill JE, Neighbors C, Carey KB. The role of alcohol-induced blackouts in symptoms of depression among young adults. Drug and Alcohol Dependence. 2020;211: 108027. DOI: 10.1016/j. drugalcdep.2020.108027

[79] Shor C, Zuo W, Eloy JD, Ye J-H. The Emerging Role of LHb CaMKII in the Comorbidity of Depressive and Alcohol Use Disorders. International Journal of Molecular Sciences. 2020;21(21):8123. DOI: 10.3390/ijms21218123

[80] Degan TJ, Kelly PJ, Robinson LD, et al. Health literacy in substance use disorder treatment: A latent profile analysis. Journal of Substance Abuse Treatment. 2019;96:46–52. DOI: 10.1016/j.jsat.2018.10.009

[81] Aaby A, Friis K, Bo C, Rowlands G, Maindal HT. Health literacy is associated with health behaviour and self-reported health: A large populationbased study in individuals with cardiovascular disease. European Journal of Preventive Cardiology. 2017; 24(17):1880–1888. DOI: 10.1177/<PHONE_NUMBER>729538

[82] Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: Longitudinal cohort study. BMJ-British Medical Journal. 2012;344:e1602. DOI: 10.1136/bmj.e1602

[83] Rolova G, Gavurova B, Petruzelka B. Exploring health literacy in individuals with alcohol addiction: A mixed methods clinical study. International Journal of Environmental Research and Public Health. 2020;17 (18):6728. DOI: 10.3390/ijerph17186728

[84] Gavurova B, Kovac V, Kulhanek A, Bartak M. Territorial distribution of alcohol and drug addictions mortality concerning regional disparities in the Slovak Republic from year 1996 to year 2015. Adiktologie. 2019;19(3):125–134. DOI: 10.35198/01-2019-003-0005

[85] Kuruc A, Smitkova H. Rod/gender ako sociálna kategória v psychoterapii a poradenstve. Československá Psychologie. 2007;51(3):269–278.

[86] Miovsky M. Evaluace adiktologických programu a služeb. In: Kalina K, et al. editors. Základy klinické adiktológie. Praha: Grada; 2008. p. 307– 315. ISBN 978–80–247-1411-0

[87] EMCDDA. 2005. Differences in patterns of drug use between men and women. Technical datasheet [Internet]. 2005. Lisbon: European Monitoring Centre for Drugs and Drug Addiction. Available from: https://www.emcdda. europa.eu/system/files/publications/ 387/TDS\_gender\_64783.pdf [Accessed: 2020-12-29]

### **Chapter 4**

## Leveraging Advanced Analytics to Understand the Impact of the COVID-19 Pandemic on Trends in Substance Use Disorders

*Ewa J. Kleczyk, Jill Bana and Rishabh Arora*

### **Abstract**

Coronavirus disease (COVID-19) caused an overwhelming healthcare, economic, social, and psychological impact on the world during 2020 and first part of 2021. Certain populations, especially those with Substance Use Disorders (SUD), were particularly vulnerable to contract the virus and also likely to suffer from a greater psychosocial and psychological burden. COVID-19 and addiction are two conditions on the verge of a collision, potentially causing a major public health threat. There is surge of addictive behaviors (both new and relapse), including use of alcohol, nicotine, and recreational drugs. This book chapter analyzed the bidirectional relationship between COVID-19 and SUD by leveraging descriptive summaries, advanced analytics, and machine learning approaches. The data sources included healthcare claims dataset as well as state level alcohol consumption to help in investigating the bi-directional relationship between the two conditions. Results suggest that alcohol and nicotine use increased during the pandemic and that the profile of SUD patients included diagnoses and symptoms of COVID-19, depression and anxiety, as well as hypertensive conditions.

**Keywords:** COVID-19, pandemic, addiction, smoking, alcohol, opioid addiction, public health, advanced analytics, linear regression, machine learning model

### **1. Introduction**

The coronavirus disease (COVID-19) has caused a large healthcare, economic, and psychosocial impact on communities in the United States and around the world in 2020 and first part of 2021. Many communities, especially those with low income and Substance Use Disorders (SUD), were particularly vulnerable to contract the infection and likely to suffered from a greater economic and psychosocial burden [1].