Many researchers, clinicians, and recovering individuals, themselves, think of recovery from substance use disorder (SUD) as an experience that includes, but is not limited to, abstinence from alcohol and other drugs.
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Despite these informative studies on the positive effects of 12-step MHO participation on abstinence, research examining the impact of attendance on recovery markers beyond abstinence is far less common.
This Wilcox et al. study investigated whether there was an effect of AA attendance, and other markers of AA participation including religious/spiritual practices and 12-step work, on decreased depression over 2 years among new AA participants with alcohol use disorder.
Researchers assessed 253 adults with alcohol use disorder, who reported at least one drinking day and had attended at least one 12-step MHO meeting in the past 90 days, but had less than 16 total weeks of lifetime AA attendance. They established these inclusion criteria to investigate the effects of AA participation in newAA members. Many prior studies have included both AA-naive and AA-experienced individuals. More research is needed on investigating the effect of AA attendance for those with minimal prior experience to inform clinical recommendations and public health policy.
The study assessed participants at intake into the study, and again at 3-, 6-, 9-, 12-, 18- and 24-month follow-ups. Two-thirds of the sample was male and the majority had at least a high school diploma or general equivalency degree (GED); the average participant was 39 years old (standard deviation = 10). The sample was also racially/ethnically diverse, comprised of 40% Hispanic, 35% non-Hispanic White, and 17% Native American participants (others were African American, Asian, or unspecific race/ethnicity).
The researchers used sophisticated statistical analyses called hierarchical linear modeling:
They used another sophisticated analytic approach called bootstrapping to investigate if either the effects of:
were explained by drinking outcomes at 12 months, over and above the effects of baseline drinking and treatment attendance over time.
The analyses examining religious/spiritual practices and AA step work also controlled statistically for the effect of AA attendance. These are often referred to as tests of mediation.
Alcohol outcomes were abstinence, measured by percent days abstinent (PDA), drinking intensity, measured by drinks per drinking day (DDD). Religious/spiritual practices were measured with the Religious Background and Behaviors Scale (RBB).
For this study, authors used this scale to measure the frequency in the past 90 days of:
Step work was assessed with completion of what authors called “surrender” steps (steps 1-3; total possible = 3), “action” steps (steps 4-9; total possible = 6), and “maintenance” steps (steps 10-12; total possible = 3). See here for the list of AA’s 12 steps and discussion of each step.
Depression was measured with the second edition of the Beck Depression Inventory (BDI-II), a 21-item self-report questionnaire (score range = 0-63). Participants entered the study with an average depression score of 20, indicating that study participants, on average, were suffering from moderate levels of depression.
Drinking outcomes at each time point were related to depression in the expected directions. Specifically, lower levels of depression were related to greater abstinence and less intensive drinking.
Importantly, AA attendance was associated with reduced depression over time, even when controlling for the effects of drinking at the time depression was measured.
This effect of AA on depression was present for both participants with low/minimal depression and those with moderate/severe depression. More religious/spiritual practices were also related to reduced depression over time. Contrary to expectations, completing AA’s “action” steps were related to increased depression; neither of the other groups of steps were related to depression over time.
Regarding the mediation analyses that looked deeper into the effect of AA attendance on helping to reduce depression symptoms, this effect was found to be explained, in part, by increasing abstinence, but not by decreasing drinking intensity (in separate mediation models). See the figure below for a graphical depiction of this mediated effect. Neither religious/spiritual practices, nor any of the step work variables, however, were found to explain a significant percentage of this AA-depression effect.
This study helps contextualize two other studies that authors also mention:
Also, at least for those who are new to AA, or who have co-occurring major depressive disorder (that would require clinical attention even if the individual’s alcohol use disorder was in remission), attendance does indeed appear to be related to less depression, beyond the decrease that comes simply from giving up drinking. These participants may derive added benefit related to mood beyond abstinence. The reasons for this are as yet unclear. One possibility is that these individuals may select aspects of the AA program or fellowship that help them address this added depression burden (e.g., participating in social activities with other AA members).
The relationship between spiritual/religious practices and depression might be even more nuanced. There is a large body of literature suggesting individuals who are more religious are less depressed, and less likely to develop depression (see here). Thus the relationship between greater religious/spiritual practices and lower depression is perhaps not surprising.
Also, there are some studies that suggest AA attendance exerts its influence on improved drinking outcomes through increases in religious/spiritual practices (see here and here, for example). However, this explanatory effect may not hold up as well when other, more socially-grounded mechanisms, like modifying one’s social network, are considered at the same time (see here). This background role of spirituality/religiosity in early recovery may be especially true for individuals with lower initial addiction severity, such as young adults (see here, for example). In other words, the effect of religiosity/spirituality on enhanced abstinence and psychological and emotional well-being may be part of the AA story, but only for some.
Finally, as the study authors pointed out, the observed relationship between working on the “action” steps of AA (steps 4 through 9), and increased depression symptoms was unexpected. Because these “action” steps involve documentation and analysis of past behavior as it has related to alcohol addiction, it is possible that for some individuals, such step work might have uncovered painful feelings. These emotional processes may have been responsible for the observed increase in depression.
Findings from this study are important, as they provide insight into whether participation in AA can uniquely reduce depressive symptoms among attendees, separate from its ability to promote increased abstinence rates.
This research suggests that a clinician can refer patients to AA that present with depressive symptoms in addition to alcohol use disorder, as it is likely to help enhance recovery. These gains may occur both for alcohol abstinence as well as other aspects of well-being, such as reduced depressive symptoms.
There are several mechanisms of action known to aid enhanced recovery in 12-step MHOs that might reasonably help reduce depression but were not examined here. For example, future studies might investigate whether the effect of AA on depression is explained by forming new social-recovery relationships (e.g., with a sponsor) and engaging in activities (e.g., with other recovering individuals) facilitated by the rich 12-step MHO milieu.
Wilcox, C. E., Pearson, M. R., & Tonigan, J. S. (2015). Effects of long-term AA attendance and spirituality on the course of depressive symptoms in individuals with alcohol use disorder. Psychol Addict Behav, 29(2), 382-391. doi: 10.1037/adb0000053
l
Despite these informative studies on the positive effects of 12-step MHO participation on abstinence, research examining the impact of attendance on recovery markers beyond abstinence is far less common.
This Wilcox et al. study investigated whether there was an effect of AA attendance, and other markers of AA participation including religious/spiritual practices and 12-step work, on decreased depression over 2 years among new AA participants with alcohol use disorder.
Researchers assessed 253 adults with alcohol use disorder, who reported at least one drinking day and had attended at least one 12-step MHO meeting in the past 90 days, but had less than 16 total weeks of lifetime AA attendance. They established these inclusion criteria to investigate the effects of AA participation in newAA members. Many prior studies have included both AA-naive and AA-experienced individuals. More research is needed on investigating the effect of AA attendance for those with minimal prior experience to inform clinical recommendations and public health policy.
The study assessed participants at intake into the study, and again at 3-, 6-, 9-, 12-, 18- and 24-month follow-ups. Two-thirds of the sample was male and the majority had at least a high school diploma or general equivalency degree (GED); the average participant was 39 years old (standard deviation = 10). The sample was also racially/ethnically diverse, comprised of 40% Hispanic, 35% non-Hispanic White, and 17% Native American participants (others were African American, Asian, or unspecific race/ethnicity).
The researchers used sophisticated statistical analyses called hierarchical linear modeling:
They used another sophisticated analytic approach called bootstrapping to investigate if either the effects of:
were explained by drinking outcomes at 12 months, over and above the effects of baseline drinking and treatment attendance over time.
The analyses examining religious/spiritual practices and AA step work also controlled statistically for the effect of AA attendance. These are often referred to as tests of mediation.
Alcohol outcomes were abstinence, measured by percent days abstinent (PDA), drinking intensity, measured by drinks per drinking day (DDD). Religious/spiritual practices were measured with the Religious Background and Behaviors Scale (RBB).
For this study, authors used this scale to measure the frequency in the past 90 days of:
Step work was assessed with completion of what authors called “surrender” steps (steps 1-3; total possible = 3), “action” steps (steps 4-9; total possible = 6), and “maintenance” steps (steps 10-12; total possible = 3). See here for the list of AA’s 12 steps and discussion of each step.
Depression was measured with the second edition of the Beck Depression Inventory (BDI-II), a 21-item self-report questionnaire (score range = 0-63). Participants entered the study with an average depression score of 20, indicating that study participants, on average, were suffering from moderate levels of depression.
Drinking outcomes at each time point were related to depression in the expected directions. Specifically, lower levels of depression were related to greater abstinence and less intensive drinking.
Importantly, AA attendance was associated with reduced depression over time, even when controlling for the effects of drinking at the time depression was measured.
This effect of AA on depression was present for both participants with low/minimal depression and those with moderate/severe depression. More religious/spiritual practices were also related to reduced depression over time. Contrary to expectations, completing AA’s “action” steps were related to increased depression; neither of the other groups of steps were related to depression over time.
Regarding the mediation analyses that looked deeper into the effect of AA attendance on helping to reduce depression symptoms, this effect was found to be explained, in part, by increasing abstinence, but not by decreasing drinking intensity (in separate mediation models). See the figure below for a graphical depiction of this mediated effect. Neither religious/spiritual practices, nor any of the step work variables, however, were found to explain a significant percentage of this AA-depression effect.
This study helps contextualize two other studies that authors also mention:
Also, at least for those who are new to AA, or who have co-occurring major depressive disorder (that would require clinical attention even if the individual’s alcohol use disorder was in remission), attendance does indeed appear to be related to less depression, beyond the decrease that comes simply from giving up drinking. These participants may derive added benefit related to mood beyond abstinence. The reasons for this are as yet unclear. One possibility is that these individuals may select aspects of the AA program or fellowship that help them address this added depression burden (e.g., participating in social activities with other AA members).
The relationship between spiritual/religious practices and depression might be even more nuanced. There is a large body of literature suggesting individuals who are more religious are less depressed, and less likely to develop depression (see here). Thus the relationship between greater religious/spiritual practices and lower depression is perhaps not surprising.
Also, there are some studies that suggest AA attendance exerts its influence on improved drinking outcomes through increases in religious/spiritual practices (see here and here, for example). However, this explanatory effect may not hold up as well when other, more socially-grounded mechanisms, like modifying one’s social network, are considered at the same time (see here). This background role of spirituality/religiosity in early recovery may be especially true for individuals with lower initial addiction severity, such as young adults (see here, for example). In other words, the effect of religiosity/spirituality on enhanced abstinence and psychological and emotional well-being may be part of the AA story, but only for some.
Finally, as the study authors pointed out, the observed relationship between working on the “action” steps of AA (steps 4 through 9), and increased depression symptoms was unexpected. Because these “action” steps involve documentation and analysis of past behavior as it has related to alcohol addiction, it is possible that for some individuals, such step work might have uncovered painful feelings. These emotional processes may have been responsible for the observed increase in depression.
Findings from this study are important, as they provide insight into whether participation in AA can uniquely reduce depressive symptoms among attendees, separate from its ability to promote increased abstinence rates.
This research suggests that a clinician can refer patients to AA that present with depressive symptoms in addition to alcohol use disorder, as it is likely to help enhance recovery. These gains may occur both for alcohol abstinence as well as other aspects of well-being, such as reduced depressive symptoms.
There are several mechanisms of action known to aid enhanced recovery in 12-step MHOs that might reasonably help reduce depression but were not examined here. For example, future studies might investigate whether the effect of AA on depression is explained by forming new social-recovery relationships (e.g., with a sponsor) and engaging in activities (e.g., with other recovering individuals) facilitated by the rich 12-step MHO milieu.
Wilcox, C. E., Pearson, M. R., & Tonigan, J. S. (2015). Effects of long-term AA attendance and spirituality on the course of depressive symptoms in individuals with alcohol use disorder. Psychol Addict Behav, 29(2), 382-391. doi: 10.1037/adb0000053
l
Despite these informative studies on the positive effects of 12-step MHO participation on abstinence, research examining the impact of attendance on recovery markers beyond abstinence is far less common.
This Wilcox et al. study investigated whether there was an effect of AA attendance, and other markers of AA participation including religious/spiritual practices and 12-step work, on decreased depression over 2 years among new AA participants with alcohol use disorder.
Researchers assessed 253 adults with alcohol use disorder, who reported at least one drinking day and had attended at least one 12-step MHO meeting in the past 90 days, but had less than 16 total weeks of lifetime AA attendance. They established these inclusion criteria to investigate the effects of AA participation in newAA members. Many prior studies have included both AA-naive and AA-experienced individuals. More research is needed on investigating the effect of AA attendance for those with minimal prior experience to inform clinical recommendations and public health policy.
The study assessed participants at intake into the study, and again at 3-, 6-, 9-, 12-, 18- and 24-month follow-ups. Two-thirds of the sample was male and the majority had at least a high school diploma or general equivalency degree (GED); the average participant was 39 years old (standard deviation = 10). The sample was also racially/ethnically diverse, comprised of 40% Hispanic, 35% non-Hispanic White, and 17% Native American participants (others were African American, Asian, or unspecific race/ethnicity).
The researchers used sophisticated statistical analyses called hierarchical linear modeling:
They used another sophisticated analytic approach called bootstrapping to investigate if either the effects of:
were explained by drinking outcomes at 12 months, over and above the effects of baseline drinking and treatment attendance over time.
The analyses examining religious/spiritual practices and AA step work also controlled statistically for the effect of AA attendance. These are often referred to as tests of mediation.
Alcohol outcomes were abstinence, measured by percent days abstinent (PDA), drinking intensity, measured by drinks per drinking day (DDD). Religious/spiritual practices were measured with the Religious Background and Behaviors Scale (RBB).
For this study, authors used this scale to measure the frequency in the past 90 days of:
Step work was assessed with completion of what authors called “surrender” steps (steps 1-3; total possible = 3), “action” steps (steps 4-9; total possible = 6), and “maintenance” steps (steps 10-12; total possible = 3). See here for the list of AA’s 12 steps and discussion of each step.
Depression was measured with the second edition of the Beck Depression Inventory (BDI-II), a 21-item self-report questionnaire (score range = 0-63). Participants entered the study with an average depression score of 20, indicating that study participants, on average, were suffering from moderate levels of depression.
Drinking outcomes at each time point were related to depression in the expected directions. Specifically, lower levels of depression were related to greater abstinence and less intensive drinking.
Importantly, AA attendance was associated with reduced depression over time, even when controlling for the effects of drinking at the time depression was measured.
This effect of AA on depression was present for both participants with low/minimal depression and those with moderate/severe depression. More religious/spiritual practices were also related to reduced depression over time. Contrary to expectations, completing AA’s “action” steps were related to increased depression; neither of the other groups of steps were related to depression over time.
Regarding the mediation analyses that looked deeper into the effect of AA attendance on helping to reduce depression symptoms, this effect was found to be explained, in part, by increasing abstinence, but not by decreasing drinking intensity (in separate mediation models). See the figure below for a graphical depiction of this mediated effect. Neither religious/spiritual practices, nor any of the step work variables, however, were found to explain a significant percentage of this AA-depression effect.
This study helps contextualize two other studies that authors also mention:
Also, at least for those who are new to AA, or who have co-occurring major depressive disorder (that would require clinical attention even if the individual’s alcohol use disorder was in remission), attendance does indeed appear to be related to less depression, beyond the decrease that comes simply from giving up drinking. These participants may derive added benefit related to mood beyond abstinence. The reasons for this are as yet unclear. One possibility is that these individuals may select aspects of the AA program or fellowship that help them address this added depression burden (e.g., participating in social activities with other AA members).
The relationship between spiritual/religious practices and depression might be even more nuanced. There is a large body of literature suggesting individuals who are more religious are less depressed, and less likely to develop depression (see here). Thus the relationship between greater religious/spiritual practices and lower depression is perhaps not surprising.
Also, there are some studies that suggest AA attendance exerts its influence on improved drinking outcomes through increases in religious/spiritual practices (see here and here, for example). However, this explanatory effect may not hold up as well when other, more socially-grounded mechanisms, like modifying one’s social network, are considered at the same time (see here). This background role of spirituality/religiosity in early recovery may be especially true for individuals with lower initial addiction severity, such as young adults (see here, for example). In other words, the effect of religiosity/spirituality on enhanced abstinence and psychological and emotional well-being may be part of the AA story, but only for some.
Finally, as the study authors pointed out, the observed relationship between working on the “action” steps of AA (steps 4 through 9), and increased depression symptoms was unexpected. Because these “action” steps involve documentation and analysis of past behavior as it has related to alcohol addiction, it is possible that for some individuals, such step work might have uncovered painful feelings. These emotional processes may have been responsible for the observed increase in depression.
Findings from this study are important, as they provide insight into whether participation in AA can uniquely reduce depressive symptoms among attendees, separate from its ability to promote increased abstinence rates.
This research suggests that a clinician can refer patients to AA that present with depressive symptoms in addition to alcohol use disorder, as it is likely to help enhance recovery. These gains may occur both for alcohol abstinence as well as other aspects of well-being, such as reduced depressive symptoms.
There are several mechanisms of action known to aid enhanced recovery in 12-step MHOs that might reasonably help reduce depression but were not examined here. For example, future studies might investigate whether the effect of AA on depression is explained by forming new social-recovery relationships (e.g., with a sponsor) and engaging in activities (e.g., with other recovering individuals) facilitated by the rich 12-step MHO milieu.
Wilcox, C. E., Pearson, M. R., & Tonigan, J. S. (2015). Effects of long-term AA attendance and spirituality on the course of depressive symptoms in individuals with alcohol use disorder. Psychol Addict Behav, 29(2), 382-391. doi: 10.1037/adb0000053
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